Reflections on the implications of the trends in dental status for trends in dental care utilization 2001–2021 among adult Danes

Abstract

This study aimed to explore trends in dental status and utilization of dental care services over time and to assess the relationship between dental service utilization and dental status among adult Danes aged 20+ years. A register‐based cohort study linked individual‐level information on dental services received, age, gender, municipality/region, highest completed education, socioeconomic position, income, and immigrant/descendant status for each calendar year in the period 1990–2021. Also included were data reported by dentists since 2001 on number of teeth present, number of teeth with decay, and number of teeth with fillings for 25‐, 40‐, and 65‐year‐old patients. About 58% of all adults had used the dental health care system in 2021, less than that seen in previous decades. Non‐users were younger, male, had lower income, lower education, lower socioeconomic position, and were immigrants or descendants. Dental attendance has substantially reduced over time among age groups younger than 70 years but increased among the older age groups. Considerable improvements in dental health were noted, with greater tooth retention, fewer caries, and fewer filled teeth in the indicator age groups since 2001. The findings suggest a need for redistribution of resources for oral health care to target vulnerable subgroups carrying larger disease burdens.

INTRODUCTION

Over the past decades, the oral disease patterns among adults and elderly have changed considerably in many countries. Edentulism has declined [1, 2, 3, 4, 5] and tooth retention has increased, particularly among the older age groups [4, 5, 6, 7, 8]. The dental caries decline, which has been evident for at least half a century among children and adolescents in the highly industrialized countries [9, 10, 11, 12] has now also trickled into the adult and elderly age groups [1, 3, 6, 7, 8, 13, 14, 15]. Even so, some reports indicate more caries among contemporary older age groups [5], possibly as a result of the increased tooth retention, rendering more teeth at risk for caries lesions and restorations. The trends in the occurrence of periodontitis are less clear, with some observing a decline [16], while others have found no consistent trends [4], an increase attributable to “more confident case definitions” [17], trends depending on country economy [3], or insufficient evidence for declaring any change [14].

The reduced oral disease burden and the increased tooth retention among the older age groups will have profound implications for a better way to structure and organize the oral health care system [18, 19]. The dental care needs of the younger age groups are increasingly changing towards non‐operative interventions for disease control and prevention rather than repair and rehabilitation, whereas the growing number of elderly with more teeth represents the cohorts that have lived through the “restorative era” of the dental profession [19, 20, 21]. Currently, their needs therefore involve restoration maintenance and complex rehabilitation as they represent the generations subjected to the deleterious effects of the “cycle of re‐restorations” eloquently described by Elderton [22]. However, the elderly of tomorrow are the young of today, and there can be little doubt that the current cohorts of elderly with their higher repair and rehabilitation needs represent a transient phenomenon.

Based on these observations, it can be expected that the utilization of the dental health care services for adults may be characterized by complex trends. The improved oral health conditions among the younger adults may lead these to reduce their dental care utilization [23, 24], a trend which is supported by national guidelines promoting longer recall intervals for groups of low risk to oral diseases, as seen in the UK and the Nordic countries [25, 26, 27, 28]. However, these guidelines may be challenged by the preference of both patients and professionals [29, 30]. Moreover, periodontal specialist societies have recommended 3–12‐monthly supportive periodontal care visits for adults with Stage I–III periodontitis [31], which would seem to entail the vast majority of any adult population, if recent epidemiologic evidence is taken at face value [32, 33, 34, 35, 36, 37, 38]. However, indications are that the estimates provided are greatly exaggerated and out of proportion to the public health importance of periodontitis [39, 40, 41]. The increased tooth retention among the elderly may lead to increased dental care utilization among these age groups [24], though probably only up to the point where age‐related functional declines and frailty may cause a diminished and ultimately lost contact with the dental health care system [42, 43, 44]. Adding to this complexity is the fact that across all ages, socially, physically, or mentally disadvantaged groups exist, for whom dental health care utilization remains difficult, despite initiatives to offer oral health services through dedicated special programs [45].

