Utilization of dental services in Southern China.
ABSTRACT A population's utilization of dental services is an important parameter in oral health care planning, which has rarely been studied in China. The objectives of this report were to describe the dental service utilization pattern of middle-aged and elderly Chinese and to analyze the influence of selected variables on the use of dental services. A Guangdong Province population of 1,573 35- to 44-year-olds and 1,515 65- to 74-year-olds recruited from urban and rural communities was interviewed in their local dialect. It was found that 23% of the middle-aged and 24% of the elderly subjects had visited a dentist within the preceding year. The two most commonly cited reasons for not having seen a dentist for at least 3 years were: no perceived need, and no serious dental problems. Among subjects who had visited a dentist within 3 years, the 3 most commonly received treatments were: fillings, extractions, and dental prostheses. Furthermore, a logistic regression analysis showed that women, subjects who lived in urban areas, were better educated, were wealthier, and had better oral health knowledge were more likely to be a recent dental service user. In conclusion, dental service utilization among the adult Southern Chinese was found to be low, problem-driven, and influenced by some socio-economic factors.
- SourceAvailable from: May Chun Mei Wong[show abstract] [hide abstract]
ABSTRACT: Relatively limited information is available about the oral health in the Guangdong Province of Southern China, the closest neighbor to Hong Kong. The study intended to explore the oral health status, knowledge, attitudes, and dental care utilization in the Guangdong population as a basis for formulating strategies for oral health prevention and treatment. Through multi-stage stratified and quota-sampling, individuals from urban as well as rural communities were selected (5- to 6-; 12-; 35- to 44-; and 65- to 74-year-olds; total N = 6251). Structured interviews and clinical examinations were performed. Inter-examiner reliability was high (kappa = 0.60-0.96). Samples of community water were taken for fluoride assessment. Overall, the sample surveyed was acceptably representative of the population, with some under-representation of rural residents and agricultural workers. Re-weighting was performed in appropriate analyses. The data analysis model used in the Second International Collaborative Study was used as a guide for the present data analysis. This approach has not previously been used on a Mainland Chinese population.Journal of Dental Research 06/2001; 80(5):1453-8. · 3.83 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: A sample of 765 elderly people living in London was interviewed and examined. Barriers to dental care stemmed from: elderly people's beliefs that dentures should last a life-time and dental visits are unnecessary for edentulous persons: mobility difficulties; fear; problems with access to NHS care and with access to satisfactory care. The attitudes of general dental practitioners, community dentists and final year dental students towards elderly people were favourable. Sixty per cent of surgeries were on the ground floor, and 46 per cent of premises were unsuitable for wheelchair access. Carers wanted improvement in domiciliary services. The provision of domiciliary care was significantly related to training. There was a paucity of experience in this field amongst dental students. Community dentists recognized a need for retraining before providing care for handicapped elderly people.Journal of Dentistry 11/1990; 18(5):236-42. · 3.20 Impact Factor
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ABSTRACT: The objectives of this analysis were to describe the dental service use pattern of the 35-44- and 65-74-yr-old age groups and to determine to what extent this pattern could be explained by selected sociodemographic and attitudinal variables. The study populations comprised 398 35-44-yr-old and 559 65-74-yr-old Hong Kong Chinese. Use of dental services was determined on the basis of the respondents' own perception of the regularity of their dental visits and by the time since the last dental visit. The younger groups was categorized into regular users, irregular users, and nonusers, and the older group was categorized into three groups according to last dental visit (within 2 yr, 2-5-yr, 5 yr or more). A modification of the Andersen and Newman model for individual determinants of health care use was used as the framework for a logistic regression analysis. Predisposing variables were sex, education, occupation, attitudes, knowledge, preventive orientation, and dental anxiety; enabling variables were Family Possession Index, income, family support and access to a dental programme; need variables were perceived conditions of teeth, dental problems, dental pain, need for treatment, normative need for treatment, and denture wearing. In general, use of dental services was low. For the 35-44-yr-olds, the best regression model (sensitivity: 62%, specificity: 95%, overall correct classification: 88%) indicated that there was an increased probability of having a regular dental care pattern if respondents were prevention oriented, had access to a dental benefit programme, had not experienced pain, had a higher income, perceived their teeth as fair or poor, and perceived a need of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)Community Dentistry And Oral Epidemiology 11/1994; 22(5 Pt 2):374-80. · 1.80 Impact Factor
