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International Dental Journal logoLink to International Dental Journal
. 2020 Oct 28;67(3):139–147. [Article in French] doi: 10.1111/idj.12273

Portuguese self-reported oral-hygiene habits and oral status

Paulo Melo 1,2,3,*, Sandra Marques 4, Orlando Monteiro Silva 1
PMCID: PMC9376680  PMID: 27981568

Introduction

The World Health Organization (WHO) defines oral health as ‘a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking and psychosocial wellbeing’1. Also, as stated by the World Dental Federation (FDI), ‘Good oral health enables us to speak, smile, kiss, breathe, whistle, smell, taste, drink, eat, bite, chew, swallow and express feelings. The oral cavity plays a central role for intake of basic nutrition and protection against microbial infections’2.

There is a close relationship between oral health of individuals and their social life3. Having good oral health implies being caries-free and not having periodontal diseases. Poor oral-hygiene habits promote oral infection, may result in poor oral health4 and affect the appearance, well-being and self-esteem of the individual. This situation might ultimately be associated with sleep, mastication and speech problems, as well as cognitive impairment5., 6., 7., 8..

Diseases of the oral cavity and odontalgia (dental pain) are particularly interesting issues for the WHO9, which stated that ‘Worldwide, 60–90% of school children and nearly 100% of adults have dental cavities’1. The WHO recommended that all countries include a significant annual budget for preventing and treating these diseases10. The WHO recognises oral diseases as an important public health problem as a result of the costs involved, their association with other diseases and their strong influence on people's quality of life; accordingly, the FDI suggests that oral health should be included in all national health policies11., 12., 13.. As dental pain is mainly caused by dental caries − a disease that affects a significant proportion of the world's population, especially younger and lower social-class individuals14 − it is very important to implement preventive programs. Primary prevention is essential to reduce the incidence and prevalence of such oral diseases11., 15.. Behavioural factors, oral as regular toothbrushing, use of dental floss and mouthwashes, a balanced diet and regular visits to oral-health professionals, are associated with a decreased risk of dental-caries16., 17.. Toothbrushing must include the tongue and gingiva and should be performed at least twice per day, preferably at night before bed and within 30 minutes after every meal. It is after these critical periods that the acids produced by cariogenic bacteria begin to demineralise the tooth structure18., 19.. Dental floss and mouthwash should be used as complementary to toothbrushing, in order to remove the plaque from interdental surfaces more effectively16. Furthermore, visits to a dentist should be regular (ideally, once every 6 months), to increase the chance of early detection of oral diseases. During visits, patients can also receive preventive-care procedures specific for their age, mainly regarding brushing techniques, use of the correct dose of fluoride and sealants16., 20..

Although significant oral-health problems, associated with severe impacts on general health and quality of life, have been detected in the Portuguese population, particularly in the Portuguese Health Plan 2011–201621, few studies quantify and identify behaviours and perceptions among adults. This type of research is essential for imposing regulatory pressure on those involved in advocacy and lobbying activities related to dental public health.

Therefore, this study aims to characterise the oral-health habits, behaviours, perceptions and reasons for seeking oral health care in the Portuguese population. Whenever appropriate, demographic aspects, such as age, gender, social classes and regions, were considered.

Methods

A national cross-sectional survey was conducted with a sample of 1,395 persons of > 15 years of age, randomly selected from the last population census of Portugal, including the autonomous regions of Madeira and the Azores. The final sample was composed of 1,102 (79%) people, who responded to a face-to-face questionnaire22.

A stratified sampling method was used for the age and gender variables, according to data from the Portuguese National Statistics Institute (INE)23. Regarding the region variable, the autonomous regions of Madeira and the Azores have relatively few inhabitants and hence a much lower proportional weight compared with the other Portuguese regions. Therefore, the sample was disproportionately stratified by region using a post-sample weighting factor, to ensure a low error rate on the overall performance. National results included a weighting coefficient applied to the residents of each of the seven health regions studied, in order to cancel out the influence of their different population sizes (Appendix S1). Thus, this sample was considered as representative of the whole Portuguese population > 15 years of age.

