Predictors influencing dental clinic utilization in primary health care: A retrospective analysis of 233,069 patient records in Riyadh, Saudi Arabia

Abstract

Aim

This study aims to identify and address the predictors that promote or prevent the utilization of dental services in primary health care (PHC) centers located in Riyadh, Saudi Arabia, with an ultimate goal to increase the uptake of oral health care (OHC) services.

Methodology

Registration data from 99 PHC centers was used. For each patient visiting a PHC center, information on the number of dental visits was captured. Continuous data was summarized as means, medians, and ranges, and categorical data as frequencies (%). The strength of association was reported as an incidence rate ratio (IRR) with 95% confidence interval (CI) and a p-value. Further analysis was conducted to illustrate the association between dental care visits and factors found independently significant in the final multivariate model using Karl Pearson correlation coefficient and t-test. All tests were two-sided and a p-value of p < 0.05 was considered significant.

Results

The comorbidity profile of patients shows that 11,751(5%) were diabetic, while hypertension amounted to 10,712(4.6%). A statistically significant inverse correlation was observed between dental care visits and both age (r = −0.025, p < 0.001) and BMI (r = −0.013, p < 0.001). Mean dental care visits were significantly higher in patients without hypertension compared with those with hypertension (p < 0.001). Moreover, there was an approximate 4% increase in dental care visits among females compared to males, although this difference was not statistically significant.

Conclusion

The study identified three predictors contributing to the low utilization of dental services in PHC centers in Riyadh. These include an inverse association between both age and body mass index (BMI) and the utilization of OHC. Additionally, the mean dental care visits were significantly higher for patients without hypertension in comparison to hypertensive patients.

1. Introduction

The “health for all” primary health care (PHC) strategy, introduced by the World Health Organization (WHO) in 1978, has significantly improved global health by early disease detection, reducing mortality, and optimizing resource allocation. Worldwide, PHC services have contributed to enhancing overall health through health promotion and education, improved access to care, and the delivery of efficient and high-quality health care services.

Within PHC, oral health care (OHC) is integral due to its close integration with systemic health. This is exemplified by the established relationship between periodontal diseases and conditions such as diabetes mellitus (Grossi and Genco, 1998). Furthermore, regular dental visits lead to improved oral health, a prerequisite for enhancing the quality of life (Mc Grath and Bedi, 2001). Hence, governments and dental health authorities must prioritize oral health in policy design to meet population needs.

The healthcare system at the Kingdom of Saudi Arabia (KSA) encompasses both public (government) and private sectors. Every citizen has the right to full and cost-free healthcare access in public sector facilities, whether they are primary, secondary, or tertiary (Orfali and Aldossary, 2020). Oral health is a significant public health challenge in KSA, especially among young children in Riyadh, where dental caries prevalence is expected to reach 94% among 9-year-olds. This is accompanied by limited knowledge and negative attitudes among high-risk groups (AlSadhan et al., 2017). Additionally, KSA is facing an increasing burden of lifestyle-related risk factors, and oral diseases that contribute to around 0.8% of daily-adjusted life years (DALYs) (Tyrovolas et al., 2020).

To this end, KSA adopted the WHO “health for all” strategy in 1980 through PHC to achieve the goal of providing integrated curative and preventive care (Al-Jaber and Da’ar, 2016). Furthermore, the Saudi Arabia National Transformation Program (NTP) prioritized increasing access to and awareness about dental health care services. Accordingly, the NTP was developed to fulfill the Saudi Arabian Vision 2030 with focus on strengthening the public health sector (Vision, 2020).

Despite the described efforts, the disproportionate distribution of PHC centers strains resources in some and underutilizes them in others, hindering their ability to meet KSA's population needs. For instance, free access to PHC dental services sees low utilization, leading to a burden of dental diseases, while knowledge and awareness around oral health remains low (Khan et al., 2013).

Some of the current challenges include the shortage of dentists in PHC centers (Almutlaqah et al., 2018, Orfali and Aldossary, 2020) and the high cost of the private dental clinics (Al Johara, 2010, Al-Jaber and Da’ar, 2016). Despite increased availability of PHC dental clinics in Riyadh, the scarcity of dentists, lengthy waitlists, and limited advanced treatments drive people in Riyadh to prefer private clinics over PHC centers (Almutlaqah et al., 2018, Orfali and Aldossary, 2020). Meanwhile, socioeconomic factors, education levels and patients’ satisfaction with dentists are among the major indicators for the utilization of dental clinics in PHC centers (AI-Osimy, 1994, Maltz et al., 2010, Orfali and Aldossary, 2020). Hence, it is crucial to explore patient satisfaction to design targeted policies for enhancing oral health indicators. Overall, this study aims to identify the predictors of the utilization of dental clinics in PHC centers in Riyadh, KSA and provide evidence to inform policy making and promote the utilization of dental clinics.

