Dental care use in Ontario: the Canadian community health survey (CCHS)

Oral health is an essential facet of health-related quality of life and a periodic dental visit is an indicator of adequate oral health care utilization [1]. Regular dental visits provide an opportunity to ensure optimal oral health, and to help prevent serious and costly future conditions such as tooth loss, oral cancer and periodontal (gum) disease [2‐4]. Moreover, preventive dental behavior is shown to be effective in improving health outcomes among the general population [5], since oral health is also linked to overall health with various studies showing a positive association between poor oral hygiene and pancreatic cancer, respiratory, and cardiovascular diseases [3‐6]. The frequency of dental check-ups varies for individuals, depending on their oral health needs, oral health history, and medical status [2]. It is generally recommended to visit the dentist at least once per year [7, 8].

The Canadian dental health care system, unlike the medical care system, is not publicly funded and universal, therefore, dental care expenses are managed through employment based insurance, out-of-pocket payments, or government assistance offering support for low-income groups, children, seniors and welfare recipients [9]. According to the Canadian Health Measures Survey, 62.6% of Canadians have employment-related insurance, 31.9% pay directly out of pocket, and 5.5% are under government public programs [10]. The privatization of dental care not only presents financial barriers in accessing dental services among the lower socioeconomic class, but also among those having a higher economic status, as a consequence of their lack of dental insurance plans [3, 11, 12]. For example, Ramraj et al. [11] found that uninsured middle-income Canadians reported greater financial barriers in accessing dental care compared to their insured counterparts. Furthermore, individuals with lower incomes and without insurance were four times more likely to avoid visiting a dental professional due to financial barriers [13]. Thus, income and dental insurance coverage are known to be the major determinants of dental care use as they mitigate the barriers associated with financial costs [14]. Dental care use, in addition to being influenced by economic factors such as income and insurance coverage, is also related to socio-demographic characteristics. In fact, the Andersen Behavioral Model of Health Care Utilization suggests that age, gender, education, occupation and ethnicity also affect dental care seeking behavior, as well as enabling resources such as income and insurance plans that eliminate financial barriers to dental care use, and need factors such as perceived and actual need for dental care [7].

Conflicting and inconclusive evidence as to the oral health benefits of routinely attending dental care for checkups exists. According to systematic reviews, no high-quality evidence is available to support or refute recommending dental attendance to adults with a frequency of less than once a year or any other specific frequency [15‐17] .However, some observational studies have shown that individuals who visit a dentist regularly have better clinical and perceived oral health than their counterparts [18‐20]. Therefore, the recommendation to have an oral examination on a regular basis remains a key practice in preventive dentistry.

Despite the importance of regular dental visits in improving oral health and oral health-related quality of life [21], less than two-thirds of Canadians attend routine dental visits each year [1]. In fact, the mean frequency of dental visits varies across Canada with Ontario having the highest mean frequency of dental visits [14].To date, the majority of research has focused on the determinants of dental care use among specific populations in Canada such as, youth, elderly, pregnant women, and those receiving government assistance [7, 22‐24]. In fact, there is little to no information available on estimates of dental care use in Ontario, Canada’s most populated province, with approximately 14 million residents, 20% of whom are visible minorities. Therefore, the findings of this study might provide more effective preventive services to improve the oral health of Ontarians. The aim of this study is to examine the factors associated with dental care use in Ontario. Findings of this study might elucidate more effective preventive services to be provided.

The analytic sample comprised a total of 20,864 subjects weighted to represent 11,713,800 people, where 27.8% reported not having visited a dentist within the past year, and 19.3% reported usually visiting a dentist only for emergencies (data not shown). Table 1 presents sample characteristics related to patterns of dental care use. Over 50% of participants were female, and 49% were males. More than 30% of participants had no dental insurance. Results of the multivariable logistic regression model are shown in Table 2. Compared to those aged less than 18 years old, older individuals were at increased odds of not having visited a dentist within the past year and having emergency visits. Similarly, males had a 1.43 (95% CI: 1.22–1.67) increased odds of not visiting a dentist within the past year, and usually visiting a dentist for emergency care compared to females (OR = 1.54, 95% CI: 1.22–1.85). Aboriginal people were 1.47 (95% CI: 1.02–2.12) times more likely to visit a dentist for emergency purposes compared to non-Aboriginals. Furthermore, subjects with a private dental insurance plan, a household income of 150,000 CAD and over, a university education, and who consumed alcohol at least once per month, or at least once per week were at significantly reduced odds of having a delayed dental visit and visiting for emergency care purposes. Smokers were 1.40 (95% CI: 1.16–1.66) times more likely to report not visiting a dentist within the last year and visiting for emergency care (OR = 1.49, 95% CI: 1.21–1.85). Moreover, those with less frequent teeth brushing and poor health of teeth and mouth were at increased odds of not visiting a dentist within the last year and visiting for emergency care. Lastly, those with diabetes (either Type 1 or Type 2) were 1.48 (95% CI: 1.11–1.97) times more likely to have emergency dental visits compared to those without diabetes (Table 2).

This study is the first to examine the characteristics of dental care use in Ontario. The results demonstrated that male gender, Aboriginal status, low educational attainment, low household income, and no dental insurance were significantly positively associated with poor dental care use. Likewise, those who smoked, seldom had alcohol, had less frequent teeth brushing, poor health of teeth and mouth, and had diabetes were at significantly increased odds of poor dental care use.