Research indicates that it is important to balance carefully the supply of dental services with the needs and demands for such services. Particularly in publicly funded systems, resources allocated to one area inevitably reduce availability in another, highlighting that undersupply and oversupply are closely interconnected through opportunity costs. Where dental services are undersupplied one consequence may be a lower quality of care, less prevention, and a greater likelihood of more radical treatments such as tooth extractions [46, 47]. In contrast, oversupply of dental services may lead to increased numbers of treatment items per visit and decreased recall intervals [48]. Indications are that the supply/demand balance may have shifted unfavorably in some countries towards more dentists having too few patients [49]. In a fee‐for‐service payment system [50] supplier‐induced demands are likely [48, 51, 52, 53, 54, 55] but these may be insufficient to fully compensate the dentists’ income expectations. An oversupply of dental services may therefore hold prospects of income reductions for dentists in the future [49], and be unnecessarily costly to patients and society, at least in countries with improving dental health and pressures to prolong the traditional annual or biannual recall intervals.

In view of the above considerations, the aim of this study was to explore the trends in the dental status and the utilization of dental services over time and to assess the relationship between dental service utilization and dental status in the adult Danish population during 2001–2021. The further view was to spur a discussion of the possible consequences of the findings for the better structure and organization of the dental health care system for adults.

MATERIAL AND METHODS

The data used in the present study originate from a large, prospective dynamic cohort study based on Danish register data. All permanent residents in Denmark have a unique civil personal registration number, which, via the Danish Civil Registration System, allows follow‐up and linkage of individual‐level information from multiple, usually administrative, registers. We generated the cohort by linking information from the Civil Registration System, the Educational Register, the Income Statistics Register, and the National Health Insurance Service Register. All permanent residents of Denmark were included in the cohort if they were or had reached the age of 20 years in the period from 1 January 1990 to 31 December 2021 and were permanent residents of Denmark. The study was approved by the Danish Data Protection Agency [2015‐57‐0002] and Aarhus University (2016‐051‐000001‐914).

In Denmark, private dental practitioners operating on a fee‐for‐service basis are the main providers of dental health care to the adult population. In the period from 2000 to 2015, the private dental practitioners have been obliged to report the number of natural teeth present, the number of filled teeth, and the number of decayed teeth for all patients who have received a routine diagnostic examination (service codes 1140, 1141) or a diagnostic and preventive service (service code 2910) and have turned 25, 40, or 65 years during the ongoing calendar year [56]. Pursuant to a new collective agreement between the Danish Dental Association and the Danish regions, the service codes numbers entailing compulsory reporting of dental status data for 25‐, 40‐, and 65‐year‐olds were changed to codes 1111–1115. The number of natural teeth include natural roots and wisdom teeth, and the number of decayed teeth include both primary and secondary (filling‐associated) lesions in need of treatment. The number of filled teeth include teeth with crown restorations [56]. Data are reported to the National Board of Health and have become integrated with the National Health Insurance Service Register. From the National Health Insurance Service Register, we also obtained information on the dental treatments covered by the National Health Insurance scheme for subsidized dental care for all residents in Denmark between 1990 and 2021. This register holds information on all patients, providers, and services provided insofar as these are publicly subsidized, regardless of any additional private insurance.

The registers used and the variables extracted for the purpose of the present analysis are further detailed in the Supporting Information document. All analyses were conducted in R (https://www.r‐project.org/), utilizing mainly the tidyverse, ggplot2, survey, and WeightIt packages, on Statistics Denmark's research servers. Some of the visualizations were made using STATA 17 (StataCorp).

A person was recorded with a dental visit in a calendar year if the person had at least one dental service code recorded in the National Health Insurance Service Register. In addition to descriptions of the dental visiting patterns observed among the population of Danish adults aged 20+ years since 1990, we also describe the dental status data reported for the indicator age groups of 25‐, 40‐, and 65‐year‐olds since 2001. We also determined, for each calendar year 2001–2018 the number of teeth present, the number of decayed teeth, and the number of filled teeth as a function of the subsequent dental visiting behavior in the following 3 years (coded 1 if at least one visit in the subsequent 3 years, and 0 if no visit) with a view to understanding to what extent the dental status is related to subsequent dental visiting behavior. Those who died or emigrated during the 3 subsequent years were excluded from these analyses.