A face-to-face questionnaire was administered to all subjects. With the aim to answer the research questions, the questionnaire was composed of questions (constructs) in the following categories: socio-demographic data; oral hygiene habits; oral health perceptions; and oral health-care access. The internal consistency of the model was estimated based on the scale questions (items = 26), obtaining a good Cronbach's alpha coefficient (0.868). Before the interviews, the questionnaire was subjected to a pretest of coherence (n = 20) and, after the interviews, logic tests were applied to analyse and revalidate 15% of the interviews.

This research was conducted in full accordance with the Declaration of Helsinki. All participants involved in the study read the answers to the questionnaire and gave verbal consent to take part, declaring that they understood the purpose of the study and consented to data collection. Participants between 16 and 18 years of age gave verbal consent themselves, as allowed by Portuguese law. People who refused to participate were not replaced by others. This study, including the above-mentioned procedures, was independently reviewed and approved by the Ethics Committee of the Faculty of Dental Medicine of the University of Porto.

Data were submitted for statistical analysis using SPSS (v. 22; SPSS Inc., Chicago, IL, USA), as described by Maroco24. Statistical descriptive methods, inferential tests (chi-square test), and the multivariate method (Factorial Analysis) were used. All tests were applied at a significance level of 5%.

Results

The final sample of 1,102 (79%) persons, considered as a representative sample of the whole Portuguese population > 15 years of age, was associated with a theoretical margin of error of 2.95% in the case of maximum indetermination and a confidence interval of 95%. Of the 1,102 individuals, 518 (47.0%) were male and 584 (53.0%) were female. The majority lived in a household with more than three people (60.1%). Regarding social distribution, 47% of respondents were from the lower middle class, 27.3% from the lower class, 15.5% from the middle class and 10.2% from the upper/upper middle classes (Table 1).

Table 1.

Characteristics of the sample

Characteristics n %
Region
Greater Lisbon 203 18.4
Greater Porto 110 10.0
Littoral North 183 16.6
Littoral Center 146 13.2
Interior North 199 18.1
South 111 10.1
Madeira 75 6.8
Azores 75 6.8
Gender
Male 518 47.0
Female 584 53.0
Age
16–24 years 143 13.0
25–34 years 162 14.7
35–44 years 186 16.9
45–54 years 192 17.4
55–64 years 167 15.2
>65 years 252 22.9
Education
Illiterate 27 2.5
Basic education
1st cycle (age 6–10) 284 25.8
2nd cycle (ages 10–12) 103 9.3
3rd cycle (ages 12–15) 227 20.6
Secondary education 316 28.7
Professional technical education 12 1.1
BA degree 12 1.1
Bachelor's degree 110 10.0
Postgraduate studies 11 1.0
Employment status
Retired/Pensioner 239 21.7
Unemployed 96 8.7
Housewife/Househusband 40 3.6
Student 93 8.4
Employed 513 46.6
Self-employed 121 11.0
Household (number of people)
1 133 12.1
2 307 27.9
3 303 27.5
≥ 4 359 32.6
Social class
Lower 301 27.3
Lower middle 518 47.0
Middle 171 15.5
Upper/Upper middle 112 10.2
Total 1,102 100
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According to our sample's population (Table 2), most of the Portuguese population brush their teeth daily (97.6%) but did not use dental floss (76.7%) and/or mouthwash (54.6%). In addition, among those who brush their teeth, 72.7% do it more than twice per day. Twice-daily toothbrushing was reported by proportionally more women than men (77.3% and 68.9%, respectively, P < 0.01). Women also use mouthwash (52.4% vs. 40%, P < 0.01) and dental floss (29.3% vs. 17.6%, P < 0.01) more frequently than men. Comparing social classes, significantly fewer people from the lower social class brushed their teeth twice a day (65% vs. weighted total of 72.7%, P < 0.01).