2. Materials and methods

The research received review and approval from the Research and Ethics Committee at King Fahad Medical City (Riyadh’s second health cluster, Ministry of Health Saudi Arabia). Written informed consent was taken from patients to participate in this study.

This study used registration data from 99 PHC centers in cluster 2, covering Riyadh and surrounding cities, including Al-Majmaah, Wadi Al-Dawaser, Al-Zulfi, Hawtat Tameem, Rimah, and Al-Ghat, offering diverse medical and dental services. During routine PHC center visits, patient data including residence city, birthdate, gender, occupation, education level, height, weight, and comorbidities (diabetes, hypertension, hyperlipidemia, dementia, Alzheimer's disease, Parkinson's disease, asthma, obstructive pulmonary disease, and other communicable diseases), is recorded in electronic health records. Additionally, dental visit frequency is documented.

The data obtained from these centers is then consolidated into a central database hosted in King Fahd Medical City to analyze factors affecting visit frequency. The study covers January 2021 to October 2022. For continuous data, means (SD), medians [Interquartile range (IQR)], and ranges (Minimum and maximum) were used. Categorical data were recorded as frequencies (%).

To address frequent non-attendance to dental care visits (zero frequency), a zero-inflated binomial regression model was fitted to identify associated factors. All patient demographic and clinical characteristics were included in the analysis. Factors demonstrating significance in the initial univariate analysis were integrated into the final multivariate model. Strength of association was reported as the incidence rate ratio (IRR) with a 95% confidence interval (CI) and a p-value. A further analysis was conducted to illustrate the association between dental care visits and factors found independently significant in the final multivariate model using Karl Pearson correlation coefficient and t-test. All tests were two-sided and a p-value of p < 0.05 was considered significant. The statistical analysis was performed using Stata software (version 11, StataCorp, Texas, USA).

3. Results

The study included 233,069 patients, 44.4% of whom were females. Ages ranged from 18 to 99.3 years, with a mean (SD) of 39.5 (14.5) years and a median (IQR) of 36.9 (26.2–48.1) years. The Overall Body Mass Index (BMI) of patients ranged from 15 to 50, with a mean (SD) BMI of 28(5.9), and median (IQR) BMI was 27.3(23.8 to 31.5). Approximately 1.5% of the patients reported having one or more dental visits (Table 1).

Table 1.

Study participants’ characteristics.

Characteristic	n(%)
Age
Mean(S.D)	39.5(14.5)
Median(IQR)	36.9(26.2–48.1)
Minimum-Maximum	18–99.37
Sex
Male	103,538(44.4)
Female	129,531(55.6)
Body Mass Index
Mean(S.D)	28(5.9)
Median(IQR)	27.3(23.8–31.5)
Minimum-Maximum	15–50
Number of dental visits
0	229,505(98.5)
1	2,804(1.20)
2	499(0.21
3	156(0.06)
≥ 4	111(0.05)

Comorbidities included diabetes in 5% (11,751), hypertension in 4.6% (10,712), confirmed hyperlipidemia in 0.5%, unconfirmed hyperlipidemia in 0.2%, and 2.6% had Asthma or other obstructive pulmonary diseases. Dementia, Alzheimer's, or Parkinson's were diagnosed in 0.02% of participants (Table 2).

Table 2.

Comorbidity profile of study subjects.

Comorbid condition	n(%)
Diabetes
Yes	11,751(5)
No	221,318(95)
Hypertension
Yes	10,712(4.6)
No	222,357(95.4)
Hyperlipidemia
Yes	1131(0.5)
No	231486(99.3)
Unknown	452(0.2)
Asthma-obstructive-pulmonary disease
Yes	4738(2.6)
No	228,331(98)
Hypertension
Yes	10,712(4.6)
No	222,357(95.4)
Dementia-Alzheimer-Parkinson
Yes	38(0.02)
No	233031(99.98)

