- Research article
- Open Access
- Open Peer Review
This article has Open Peer Review reports available.
Factors associated with dental attendance among adolescents in Santiago, Chile
© Lopez and Baelum; licensee BioMed Central Ltd. 2007
Received: 04 December 2006
Accepted: 10 April 2007
Published: 10 April 2007
Dental treatment needs are commonly unmet among adolescents. It is therefore important to clarify the determinants of poor utilization of dental services among adolescents.
A total of 9,203 Chilean students aged 12–21 years provided information on dental visits, oral health related behavior, perceived oral health status, and socio-demographic determinants. School headmasters provided information on monthly tuition and annual fees. Based on the answers provided, three outcome variables were generated to reflect whether the respondent had visited the dentist during the past year or not; whether the last dental visit was due to symptoms; and whether the responded had ever been to a dentist. Aged adjusted multivariable logistic regression models were used to assess the influence of the covariates gender; oral health related behaviors (self-reported tooth brushing frequency & smoking habits); and measures of social position (annual education expenses; paternal income; and achieved parental education) on each outcome.
Analyses showed that students who had not attended a dentist within the past year were more likely to be male (OR = 1.3); to report infrequent tooth brushing (OR = 1.3); to have a father without income (OR = 1.8); a mother with only primary school education (OR = 1.5); and were also more likely to report a poor oral health status (OR = 2.0), just as they were more likely to attend schools with lower tuition and fees (OR = 1.4). Students who consulted a dentist because of symptoms were more likely to have a father without income (OR = 1.4); to attend schools with low economic entry barriers (OR = 1.4); and they were more likely to report a poor oral health status (OR = 2.9). Students who had never visited a dentist were more likely to report infrequent tooth brushing (OR = 1.9) and to have lower socioeconomic positions independently of the indicator used.
The results demonstrate that socioeconomic and behavioral factors are independently associated with the frequency of and reasons for dental visits in this adolescent population and that self-perceived poor oral health status is strongly associated with infrequent dental visits and symptoms.
It is widely recognized that adolescents are among the least likely to use the health services [1–4] and some studies have shown that dental care is the most common type of unmet health care need in adolescence [5, 6]. It is therefore worrying that adolescents reduce their utilization of dental services , and may altogether cease to attend the dentist upon leaving school. This would suggest that emphasis be placed on efforts to secure and reinforce stable dental attendance patterns among children and adolescents. Lack of utilization of dental services is not a random phenomenon, and studies suggest that the dental attendance patterns among the young are related to age , gender [8–15], socioeconomic position [9–11, 13–17], ethnic background [8, 14, 15], oral health related behaviors, such as smoking habits , and poor self perceived oral health status [14, 18]. However, explicit conceptual models have not been presented, and only a single large study comprising a well-defined study group has considered simultaneously the effects of age, gender, and socioeconomic position . This study focused on the frequency of dental visits and selected socioeconomic factors, thus leaving aside possibly important determinants such as the presence of symptoms and the relationship with other oral health related behaviors.
In Chile, the National Health Fund (FONASA) is responsible for providing health care to those 70% of the Chilean population who do not have a private insurance [19–21]. The health care needs of the most affluent 30% of the population are covered by the private insurance system . According to the Chilean legislation, the beneficiaries of FONASA have the right to receive primary dental care free of charge. This dental care includes dental examinations, common intraoral radiographs, emergency treatments, extractions, dental fillings, supragingival scaling and polishing, sealants in permanent molars, topical fluoride, pulpotomies, and endodontic treatment in permanent teeth. Most adolescents are therefore covered by the public oral health-care system.
The aims of this paper were to describe the patterns of dental visits in an adolescent population identified by cluster random sampling; and to explore whether selected socio-demographic and behavioral indicators for oral disease were associated with the dental attendance patterns of adolescents using multivariable models.
This analysis was based on data originating from an epidemiological study conducted during year 2000 in Santiago, Chile [23, 24]. The local Committee of Ethics of the University of Chile approved the study protocol. The target population comprised all students attending the four grades covering adolescence in the high schools of the Province of Santiago (N ≈ 250,000). This target population represents 85% of the adolescent population of the Province . We used a two-stage random-cluster sampling strategy. Using information on governmental support and the full list of high schools from the Province provided by the Ministry of Education of Chile (N = 618), we generated a list of high schools receiving funds from the public system and another with the private institutions. Each list was permuted at random , and lists were then merged to get a random permutation of high schools with publicly funded schools alternating with privately funded schools. The first 133 high schools of the list were contacted to obtain information on the number of students in the last four grades and the number of classes. A total of 104 high schools provided the necessary information and were invited to participate in the study. Six institutions declined to participate, leaving 98 schools in the study.
Second-stage sampling: The size of the schools varied noticeably and a second sampling stage was applied. For schools with few students or fewer than 4 classes, all classes were included in the study. In larger schools, where the number of students in the last four grades was >100 and the number of classes was >3, three classes were randomly selected [23, 26]. A total of 310 classes were finally selected and included in the study.