Not all adults in the Danish population visit the dentist, and some dental patients do not have their data reported after examination. Therefore, in order to ensure over‐time comparability of estimates as well as representativeness for the total Danish population of the relevant indicator ages, we have used Bayesian additive regression trees [57, 58] propensity scores to weight the estimates for important sociodemographic characteristics. Hence, these weights were calculated separately for each calendar year using the variables age, gender, municipality/region, immigrant/descendant status, highest completed education, socioeconomic position, and income percentile in that year (see Supporting Information for further detail), to balance differences in these characteristics among adults with or without dental examination with dental status reporting [58].

RESULTS

Table 1 shows that the size of the Danish population of adults aged 20 years or more increased by about 500,000 persons in the period from 2001 to 2021 and amounted to about 4.5 million people in 2021. Of these, 58% had used the dental health care system for adults in the year 2021. This percentage was lower than that seen in 2011 (63%) and 2001, where 65% were users. Women were more likely to be users than men, and ethnic Danes were much more likely to be users than immigrants or their descendants. People with primary school, high school or entry qualifications as their highest completed education were less likely to be users than were people with higher educations. The probability of use of dental services decreased over all the above‐mentioned categories from 2001 to 2021.

TABLE 1.

The absolute number of people in the population, and the proportion of users of the dental health care system for adults, in each of the years 2001, 2011, and 2021, according to selected sociodemographic characteristics.

	2001		2011		2021
	N	% users	N	% users	N	% users
Total population	4,076,172	65.1	4,244,858	62.9	4,583,819	58.0
Age group
20–29	690,527	60.4	663,618	48.2	781,502	44.9
30–39	815,829	66.6	716,026	57.4	713,757	46.6
40–49	746,477	72.8	814,761	64.9	736,243	55.8
50–59	755,219	75.1	721,517	71.1	805,847	62.9
60–69	497,465	66.7	690,717	74.9	673,946	69.4
70–79	354,109	51.6	397,856	66.5	581,036	72.7
80–89	183,962	34.7	190,528	48.6	246,023	61.4
90+	32,584	16.5	39,835	28.1	45,465	38.6
Sex
Men	1,991,780	61.9	2,077,330	59.0	2,261,533	54.0
Women	2,084,392	68.2	2,157,528	66.5	2,322,286	62.0
Origin
Denmark	3,789,226	66.7	3,794,065	66.1	3,913,464	62.6
Immigrant	271,945	43.8	405,418	33.7	587,499	30.5
Descendant	15,001	47.8	35,375	40.3	82,856	38.7
Highest completed education
Primary school	1,306,433	56.4	1,170,540	53.0	925,512	48.9
High school	319,814	66.6	333,589	58.5	397,316	50.7
Entry qualification	1,021	59.5	4,026	52.5	2,239	41.7
Vocational	1,353,111	72.8	1,436,293	68.8	1,465,795	62.5
Short‐cycle higher education	136,120	76.2	177,734	71.3	236,068	62.1
Medium‐cycle higher education	440,377	79.6	562,676	75.3	760,848	65.2
Bachelor	40,642	70.9	73,091	62.9	105,878	54.7
Long‐cycle higher education	181,487	74.6	283,121	70.8	505,293	61.9
PhD or researcher education	8,251	76.0	18,482	69.5	43,323	58.1
No recording	288,916	32.9	175,306	24.8	141,547	35.0
Socio‐economic position (main source of income)
Self‐employed or wage earner	2,411,516	73.2	2,397,209	67.8	2,585,871	59.2
Disability pension, sick pay, social security, unemployment benefit	527,668	53.9	485,907	48.9	526,833	45.5
Retirement pension or early retirement benefit	827,176	51.0	983,153	64.8	1,047,702	68.5
Educational grant, other	309,812	59.2	368,589	43.7	423,413	40.6