A Zero-inflated negative binomial regression model was fitted to identify factors influencing dental care visit frequency. Initial univariate analysis indicated significant associations between age, sex, BMI, diabetes, and hypertension and dental care visits. However, in the final multivariate analysis, the only variables with significant association were age (IRR = 0.986, 95%, CI 0.983–0.988, p < 0.0001), BMI (IRR = 0.989, 95%, CI 0.985–0.996, p = 0.002), and hypertension (IRR = 0.701, CI 0.95, p < 0.0001) (Table 3). These findings indicate that dental care visits decrease by approximately 0.01% per year of age and per unit increase in BMI. Hypertensive patients have a 30% lower dental visit rate than non-hypertensive individuals (Table 3, Fig. 1). Statistically significant inverse correlations were observed between dental care visits and age (r = −0.025, p < 0.001) and BMI (r = −0.013, p < 0.001). Dental care visits were significantly higher among patients without hypertension than among those with hypertension (p < 0.001). Additionally, while females had a 4% higher dental care visit rate than males, this difference was not statistically significant.

Table 3.

Zero-inflated Negative Binomial Regression Model for Factors Associated with Dental Care Visits.

	Univariate analysis		Multivariate analysis
Factor	IRR(95%CI)	p	IRR(95%CI)	P
Age	0.983(0.980–0.985)	<0.0001	0.986(0.983–0.988)	<0.0001
Sex
Female	1.055(0.979–1.138)	0.161	1.041(0.966–1.122)	0.294
Male	1		1
BMI	0.979(0.973–0.995)	<0.0001	0.989(0.985–0.996)	0.002
Diabetes
Yes	0.617(0.509–0.753)	<0.0001	0.875(0.713–1.074)	0.202
No	1		1
Hypertension
Yes	0.499(0.401–0.622)	<0.0001	0.701(0.558–0.883)	0.002
No	1		1

IRR: Incidence rate ratio.

Fig. 1.

Association of dental care visits and age, BMI and hypertension status.

4. Discussion

The study aimed to identify predictors of OHC service utilization in Riyadh's PHC centers, addressing a research gap due to limited existing data. Due the retrospective nature of this study and its reliance on the analysis of secondary data, the scope of investigation was constrained to examining associations between specific medical conditions, demographic data, and dental visits in PHC centers.

Despite high demand for OHC in PHC centers due to the cost of private dental care (Alsalleeh et al., 2018), barriers like dentist availability, long waiting times, and dissatisfaction with PHC centers’ services hinder utilization (AlHumaid et al., 2018, Al-Jaber and Da’ar, 2016; Al-Ahmadi and Roland, 2005). Understanding these obstacles is crucial for effective policy development, particularly in Riyadh. Despite the considerable emphasis on oral health, it's pertinent to note that many PHC centers in KSA continue to encounter challenges in delivering high-quality oral care, highlighting urgent and unfulfilled oral health needs among the population (AlHumaid et al., 2018, Sahab et al., 2022).

The study’s population included 233,069 patients, predominantly male, aged 18–99 years. Key findings of this study include an inverse association between age and BMI with OHC service use, and a direct association between absence of hypertension and dental clinic visits in PHC centers. With advancing age, a deceleration in OHC service utilization was noted, possibly owing to infrequent dental visits, often restricted to periods of pain. The infrequent routine dental visits undermine oral health practices, resulting in a gradual deterioration of oral health over time (Al-Sakkak et al., 2008). This observation among older populations may be linked to factors such as household income, lack of oral health awareness (Linjawi et al., 2019), limited access to healthcare services, and the lack of nearby PHC centers (Nazir, 2019). Additional contributing factors can stem from extended wait times and unsatisfactory interaction with medical professionals. Moreover, advancing age may also be influenced by the presence of other health conditions, potentially leading to fewer dental visits. Individuals may prioritize managing these health conditions over their oral health. Previous research has identified an inverse correlation between age and OHC utilization, often attributed to the tendency to overlook oral health as frailty, cognitive impairment, and mobility issues increase with age. This care neglect can set off a domino effect where straightforward, preventable dental issues transform into complex problems over time, causing significant logistical, personal, and financial challenges. It's now more critical than ever to ensure consistent OHC utilization among the aging population, especially as advancements in modern dentistry enable more older individuals to retain their natural teeth well into later years. The inverse age-dental visit relationship is crucial for policy development, emphasizing the need for regular check-ups, preventive procedures, and promoting dental services for good oral health (Harris et al., 2017, Beil et al., 2014). Infrastructural changes and designing clinical settings for accessibility, especially for older patients with mobility issues, are essential.