Journal of Dental Research
The online version of this article can be found at:
2001 80: 1471J DENT RES
E.C.M. Lo, H.C. Lin, Z.J. Wang, M.C.M. Wong and E. Schwarz
Utilization of Dental Services in Southern China
On behalf of:
International and American Associations for Dental Research
can be found at:
Journal of Dental Research
Additional services and information for
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E.C.M. Lol*, H.C. Lin2, Z.J. Wan 3,
M.C.M. Wong1, and E. Schwarz"4
'Faculty of Dentistry, The University ofHong Kong, 3/F,
Prince Philip Dental Hospital, 34 Hospital Road, Hong
Kong; 2Department of Preventive Dentistry, Sun Yat-sen
University ofMedical Sciences; and 3Department of
Epidemiology, Sun Yat-sen University ofMedical Sciences;
4present address, 1619 Duke St., Alexandria, VA 22314,
USA; *corresponding author, firstname.lastname@example.org
J Dent Res 80(5):1471-1474, 2001
A population's utilization of dental services is an
important parameter in oral health care planning,
which has rarely been studied in China. The
objectives of this report were to describe the
dental service utilization pattern of middle-aged
and elderly Chinese and to analyze the influence
of selected variables on the use of dental services.
A Guangdong Province population of 1573 35- to
44-year-olds and 1515 65- to 74-year-olds
recruited from urban and rural communities was
interviewed in their local dialect. It was found that
23% of the middle-aged and 24% of the elderly
subjects had visited a dentist within the preceding
year. The two most commonly cited reasons for
not having seen a dentist for at least 3 years were:
no perceived need, and no serious dental
problems. Among subjects who had visited a
dentist within 3 years, the 3 most commonly
received treatments were: fillings, extractions, and
dental prostheses. Furthermore, a logistic
regression analysis showed that women, subjects
who lived in urban areas, were better educated,
were wealthier, and had better oral health
knowledge were more likely to be a recent dental
service user. In conclusion, dental service
utilization among the adult Southern Chinese was
found to be low, problem-driven, and influenced
by some socio-economic factors.
KEY WORDS: adult, use of dental care, oral health
The Oral Health Survey in Southern China, 1997, was
conducted under the auspices of the Department of
Periodontology and Public Health of the Faculty of
Dentistry, the University of Hong Kong, and publication
of these papers is made possible by funding from The
Research Grants Council of the Hong Kong Special
Administrative Region, China, HKU 232/95M,
with the University of Hong Kong Committee for
Research and Conference Grants.
Utilization of Dental Services
in Southern China
It is well-established that early diagnosis and appropriate treatment,
including preventive and curative measures, can prevent dental diseases
from reaching a stage where pain or other symptoms would force a person to
seek professional dental care (WHO, 1984; Glavind and Nyvad, 1986), and
that adopting a habit of visiting a dentist regularly is one of the common
messages in oral health education (Ashley, 1989). There have been many
studies on people's dental service utilization behaviors, but these were
mainly conducted in the highly industrialized countries (Petersen and Holst,
1995). In fact, there are very few published oral epidemiological studies on
adults in Mainland China, and none of them has reported specifically on the
use of dental services. Around half of the adult urban residents in Hunan
Province (Zhu, 1993) and around 90% of the adults in Hubei Province
(Petersen et al., 1997) stated that their main reason for visiting a dentist was
due to a dental problem. Another study in Southern China reported that only
15% ofthe urban residents and 5% of the rural residents had visited a dentist
when they last had dental problems (Sun, 1992). Thus, one can speculate that
the dental service utilization rate among Chinese adults is low because ofthe
above-mentioned dental visit behavior, a very high dentist-to-population
ratio (1:100,000), and the poorly developed dental care delivery system
(FDI, 1990). A survey conducted in Hong Kong, a city in Southern China
adjoining Guangdong Province, found that around one-third of the Chinese
adults had visited a dentist within a year, and few were regular users (Lo and
Schwarz, 1994). This utilization rate was low compared with that found in
most Western industrialized countries (Petersen and Holst, 1995).
