Barriers to oral health across selected European countries and the USA

Abstract

In this review we consider oral-health access among older adults within and between the USA and various European countries with regard to possible primary financial and modifiable secondary non-financial factors. For older adults, the likelihood of using dental services has been associated, in the health literature, with a multiplicity of factors. These factors are traditionally classified into predisposing, enabling and need categories, and can be further classified into modifiable and non-modifiable subcategories. This raises the question of which single factor or group of factors has the most influence in keeping older adults from seeking care, and how these influences might differ between the USA and various other (European) countries. As it turns out, there is variation in the magnitude of effects across certain measurable potential barriers, but generally it takes a combination of characteristics associated with non-use to have a substantial impact.

Introduction

In this paper we provide a concise review of the literature on barriers to oral health for older adults across selected European countries and the USA. In the health economics literature, the likelihood of older adults using dental services has been associated with a multiplicity of factors. We include possible primary financial and modifiable secondary non-financial factors that may impede access to dental care for an older population. These factors are traditionally classified into predisposing, enabling and need categories, and can be further classified into modifiable and non-modifiable subcategories1., 2.. For example, age and sex are considered as non-modifiable predisposing factors, whereas dental anxiety is a potentially modifiable predisposing correlate of dental use. We begin our review by first examining modifiable financial barriers to oral health care.

Financial Factors

‘Dental tourism could save you big money’ was the headline of a story in the travel section of a national news network just a few years back³. Noting that somewhat less than half of Americans had dental insurance and a report by Senator Sanders on the ‘Dental Crisis in America’, this story estimated that about 400,000 Americans travelled beyond the US border to receive less expensive dental care³. Dental tourism is not unique to the USA; according to International Medical Travel Journal, cost savings is the primary driver for UK citizens to seek dental care abroad, noting that a filling ranged in cost from €8 in Hungary to €156 in England⁴. There is no doubt that cost is a significant factor in patients’ decision to seek dental care5., 6., 7., 8.. Dating back to 1986, Bomberg and Ernst⁵ reported that paying for dental care can be difficult, and among the reasons given for not going to the dentist were out-of-pocket costs. Other studies showed that patients often feel that dental care is too expensive and therefore choose to delay seeking care, suggesting that cost does influence the decision to seek dental care in the long term as well as in the short term6., 7., 8.. It is therefore not surprising that both wealth and income have a strong and independent positive effect on dental-care use among the elderly⁹. Similarly, it is not surprising that having dental insurance coverage, which lowers the out-of-pocket cost of care, also increases the likelihood of dental-care use10., 11.. Whereas the effect of dental coverage is universally positive, there does exist considerable variation, according to country, among respondents reporting dental coverage; the highest rates of coverage are reported in Germany (98%), the Czech Republic (96%), Denmark (92%) and the Netherlands (87%), medium rates of coverage are reported in Greece (57%), the USA (48%) and Spain (31%) and the lowest rates of coverage are reported in Switzerland (21%) and Italy (21%)¹².

Countries have adopted different approaches to providing publicly subsidised dental insurance coverage¹³. In the USA, private dental insurance dominates the dental coverage marketplace with about 53.9% of the community population having private dental insurance, 11.5% having public dental coverage and 34.6% having no dental coverage at all¹⁴. Among an older population, approximately 70% do not have any dental coverage, with only 24% having private coverage and about 6% having public coverage. Unique to the USA, public dental coverage is not included in Medicare, an otherwise universal health-care plan for the elderly, and because private coverage in the USA is typically job based it is usually unavailable among the retired¹⁵. Other countries provide support through comprehensive Social Health Insurance (SHI) and maintain a less robust private dental insurance market¹³.

Despite considerable variation in rates of dental coverage, the variation between dental insurance and dental attendance across countries was less than expected, especially when compared with the effect of other use factors such as income and education¹⁶. To isolate the effect of dental coverage, a recent study simulated the effect of providing dental coverage to a previously uninsured group of older USA community population members¹⁷. The results of this study showed that dental use rates would increase but at rates lower than those of the previously insured. The study also suggested that users with dental-care coverage differ from dental-care non-users without dental-care coverage in ways that are important to consider when developing policy to improve dental access1., 17.. In countries with low rates of dental attendance, expanding dental coverage to the previously uninsured, without consideration of programmes to address social determinants of oral health complementary to dental coverage, could result in less utilisation than expected¹.

Other Barriers to Oral Health

Kiyak and Reichmuth¹⁸ reviewed barriers to access to dental-care services for older USA adults in previous studies. In summary, they found lower use rates among older persons who are edentulous; are dentate but have few natural teeth remaining; have negative attitudes towards oral health; are ethnic minorities rather than white; are not covered by dental insurance; are living alone rather than married or living with others; and have low socio-economic status as measured by income and education. Poor general health and chronic diseases were also found to limit dental-care use even if a need exists, particularly for those in long-term care facilities or those with various limitations in their activities of daily living. The belief that oral treatment was not needed was found to be the main reason for irregular or non-use of dental services, and the perceived importance of oral health best discriminated preventive, instead of emergency or non-use, of dental services in another study¹⁸.

