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The use of dental services in a population in Northern Norway Per W. Norheim
a
a
Department of Prosthetic Dentistry, Dental Faculty, University of Oslo, Oslo, Norway Published online: 23 May 2015.
To cite this article: Per W. Norheim (1979) The use of dental services in a population in Northern Norway, Acta Odontologica Scandinavica, 37:5, 285-292 To link to this article: http://dx.doi.org/10.3109/00016357909004698
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
The use of dental services in a population in Northern Norway
PER W. NORHEIM Department of Prosthetic Dentistry, Dental Faculty, University of Oslo, Oslo, Norway
Acta Odontologica Scandinavica 1979.37:285-292.
Norheim, P.W. The use of dental services in a population in Northern Norway, Acta Odontol. Scand. 1979,37, 285-292 The utilization of dental services was studied by means of records from dentist’s files, a method which permits gathering of detailed information with high reliability and validity. 5 3 % of the adult population of 358 persons living in a coastal community in Northern Norway had visited a dentist during a period of two years. In the group of 13 % who were considered to be regular treatment attenders, number of teeth, sex and socio-economical status were the most influential predictors of utilization. Among the 182 persons with 10 or more remaining teeth, 59 % had made preventive and restorative dental visits, and in this group there was a dominating proportion of women, young people and people with high income and/or social class. In contrast, only six persons out of 61 with one to nine remaining teeth had made such visits. People in social class 3 were overrepresented among the 2 6 % of the population who visited a dentist because of extractions or complete denture services. The treatment profile according to age showed that younger people used most of their treatment tune on consultations, preventive measures and conservative treatments, while fued and removable prosthetics constituted a major part of the treatment time among elderly people.
Keywords: Dentists’ files; treatment profile
P. W. Norheim, Department of Prosthetic Dentistry, Dental Faculty, Box I 1 09, Blindern, Oslo 3, Norway
Studies on utilization of dental services may provide useful information about treatment, dental habits and about the usefulness of the dental service system (7,21,26). Practically all utilization studies up to now have been conducted by means of personal interviews or self-administered questionnaires (21). The parameter most frequently applied has been the time interval since the last dental visit (21). The last appointment appears easy to date for most interviewers, and this parameter has thus a
Received for publication, April 25, 1979
high reliability (1 7) and validity (1 5 , 2 3 ) . Information concerning the regularity of dental visits, and the composition of the dental services received, however, are more complex, and obtained by interviews the validity tends to be low (15). Therefore, in studies pertaining to the treatment rendered the data collected directly from the dentists’ files might be more accurate (1 5). The present study was undertaken to investigate the use of dental services in a population employing the dentists’ files as the data source.
286
PER W. NORHEIM
Acta Odontologica Scandinavica 1979.37:285-292.
MATERIAL AND METHODS
The population studied consisted of all 358 persons aged 20-69 years living in the coastal village Lyngseidet in Northern Norway (16). The community had no permanent dental clinic before 1959, when the Public Dental Service (PDS) was introduced. The prime duty of the dental health officers of the PDS is to render free and systematical dental services to persons from 6-17 years of age. However, they may also spend about one third of their working time working on adults at fixed fees, generally lower than those in private practice. Due t o the limited treatment capacity for adult patients at the PDS clinic at Lyngseidet, patients with pain were given priority, while preventive and restorative dental services were provided according to a waiting list, usually implying from six to nine months of waiting. lnformation concerning sex, age, income, and occupation was obtained from the tax authorities. The total income for each family was registered for each family member. The social index comprised three classes. Class 1: professionals and executives; Class 2: ”white collar” employees and foremen; Class 3: ”blue collar” workers (4). Each family member was classified according to the member of the family ranking highest. Information about the number of remaining teeth was obtained through a clinicai examination of 297 persons at the PDS clinic in the period May 1972 to April 1973. Inaddition,46persons gave information about their number of remaining teeth in a self-administered questionnaire conducted from July t o August 1973 (16). These 343 persons, i.e. 96 96 of the population, constituted the study group. Due to the high participation-rate the study group was considered to be representative of the whole study population (16). The data Concerning the utilization of dental services were collected from the patient files of the PDS clinic at Lyngseidet. In these files both the type of dental treatment given and the time used were recorded for each patient at each sitting. An evalu-
ation of the validity of these utilization data from the dentists’ files as a predictor of the total utilization of dental services in the population and the dental treatment given at each visit at the PDS clinic, was performed as reported elsewhere (1 5). This test seemed to confirm that the PDS records were complete and that the data used in this study were representative for the total use of dental services in the population. The few people who may have seen dentists outside Lyngseidet during the period this study was undertaken, were probably mainly commuting labourers, mostly men, and probably a few persons with high income and/or social class who may have preferred to see a dentist in private practice. The material comprised all the dental visits of the study group at the PDS clinic during a period of 2 years (1 May 1970 to 30 April 1972). lnformation was obtained on number of dental visits, time in 15 minutes intervals spent by the dentist and the type of dental treatment received. The dental services were divided in two categories: Preventive and restorative dental services: Consultations, preventive measures including periodontal treatment, conservative treatment (filling therapy), endodontic treatment, crowns, bridges and partial dentures were registered. Only persons who had received at least one full course of treatment were registered. One full treatment course was defined according to hchards (21) as the provision of all treatment necessary to make the patient dentally fit. Extractions and complete denture services: This group comprised including SUIgery and complete denture services.
