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. 2024 Oct 6;31(3):1017–1023. doi: 10.1111/odi.15136

The psychosocial background of dental care avoidance: A qualitative study

Márton Lukács 1,2, Balázs Fábián 3,✉, Antal Bugán 1, István Varga 4
PMCID: PMC12021311  PMID: 39370763

Abstract

Introduction

Dental care avoidance affects individuals' oral health status. There is limited literature examining the context of dental avoidance behavior.

Aim

The aim of the study is to examine attitudes toward dental care services among adults.

Methods

Overall, 16 patients participated in semi‐structured interviews. The interviews were analyzed using inductive thematic analysis. Through independent reviews of the themes that comprise the patients' experience, a consensus was established among the researchers.

Results

Ten major themes were identified that encapsulate patients' attitudes toward dental care attendance: Effect of environment and equipment, Fear and anesthesia, Procrastination, Dissatisfaction with the dental care system, Expectations of dentists, Quality of dental care, Edentulousness and social status, Financial involvement, Aesthetics, and Dentists' behavior. Compliance with oral health maintenance can be enhanced by specific training for professionals and dentistry students and by fine tuning the dental care system.

Conclusions

This is the first comprehensive study in Hungary investigating attitudes among dentist patients toward dental care. The results suggest that there are many factors that may affect dental care attendance. Thus, these findings make a potentially fundamental contribution to the improvement of dental care and support practitioners in enriching their understanding of dental avoidance behavior.

Keywords: dental anxiety, dental care avoidance, health services, Patients' attitudes, qualitative research

1. INTRODUCTION

Despite the potential health benefits of modern medicine, for some reason many adults paradoxically avoid medical care that could possibly prevent avoidable human suffering or life‐threatening situations. More than one third of respondents surveyed nationally stated that they refrained from seeking medical attention, even when they suspected it was necessary (Kannan & Veazie, 2014; Persoskie et al., 2014; Vanderpool & Huang, 2010). Even those facing significant health issues (Lund‐Nielsen et al., 2011; Smith et al., 2005) or with symptoms (Barbour et al., 2012; Ristvedt & Trinkaus, 2005) tend to refrain from seeking medical attention.

The avoidance and postponement of medical care are characterized by an individual's inclination (i) to evade or postpone consultations with healthcare professionals, (ii) to forego treatment or necessary medical examinations, or (iii) to refrain from utilizing any health services encompassing the diagnosis and treatment of diseases, and the promotion, preservation, and restoration of health (Montagni et al., 2018). Avoiding visiting the doctor even when deemed necessary can result in delayed screening, missed chances for optimal recovery, heightened risk of developing a serious illness, increased burden on family caregivers, decreased quality of life, and decreased satisfaction with life (Byrne, 2008; Moore, Sickel, et al., 2004; Moser et al., 2006; Powell et al., 2019; Richards et al., 1999; Zhang et al., 2022).

Since it has significant negative effects on health, medical care avoidance increases overall medical expenditure, and reduces the efficiency of medical resource utilization (Masroor, 2020; Rajsic et al., 2019; Rice et al., 1985; Taber et al., 2015; Weller et al., 2012). Medical care avoidance leads to increased emergency room visits, nonadherence to treatment protocols, and increased morbidity and mortality across a range of diseases (Caplan, 2014; Moser et al., 2006; Richards et al., 1999). Treatments carried out at the advanced stage of the disease place a significant burden on healthcare costs by increasing the implementation of more radical treatments, extending hospitalization and operation times and using limited hospital resources (Kannan & Veazie, 2014; Prasanna et al., 2013; Richards et al., 1999; Rogers et al., 2011).