The pattern of use of dental services according to age was rather complex (Figure 1A, Table 1). In the age groups between 20 and 59 years, the probability of a dental visit in a calendar year declined from 2001 to 2021. The 60–69‐year‐olds presented their highest probability of a dental visit in 2011, and in the 70+ year age groups, the frequency of use of dental services increased from 2001 to 2021. In order to explore if these trends were related to people dropping out from the dental health care services or just postponing their dental visits, we calculated the proportion of people with a dental visit within the past 3 years or within the past 5 years (Figure 1B,C), and found evidence that the younger age groups (20–59‐year‐olds) tend to stay in the service system, but they extend the time between visits. Hence, more than 80% of the 20–59‐year‐olds had a dental visit within a 5‐year period, and while the decline over time in annual visits was marked, it was much less pronounced when the period considered for visits was 5 years. Overall, Figure 1A shows a reducing use of services among the 20–59‐year‐olds, a peak reached for the 60–69‐year‐olds, and an increasing use of services among the 70+‐year olds (Figure 1A). It can also be seen from Figure 1A that a cohort effect is prominent: In 2021, the most frequent users were the 70–79‐year‐olds; in 2011 the 60–69‐year‐olds; in 2001 the 50–59‐year‐olds, and in 1991 the 30–49‐year‐olds.

FIGURE 1.

Frequency of dental visits among Danish adults aged 20 years or more. (A) The proportion of the Danish population with a dental visit in the calendar year between 1990 and 2021. (B) The proportion of the Danish population with a dental visit within the past 3 years from the calendar year in the period between 2001 and 2021. (C) The proportion of the Danish population with a dental visit within the past 5 years from the calendar year in the period between 2001 and 2021. Owing to the truncation of entry into the cohort at age 20 years, the frequencies for the 20–29‐year‐olds are likely to be slightly underestimated with respect to dental visits within the past 3 or 5 years.

Table 2 shows that the median income percentile for users was quite stable around 56–57 over the years 2001, 2011, and 2021, whereas the median income percentile for non‐users increased from 36 in 2001 to 40 in 2011 and 43 in 2021.

TABLE 2.

The median value and the interquartile range and the lower and upper quartiles (Q1, Q3) of the income percentile for users (with a dental visit in the year) and non‐users (no dental visit in the year) of the dental health care system for adults, in each of the years 2001, 2011, and 2021.

	2001		2011		2021
	Non‐user	User	Non‐user	User	Non‐user	User
Median income percentile (Q1, Q3)	36 (18, 64)	57 (33, 79)	40 (19, 66)	57 (31, 79)	43 (21, 70)	56 (30, 79)

Figure 2 shows that while the frequency of dental examinations differed between the three indicator age groups 25‐, 40‐, and 65‐year‐olds over the time period 2001–2021, the frequency of reporting the dental health status parameters were essentially identical in the indicator age groups, but differed over the time period, reaching a low of about 60% between 2006 and 2008, and a plateau of approximately 90% from 2015 onwards (Figure 2B).

FIGURE 2.

The frequency of dental examinations, and the frequency of reporting of the dental health status parameters among 25‐, 40‐, and 65‐year‐olds between 2001 and 2021. (A) The proportion of the entire population in the three age groups that had a dental examination service in the calendar year over the period 2001–2021. (B) The proportion of patients with a dental examination in the calendar year for whom the dental health parameters were reported to the National Board of Health. Note that not all dental examination services are mandated to be associated with the reporting of dental health parameters. Note also that changes made to the structure of the National Health Service register in 2014 caused a continuity break in the data.

Figure 3 shows the distribution of the 25‐, 40‐, and 65‐year‐olds according to the reported number of teeth present in the years 2001–2021. The 25‐year‐olds retained most of their teeth, and less than 5%–8% had less than 28 teeth present. Among the 40‐year‐olds, a decline over time, from 24% in 2001 to 14% in 2021, was noted in the proportion with less than 28 teeth present among those for whom dental status was reported. Among the 65‐year‐olds, the proportion with less than 28 teeth present declined from 80% in 2001 to 56% in 2021 (Figure 3). The proportion of 65‐year‐olds with less than 20 teeth present declined from 31% in 2001 to 8% in 2021.

FIGURE 3.

Dental status of 25‐, 40‐, and 65‐year‐old patients as reported to the National Board of Health during 2001–2021. (A) The cumulative % of 25‐year‐olds according to the number of teeth present as reported in the period from 2001 to 2021. (B) The cumulative % of 40‐year‐olds according to the number of teeth present as reported for the years 2001–2021. (C) The cumulative % of 65‐year‐olds according to the number of teeth present reported between 2001 and 2021.