Table 2.

Answers to the survey regarding self-reported oral hygiene habits, loss of more than six permanent teeth or all permanent teeth (not accounting for third molars) and use of a removable prosthesis or fixed dental prosthesis, according to the respondents' characteristics

Daily toothbrushing Toothbrushing twice per day Use of dental floss Use of mouthwash Loss of permanent teeth Loss of more than six permanent teeth Loss of all permanent teeth Replacement of lost teeth*
n % n % n % n % n % n % N % n %
Yes 1,072 97.3 787 73.4 262 23.8 513 46.6 778 70.6 360 32.7 77 7.0 342 44.0
No 30 2.7 315 28.6 840 76.2 589 53.4 324 29.4 742 67.3 1,025 93.0 436 56.0
Gender
Male 499 96.3 344 68.9 91 17.6 207 40.0 346 66.8 148 28.6 26 5.0 133 38.4
Female 573 98.1 443 77.3 171 29.3 306 52.4 432 74.0 212 36.3 51 8.7 209 48.4
P 0.069 <0.01 <0.01 <0.01 0.015 0.274 0.016 0.021
Age
16–24 years 143 100.0 120 83.9 46 32.2 78 54.5 27 18.9 0 0 0 0 2 7.4
25–34 years 162 100.0 134 82.7 59 36.4 80 49.4 78 48.1 4 2.5 0 0 12 15.4
35–44 years 186 100.0 145 78.0 61 32.8 92 49.5 122 65.6 25 13.4 0 0 34 27.9
45–54 years 191 99.5 131 68.6 53 27.6 94 49.0 157 81.8 63 32.8 8 4.2 60 38.2
55–64 years 164 98.2 116 70.7 27 16.2 74 44.3 152 91.0 90 53.9 12 7.2 80 52.6
>65 years 226 89.7 141 62.4 16 6.3 95 37.7 242 96.0 178 70.6 57 22.6 154 63.6
P <0.01 <0.01 <0.01 0.019 <0.01 <0.01 0.00 (0.00–0.00)† <0.01
Social class
Lower 274 91.0 178 65.0 20 6.6 111 36.9 263 70.1 182 60.5 52 17.3 146 55.5
Lower middle 515 99.4 372 72.2 137 26.4 246 47.5 327 63.1 123 23.7 18 3.5 116 35.5
Middle 171 100.0 137 80.1 50 29.2 91 53.2 124 72.5 43 25.1 7 4.1 50 40.3
Upper/Upper middle 112 100.0 100 89.3 55 49.1 65 58.0 64 57.1 12 10.7 0 0 30 46.9
P <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 0.00 (0.00–0.00)† <0.01
Total 1,072 97.3 787 73.4 262 23.8 513 46.6 778 70.6 360 32.7 77 7.0 342 44.0
Weighted total 1,076 97.6 782 72.7 257 23.3 501 45.4 775 70.3 358 32.5 74 6.4 340 43.9
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*

Removable prosthesis (83.6%) or fixed dental prosthesis (16.4%).

†

Chi-square Monte-Carlo simulation.

As indicated in Table 2, 32.5% of the population and 70.6% of people older than 65 years of age had lost more than six permanent teeth, not including third molars. Accordingly, loss of permanent teeth was shown to increase significantly with age (P < 0.01). Also, 60.5% of those in the lower social-class had lost more than six permanent teeth, indicating a significantly higher risk of tooth loss in comparison with the other social classes (weighted total of 32.5%, P < 0.01). Moreover, the loss of permanent teeth, not accounting for third molars, is correlated (r = 0.30; P < 0.001) with the toothbrushing habit. The lower social-class population and people older than 65 years of age also showed significantly worse results concerning the loss of all permanent teeth (17.3% and 22.6%, respectively, vs. weighted total of 6.4%; P < 0.01). Regarding gender, loss of permanent teeth was higher in women than in men (8.7% vs. 5.0%, respectively). It should also be noted that 56.0% of our sample population who had lost permanent teeth had not replaced them with removable or fixed dental prostheses (Table 2). Regarding the other 44% of our sample population, some (16.4%) had fixed dental prostheses; however, the majority (83.6%) had a removable prosthesis.