Another notable finding is that individuals with higher BMI visit PHC centers less frequently. This pattern warrants further research into the impact of oral health on overall wellbeing, as it aligns with previous studies highlighting a lack of awareness of preventive dental practices among those with high BMI (Abdellatif and Hebbal, 2020; Crocombe et al., 2012). Addressing this gap can potentially encourage routine oral health check-ups. Additionally, a study showed that individuals reporting excellent oral health visited dental clinics more frequently, highlighting the importance of promoting PHC center visits for better oral health.

The study also found that individuals with hypertension were less likely to seek dental services at PHC centers, in line with previous findings emphasizing the positive impact of healthy lifestyles on health decisions. It's crucial to recognize that OHC is essential for overall health, helping control oral diseases and related issues. Understanding people's motivations for oral care can inform policies that promote oral health, especially among those who may overlook it.

Another critical finding is that over 98% of patients have never sought dental care services, emphasizing the urgent need for policymakers to investigate barriers to accessing dental care in PHC centers. Despite a rising trend in routine oral health check-ups, there's a pressing need to promote OHC more widely. These findings are consistent with similar studies in KSA, where only 12% of individuals under 15 had routine check-ups in 2020, with many attending due to specific complaints (Farrash, 2020). This highlights the need for targeted oral health promotion programs to raise awareness and reduce oral disease burden in Riyadh. The underutilization of PHC centers for OHC suggests underlying challenges in service provision, necessitating further research to assess access barriers.

Our study found that women are 4% more likely to visit OHC providers compared to men, consistent with previous research (Rajeh, 2022). These results call for a profound examination of the factors that foster frequent dental visits among women and inhibit such visits among men. Examining the behavioral patterns of those who prioritize oral health is vital, particularly in a population heavily affected by oral diseases. It allows the assessment of individual motivations and serves as a foundation to propagate such healthy behaviors among the broader population. Women tend to exhibit higher vigilance about their physical appearance, including dental aesthetics. Moreover, research illustrates that women are more compliant with following oral care instructions and adhering to appointments (Hamasha et al., 2018). Planning targeted interventions aimed at promoting positive oral health attitudes among males is crucial. Moreover, healthcare providers need to intensify their focus on promoting positive dental habits among men during their dental visits, paving the way for the adoption of healthier dental practices.

Enhancing oral health services in Riyadh is critical to address unmet needs and improve overall health. Research has shown that regular visits to OHC providers lead to better oral health outcomes (Al-Rafee et al., 2019). Given this, there is a pressing need for further research to explore the reasons behind the underutilization of OHC services within Riyadh. In the past, factors such as unsatisfactory provider conduct, clinic capacity, appointment availability, and lack of cutting-edge technology in PHC centers have played a significant role in the low utilization rates of OHC (Al-Rafee et al., 2019). Understanding these issues is vital for patient-centric policy development and improving the quality of OHC services in Riyadh.

While our study highlights OHC challenges in PHC centers in Riyadh, its generalizability is limited due to a low dentist visitation rate (1.5%) within our sample. Additionally, the focus on a 22-month period may not capture all dental care visits, potentially missing annual check-ups. Our analysis sheds light on factors affecting dental care within our subset, but comprehensive population-based research, examining reasons for dental visits or non-visits, including long waiting times, service dissatisfaction, dental anxiety, and awareness gaps, is necessary for a more holistic understanding. In conclusion, our study provides insights into determinants of dental care visits, but addressing these limitations in future research is essential for a comprehensive understanding of oral health-seeking behaviors in Riyadh's population.

5. Conclusion

The study identified three predictors contributing to the low utilization of dental services in PHC centers in Riyadh. These include an inverse association between both age and BMI and the utilization of OHC. Additionally, the mean dental care visits were significantly higher for patients without hypertension in comparison to hypertensive patients.

These findings offer actionable insights for policymakers in several ways including targeted interventions, educational initiatives, reducing barriers and a comprehensive policy design. The associations we found between age, BMI, and hypertension with OHC service utilization can guide targeted interventions. For instance, policies can promote routine check-ups and preventive measures, especially for older individuals who visit PHC centers less often. Approaches for increasing oral health awareness among individuals with higher BMIs can be developed, including educational campaigns and initiatives to reduce care barriers for this group. To conclude, focusing on increasing awareness about the importance of routine check-ups as a preventive measure rather than symptomatic treatment-seeking could be an imperative policy implication to improve oral health and reduce the burden of dental diseases in Riyadh.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.