RESULTS
Frequency of dental visits The files showed that 53% of the study group had visited the dental office at Lyngs-
THE USE OF DENTAL SERVICES
287
Table 1. Percentage of persons with I0 or more remaining teeth who had made one or more "courses of preventive andfor restorative dental visits" over a period of two years according to sex, age, income, social class, and number of teeth
of persons with 10 teeth or more
No.
%
%
%
%
98 84
100 100
53 29
30 38
17 33
101 67 14
100 100 100
43 40 42
36 30 36
22 30 21
Family income (Norw. Kr.) < 30 000 30 000-49 000 2 50 000
63 64 55
100 100 100
59 31 29
27 36 38
14 21 35
Social class 1 2 3
31 86 65
100 100 100
11 34 63
35 40 25
48 26 12
55 131
100 100
43 40
39 31
18 21
182
100
41
34
25
Sex Men Women Age Ivrs.) 20-29 30-49 50-69
Acta Odontologica Scandinavica 1979.37:285-292.
'ersons with no 'ersons with one 'ersons with twc course course Dr more courses of treatment of treatment of treatment
Number of teeth (above 9) 10-19 20 or more Total/Mean I
eidet in the two-year-period while only 13 % of the group had received two or more courses of treatment, indicating treatment attendance on a regular basis. Preventive and restorative dental services
Of the 182 persons with 10 teeth or more, 59% had been given one or more courses of treatment in the period including six percent who, in addition, had received extractions and/or complete denture services. In this treatment group there was a higher proportion of women than of men (Tables 1,2). This tendency was strengthened when the overrepresentation of elderly people and people with low income and/or social class among the women was adjusted. The apparent lack of effect of age on the
utilization of preventive and restorative visits shown in Table 1 and 2 is spurious because people with high income and/or high social class were overrepresented in the age groups above 30 years. Fig. 1 illustrates that young people had made preventive visits more often than elderly people, a tendency which persisted also after adjusting for number of teeth. In the group which had received one or more courses of treatment, there wasan overrepresentation of persons with high income and/or high social class (Table 1, Fig. 1). The proportion of people with 10-19 remaining teeth who had made preventive and restorative dental visits was similar to that of persons with 20 or more remaining teeth (Table 1). However, among the 6 1 persons with 1-9 teeth only six people had
288
PER W.NORHEIM
Table 2. Percentage of time spent (in 15 minutes intervals) b y persons with 10 or more remaining teeth on preventive andlor restorative treatments in a period of t w o years according to sex, age, income, social class, and number of teeth
1
I
Total number of 15 minutes intervals
Acta Odontologica Scandinavica 1979.37:285-292.
1
Time spent on ”preventive and restorative dental services” Consultations and preventive measures
Conservative and endodontic treatments
No.
%
%
%
Sex Men Women
5 30 69 3
100
35 35
49 49
Age W.) 20-29 30-49 50-69
642 469 112
100
33 39 26
58 35 51
Family income (Norw. Kr.) < 30 000 30 000-49 000 5 0 000
304 423 496
100
100
27 37 38
56 48 46
3
382 587 254
100 100 100
38 34 31
Number of teeth (above 9) 10-19 20 or more
284 939
100
30 36
1223
100
100
100 100
100
Crowns, bridges and partial dentures
17 16
Social class 1
Tot al/Mean
1
100
made such visits during the period the study took place. Approximately half of the total time spent on preventive and restorative dental visits was used on conservative and endodontic treatment, while another third was used on consultations and preventive work, leaving the rest for crowns, bridges and removable partial dentures (Table 2). People belonging to social class 1 had received relatively more of the total treatment time than patients in social class 2 and 3. Ten other persons had visited the dentist on one occasion to have a filing replaced.