The main objectives of this analysis were to describe the dental service
utilization patterns of the middle-aged and the elderly Southern Chinese
and the influence of various factors on the use of dental services in these
two age groups.
MATERIALS & METHODS
The sample was comprised of 1573 35- to 44-year-old and 1515 65- to 74-year-
old Chinese living in different areas ofGuangdong Province, Southern China. The
subjects were recruited from 16 survey sites (8 urban and 8 rural) through a
combination of multi-stage stratified sampling and quota sampling. First, 4 major
administrative regions of the Province were chosen for the survey, mainly based
on their geographic location. Then, by two-stage stratified simple random
sampling, 2 urban sub-districts and 2 rural townships in each region were selected
to be the survey sites. With assistance from the local government and health
authority, about 100 subjects in each age group were recruited either from their
work place or from their houses. Details of the sampling methods and recruitment
of subjects have been described in a preceding paper (Schwarz et al., 2001).
Information for this analysis was collected by a face-to-face interview
conducted by means of a structured questionnaire. Because some of the subjects,
especially the elderly, could communicate only in their local dialect, interviewers
fluent in that dialect were recruited from staffs of the local government or
hospital. Training was provided to the interviewers prior to the interviews, and
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J Dent Res80(5) 2001
the researchers monitored their performance throughout the survey.
In the interview, besides providing information on their socio-
economic background, the subjects were asked when they last
visited a dentist. Those respondents who had not made a dental
visit within the previous 3 years were asked to give the reasons for
not doing so. Respondents who had visited a dentist within 3 years
were asked to give information on the treatments they had received
in their last dental visit.
Four questions were asked so that the dental knowledge of
the subjects could be measured. Two questions were on the causes
and the prevention of tooth decay, and the other two were on gum
disease. Up to 3 answers were recorded for each question. We
constructed a dental knowledge score by counting the total
number of acceptable answers given by the subjects, excluding
those responses like "do not know" and "no answer". Thus, the
dental knowledge score was in an interval scale and ranged from 0
to 12, with a higher dental knowledge score indicating better
Eight statements conceming the importance of oral health,
importance ofretaining natural teeth, dental service utilization, and
dental health beliefs were designed to explore the subjects'
attitudes toward oral health. The subjects were asked to indicate
whether they agreed with, disagreed with, or had no comment on
each of the statements. We constructed a dental attitude score by
counting the total number of statements to which the subjects, in
their responses, showed a positive attitude. Again, this score was in
an interval scale and ranged from 0 to 8, with a higher score
indicating a more positive attitude.
According to the analytic model used in this study (Schwarz et al.,
2001), location of residence (urban/rural areas), gender, education
level, material wealth measured by the Family Material Possession
Index (FMPI), dental knowledge, dental attitudes, and dental fear
were selected as possible factors affecting the subjects' use of
The study subjects were categorized into two groups
according to the time lapsed since their last dental visit, within 3
years and more than 3 years. This was used as the dependent
variable in the bivariate analysis. Statistical analysis was
performed by the software Statistical Package for Social
Sciences (SPSS). Chi-square tests were used to detect
significantly different distributions of dental service users in
relation to the various independent variables. For the analysis
Table 1. Recency of Last Dental Visit in the Two Age Groups According
to Location of Residence (%)
35- to 44-year-oldsa
65- to 74-year-oldsa
(n = 741)
< 12 months
Never visited dentist
Significant between urban and rural residents, p < 0.0001 (Chi-
with mean score variables, a two-sample t test was used. The
statistical significance level was set at 0.05.
For assessment of the relative importance of the independent
variables in explaining the use of dental services within 3 years, a
backward stepwise logistic regression analysis was performed.