The number of teeth with manifest dental caries has declined in all three indicator age groups over the period from 2001 to 2021 (Figure 4). Where about 35% of the patients had caries lesions in 2001, the figures for 2021 were 22%, 23%, and 18%, respectively, for the 25‐, 40‐, and 65‐year‐olds (Figure 4). The distribution adults according to of the number of teeth with caries was very skewed in all age groups.

FIGURE 4.

The cumulative frequency distribution of adults according to the number of teeth with dental caries among 25‐ (A), 40‐ (B), and 65‐year‐old (C) patients reported to the National Board of Health during 2001–2021. Data are continuous in the range from 0 to 9 teeth, but two data points (10–14 teeth at 10, and 15–32 teeth at 15) cover the remainder of the distribution.

The cumulative distribution of the patients according to the number of teeth with fillings reported show a clear reduction, year by year, among the 25‐ and 40‐year‐olds (Figure 5). Among the 65‐year‐olds, the changes over time have been relatively minor, although the more recent birth cohorts have more teeth with fillings in the range from 1 to 10 teeth and fewer teeth with fillings in the range from 12 teeth and above than that seen among earlier birth cohorts.

FIGURE 5.

The cumulative frequency distribution of adults according to the number of teeth with fillings among 25‐ (A), 40‐ (B), and 65‐year‐old (C) patients reported to the National Board of Health during 2001–2021. Data are continuous in the range from 0 to 19 teeth, but two data points (20–24 teeth at 20, and 25–32 teeth at 25) cover the remainder of the distribution.

Figure 6A shows that more than 90% of adults in the three indicator age groups who had had their dental status reported in a calendar year would visit the dentist again within the next 3 years. This proportion was highest for the 65‐year‐olds (>97%) and lowest for the 25‐year‐olds (>90%). The proportion of non‐reported adults in the three indicator age groups who would visit the dentist within the ensuing 3 years differed between the age groups until 2007. Between 2001 and 2007 the proportion of non‐reported 65‐year‐olds with an ensuing dental visit within the next 3 years would increase from 47% to 65% (Figure 6A). From 2008 onwards, the probability of a dental visit within the next 3 years was fairly similar among the non‐reported adults in the three indicator age groups, showing a trend for decline from 68%–72% to 58% in 2018. Propensity‐score adjustment for key socioeconomic and demographic characteristics explained only a small part of the detected difference in the probability of a dental visit within the coming 3 years between those who had their dental status reported and those who did not (Figure 6B).

FIGURE 6.

The proportion of adults in the three indicator age groups of 25‐, 40‐, and 65‐year‐olds, who visited a dentist during the next 3 years according to their status as having had their dental status reported, or not. People in the “No” group comprise people with an examination but no status reporting as well as people with no dental visit (and therefore no status reporting) in the calendar year. (A) Raw, unadjusted averages. (B) For each examination year, the average estimates have been weighted/balanced for age, gender, municipality/region, immigrant/descendant status, highest completed education, socioeconomic position, and income using Bayesian additive regression tree‐based propensity scores to balance differences in these characteristics among adults with or without dental examination with dental status data reporting in calendar year.

Figure 7A shows the average number of teeth present in the indicator age groups, according to year of dental status reporting and their dental visiting behavior in the ensuing 3 years. Sixty‐five‐year‐olds who did not visit a dentist for the next 3 years had substantially fewer teeth present at the last dental examination than did 65‐year‐olds who visited a dentist again within the next 3 years. This difference among 65‐year‐olds was seen over the entire period considered, and propensity‐score adjustment of the estimated number of teeth only reduced this difference marginally (Figure 7B). Among the 25‐ and 40‐year‐olds, the average number of teeth present did not differ whether the person had a dental visit within the next 3 years or not.

FIGURE 7.

The average number of teeth present among 25‐, 40‐, and 65‐year‐olds with a dental visit and a dental status report in the calendar year. Given separately for those that had a dental visit at least once during the next 3 years, and for those that did not. (A) Raw, unadjusted averages. (B) For each examination year, the average estimates have been weighted/balanced for age, gender, municipality/region, immigrant/descendant status, highest completed education, socioeconomic position, and income using Bayesian additive regression tree‐based propensity scores to balance differences in these characteristics among adults with or without dental examination with dental status data reporting in calendar year.