Extractions and complete denture services In the two-year-period studied one fourth
1
35
I
1 I
I
42 50 57
19
36 53
34
16 12
11
49
16 I
of the group had seen a dentist at Lyngseidet for extractions and/or complete denture services (Table 3) including the 29 people who in addition had received a full course of preventive treatment. People in social class 3 visited the dentist for extractions and complete denture services more often than those in social class 1 and 2 (Table 3 , Fig. l), and they had also used a higher proportion of the total time spent on this type of treatment than persons in higher social classes (Table 3). Extractions were most frequent among young people, and persons with 10 teeth or more, while complete denture services increased with increasing age and decreasing number of teeth (Table 3,. Fin. - 1,. 2). ,
289
THE USE OF DENTAL SERVICES
Table 3. Number of persons who had received extractions and/or complete denture services and time used (at I5 minutes intervals)overa period of two years according t o sex, age, income, social class, and number of teeth
Total number of participants
Number of persons who had received extractions or complete denture services
Acta Odontologica Scandinavica 1979.37:285-292.
No.
Time spent on extractions and denture services Total number
Complete
intervals
services
No.
%
%
%
Sex den Komen
167 176
46 42
191 171
100 100
60 47
40 53
Ige lyrs.) !O-29 10-49 i0-69
105 136 102
25 36 21
76 173 113
100 100 100
88 51 35
12 49 65
‘amily income Nor w. Kr.) :30 000 10 000-49 000 a 50 000
152 115 76
36 35 17
161 141 60
100 100 100
51 43 72
43 56 28
39 129 175
I 26 55
26 69 267
100 100 100
62 67 50
38 33 50
92 94 63 113
100 100 100 100
0 43 84 90
100 51 16 10
362
100
;ocial class ! 1
Vumber of teeth Jone . -9 .O-19 !O or more
131
18 21 21 28
rot al/Mean
343
88
93 64
55
The treatment profile Fig. 2 illustrates the profile of all treatments given in the two-year period. Young people spent most of their treatment time on consultations, preventive measures and conservative treatments, while fxed and removable prosthetics constituted a major part of the treatment time among elderly people.
DISCUSSION
Frequency of dental visits The proportion of individuals who had made
1
54
I
46
dental visits on a regular basis in the population of Lyngseidet is low compared to interview studies among the adult population in the Scandinavian countries (6, 7, 20, 22, 23, 28) which have estimates varying from 40% to 56%. When comparing the utilization data from the present study with data from other studies it should, however, be considered that differences both in the methods of data collection and in the definition of concepts may have caused data variations (15). Still, there is no doubt the present population has an unfavourable utilization profile, a finding which primarily may be related to the poor accessibility of dental
290
PER W. NORHEIM
services in the population, a factor which partly determines the need for dental treatment (5, 21) and the demand for such treatment (20, 21). Furthermore, it is known that edentulous persons rarely visit the dentist (18). Therefore, the fact that more than one fourth of the present population was edentulous (Table 3), may also have contributed to the low number of individuals who visited the dentist on a regular basis.
8'0
SCClAL C L A S S 1 SOCIAL CLASS 2 SOCIAL C L A S S 3
n 29 49 69
29 49 69
20
Acta Odontologica Scandinavica 1979.37:285-292.
Preventive and restorative dental services In the present study the number of remaining teeth was registered up to 16 months after the two-year-period described. This underregistration was corrected by adding the number of teeth extracted during and after the two-year-period to the number of teeth registered in the clinical examination and the questionnaire. Individuals with few remaining teeth are known to visit the dentist infrequently (3, 9), and the number of teeth is also interrelated with demographic and socioeconomic characteristics (7, 21, 22, 24). Thus, in the analysis of preventive and restorative dental visits, persons with less than 10 teeth were excluded. The dominance of women among people who had had one or more courses of treatment (Table l), may partly be related to a more general preventive attitude and willingness to follow preventive dental health practices (9,25). The influence of age on the utilization of preventive and restorative visits indicates attitudenal and habitual differences between young and elderly people, which may partly be related to the fact that young people have received regular dental treatment during their years at school (7). The findings in the present study support the relationship between high socio-economic status and high utilization of preventive and restorative dental care (2, 1 1 , 12, 13,21, 27) (Tables 1,2).
0P R E V E N T I V E 80
-
A N 0 RESTORATIVE DENTAL V I S I T S
EXTRACTIONS C O M P L E T E D E N T U R E SERVICES
The marked drop in utilization from 58 % among people with 10 teeth or more who had received one course of treatment in the period, to 10 % for persons with one to nine remaining teeth, may indicate that approximately 10 teeth per person represent a borderline in the utilization of preventive dental care. The finding that people in social class 1 had spent considerable time on consultations, preventive treatments and crowns, bridges, and partial dentures may indicate that they are more willing to follow preventive dental health practices and when necessary they are also willing and able to carry into effect expensive treatment like crowns and bridges (10).