Dental anxiety is characterized by an anticipatory negative feeling related to dental procedures, leading to considerable suffering experienced by patients seeking dental care. It has been shown that dental anxiety can lead to less frequent dental visits (Taani, 2002), delays in dental treatment (Armfield et al., 2007; Yu et al., 2021), and cause future avoidance of dental visits (Busato et al., 2017; Skaret et al., 1999; Versloot et al., 2008). Dental anxiety can be especially severe in children, making it especially challenging for them to cope with dental visits (Vasiliki et al., 2016). Furthermore, embarrassment related to one's oral health (Moore, Brødsgaard, & Rosenberg, 2004) and dental indifference, and a lack of interest, concern, or attention to one's dental health or dental care (Nuttall, 1996) might also lead to avoidance behavior. Since patients would only visit dental clinics for painful dental problems, this behavior might cause poor oral health and more severe dental problems (Armfield et al., 2007; Ng & Leung, 2008). As unmanaged dental anxiety can act as an obstacle to good quality dental care and patient experience, it is fundamental that practitioners learn to recognize and manage dental anxiety.

The level of dental anxiety captured by existing self‐report instruments provides valuable insight into the patient's condition. However, no studies to date have explored the broader spectrum of patients' attitudes toward dental care where the experience of anxiety or other negative emotions are encountered. A better understanding of the psychosocial context of dental avoidance can help clinicians to have better management skills of the patient's feelings and to address specific concerns of the patient more effectively. The Hungarian population is in a worrisome situation regarding oral health. According to the 2010 Eurobarometer data, on average 41 percent of EU citizens have all their natural teeth. However, in the list of EU member states Hungary ranks last with only 19 percent (Europaische, 2012).

Therefore, the aim of the present study is to fully explore the themes that comprise the patient's experience of dental care focusing on those factors that might influence dental care attendance behavior. In order to explore the psychosocial context of dental avoidance, we chose to examine the attitudes toward dental care among adults. Since no qualitative research studies to date have explored the patient experience of dental care in Hungary, to this end, we decided to apply qualitative research methods in the present study.

2. METHODS

2.1. Design and data collection

Given the exploratory nature of the study, a qualitative approach was chosen. Semi‐structured interviews were conducted by the first author using a set of 21 questions to explore perceptions and experiences. The interviews were conducted with randomly selected patients who visited the Dental Clinics of the University of Debrecen. Potential participants were contacted directly and informed about the study. Inclusion criteria were no manifest mental disorders, and informed consent by the patient. An age range of 18–70 years was applied as an inclusion criterion to capture the diversity of dental care attendance attitudes and include as many viewpoints, experiences, and interpretations as possible. The initial set of questions was developed based on the literature and the experience of our research team. The research team met after the initial interviews to discuss the suitability of the initial questions and adapted them if it was necessary. The interview questions developed by the research team explored the following key areas: reasons for dental attendance and nonparticipation, procrastination, satisfaction with the oral health system, dental health issues, dentist preferences, importance of health, motivation for regular visits, pain management, best and worst experiences with treatments, opinion on anesthetics, expectations, decision making about treatment, principles involved when choosing a dentist, and dental anxiety. On average, the interviews lasted between 30 and 60 min. The interviews were conducted in a private space to ensure privacy and openness, either in an office or an empty waiting room. None of the interviews were disturbed in any way. The first author (M.L.) conducted all the interviews. The responses were written down on paper during and immediately after the interviews. Audio recording was not used due to methodological and ethical considerations. Data collection and analysis were conducted simultaneously. Interviews were conducted until thematic saturation was achieved and no new topics emerged.

2.2. Data analysis

Qualitative content analysis was applied inductively to the raw data. To prevent potential personal biases from impacting the results, three authors (M.L., B.F., A.B.) first independently reviewed the interview transcripts, organized the keywords into meaningful groups, and defined these groups based on their psychological interpretations to form a conceptual framework. The authors then discussed their results until they reached a shared consensus. The thematic content analysis method was based on previous guidelines (Naeem et al., 2023). All the authors are experienced in clinical counseling, therapy, and/or interdisciplinary medical research (A.B., M.L.: psychotherapist, clinical psychologist; B.F.: health‐psychologist) with previous experience in systematic thematic analysis (Fábián et al., 2018; Illés et al., 2016), enabling them to establish a reliable conceptual framework. The results were reviewed and validated by the last author (I.V.: dentist, periodontologist). Based on their expertise and experiences, all authors agreed on the final concept. When the consensus on the findings was reached, comprehensive descriptions and illuminative quotations of each theme were established. Quotes were chosen based on their ability to vividly capture and convey the essence of the identified themes. We prioritized quotes that were clear, articulate, and representative of the respective content group.