Holm-Pedersen et al.¹⁹ reviewed previous research, performed in selected European countries on the use of dental care by older Europeans. They found lower use of dental services for older persons in Sweden as they aged; among male subjects compared with female subjects; having removable dentures or few remaining teeth; living alone; having functional impairments; being smokers; having low levels of education; and having limited social and physical activity. In the UK, difficulties in accessing dental care were discovered among functionally dependent elderly living in long-term care facilities or at home. In Denmark, correlates of irregular or non-use of dental services were found to include older persons with lower incomes, low lifestyle activity and general functional limitations. In Nordic locales, irregular dental use was also correlated with older persons having impaired general health, having high numbers of prescribed medicines, incurring economic problems, not being native born and living in rural areas¹⁹.

More recently, a multi-European country study investigated reasons for dental non-attendance throughout the lifetimes of persons 50 years and older using 2006–2009 SHARE data²⁰. Non-attendance percentages ranged from 4.6% and 9.5% in Sweden and Denmark, respectively, to over 50% in Greece, Spain, Poland and Italy. Other countries, including Germany, Austria, France and Switzerland, had rates of non-attendance of between 19% and 29%, while the rate for the Czech Republic rate fell to nearly 11%. Survey respondents who had not sought regular dental care throughout their lifetime were asked to check as many as nine possible reasons why they did not, including enabling factors (not affordable, no health insurance coverage, time constraints), predisposing factors (insufficient information about type of care, not usual to obtain this type of care), need factors (not considered to be necessary) and system level factors (no place close to home to receive this type of care). Across all countries, the most common reason cited for non-attendance over the lifetime was that dental care was not considered necessary, but this reason was cited significantly more often in the non-Scandinavian countries. Among the Scandinavian countries, predisposing factors were cited more commonly, and the health system-level factors less commonly, as reasons for non-attendance than in the other countries. Predisposing factors were cited more often among older and more highly educated individuals, while enabling factors were cited more often by women and by those with lower educational and other socio-economic status²⁰.

Quantifying Barrier Impacts

Clearly there is a multiplicity of potential barriers to seeking dental care across countries. This raises the question as to which single factor or group of factors has the most influence in keeping older adults from seeking care, and how these influences might differ between the USA and various other (European) countries. The previous studies cited in our review typically report which characteristics have a statistically significant association with dental non-attendance but do not illustrate quantitatively the extent to which such effects reduce the probability that older persons will seek dental care. In Table 1 we provide these previously unpublished estimates by using the logistic regression results from Manski et al.¹² to illustrate how this probability changes with an older person's characteristics. As it turns out, there is variation in the magnitude of effects across certain measurable potential barriers, but generally it takes a combination of characteristics associated with non-use to have a substantial impact on this probability. The top row of the table shows the mean estimated dental attendance rates (in percentage) for each country. In the next row we show the estimated attendance rate (i.e. probability of attendance) from our statistical analysis for a base case with characteristics most likely to be associated with dental attendance for an older adult based on our own and previous studies [i.e. a highly educated, high-income, insured, relatively younger woman, still in the labour force and with excellent general health, without dentures and problems biting or chewing (European countries) or not edentulous (USA)]. For each country as we move down each column we successively alter each assumption of the base case that was estimated to be statistically significant in our logistic regression analysis and show the impact on our base case in terms of the likelihood of dental attendance. For example, in Austria our base case has an 83.3% probability of going to the dentist during the survey year. If the person is 80–84 years old instead of under 65, then this probability drops to 67.7%, but by combining growing older with dropping out of the labour force (but not retiring) with moving from the highest to the next-lowest household income quintile, then the likelihood of dental use declines to 36.3%, nearly 50% lower than the original base case. Finally, if the person also happens to have dentures, then the probability drops to less than 25%.

Table 1.

Cumulative percentage estimated likelihood of dental attendance for persons with characteristics significantly different from the base case: USA and selected European Countries (Health and Retirement Study, 2004–2006, and Survey of Health, Aging, and Retirement in Europe, 2006–2007, respectively)