THE USE OF DENTAL SERVICES PERCENT OF TREATMENT T I M E
40
-
The treatment profile
CONSERVATIVE AND ENDODONTIC TREATMENTS
Acta Odontologica Scandinavica 1979.37:285-292.
2o - CONSULTATIONS A N D
PREVENTIVE MEASURES L
20
-29
30 -39
29 1
40 50 -49 -59 AGE GROUP (YRS.1
60 - 69
Fig. 2 . Treatment profile of the population over a period of two years according to treatment time (in percent) required by different age groups.
Extractions and complete denture services It was a striking observation that almost half of the persons who had visited a dentist during the study period had been in pain or had been denture-orientated patients. This finding indicates that the dental health of the present population in Lyngseidet has lagged behind that of the general Norwegian population where only every third adult was estimated to have received extractions or complete denture services at the last dental visit (7). Extractions and complete denture services were associated with social class whereas the corresponding influence of income was modest. These tendencies which remained also after adjusting for interactions between variables support previous findings that differences in the use of dental services in a population not necessarily depends primarily on financial circumstances, but also on attitudinal differences related to social identities (8, 10, 14).
The treatment pattern shown in Fig. 2 should be looked upon mainly as a result of the high tooth mortality, giving young persons a high need for conservative treatments while elderly and aged persons needed prosthetic treatment to replace their missing teeth. However, in spite of a more preventive treatment behavior among younger persons, there was a high rate of extractions in this age group. This indicates that previous preventive and conservative dental services had been inadequate to prevent massive tooth loss due to caries among young people with low socio-economic status (Fig. 1). These findings are in accordance with the WHO international dental study (1) which underlines the universal need to improve the preventive component in the existing systems for delivery of dental services. The treatment profde measured periodically according to strategic background characteristics could demonstrate such developments in treatment patterns. In conclusion it may be stated that in the population presently studied, the observed dental treatment pattern among adults was limited by the accessibility of dental S ~ T vices. However, within the frame of available treatment capacity the utilization rate and the treatment profile were affected by characteristics like sex, age, income, social class and number of teeth. The use of dentists’ files as data source permits gathering of detailed information with high reliability and validity (15). As such, this method may be used in analysing the pattern of dental care utilization, and it may thus assist in the planning and evaluation of dental care programs.
292
PER W. NORHEIM REFERENCES
1. Barmes, D.E. A progress report on adult data
2.
3.
4.
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5.
6. 7.
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11. 12.
13. 14.
15.
analysis in the WHO/USPHS International Collaborative Study. Int. Dent. J. 1978, 28, 348-363 Bulman, J.S., Richards, N.D., Slack, G.L.& Willcocks, A.J. Demand and need for dental care. Oxford University Press, London 1968, 37-41 Gray, P.G., Todd, J.E., Slack, G.L. & BuIman, J.S. Adult dental health in England and Wales in 1968. Her Majesty’s Stationery Office, London 1970 Helee, B. & HeLe, L.A. Characteristics of a group o f patients with temporomandibular joint disorders. Community Dent. Oral Epidemiol. 1975,3,72-79 Helee, L.A. Dental health knowledge and attitudes in a disadvantaged, rural population. Acta Odontol. Scand. 1973, 31, 231-240 Helee, L.A. Changes of dental treatment pattern in Norway in the 1970s. Community Dent. Oral Epidemiol. 1978,6,53-56 Helee, L.A. & Tronstad, L. The use of dental services among Norwegian adults in 1973. Community Dent. Oral Epidemiol. 1975, 3, 120-125 Jensen, K. Dental care practices and socioeconomic status in Denmark. Community Dent. Oral Epidemiol. 1974,2,273-281 Kegeles, S.S. Why people seek dental care: A review of present knowledge. Am. J. Public Health. 1961.5 1, 1306- 1 311 Koos, E.L. The health of Regionville, what the people thought and did about it, Columbia University Press, New York 1954, 118-125 Kriesberg, L. The relationship between socioeconomic rank and behavior. SOC. Probl. 1963, 10,334-353 Kriesberg, L. & Treimann, B.R. Socioeconomic status and the utilization of dentists’ services. J. Am. Coll. Dent. 1960, 27, 147-164 Nikias, M.K. Social class and use of dental care under prepayment. Med. Care 1968, 6, 381-393 Nikias, M.K., Fink, R. & Shapiro, S. Comparisons of poverty and nonpoverty groups on dental status, needs, and practices. J. Public Health Dent. 1975,35,237-259 Norheim, P.W. Validity of information concerning the use of dental services obtained