In all indicator age groups, the average number of decayed teeth was lower for adults who had a dental visit within the ensuing 3 years than for adults who did not have a dental visit during the next 3 years (Figure 8A). While propensity score adjustments reduced the differences between people with and without dental visits in the next 3 years (Figure 8B), the overall pattern remained the same as seen for the unadjusted data.

FIGURE 8.

The average number of decayed teeth among 25‐, 40‐, and 65‐year‐olds with a dental visit and a dental status report in the calendar (examination) year. Given separately for those that had a dental visit at least once during the next 3 years, and for those that did not. (A) Raw, unadjusted averages. (B) For each examination year, the average estimates have been weighted/balanced for age, gender, municipality/region, immigrant/descendant status, highest completed education, socioeconomic position, and income using Bayesian additive regression tree‐based propensity scores. As reports on the number of decayed teeth for the years 2014 and 2015 were implausibly high compared with other years, we elected not to include these observations in this analysis.

In all indicator age groups, the average number of filled teeth was higher for adults who had a dental visit within the ensuing 3 years than for adults who did not (Figure 9A). This difference was very marked for the 65‐year‐olds, less marked for the 40‐year‐olds and least pronounced for the 25‐year‐olds. While propensity score adjustments reduced slightly the difference in the average number of filled teeth among 65‐year‐olds with or without dental visits in the ensuing 3 years, the differences remained marked (Figure 9B).

FIGURE 9.

The average number of filled teeth among 25‐, 40‐, and 65‐year‐olds with a dental visit and a dental status report in the calendar (examination) year. Given separately for those that had a dental visit at least once during the next 3 years, and for those that did not. (A) Raw, unadjusted averages. (B) For each examination year, the average estimates have been weighted/balanced for age, gender, municipality/region, immigrant/descendant status, highest completed education, socioeconomic position, and income using Bayesian additive regression tree‐based propensity scores.

DISCUSSION

The findings presented in this analysis clearly show that the dental health care utilization patterns have changed considerably in the adult Danish population since the 1990s. The dental attendance frequency has shown a steady reduction among age cohorts up to 60 years. The findings indicate that this relates to longer time intervals between visits and, to a lesser extent, to genuine loss of contact with the dental health care system. Hence, the 5‐year attendance rates have reduced over time since 2000 by no more than about 10% in the age cohorts up to 70‐year‐olds and in these age groups, the 5‐year attendance rate still exceeds 80%. In contrast, the dental attendance frequency has increased over time for the age cohorts from age 70 years, and the proportion of adult Danes with a dental visit in the past 5 years is by 2021 almost the same in all age groups, except for the 90+‐year‐olds, among whom about 60% have had a dental visit within the past 5 years. Indications are that the dental attendance increase among the older age cohorts parallels their increased tooth retention. However, the structure and organization for dental health care for adult Danes, with services being provided mainly from private dental practices, probably also limits the extent to which dental attendance rates may continue to increase in the oldest age groups. Evidence thus suggests that when physical or mental frailty set in, it may become very difficult for the older person to maintain contact with the oral health care system [42, 43], even though the Danish municipalities are obliged to provide a public municipal oral health care program for adults who cannot access or use the regular private clinics owing to mental or physical impairments [59]. Unfortunately, many more are considered eligible for these municipal oral health care programs for the vulnerable than are actually served [59, 60], most likely owing to the bureaucratic barriers posed by application and visitation procedures [61] necessary for enrolment.