The significance level chosen for retention of a variable in the
model was 0.05, and 95% confidence intervals of the odds ratio
were calculated for all variables that were retained in the final
Table 1 shows the percentage distribution of the study subjects
according to the time lapsed since their last dental visit, age
group, and location of survey site. It can be seen in both age
groups that less than one-third of the urban residents and less
than 20% of the rural residents had visited a dentist within the
preceding year. The dental service utilization pattems of the
two age groups were similar, and proportionally more of the
urban residents had made a recent dental visit than the rural
residents (p < 0.001).
The most commonly cited reason for not having seen a
dentist for at least 3 years was no perceived need. This was
more commonly cited by the urban residents (62-73%) than by
the rural residents (43-55%) in both age groups (p < 0.001).
The second most commonly reported reason was that the dental
problems were not perceived as serious (25-31%). Close to
one-third of the rural elderly said that financial difficulty was a
barrier to receiving dental care, but the percentages ofthe urban
elderly and the middle-aged who cited financial difficulty as a
barrier were significantly smaller (p < 0.001).
Among the subjects who had visited a dentist within 3
years, the 3 most common treatments which they received in
their last dental visit were fillings, extractions, and dental
prostheses (Table 2). It was further found that proportionally
more of the urban residents had received fillings, while more of
the rural residents had received extractions and fixed dental
prostheses (p < 0.05). Furthermore, a rather low percentage of
the subjects received scaling in their last dental visit-less than
20% in the middle-aged and only a few percent in the elderly.
Table 2. Treatments Received in the Last Dental Visit among Those Who
had Visited a Dentist within the Past 3 Years (multiple response analysis;
percentages total more than 100)
35- to 44-year-olds
(n = 385) (n = 265)
65- to 74-year-olds
(n = 415) (n = 268)
Significant between urban and rural residents in both age groups,
p < 0.05 (Chi-square test).
Significant between urban and rural residents in 35- to 44-year-
olds only, p < 0.05 (Chi-square test).
Lo et a/.
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Use of Dental Services in Southern China
In the 35- to 44-year-old subjects,
having made a dental visit within 3 years
was more commonly found among the
urban residents, women, those who were
better educated or wealthier, and those who
had better oral health knowledge or more
positive dental attitudes (Table 3). It was
interesting to find that having had a more
recent visit to a dentist was related to being
afraid of dentists. A similar pattern was
also found in the 65- to 74-year-olds,
except that gender and dental fear did not
have a statistically significant relationship
with dental service utilization. Results of
the logistic regression analysis (Tables 4
and 5) were similar to those found in the
bivariate analysis. In the 35- to 44-year-
olds, 4 of the 7 independent variables
remained in the final logistic regression
model. These were location of residence,
gender, fear of dentists, and dental
attitudes. The variables retained in the final
logistic regression model in the 65- to 74-
year-olds were slightly different from those
in the younger age group. Five variables
were retained: location of residence,
gender, educational attainment, material
wealth, and dental knowledge.
Findings from this study confirmed the
speculation that dental service utilization among adults in
Mainland China was very low. Compared with the highly
industrialized countries, where about 60 to 80% of the adults
would have visited a dentist within a year (Miller et al., 1987;
Todd and Lader, 1991; Petersen and Holst, 1995), the utilization
rate of the study subjects was only about one-third. Even when
compared with the situation in Hong Kong, where most of the
people are Southern Chinese (Lo and Schwarz, 1994), the
utilization rate of the middle-aged Guangdong subjects was
lower, while that of the elderly subjects was similar. The dental
service utilization rate of the Guangdong adults found in this
study is very close to that of adults in Central China (Petersen et
al., 1997; Petersen and Esheng, 1998). In these studies, it was
found that the dental utilization rate of the younger adults was
rather low, and that ofthe elderly was higher.
Similar to the findings of other Chinese studies (Zhu, 1993;
Peng et al., 1997; Petersen et al., 1997), it was found that the
use of dental services among the Southern Chinese was very
much symptom-driven, and preventive dental visits were rare.