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in interviews. Community Dent. Oral Epidemiol. 1979,7,91-95 Norheim, P.W. & Helee, L.A. Comparison between participants and non-participants in a dental health survey in Northern Norway. Community Dent. Oral Epidemiol. 1975, 3, 56-60 Norheim, P.W. & Helee, L.A. Reliability and constancy of information obtained in dental health interviews. Community Dent. Oral Epidemiol. 1976,4,98-101 Norheim, P.W. & Valderhaug, J. Distribution and evaluation of complete dentures in a population in Northern Norway. J. Oral Rehabil. 1979,6, 257-266 Nyman, K. Variationen i tandstatus och tandvirdskonsumtion hos vuxna i Finland. Socialmedicinsk Tidskr. 1973, 50, 270-276 Rayner, J.F. Socioeconomic status and factors influencing the dental health practices of mothers. Am. J . Public Health. 1970, 60, 1250-1258 Richards, N.D. Utilization of dental services. In: Richards, N.D. & Cohen, L.K. eds. Social sciences and dentistry: a critical bibliography. FtkldBration Dentaire Internationale, The Hague 197 1,209-240 Schwarz, E. & Hansen, E.R. Utilization of dental services in the adult Danish population 1975. Community Dent. Oral Epidemiol. 1976,4,221-226 Smedby, B. Tandvirdsvanor och tandvirdskostnader. In: Tandvirdsforsikring. 1961 irs sjukforsiikringsutredning betankande I. Statens offentliga utredningar 1965, 4, Stockholm 1965,pp. 169-184 Smedby, B. Betydelsen av vissa faktorer for tandvirskonsumtionen. Socialmedicinsk tidsskrifts skriftserie no. 37. Stockholm 1972 Tash, R.H., O’Shea, R.M. & Cohen, L.K. Testing a preventive-symptomatic theory of dental health behavior. Am. J. Public Health. 1969,59,514-521 Young, W.O. & Striffler, D.F. The dentist, his practice, and his community. W.B. Saunders Company, Philadelphia 1969, 183-201 American Dental Association. A motivational study of dental care. 11. Social class and dental care attitudes and practices. J. Am. Dent. Assoc. 1958,56,566-571 Sifo. Tandlakare och tandlakarbesok 1974. Tandliikartidningen 1974,66,794-796
Acta Odontologica Scandinavica Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/iode20
The use of dental services in a population in Northern Norway Per W. Norheim
a
a
Department of Prosthetic Dentistry, Dental Faculty, University of Oslo, Oslo, Norway Published online: 23 May 2015.
To cite this article: Per W. Norheim (1979) The use of dental services in a population in Northern Norway, Acta Odontologica Scandinavica, 37:5, 285-292 To link to this article: http://dx.doi.org/10.3109/00016357909004698
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
The use of dental services in a population in Northern Norway
PER W. NORHEIM Department of Prosthetic Dentistry, Dental Faculty, University of Oslo, Oslo, Norway
Acta Odontologica Scandinavica 1979.37:285-292.
Norheim, P.W. The use of dental services in a population in Northern Norway, Acta Odontol. Scand. 1979,37, 285-292 The utilization of dental services was studied by means of records from dentist’s files, a method which permits gathering of detailed information with high reliability and validity. 5 3 % of the adult population of 358 persons living in a coastal community in Northern Norway had visited a dentist during a period of two years. In the group of 13 % who were considered to be regular treatment attenders, number of teeth, sex and socio-economical status were the most influential predictors of utilization. Among the 182 persons with 10 or more remaining teeth, 59 % had made preventive and restorative dental visits, and in this group there was a dominating proportion of women, young people and people with high income and/or social class. In contrast, only six persons out of 61 with one to nine remaining teeth had made such visits. People in social class 3 were overrepresented among the 2 6 % of the population who visited a dentist because of extractions or complete denture services. The treatment profile according to age showed that younger people used most of their treatment tune on consultations, preventive measures and conservative treatments, while fued and removable prosthetics constituted a major part of the treatment time among elderly people.
Keywords: Dentists’ files; treatment profile
P. W. Norheim, Department of Prosthetic Dentistry, Dental Faculty, Box I 1 09, Blindern, Oslo 3, Norway
Studies on utilization of dental services may provide useful information about treatment, dental habits and about the usefulness of the dental service system (7,21,26). Practically all utilization studies up to now have been conducted by means of personal interviews or self-administered questionnaires (21). The parameter most frequently applied has been the time interval since the last dental visit (21). The last appointment appears easy to date for most interviewers, and this parameter has thus a
Received for publication, April 25, 1979
high reliability (1 7) and validity (1 5 , 2 3 ) . Information concerning the regularity of dental visits, and the composition of the dental services received, however, are more complex, and obtained by interviews the validity tends to be low (15). Therefore, in studies pertaining to the treatment rendered the data collected directly from the dentists’ files might be more accurate (1 5). The present study was undertaken to investigate the use of dental services in a population employing the dentists’ files as the data source.