2.3. Ethical approval

The study was approved by the Centre's Regional and Institutional Ethics Committee at the University of Debrecen (registration number: RKEB/IKEB 6044–2022, 20 April 2022). Study participants were guaranteed anonymity and assured that the information obtained from them would be kept confidential and would be only used for study purposes. All participants interviewed gave informed consent for participation in the study and for publication of the project findings and written quotations prior to the interview in compliance with data protection regulations.

3. RESULTS

In total, 16 patients (seven men and nine women) participated in the interviews. Participants were between 22 and 70 years old (mean 45.81). Four patients had secondary school education, and 12 patients had higher education. Ten major themes were identified that encapsulate patients' attitudes toward dental care attendance: Effect of environment and equipment, Fear and anesthesia, Procrastination, Dissatisfaction with the dental care system, Expectations of dentists, Trust, Edentulousness and social status, Financial involvement, Aesthetics, and Dentists' behavior. These themes are discussed in detail in the following sections. The possibility of developing a hierarchical structure of topics including main themes and sub‐themes was thoroughly discussed but rejected. Themes are summarized in Table 1.

TABLE 1.

Overview and short description of the themes.

Theme Description
1. Effect of environment and equipment The anxiety‐provoking nature of the dentist's office and the sight, the sound, and the touch of medical equipment.
2. Fear and anesthesia The role of the personal need for control over pain and the motivation behind seeking anesthesia.
3. Procrastination Motivations for procrastination
4. Dissatisfaction with the dental care system The lack of financially supported special dental care services.
5. Expectations of dentists Expectations of dentists' professional skills and technical background.
6. Trust Trust in the free/private dental care and the provider.
7. Edentulousness and social status Experiences of disadvantage from social status and lack of self‐care.
8. Financial involvement Willingness for financial sacrifices for efficient and high‐quality dental care.
9. Aesthetics The importance of having a beautiful set of teeth and motivations for aesthetic interventions.
10. Dentists' behavior The behavioral factors of the professional which determine treatment adherence.
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3.1. Effect of environment and equipment

Many of the patients noted that the environment of the dentist's office and medical apparatus can trigger feelings of anxiety and fear. Specifically, the smells, the sight, the sound, and physical contact of the dentists' tools during medical procedures are usually considered frightening. A 54‐year‐old female patient explained: “The sight of the syringe, the sound of the drill and the typical dental office smell. These scare me the most.” And: “Inside the dental office the sounds are the scariest things.”

3.2. Fear and anesthesia

Patients expressed different opinions about anesthesia, depending on their degree of dental anxiety and their individual attitudes toward experiencing pain. In general, patients with higher levels of anxiety tended to prefer anesthesia as opposed to relying solely on painkiller medications. A 35‐year‐old female patient stated: “I would ask for it if I was very scared or the treatment itself was very scary.”

3.3. Procrastination

While some of the patients mentioned that they immediately seek medical assistance upon experiencing symptoms, several patients stated that they usually postpone dental care attendance as long as possible. These patients highlighted that they tend to procrastinate until the discomfort and pain becomes unbearable, significantly affecting their daily lives. Some patients said that they would avoid dental care for weeks or even months. According to a 52‐year‐old male patient: “Yes, I usually do procrastinate until it is hurting like crazy.”

3.4. Dissatisfaction with the dental care system

The interviews revealed discontent with the dental care system. Certain patients complained about the absence of financially supported dental care services, particularly concerning specialized treatments such as modern tooth replacement procedures and technologically advanced aesthetic‐focused interventions. A 48‐year‐old female patient said: “I exclusively seek dental care from private practices. (…) Later it turned out that he was not familiar with the newest methods used in private dental care.”