The data in Table 3 indicates that half (50.1%) of the sample's population had experienced difficulty in eating and/or drinking because of some problem in their mouth, 18.0% had felt ashamed of the appearance of their teeth at least once in their life and 69.3% had felt pain in the teeth and/or gums. In general, older people reported higher sensitivity to oral problems, either for aesthetic or for health reasons (P < 0.01). People living in Greater Porto and Madeira showed statistically (P < 0.01) more cases of ‘difficulty eating and/or drinking’ (62.7% and 76.0%, respectively) and people in the south region and Madeira reported more ‘pain in their teeth and/or gums’ (82.9% and 82.7%, respectively). On the other hand, significantly (P < 0.01) more people were ashamed of the appearance of their teeth in Greater Porto and Greater Lisbon (23.6% and 22.2%, respectively). People older than 45 years of age reported significantly (P < 0.01) more problems with their oral health status in general.

Table 3.

Answers to the survey regarding oral health perceptions, according to the respondents’ characteristics

Difficulty eating and/or drinking Have felt ashamed of their appearance Have felt pain in the teeth and/or gums
n % n % n %
Gender
Male 247 47.7 76 14.7 349 67.4
Female 316 54.1 120 20.5 422 72.3
P 0.033 0.011 0.077
Age
16–24 years 58 40.6 15 10.5 80 55.9
25–34 years 71 43.8 19 11.7 104 64.2
35–44 years 86 46.2 28 15.1 128 68.8
45–54 years 111 57.8 39 20.3 147 76.6
55–64 years 102 61.1 32 19.2 126 75.4
>65 years 135 53.6 63 25.0 186 73.8
P <0.01 0.01 (0.00–0.002)* <0.01
Region
Greater Lisbon 104 51.2 45 22.2 150 73.9
Greater Porto 69 62.7 26 23.6 80 72.7
Littoral North 74 40.4 26 14.2 99 54.1
Littoral Center 62 42.5 24 16.4 109 74.7
Interior North 96 48.2 32 16.1 126 63.3
South 67 60.4 20 18.0 92 82.9
Madeira 57 76.0 4 5.3 62 82.7
Azores 34 45.3 19 25.3 53 70.7
P <0.01 0.012 (0.009–0.015)* <0.01
Social class
Lower 150 49.8 73 24.3 222 73.8
Lower middle 267 51.5 73 14.1 364 70.3
Middle 92 53.8 34 19.9 117 68.4
Upper/Upper middle 54 48.2 16 14.3 68 60.7
P 0.775 0.02 (0.001–0.003)* 0.077
Total 563 51.1 196 17.8 771 70.0
Weighted total 552 50.1 199 18.0 763 69.3
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*

Chi-square Monte-Carlo simulation.

Table 4 shows that 47.4% of our sample's population had not visited a dentist for more than a year and 29.5% did not go to the dentist at all or only went for urgent treatment or because of pain. Conversely, 23.3% visited the dentist more than twice per year. Women reported going to the dentist more often compared with men (P < 0.01). People older than 45 years of age stated that they had not visited a dentist for more than a year, or that they did not go to the dentist or only went for urgent treatment or because of pain, significantly more frequently (P < 0.01) than did younger people. People living in the Interior North and Littoral Center regions stated that they had not visited a dentist for more than a year significantly more frequently (P < 0.01) than did people in other regions. On the other hand, significantly more people living in Madeira, the Azores, Greater Porto and Greater Lisbon stated that they did not go to the dentist or only went for urgent treatment or because of pain (P < 0.01) compared with other regions. People from higher social classes and people younger than 45 years of age reported going more often to the dentist (P < 0.01).

Table 4.