The caries decline, which has been evident for decades among children and adolescents has clearly also trickled into the adult and elderly age groups [1, 4, 6, 8, 15]. Hence, the number of teeth with caries lesions among those 25‐, 40‐, and 65‐year‐old Danes who have had their dental status reported has diminished steadily since the commencement of data reporting in 2000. However, it is noteworthy that people who had their dental status reported but had no dental visits in the next 3 years had more decayed teeth than those who had their dental status reported and had visits in the next 3 years. Two different dynamics may be involved in the explanation of this observation. One is the existence of barriers to dental service use for those adults who would seem to be in the greater need of care, while the other relates to increasing numbers of people having adopted a “by perceived needs only” dental visiting pattern. Barriers to dental service utilization have been frequently studied [62, 63, 64, 65, 66], though mainly focusing on the older population segments or special needs groups, which limits the generalizability of the findings. Identified barriers include, but are not limited to, older age, male gender, immigrant status, lower income, lower socioeconomic position and lower educational attainment, and the present findings corroborate these barriers in the sense that non‐users were more frequently found among people with such characteristics. Among the barriers identified but not investigated in the present study are the costs of care, dental anxiety, and lack of perceived need [66]. However, Eurostat [67] provides estimates of the share of people in EU countries who self‐report unmet dental care needs, and in 2023, a total of 13.2% of Danes aged 16+ years reported an unmet dental care need. Of these, 8% considered services too expensive, while 0.9% stated fear of dentists as the reason. Interestingly, the younger adults (16–44‐ and 45–64‐year‐olds) were most likely (10%) to report too expensive services as the reason for reporting an unmet need, while only 2% of the 65+ year‐olds reported expensive services as the reason for an unmet dental care need. This might indicate that the response “too expensive” covers a “too little value for money” evaluation of the services. Unfortunately, the Eurostat data do not reveal the proportion who perceive no need for dental care, but Listl and coworkers [68] investigated the reasons given for dental non‐attendance across European countries, stratified according to welfare‐state regime. They grouped the reasons given for non‐attendance according to Andersen's conceptual framework including perceived needs, predisposing factors, enabling factors, and system‐level factors and found that the most frequently cited reason for non‐attendance was no perceived need, irrespective of the welfare‐state regime considered. Bearing in mind that the costs of care were part of the enabling factors response option, this finding might indicate that no perceived need is an additional factor explaining the decline in dental attendance observed in the adult Danish population, particularly among the ages below 60 years.

Clearly, a perceived need for dental care may differ from a real need for care. Hence, the presence of a dental condition for which appropriate preventive or treatment measures could bring about a health gain for the patients might go unnoticed by the patients themselves for longer periods. Thereby, people who perceive no need may have opted out of a dental health gain that could have materialized had they been more frequent users of the dental health care system. Unfortunately, despite the many claims made regarding the importance of regular dental care, the evidence for the health gains lost when reducing the frequency of dental care is limited. The practice‐based INTERVAL trial [69] carried out in the United Kingdom thus found no evidence of differences over a 4‐year follow‐up period in key oral health parameters of patients whether they had been allocated to a 6‐monthly or a risk‐based recall interval, or to a 6‐monthly, 24‐monthly, or risk‐based recall interval (provided they were considered eligible for a 24‐monthly recall period). This is remarkable insofar as the primary oral health outcomes studied were gingival bleeding on probing and oral health‐related quality of life, and the secondary outcomes included periodontal probing depth, dental caries, and calculus. One caveat of the INTERVAL study is that patients could be randomized to a 24‐monthly recall period only if the practicing dentist considered them eligible for this. Evidence suggests that dental professionals are quite reluctant to extend recall intervals to 24 months, even for their low‐risk patients [29]. Participants in the eligible for 24‐month recall stratum were thus younger, self‐reported to attend the dentist less regularly and had lower Oral Health Impact Profile‐14 scores, that is, less impacts, than those in the ineligible stratum. Even so, the findings of this trial indicate that dental care, at least as practiced in the United Kingdom, is ineffective for the management of the most common oral conditions. However, we have no reason to believe that the results would be markedly different had the trial been carried out in other settings.

An alternative explanation for the findings of no impact on dental health parameters of the recall interval in the INTERVAL trial [69] may be that the dental care provided does not match the needs of the patients. It is increasingly recognized that neither dental caries nor periodontal diseases can be defeated by the highly technical operative dental treatments for which the dentists are trained [70]. Rather, a more “preventionist” or disease‐controlling practice style should be adopted [19, 21, 70], which does not necessitate the skills of the highly trained technical dentist but could be undertaken by oral health care professionals trained to focus on disease detection and control of oral disease activity using non‐operative means.