286
PER W. NORHEIM
Acta Odontologica Scandinavica 1979.37:285-292.
MATERIAL AND METHODS
The population studied consisted of all 358 persons aged 20-69 years living in the coastal village Lyngseidet in Northern Norway (16). The community had no permanent dental clinic before 1959, when the Public Dental Service (PDS) was introduced. The prime duty of the dental health officers of the PDS is to render free and systematical dental services to persons from 6-17 years of age. However, they may also spend about one third of their working time working on adults at fixed fees, generally lower than those in private practice. Due t o the limited treatment capacity for adult patients at the PDS clinic at Lyngseidet, patients with pain were given priority, while preventive and restorative dental services were provided according to a waiting list, usually implying from six to nine months of waiting. lnformation concerning sex, age, income, and occupation was obtained from the tax authorities. The total income for each family was registered for each family member. The social index comprised three classes. Class 1: professionals and executives; Class 2: ”white collar” employees and foremen; Class 3: ”blue collar” workers (4). Each family member was classified according to the member of the family ranking highest. Information about the number of remaining teeth was obtained through a clinicai examination of 297 persons at the PDS clinic in the period May 1972 to April 1973. Inaddition,46persons gave information about their number of remaining teeth in a self-administered questionnaire conducted from July t o August 1973 (16). These 343 persons, i.e. 96 96 of the population, constituted the study group. Due to the high participation-rate the study group was considered to be representative of the whole study population (16). The data Concerning the utilization of dental services were collected from the patient files of the PDS clinic at Lyngseidet. In these files both the type of dental treatment given and the time used were recorded for each patient at each sitting. An evalu-
ation of the validity of these utilization data from the dentists’ files as a predictor of the total utilization of dental services in the population and the dental treatment given at each visit at the PDS clinic, was performed as reported elsewhere (1 5). This test seemed to confirm that the PDS records were complete and that the data used in this study were representative for the total use of dental services in the population. The few people who may have seen dentists outside Lyngseidet during the period this study was undertaken, were probably mainly commuting labourers, mostly men, and probably a few persons with high income and/or social class who may have preferred to see a dentist in private practice. The material comprised all the dental visits of the study group at the PDS clinic during a period of 2 years (1 May 1970 to 30 April 1972). lnformation was obtained on number of dental visits, time in 15 minutes intervals spent by the dentist and the type of dental treatment received. The dental services were divided in two categories: Preventive and restorative dental services: Consultations, preventive measures including periodontal treatment, conservative treatment (filling therapy), endodontic treatment, crowns, bridges and partial dentures were registered. Only persons who had received at least one full course of treatment were registered. One full treatment course was defined according to hchards (21) as the provision of all treatment necessary to make the patient dentally fit. Extractions and complete denture services: This group comprised including SUIgery and complete denture services.
RESULTS
Frequency of dental visits The files showed that 53% of the study group had visited the dental office at Lyngs-
THE USE OF DENTAL SERVICES
287
Table 1. Percentage of persons with I0 or more remaining teeth who had made one or more "courses of preventive andfor restorative dental visits" over a period of two years according to sex, age, income, social class, and number of teeth
of persons with 10 teeth or more
No.
%
%
%
%
98 84
100 100
53 29
30 38
17 33
101 67 14
100 100 100
43 40 42
36 30 36
22 30 21
Family income (Norw. Kr.) < 30 000 30 000-49 000 2 50 000
63 64 55
100 100 100
59 31 29
27 36 38
14 21 35
Social class 1 2 3
31 86 65
100 100 100
11 34 63
35 40 25
48 26 12
55 131
100 100
43 40
39 31
18 21
182
100
41
34
25
Sex Men Women Age Ivrs.) 20-29 30-49 50-69
Acta Odontologica Scandinavica 1979.37:285-292.