Answers to the survey regarding habits of visits to the dentist, reasons for not visiting the dentist, reduction of visits in the previous year, and influence of the residence–practice distance, according to the respondents' characteristics

Less than once a year Once a year More than twice a year Do not go/go only in urgency or pain Financial issues Think it is unnecessary Reduced visits in the previous year Reduced visits for financial reasons Residence-practice distance
n % n % n % n % n % n % n % n % n %
Gender
Male 96 18.5 144 27.8 99 19.1 179 34.6 62 31.6 71 36.2 93 19.3 58 53.7 0 0.0
Female 87 14.9 180 30.8 154 26.4 163 27.9 64 41.3 49 31.6 128 22.5 88 60.3 1 0.7
P <0.01 0.046 0.304 <0.01 <0.01 NA
Age
16–24 years 12 8.4 48 33.6 42 29.4 41 28.7 7 19.4 15 41.7 18 13.5 7 35.0 0 0.0
25–34 years 21 13.0 63 38.9 43 26.5 35 21.6 15 37.5 9 22.5 31 19.3 21 56.8 0 0.0
35–44 years 19 10.2 70 37.6 60 32.3 37 19.9 18 48.6 12 32.4 27 15.1 15 53.6 0 0.0
45–54 years 30 15.6 59 30.7 44 22.9 59 30.7 24 40.0 14 23.3 41 22.5 30 65.2 1 2.2
55–64 years 33 19.8 47 28.1 23 13.8 64 38.3 22 43.1 16 31.4 35 21.5 27 61.4 0 0.0
>65 years 68 27.0 37 14.7 41 16.3 106 42.1 40 31.5 54 42.5 69 29.4 46 58.2 0 0.0
P <0.01 0.029 (0.025–0.033)* 0.071 (0.065–0.078)* <0.01 <0.01 NA
Region
Greater Lisbon 33 16.3 63 31.0 34 16.7 73 36.0 49 54.4 11 12.2 69 34.5 60 69.8 0 0.0
Greater Porto 14 12.7 30 27.3 25 22.7 41 37.3 4 14.3 13 46.4 11 10.6 8 72.7 0 0.0
Littoral North 18 9.8 67 36.6 52 28.4 46 25.1 12 30.0 16 40.0 27 16.1 17 58.6 0 0.0
Littoral Center 37 25.3 38 26.0 39 26.7 32 21.9 22 37.9 14 24.1 30 20.7 26 66.7 0 0.0
Interior North 48 24.1 57 28.6 48 24.1 46 23.1 21 26.3 40 50.0 26 14.1 15 48.4 1 3.2
South 27 24.3 24 21.6 25 22.5 35 31.5 15 41.7 15 41.7 26 23.6 10 38.5 0 0.0
Madeira 3 4.0 24 32.0 17 22.7 31 41.3 3 33.3 5 55.6 10 13.9 8 80.0 0 0.0
Azores 3 4.0 21 28.0 13 17.3 38 50.7 0 0.00 6 60.0 22 31.9 2 9.1 0 0.0
P <0.01 <0.01 0.00 (0.00–0.00)* <0.01 <0.01 NA
Social class
Lower 79 26.2 53 17.6 48 15.9 121 40.2 61 39.6 62 40.3 86 31.2 60 57.7 1 1.0
Lower middle 82 15.8 163 31.5 120 23.2 153 29.5 52 32.7 46 28.9 96 19.3 68 62.4 0 0.0
Middle 16 9.4 63 36.8 44 25.7 48 28.1 12 38.7 8 25.8 30 17.9 14 43.8 0 0.0
Upper/Upper middle 6 5.4 45 40.2 41 36.6 20 17.9 1 14.3 4 57.1 9 8.0 4 44.4 0 0.0
P <0.01 0.425 (0.412–0.437)* 0.232 (0.238–0.260)* <0.01 <0.01 NA
Total 183 16.6 324 29.4 253 23.0 342 31.0 126 35.9 120 34.2 221 21.0 146 57.5 1 0.4
Weighted total 197 17.9 323 29.4 256 23.3 325 29.5 137 36.7 124 33.3 219 20.8 153 60.0 1 0.4
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*

Chi-square Monte-Carlo simulation.