Among various age groups, those older than 18 years were at increased odds of not visiting a dentist within the past year and visiting only for emergencies. This was in accordance with Bhatti et al. whose results suggested a decline in frequency of dental visit as an individual ages [14]. The findings of this study revealed that females were more likely to visit a dentist within the past year and not for emergency purposes, compared to males. Such gender differences in dental care utilization can be attributed to the positive attitudes and greater knowledge of oral health towards dental visits among females [24]. Also, as suggested by previous studies, females were more proactive in maintaining healthy teeth and gum, and more likely to show preventive dental visit behaviors [24].

Individuals of Aboriginal status were more likely to report visiting a dentist in cases of emergency compared to non-Aboriginal people. This reflects the reluctance of Aboriginals to seek regular dental care and delay receiving immediate treatment until symptoms are severe [25]. This reluctance to use dental care might originate from racialized views and stereotypes toward Aboriginal individuals that make them feel unwelcome at the dental office [25]. The finding of the current study is in concordance with a study by Slater on public oral health care among Aboriginal Australians, that found that those of Aboriginal status were more likely to seek emergency services rather than preventive dental care services [26].

Consistent with previous literature, smokers were found to be less likely to report visiting a dentist within the past year than non-smokers [27]. Our results also suggested that those who smoked usually visited a dentist for emergencies only compared to non-smokers. This could be due in part to the fact that smokers tend to engage in health-seeking behavior rather than preventive care behavior, even though regular dental visits are highly recommended for averting future periodontal disease, tooth loss, and other oral health complexities [28]. Interestingly, our results revealed that those who consumed alcohol at least once per week were less likely to report having poor dental care use. This result was not in concordance with a longitudinal study in Sweden, which found that individuals with high alcohol use reported having more irregular dental visits than those with lower alcohol use In fact, previous studies have been inconsistent on the relationship between alcohol use and oral health, with the literature showing an overall weak association between alcohol consumption and risk of caries and periodontitis [29]. On the other hand, light or moderate alcohol use was found to be positively associated with frequent dental checkups and with having more filled teeth in a study by Wu et al. [30] using NHANES data. Therefore, those who consumed alcohol were more likely to obtain dental fillings. A possible explanation for the relationship between heavy alcohol consumption and dental care use is that alcohol may enhance the release of fluoride from certain restorative materials in fillings, thereby reducing susceptibility to more dental caries by reducing oral cariogenic flora [31], and therefore requiring those who consume it to have less dental visits. Further research is needed to elucidate the role of alcohol consumption duration, patterns and volume in relation to dental care use and oral health outcomes.

The present study identified that less frequent teeth brushing and poor oral health of teeth and mouth were significantly associated with poor dental care use, as expected. This is in concordance with Muirhead et al. [7], who suggested that persons with poor oral health reported less dental care utilization, possibly resulting from the fear of dental cost treatment or the anxiety associated with the pain of treatment. This finding affirms that self-perception of oral health needs rather than actual oral health status is a predictor of dental care use. This fits in with Muirhead et al’s [7] “paradox of need”, where working poor individuals with worse self-rated oral health or who had a perceived need for treatment were poor dental care service users.

We also found that subjects with diagnosed diabetes were more likely to visit the dentist for emergency purposes only. This could be explained by fewer dental visits among diabetic patients due to lack of perceived need, cost barriers, and fear or anxiety [32], which may result in the development of serious dental or periodontal diseases that signifies an urgency for an emergency visit. Moreover, evidence suggests that people with diabetes are at increased prevalence of tooth decay and periodontitis, because of high levels of glucose in saliva that leads to proliferation of bacteria and occurrence of oral health complications [33]. Interventions may need to be tailored to subpopulations within the community who are at high risk of experiencing dental problems.

The study had several strengths. To our knowledge, this is the first provincially representative study that examined the relationship between various demographic, socio-economic, health behavior, oral health and other health related factors and dental care use in Ontario. This study also utilized a large sample size allowing for ample statistical power, with population weights accounting for nonresponse bias. Confounding bias was minimized due to the variety of potential covariates that were controlled for in the analysis. However, some limitations are present. Given that this study is a secondary analysis, no information regarding other important dental health variables such as number of decayed/missing/filled teeth, flossing habits, and depth of periodontal pockets was available. Moreover, all variables, including the main outcome, were self-reported and the accuracy of responses is subject to recall bias. Lastly, the cross-sectional nature of the study design does not allow us to infer causality.

This study examined the pattern of dental care use and its association with socio-demographic, oral health, and health behavior, and other oral and general health related factors in Ontario. The estimate of not visiting the dentist within the past year was high, at 27.8%, while 19% reported visiting for emergency purposes only. Males, individuals of Aboriginal status, those with low household income, low educational level, no dental insurance, less frequent teeth brushing, poor health of teeth and mouth, smokers, and diabetics were at increased odds of poor dental care use. Further validation work is needed for some of the factors included and not included in this study at the national level. Furthermore, these findings highlight the need for focusing efforts toward improving dental care use among individuals of lower socio-economic background, as well as vulnerable populations such as Aboriginals, and those with chronic diseases such as diabetes in order to achieve better oral health outcomes. Further research can elucidate the effectiveness of such programs in decision making processes associated with dental care utilization among individuals. Also, future interventions are required to change the attitudes and behaviors towards maintaining proper oral health, and implementation of health policy reforms to obtain more affordable dental care.