3.5. Expectations of dentists

As well as dental healthcare system factors that can affect patients' behavior, patients are also reflected upon person‐level factors. Patients described their expectations regarding the professional qualities and technical expertise of dentists. A 36‐year‐old male patient explained: “The doctor should be professional and prepared. He should provide a detailed and reassuring explanation about the treatment options. It is very desirable to ease the mood with humor.”

3.6. Trust

Some respondents mentioned that there was a lack of trust from their side in the freely available public dental care. Emphasizing the importance of effective communication and understanding behavior from dentists, some patients highlighted that such qualities created trust and confidence. This, in turn, could potentially enhance adherence to recommendations and lead to more frequent dental care visits. A 33‐year‐old female patient stated: “I expect him to give detailed information about the treatment. He and the assistant should be friendly, kind and trustworthy. I completely trust him, but I expect him to tell me what is going to happen and why.”

3.7. Edentulousness and social status

Participants expressed their views on edentulousness, predominantly associating it with a diminished level of oral health. Many perceived missing teeth as an indicator of lower social status, interpreting it as a signal of inadequate self‐care. Therefore, edentulousness could potentially result in social stigma, and being judged, and create disadvantages in various aspects of daily life. According to a 35‐year‐old female patient: “For me tooth loss is a sign of old age and poor social status.”

3.8. Financial involvement

Patients reflected on the costs of dental care services. There were differences among patients regarding their willingness to face more serious expenses to receive more efficient and higher quality dental care. A 65‐year‐old male patient explained: “I am satisfied with my oral health. If it is unavoidable and my condition is very painful, I would pay for it.”

3.9. Aesthetics

The patients described their relationship with aesthetic interventions, such as braces, and their motivations for seeking aesthetic procedures. Many of them held the belief that oral health is an important factor in having a good body image and substantially contributes to one's overall attractiveness. A 32‐year‐old female patient stated: “Basically I would go to the dentist because of my health, but often because of aesthetics too.”

3.10. Dentists' behavior

The participants underscored the significance of the appropriate behavior of dental healthcare providers. They emphasized that, in addition to professional proficiency on a technical level, having good communication skills, and being gentle and considerate are also very important. According to a 25‐year‐old female patient: “He should have proper education and provide care according to the best of his knowledge, but he should inform me about all the options… and he should not be rude or impatient.”

4. DISCUSSION

The present study aims to investigate the attitudes toward dental care services among adults in order to provide a deeper insight into dental care attendance. To the best of our knowledge, this is the first qualitative study in Hungary to investigate attitudes toward dental care. The results suggest that qualitative research makes a fundamental contribution to the results from quantitative studies. The present study was able to show that dental care attitudes are formed by the patient's personal needs, expectations and possibilities, the dentist's skills and behavior, the social aspects and meanings of oral health condition, and the national system of dental care, might influence dental attendance.

In previous studies it has been found that gender (Morowatisharifabad et al., 2018; Tong et al., 2014) and age (Islam et al., 2022; Leyva et al., 2020) affect medical care avoidance and female gender might be associated with dental anxiety (Muneer et al., 2022); however, in the topics discussed during the interviews these factors showed no connection with attitudes toward dental care.

It has been found that the patient's sense of shame can be a causal factor in disengagement (Gragoll et al., 2021; Moore, Brødsgaard, & Rosenberg, 2004). We also found that having low oral health and edentulousness might be a sign of lower social status and inferiority for the patients. When patients visit the dentist with feelings of guilt, shame, or embarrassment, it would be advisable for the dentist not to judge the patient's behavior. The dentist should not condemn or blame the patients but accept the patients' feelings and provide emotional support to establish further patient compliance.

Similarly to other studies (Lin et al., 2016; Paula et al., 2009) we also found that the quality of oral health could affect the sense of one's personal attractiveness and beauty. Therefore, we would also suggest reinforcing the patient's attendance behavior by remarking on tangible aesthetic improvements achieved by dental procedures.

In the present study, we found that the availability of free dental services significantly affects dental care attendance. Since disadvantaged groups are more likely to delay or avoid health care (Byrne, 2008; Moser et al., 2006; Taber et al., 2015) it is important to establish a similar quality of private and public dental care to ensure that the negative effects of financial disadvantages are overcome.