Financial issues (36.7%) and the perception that visiting the dentist is not necessary (33.3%) were the main reasons for not going to the dentist (Table 4. In the 12 months before the questionnaire, 20.8% of the participants had reduced their number of visits to the dentist. This reduction was mainly reported by women (22.5%), people older than 65 years of age (29.4%), lower social-class individuals (31.2%) and inhabitants of Greater Lisbon (34.5%). Financial issues were the main reason for the decrease in visits (60%). Very few people (0.4%) stated the distance between their area of residence and the dental practice as a reason for visiting the dentist less often. In fact, this variable does not correlate with the frequency of visits (r = 0.049; P = 0.116).

Finally, 29.3% of the population was aware that the National Health Service (NHS) provides, in some way, dental services, and that dentistry is more expensive than other areas of health care/medicine (71.8%). Accordingly, the majority think that it is important or very important to facilitate access to this health service, either by making it available on the NHS (97.1%) or by public contributions in the private sector (93.7%).

Discussion

This research is the first national study conducted in Portuguese adults on the oral-health habits, behaviours, perceptions and reasons for seeking oral health care, analysing populations living in different regions of the country. It should be pointed out that all results refer to responses obtained in the face-to-face survey. Fieldwork was subjected to rigorous analysis to obtain a homogeneous distribution throughout the country and to obtain answers that express the true opinion of the entire Portuguese population, to be considered as valid. Therefore, taking into account that sometimes respondents tend to overestimate their actual behaviours, as they are influenced by the social acceptability of their responses25, we consider this study's results an optimistic view of the current actual situation.

The social class of the participants was not indicated by them. It was determined based on the participant's education and employment status and thus should be interpreted with caution. Nonetheless, the distribution of this variable is consistent with the data available on the Portuguese population, which reports that 26.7% are from the lower social class, 31.0% from the lower middle social class, 24.9% from the middle social class and 17.4% from the upper/upper middle social classes26.

Toothbrushing is a general habit among the Portuguese as 97.6% of our study's population claims to brush at least once a day. Accordingly, in 2014, Veiga et al.27 found that 96.8% of Portuguese adolescents brushed their teeth at least once a day. Similar results have been reported in other countries. In Poland, Skorupka et al.28 found that 80% of Polish people older than 65 years of age brushed their teeth at least once a day. In New Zealand, Broadbent et al.29 reported, based on a sample of 32-year-old participants living in that country, that 96.4% of women and 85% of men brushed their teeth at least once a day. In the USA, Liu et al.30, with a sample of 505 adults, reported that almost 98% had that habit. In Italy, Villa et al.31, from a sample of postpartum Italian women, concluded that 99.3% of them brushed their teeth daily. On the other hand, 72.7% of our sample of the Portuguese population claimed that they brushed their teeth twice a day, which is a very good result compared with other European results32., 33. but still lower than what has been reported34. Other associated habits, such as using dental floss and mouthwash, were not performed as frequently in Portugal as they are in other countries30., 31.. Lower social-class individuals, older people and men seem to be less prone to daily toothbrushing. Accordingly, efforts must be made to improve toothbrushing habits, focussing mainly on older individuals and less-educated people, as they are more likely to have poor oral-hygiene habits.