Studies indicate that people value and are willing to pay for frequent dental check‐ups [30] and one may wonder if the self‐reported unmet dental care needs (according to Eurostat) represent a desire for more frequent dental visiting than is affordable. An alternative explanation might be that the annual or biannual dental visiting pattern is so deeply ingrained in the public mindset as being optimal that less frequent visiting must—in the public mind—lead to unmet needs. Dentists are clearly willing to provide frequent dental checkups [29], but this entails the risk of more treatment being provided than is needed [48, 53, 54, 55]. In a fee‐for‐service‐based dental health care system, the financial incentives for the dentist may thus override an unbiased and evidence‐based professional evaluation of the real health needs of the patients. The information asymmetry resulting from the dental professional being the expert who knows more than the patient is likely to lead to supplier‐induced demands, and indications are that dentists are less willing to share decisions with patients than is preferred by patients [71]. It is thus to be expected that future patients want a greater say in the decision‐making regarding their oral health situation [72, 73, 74]. As the dentists may be ill‐equipped to meet these demands [30, 75, 76], they may therefore inadvertently be driving patients to “vote with their feet”.

As recall intervals exceeding 2 years are not recommended in Denmark and as the socioeconomic or demographic factors accounted for in the present study seemed unable to explain the different visiting patterns observed among those who were examined (and status reported) as 25‐, 40‐, or 65‐year‐olds and those who had not been examined (and status reported), these differences probably reflect systematic differences in the preferences for not going for regular dental check‐ups. While subgroups exist within the non‐visiting groups across all ages that are particularly vulnerable to oral diseases, carry large oral disease burdens, and experience heavy barriers to access, for example, people marginalized by homelessness, substance abuse and/or mental illness [61, 77] and frail and care‐dependent elderly [42, 78, 79], they account for only a smaller proportion of the population. Hence, homelessness is currently estimated to affect about 6000 persons [80], and substance abuse affects about 99,000 [81]. About 150,000 adults were psychiatrically treated in 2022, and about 40,000 of these have a “double‐diagnosis”, that is, a mental illness coupled with substance abuse [82]. Frailty affects about 44,000 nursing home residents, and about 70,000 community‐dwelling persons over the age of 65 years are recipients of personal care [83, 84] and therefore also belong to the vulnerable group. While many of these are known to have no or only sporadic contacts with the regular oral health care system [78, 81] their numbers are too low to be able to account for the different visiting patterns at the population level.

In all probability, the provision of good oral health care (and any other medical care) to these vulnerable subgroups would necessitate a fundamentally different and outreach‐centered approach to the provision of oral health care [61, 85, 86]. Hence, the vulnerable subgroups are already burdened by a wealth of social, physical, and mental health issues, and they need real engagement from society if they are to overcome the many barriers to oral health care posed by the current organization of the oral health care systems. Tudor Hart [87] formulated the “inverse care law” as a weapon against the fact that “the availability of good medical care tends to vary inversely with the need for it in the population served”. Noting that the law “operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced” [87], he called for a selective redistribution of medical resources targeting those most in need. The findings presented here suggest that the resources for oral health care should indeed be redirected to outreach health care initiatives aiming to cover the dental (and medical and social) health of those vulnerable subgroups whose physical, social, and mental burdens are of such impact that they are effectively prevented from utilizing the systems put in place for the average, relatively healthy adult citizen.

AUTHOR CONTRIBUTIONS

Conceptualization: Vibeke Baelum, Eero Raittio, and Rodrigo Lopez. Data curation: Vibeke Baelum. Formal analysis: Eero Raittio. Funding acquisition: Rodrigo Lopez and Vibeke Baelum. Methodology: Eero Raittio and Vibeke Baelum. Project administration: Vibeke Baelum. Visualization: Vibeke Baelum and Eero Raittio. Writing—original draft: Vibeke Baelum. Writing—review & editing: Eero Raittio, Vibeke Baelum, and Rodrigo Lopez.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Supporting Information

Baelum V, Lopez R, Raittio E. Reflections on the implications of the trends in dental status for trends in dental care utilization 2001–2021 among adult Danes. Eur J Oral Sci. 2025;133:e70033. 10.1111/eos.70033