Variable/Characteristic	USA*	Bismarckian countries						Scandinavia		Southern Europe			Eastern Europe
		Austria†	Belgium†	France†	Germany†	Netherlands*	Switzerland*	Denmark†	Sweden†	Greece*	Italy*	Spain*	Czech Republic†	Poland†
Overall country mean	66.0	51.4	50.8	48.8	73.2	66.3	72.6	79.8	81.9	36.9	35.9	30.3	58.8	23.1
Base case‡	96.1	83.3	80.0	61.0	85.6	94.9	91.2	94.8	92.0	59.0	44.4	56.7	85.6	52.4
Age
51–64 years‡
65–69 years
70–74 years
75–79 years	97.1								96.2		33.9			31.6
80–84 years		67.7			58.9
85 years and older			66.0			78.6	70.4	85.8		33.2		23.9	42.5
Sex
Women‡
Men	95.4			52.1	45.2		58.5	78.9	95.0	27.0		18.7
Education (ISCED scores)§
Category 1	85.4		50.3	38.1	26.0	62.2	46.0	60.6	92.5		25.5	8.6	25.5	14.8
Category 2
Category 3‡
Marriage status
Married/partnered‡
Widowed/divorced/separated	76.6				18.9		36.1	48.6	89.1				18.7
Never married						45.7
Health status
Excellent/very good‡
Good					26.6
Fair/poor	64.5		41.2					40.5	83.5			14.2
Chewing ability (Europe only)
Can bite/chew on hard foods‡
Cannot bite/chew on hard foods			34.7	32.4				33.2
Retirement/labour force status
Not retired in labor force‡
Retired	70.6				37.8		48.7	47.6			33.1
Not retired not in labour force		53.4
Income quintile¶
1st quintile	38.3		24.4		24.4			29.5		17.7			9.6
2nd quintile		36.3					32.8		76.1					8.7
3rd quintile											19.2
4th quintile				41.6
5th quintile‡												3.3
Dental insurance coverage
Not covered	22.9			60.3		27.6		17.1			28.9			16.3
Covered‡
Objective oral health status (Europe, denture use; USA, tooth loss)
No impairment‡
Impairment	3.8	23.7	14.1			5.2	14.7	4.9	52.4	11.8			7.3
Observations (n)	16,911	1,236	2,769	2,493	2,345	2,333	1,332	2,329	2,172	2,878	2,783	1,988	2,495	2,135

Based on separate logistic regressions for each country that account for sample design. Some characteristic categories had more than one statistically significant coefficient. In these cases the largest coefficient was generally selected for the table estimates. Estimates for the USA refer to dental care use within the past 24 months; estimates for European countries refer to dental care use within the past 12 months.

^*Country does not have comprehensive social health insurance benefits incorporating dental coverage for older persons.

^†Country has comprehensive social health insurance benefits incorporating dental coverage for older persons.

^‡The base case consists of a married woman between 51 and 64 years of age with self-reported dental insurance coverage, in the highest income and educational categories, not retired and in the labour force, in excellent or very good health, with either no dentures (Europe) or not missing all permanent teeth (USA), and has no difficulty biting or chewing on hard foods (Europe).

^§Category 1, International Standard Classification of Education (ISCED) = 1,2 (Europe) or <high school degree (USA); Category 2, ISCED = 3 (Europe) or high school degree or some college (USA); Category 3, ISCED = 4,6 (Europe) or college degree (USA).

^¶Arranged lowest (1^st quintile) to highest (5^th quintile) income.

Figures 1 and 2 illustrate the extremes and the gaps between them, respectively, of the estimated likelihood of dental attendance based on the least and most disadvantageous set of characteristics in each country. Only in the table can one see the incremental effect of each predisposing, enabling and need measure as, in combination, the odds become increasingly smaller and the multiple barriers more daunting for an older person to overcome in seeking oral health care.

Figure 1.

High and low rates of dental attendance (given as a percentage) among several European countries and the USA.

Figure 2.

The percentage gap between high and low rates of dental attendance among several European countries and the USA.

Summary and Conclusion

Our review finds that older adults with limited financial resources and lacking comprehensive dental insurance coverage face considerable difficulty in using oral health-care services. We also found that marital status (living alone), health status (poor), presence of chronic diseases, perceived need for care (low) and limited education also serve as obstacles to the use of dental services among older adults. In summary, we conclude that while no single factor stands out as being the most significant barrier to older persons’ access to oral health care, characteristics often associated with limited oral health-care use, such as low income, lack of dental coverage, limited education and poor health, work together to establish a formidable barrier to the use of dental care.

Acknowledgements

The present paper uses data from RAND HRS and RAND SHARE. RAND HRS is a user-friendly version of HRS, and the HRS public use dataset is produced and distributed by the University of Michigan with funding from the National Institute on Aging (grant number NIA U01AG009740), Ann Arbor, MI, USA. RAND SHARE is a user-friendly version of SHARE, created with funding from the National Institute on Aging (grant number R01AG030153). RAND SHARE used SHARE wave 4 release 1.1.1, as of March 28th 2013, SHARE wave 1 and 2 release 2.5.0, as of May 24th 2011, or SHARELIFE release 1, as of November 24th 2010. The SHARE data collection has been primarily funded by the European Commission through the 5th Framework Programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life), through the 6th Framework Programme (projects SHARE-I3, RII-CT-2006-062193, COMPARE, CIT5-CT-2005-028857, and SHARELIFE, CIT4-CT-2006-028812) and through the 7th Framework Programme (SHARE-PREP, No. 211909, SHARE-LEAP, No. 227822, and SHARE M4, No. 261982). Additional funding from the USA National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, R21 AG025169, Y1-AG-4553-01, IAG BSR06-11 and OGHA 04-064) and from the German Ministry of Education and Research, as well as from various national sources, is gratefully acknowledged (see www.share-project.org for a full list of funding institutions).

Conflicts of interest

The authors declare that there are no conflicts of interest.

Sources of funding

This investigation was supported by the National Institute of Dental and Craniofacial Research of the USA National Institutes of Health (DE021678).