'ersons with no 'ersons with one 'ersons with twc course course Dr more courses of treatment of treatment of treatment
Number of teeth (above 9) 10-19 20 or more Total/Mean I
eidet in the two-year-period while only 13 % of the group had received two or more courses of treatment, indicating treatment attendance on a regular basis. Preventive and restorative dental services
Of the 182 persons with 10 teeth or more, 59% had been given one or more courses of treatment in the period including six percent who, in addition, had received extractions and/or complete denture services. In this treatment group there was a higher proportion of women than of men (Tables 1,2). This tendency was strengthened when the overrepresentation of elderly people and people with low income and/or social class among the women was adjusted. The apparent lack of effect of age on the
utilization of preventive and restorative visits shown in Table 1 and 2 is spurious because people with high income and/or high social class were overrepresented in the age groups above 30 years. Fig. 1 illustrates that young people had made preventive visits more often than elderly people, a tendency which persisted also after adjusting for number of teeth. In the group which had received one or more courses of treatment, there wasan overrepresentation of persons with high income and/or high social class (Table 1, Fig. 1). The proportion of people with 10-19 remaining teeth who had made preventive and restorative dental visits was similar to that of persons with 20 or more remaining teeth (Table 1). However, among the 6 1 persons with 1-9 teeth only six people had
288
PER W.NORHEIM
Table 2. Percentage of time spent (in 15 minutes intervals) b y persons with 10 or more remaining teeth on preventive andlor restorative treatments in a period of t w o years according to sex, age, income, social class, and number of teeth
1
I
Total number of 15 minutes intervals
Acta Odontologica Scandinavica 1979.37:285-292.
1
Time spent on ”preventive and restorative dental services” Consultations and preventive measures
Conservative and endodontic treatments
No.
%
%
%
Sex Men Women
5 30 69 3
100
35 35
49 49
Age W.) 20-29 30-49 50-69
642 469 112
100
33 39 26
58 35 51
Family income (Norw. Kr.) < 30 000 30 000-49 000 5 0 000
304 423 496
100
100
27 37 38
56 48 46
3
382 587 254
100 100 100
38 34 31
Number of teeth (above 9) 10-19 20 or more
284 939
100
30 36
1223
100
100
100 100
100
Crowns, bridges and partial dentures
17 16
Social class 1
Tot al/Mean
1
100
made such visits during the period the study took place. Approximately half of the total time spent on preventive and restorative dental visits was used on conservative and endodontic treatment, while another third was used on consultations and preventive work, leaving the rest for crowns, bridges and removable partial dentures (Table 2). People belonging to social class 1 had received relatively more of the total treatment time than patients in social class 2 and 3. Ten other persons had visited the dentist on one occasion to have a filing replaced.
Extractions and complete denture services In the two-year-period studied one fourth
1
35
I
1 I
I
42 50 57
19
36 53
34
16 12
11
49
16 I
of the group had seen a dentist at Lyngseidet for extractions and/or complete denture services (Table 3) including the 29 people who in addition had received a full course of preventive treatment. People in social class 3 visited the dentist for extractions and complete denture services more often than those in social class 1 and 2 (Table 3 , Fig. l), and they had also used a higher proportion of the total time spent on this type of treatment than persons in higher social classes (Table 3). Extractions were most frequent among young people, and persons with 10 teeth or more, while complete denture services increased with increasing age and decreasing number of teeth (Table 3,. Fin. - 1,. 2). ,
289
THE USE OF DENTAL SERVICES
Table 3. Number of persons who had received extractions and/or complete denture services and time used (at I5 minutes intervals)overa period of two years according t o sex, age, income, social class, and number of teeth
Total number of participants
Number of persons who had received extractions or complete denture services
Acta Odontologica Scandinavica 1979.37:285-292.
No.
Time spent on extractions and denture services Total number
Complete
intervals
services
No.
%
%
%
Sex den Komen
167 176
46 42
191 171
100 100
60 47
40 53
Ige lyrs.) !O-29 10-49 i0-69
105 136 102
25 36 21
76 173 113
100 100 100
88 51 35
12 49 65
‘amily income Nor w. Kr.) :30 000 10 000-49 000 a 50 000
152 115 76
36 35 17
161 141 60
100 100 100
51 43 72
43 56 28
39 129 175
I 26 55
26 69 267
100 100 100
62 67 50
38 33 50
92 94 63 113
100 100 100 100
0 43 84 90
100 51 16 10
362
100
;ocial class ! 1
Vumber of teeth Jone . -9 .O-19 !O or more
131
18 21 21 28
rot al/Mean
343
88
93 64
55
The treatment profile Fig. 2 illustrates the profile of all treatments given in the two-year period. Young people spent most of their treatment time on consultations, preventive measures and conservative treatments, while fxed and removable prosthetics constituted a major part of the treatment time among elderly people.
DISCUSSION
Frequency of dental visits The proportion of individuals who had made
1
54
I
46
dental visits on a regular basis in the population of Lyngseidet is low compared to interview studies among the adult population in the Scandinavian countries (6, 7, 20, 22, 23, 28) which have estimates varying from 40% to 56%. When comparing the utilization data from the present study with data from other studies it should, however, be considered that differences both in the methods of data collection and in the definition of concepts may have caused data variations (15). Still, there is no doubt the present population has an unfavourable utilization profile, a finding which primarily may be related to the poor accessibility of dental
290
PER W. NORHEIM
services in the population, a factor which partly determines the need for dental treatment (5, 21) and the demand for such treatment (20, 21). Furthermore, it is known that edentulous persons rarely visit the dentist (18). Therefore, the fact that more than one fourth of the present population was edentulous (Table 3), may also have contributed to the low number of individuals who visited the dentist on a regular basis.