As has been shown by several previous studies (Nuttall, 1996; Santos‐Puerta & Peñacoba‐Puente, 2022) dental anxiety can cause dental avoidance. Several discussion elements found in the present study can be considered as a possible anxiety provoking casual factor. The physical presence of equipment, the fact that only what is regarded as a lower quality public service is available due to financial difficulties, a lack of personal trust in the professional, and the absence of good social skills in the dentist can all be related to dental anxiety and lead to dental care avoidance. Our results support the idea that improving professional behavior and communication skills might help reduce dental care avoidance. To facilitate dental care engagement, it is crucial what kind of experiences the patients have during the first occasions when they visit a dentist. The dentist's professionalism should include professional communication skills and anxiety reducing behavior. Covering the equipment before and during the procedures might reduce anxiety. Providing a detailed explanation of the forthcoming procedure and anesthesia and facilitating questions would establish trust, create the feeling of partnership in decision making and provide the sense of personal control.

5. LIMITATIONS

Although this study provides important evidence regarding patients' attitudes toward dental care, certain limitations must be acknowledged. Since ethnicity, marital status, and socioeconomic status were not recorded, and the sample size was relatively small, it is not possible to conduct comparisons between groups based on sociodemographic characteristics. A second limitation was that the study participants were drawn from a relatively select setting in a single hospital from one large city in Hungary, where patients attend from a limited geographical area. It has been found that there are urban/rural area differences (Henning‐Smith et al., 2020; Spleen et al., 2014) and personal costs might affect adherence and dental avoidance behavior (Marcus et al., 2022; Rabin et al., 2017; Smith et al., 2018). This must be the reason why problems with accessibility did not emerge. For practical research reasons only locally available study participants were recruited, thus the study did not encompass a diverse sociodemographic background. Therefore, caution is required in interpreting and generalizing from these results. Further studies using a quantitative design are warranted to validate our current findings.

6. CONCLUSION

The findings of the present study contribute to the limited body of literature on dental patients' attitudes about participating in dental care. The present study was able to show that besides dental anxiety, several factors both on a systemic and a personal level may affect attitudes toward oral health maintenance. The results indicate the need for a more comprehensive treatment approach to the management of dental care related negative emotions. It also suggests that psychological management by practitioners may have the potential to affect help‐seeking behavior through forming the patients' attitudes. This study has identified some of the barriers related to the national dental health care system, and facilitators for participating in dental care. The affordability and accessibility of dental care might be reviewed on a national level. The study also highlights the necessity for adequate communication skills (techniques for reducing anxiety, increasing adherence, and establishing trust) which might be emphasized more during university dentistry programs.

AUTHOR CONTRIBUTIONS

Márton Lukács: Conceptualization; methodology; data curation; software; formal analysis; writing – review and editing. Balázs Fábián: Formal analysis; writing – original draft; writing – review and editing; data curation. Antal Bugán: Conceptualization; methodology; formal analysis; software; supervision; project administration. István Varga: Supervision; resources; writing – review and editing; project administration; funding acquisition.

FUNDING INFORMATION

This research received no external funding.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

INFORMED CONSENT STATEMENT

Informed consent was obtained from all subjects involved in the study.

INSTITUTIONAL REVIEW BOARD STATEMENT

The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Debrecen Clinical Centre's Regional and Institutional Ethics Committee and the Scientific (RKEB/IKEB 6044–2022, 20 April 2022).

ACKNOWLEDGEMENTS

None.

Lukács, M. , Fábián, B. , Bugán, A. , & Varga, I. (2025). The psychosocial background of dental care avoidance: A qualitative study. Oral Diseases, 31, 1017–1023. 10.1111/odi.15136

DATA AVAILABILITY STATEMENT

The entire dataset cannot be made publicly available since the analysis is still in progress. After the completion of the ongoing work, excerpts of the data can be obtained from the first authors upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The entire dataset cannot be made publicly available since the analysis is still in progress. After the completion of the ongoing work, excerpts of the data can be obtained from the first authors upon reasonable request.

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