This pattern was also found among the Chinese living in Hong
Kong (Lo and Schwarz, 1994) and those in the United
Kingdom (Kwan and Williams, 1999).
Several measures of dental services utilization have been
used in different studies (Gift, 1984). The main measure used
in the bivariate and multivariate analyses in this study was a
dichotomous variable, whether the subject had made a dental
visit within 3 years. This measure was chosen because the low
rate of utilization of dental services among the study subjects
rendered the use of more sophisticated variables
number of dental visits within a year and the regularity of
Table 3. Use of Dental Services in Adult Chinese According to Selected Demographic and
Time Since Last Dental Visit
35- to 44-year-olds
65- to 74-year-olds
< 3 yrs > 3 yrs
< 3 yrs > 3 yrs
Up to primary
Upper secondary and above
Afraid of dentistsa
Mean dental attitude scoreb
Mean dental knowledge scoreb
aSignificantbetween groupswith p<0.001 (Chi-square test).
6 Significantbetweengroups with p < 0.001(tCtest).
Table 4. Results of a Logistic Regression Analysis on the Use of Dental
Services within 3 Years among the 35- to 44-year-olds
Odds Ratio (95% CI)
Afraid of dentists
x2= 71; df = 4; p < 0.001.
dental service utilization and the main demographic variables,
e.g., gender, location ofresidence, education, and wealth, found
in this study were similar to the findings of most dental
utilization studies, including those from China (Petersenet al.,
1997), Hong Kong (Schwarz and Lo, 1994), and other parts of
the world (Gift, 1984). However, the relationship between
dental fear and utilization as found in this study is worth some
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less appropriate. The relationships between
J Dent Res80(5)2001
J Dent Res 80(5) 2001
Table 5. Results of a Logistic Regression Analysis on the Use of Dental
Services within 3 Years among the 65- to 74-year-olds
Odds Ratio (95% CI)
No formal schoolinga
Secondary and above
Dental knowledge score
x2= 102;df =6; p<0.001.
discussion. Being afraid of dentists is usually presented as a
barrier to dental service use (Feske et al., 1990; Locker et al.,
1991), and one would expect the regular or more recent dental
service users not to be afraid of dentists. This was not the case
in this study, and the odds ratio of 1.6 in the 35- to 44-year-old
subjects suggested that people who were afraid of dentists
would more likely be recent dental service users. This is
probably because the subjects in this study mainly visited a
dentist when they had serious dental problems, and one of the
most common treatments received was extraction. Thus, their
dental visits were perhaps very unpleasant, which would make
the recent users afraid of dentists. This proposition was
supported by the further analysis of the survey data which
showed that the recent users were also more likely to have
experienced pain, to perceive their oral condition as poor, and
to have perceived need for more treatment. Similar findings
were also obtained in a recent survey ofadults in Central China
(Petersen et al., 1997). This kind of attitude and behavior
hinders the development ofpreventive dental visits. Oral health
education alone most probably cannot break this vicious cycle
in the Southern Chinese. Changes in the organization of dental
care services (e.g., improving accessibility by setting up more
dental clinics or outreach dental services), provision of better
care (e.g., better pain control during treatment and the use of
more conservative approaches), and better dentist-patient
interactions (e.g., paying more attention to patients' feelings
and using a more patient-friendly approach) will probably be
required to change this situation.
Due to a severe lack of trained dental personnel in Southern
China and the low utilization ofdental services, it would be very
ineffective and inefficient to implement dental-clinic-based oral
health education and promotion activities. The use of mass
media or collaborations with other disciplines in primary health
care may be better ways to disseminate oral health messages
under the current situation in Southern China. The oral health
policy should place more emphasis on community-based
preventive programs than on clinic-based curative services.
In conclusion, dental service utilization among the adult
Southern Chinese was low, problem-driven, and influenced by
some socio-economic factors. Improvement in the dental
service utilization rate in this population will depend on the
general social and economic development as well as on the
success ofimprovements in the delivery ofdental care services
and community-based oral health promotion activities.
The University of Hong Kong (CRCG) and the Research
Grants Council ofHong Kong financially supported this study.
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