8'0
SCClAL C L A S S 1 SOCIAL CLASS 2 SOCIAL C L A S S 3
n 29 49 69
29 49 69
20
Acta Odontologica Scandinavica 1979.37:285-292.
Preventive and restorative dental services In the present study the number of remaining teeth was registered up to 16 months after the two-year-period described. This underregistration was corrected by adding the number of teeth extracted during and after the two-year-period to the number of teeth registered in the clinical examination and the questionnaire. Individuals with few remaining teeth are known to visit the dentist infrequently (3, 9), and the number of teeth is also interrelated with demographic and socioeconomic characteristics (7, 21, 22, 24). Thus, in the analysis of preventive and restorative dental visits, persons with less than 10 teeth were excluded. The dominance of women among people who had had one or more courses of treatment (Table l), may partly be related to a more general preventive attitude and willingness to follow preventive dental health practices (9,25). The influence of age on the utilization of preventive and restorative visits indicates attitudenal and habitual differences between young and elderly people, which may partly be related to the fact that young people have received regular dental treatment during their years at school (7). The findings in the present study support the relationship between high socio-economic status and high utilization of preventive and restorative dental care (2, 1 1 , 12, 13,21, 27) (Tables 1,2).
0P R E V E N T I V E 80
-
A N 0 RESTORATIVE DENTAL V I S I T S
EXTRACTIONS C O M P L E T E D E N T U R E SERVICES
The marked drop in utilization from 58 % among people with 10 teeth or more who had received one course of treatment in the period, to 10 % for persons with one to nine remaining teeth, may indicate that approximately 10 teeth per person represent a borderline in the utilization of preventive dental care. The finding that people in social class 1 had spent considerable time on consultations, preventive treatments and crowns, bridges, and partial dentures may indicate that they are more willing to follow preventive dental health practices and when necessary they are also willing and able to carry into effect expensive treatment like crowns and bridges (10).
THE USE OF DENTAL SERVICES PERCENT OF TREATMENT T I M E
40
-
The treatment profile
CONSERVATIVE AND ENDODONTIC TREATMENTS
Acta Odontologica Scandinavica 1979.37:285-292.
2o - CONSULTATIONS A N D
PREVENTIVE MEASURES L
20
-29
30 -39
29 1
40 50 -49 -59 AGE GROUP (YRS.1
60 - 69
Fig. 2 . Treatment profile of the population over a period of two years according to treatment time (in percent) required by different age groups.
Extractions and complete denture services It was a striking observation that almost half of the persons who had visited a dentist during the study period had been in pain or had been denture-orientated patients. This finding indicates that the dental health of the present population in Lyngseidet has lagged behind that of the general Norwegian population where only every third adult was estimated to have received extractions or complete denture services at the last dental visit (7). Extractions and complete denture services were associated with social class whereas the corresponding influence of income was modest. These tendencies which remained also after adjusting for interactions between variables support previous findings that differences in the use of dental services in a population not necessarily depends primarily on financial circumstances, but also on attitudinal differences related to social identities (8, 10, 14).
The treatment pattern shown in Fig. 2 should be looked upon mainly as a result of the high tooth mortality, giving young persons a high need for conservative treatments while elderly and aged persons needed prosthetic treatment to replace their missing teeth. However, in spite of a more preventive treatment behavior among younger persons, there was a high rate of extractions in this age group. This indicates that previous preventive and conservative dental services had been inadequate to prevent massive tooth loss due to caries among young people with low socio-economic status (Fig. 1). These findings are in accordance with the WHO international dental study (1) which underlines the universal need to improve the preventive component in the existing systems for delivery of dental services. The treatment profde measured periodically according to strategic background characteristics could demonstrate such developments in treatment patterns. In conclusion it may be stated that in the population presently studied, the observed dental treatment pattern among adults was limited by the accessibility of dental S ~ T vices. However, within the frame of available treatment capacity the utilization rate and the treatment profile were affected by characteristics like sex, age, income, social class and number of teeth. The use of dentists’ files as data source permits gathering of detailed information with high reliability and validity (15). As such, this method may be used in analysing the pattern of dental care utilization, and it may thus assist in the planning and evaluation of dental care programs.
292
PER W. NORHEIM REFERENCES
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