In Portugal, the loss of permanent teeth is frequent, as about 70.3% of our sample of the Portuguese population had lost at least one permanent tooth, not including third molars, and 32.5% had lost more than six permanent teeth. The exact number of lost teeth and the conditions that required tooth replacement are unknown35. However, we can presume that the loss of more than six permanent teeth causes significant changes in the facial and intraoral tissues, thus compromising mastication and muscle function, as well as interfering with psychosocial behaviours, and perhaps with cognitive function7., 36.. In the present study, the higher number of teeth lost in women is in line with the results from other reports7., 37.. The loss of all permanent teeth found in 6.4% of our sample of the Portuguese population confirms the results from the European Commission Eurobarometer38. The percentage of edentulous people older than 65 years of age, in our sample, was higher (22.6%) than in that study, but not as high as for Polish people (36%)28. This percentage is expected to increase with age, as older people tend to have more dental problems39., 40., 41.. This study also revealed that the loss of permanent teeth, not including third molars, is correlated with the toothbrushing habit. These results are consistent with other studies that reported tooth loss as a result of poor oral-hygiene habits that can result in caries and periodontal diseases31., 42.. According to our study, in Portugal, being older than 65 years of age, being a woman and from a lower social class seems to increase the risk of tooth loss.

There is a huge difference between our sample of the Portuguese population (47.9%) and the European population in general (31%) regarding people who replaced lost permanent teeth with a removable prosthesis38. As expected, our study showed that the rate of Portuguese people who had their teeth replaced (with a removable prosthesis or a fixed dental prosthesis) was directly proportional to the number of lost permanent teeth. This situation might be due to financial reasons or because of not understanding the relevance of replacing missing teeth, regardless of the number36.Ghorbani et al.43 found the same results in Tehran, Iran, where the most frequent behaviour among lower social-class people was not to replace teeth.

The analysis of our data regarding self-reported difficulty eating and/or drinking as a result of problems in the mouth (50.1%), feeling ashamed of the appearance of their teeth (18.0%) and experiencing toothache or gingival pain (69.3%) shows that Portuguese people have more oral problems than the average of the European population (15%, 16% and 7%, respectively)38. These situations are worse for people older than 45 years of age. Accordingly, efforts should be made to promote good oral-hygiene habits among older persons and persons of lower social classes as they are more likely to have poor oral-hygiene practices that lead to poor oral-health.

Almost 50% of the population reported not having visited a dentist for more than a year. This result might be related to the economic crisis in Portugal, as well as the fact that the public health system does not offer oral health services in most regions of the country. However, these results are similar to those of the UK, where 46% of the population do not visit a dentist44. Thus, costs associated with private services of dentistry may be the main reason for the high percentage of people who had not visited the dentist for more than a year. According to these results, Portuguese people older than 45 years of age and men are more likely to not visiting a dentist for more than a year. This study also showed that the distance between the area of residence and the dental practice is not an inhibitor of visits, which is in line with the idea that Portugal has good oral-health coverage regarding dental practices, as do the majority of European countries38. On the other hand, it revealed that financial issues and the perception of no need are the most frequent reasons for not visiting a dentist.

Regarding the options for NHS services or a public contribution in the private sector for oral health, this study showed that there is no preference at this time. However, people have the perception that dentistry is more expensive than other areas of health care/medicine and that is important to make it more accessible. Accordingly, it should be noted that the WHO has stated oral disease as the fourth most expensive disease to treat9. Considering the results, to increase the use of dental services in Portugal, the integration of oral health in the NHS or a public contribution in the private sector for this area could be considered.

Conclusion

Portuguese oral-health habits, as well as the loss of teeth, are similar to the reported European average. Nevertheless, signs show that, in Portugal, oral diseases might be more prevalent in adults when compared with the Europeans in general. In particular, people from a lower social-class and older people seem to be more prone to having worse oral-health status and more difficulty in accessing oral health care. Efforts should be made to promote good oral-hygiene habits among risk groups. Furthermore, the Portuguese feel that visits to oral-health professionals should be partially funded by the public service so that more people can regularly visit a dentist.

Acknowledgements

The study was funded by the Portuguese Dental Association, of which two of the authors are members.

Conflict of Interests

The authors do not have any conflict of interest to disclose.

Supporting Information

Additional supporting information may be found in the online version of this article:

Appendix S1. Proportion and weighting factor of each region.

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