Participation approval was obtained from the headmasters of each selected high school, and informed consent was obtained from the parents of the students. Students were informed about their right to withdraw from the study at any point in time.
A total of 9,203 students aged 12–21 years present in the selected classes were invited to participate and were offered a toothbrush for their participation. All students accepted to fill a brief questionnaire on oral health-related behaviors and conditions , while 40 students refused to participate in the clinical examinations. The questionnaire included information on tooth brushing frequency (How often do you brush your teeth? Less than once a day, once a day, more than once a day), smoking habits (Do you smoke cigarettes? No; Yes, sometimes; Yes, daily), their last dental visit (When was the last time you visited a dentist? Less than 6 months ago; 6 to 12 months ago; more than a year ago; never seen a dentist) and the reason for the last dental visit. Why did you visit the dentist?) . The students who received a clinical examination also filled an additional questionnaire on several dimensions of their socioeconomic position. A full description of the questionnaire variables can be found in previous publications [23, 27]. Previous analyses showed that some of these indicators were associated with several poor oral health outcomes, including tooth loss, periodontal attachment loss and necrotizing ulcerative gingival lesions [27, 28] and these were therefore used in the present analysis. These socioeconomic indicators include the monthly paternal income in thousands of Chilean pesos (no income; <$100; $100–$299; $300–$499; $500–$999; ≥$1000); and the level of education achieved by each of the parents (no education; incomplete primary school; primary school completed; incomplete high school; high school completed; incomplete technical education; technical education completed; incomplete university education; university education completed). The headmasters of the participating schools provided information on the monthly tuition and the annual school fees and this information was used to derive a single 'annual education expense' variable, which was used as an indicator of wealth. Three dichotomous outcome variables were considered. DENTVIS was coded 0 if the student reported to have visited a dentist within the last year, and 1 if this was not the case. SYMPTOM was coded 1 if the student reported that the last dental visits had been due to symptoms, such as pain, bleeding and infection, and coded 0 if the visit was not prompted by the presence of symptoms. NEVER was coded 1 if the student reported to never have visited a dentist, and coded 0 if this was not the case.
Univariable logistic regression analyses were carried out for the three outcomes investigated and the covariates gender; tooth brushing frequency; smoking habits; self-perceived oral health status, and each of the socioeconomic indicators investigated. Variables showing a P-value < 0.25 in the univariable analyses were selected to be included as covariates in age-adjusted multivariable logistic regression analyses for each outcome. The models were built by the consecutive exclusion of one variable from each full model using the likelihood ratio test as described by Hosmer and Lemeshow , refitting and verifying the stability of the model after each deletion.
In order to use this modeling approach, only subjects for whom complete data were available for all variables in all models were included in the analyses. At most this led to the exclusion of 11% of the total study population.
Non-significant variables were retained in the models as confounders if their exclusion would result in a change of the estimates by more than 15%. We assessed the interaction between age and gender and the socioeconomic variables included in the models and none was found. It was impossible to assess the presence of other interactions due to collinearity between the variables. Once the final models were built, the goodness-of-fit of each model was evaluated using the Hosmer-Lemeshow goodness-of-fit test using the command 'lfit' in Stata . The option 'robust cluster' for the procedure 'logit' in Stata  was used to take into account the fact that the students were nested in classes, which were the ultimate sampling units .
Distribution of the dental visits outcomes according to the demographic and socioeconomic characteristics of the study population.
Dental attendance outcomes (%)
Overall % in population (100%)
Infrequent visits (n = 8,530)
Never (n = 9,202)
Symptoms related visit (n = 7,826)
12–14 years (22.5%)
15–17 years (69.5%)
18–21 years (8%)
More than once a day (70.7%)
Once a day (25.6%)
Less than once a day (3.7%)
Do you smoke cigarettes?
Yes, sometimes (21.8%)
Yes, daily (25%)
Income – father#
No income (7%)
Education – father&
Technical/university completed (32%)
High school completed (33.9%)
Up to primary school completed (34.1%)
Education – mother&
Technical/university completed (27%)
High school completed (34.7%)
Up to primary school completed (38.3%)
Annual education expenses
Self-perceived oral health status (Good)
Age adjusted logistic regression analysis of socioeconomic determinants of dental attendance patterns among adolescents.
Dental attendance outcomes
Symptoms related visit
Tooth brushing (>once a day)
Once a day
Less than once a day
Do you smoke cigarettes? (No)
Income – father# (≥$500)
Education – father&(Techn/univ)
High school completed
Up to primary completed
Education – mother&(Techn/univ)
High school completed
Up to primary completed
Annual education expenses (>$760)
Self-perceived oral health status (Good)
Students who had never attended a dentist were more likely to have a relatively lower socioeconomic position than those who had visited a dentist at least once, and this finding was consistent whether socioeconomic position was assessed using paternal income, parental achieved education or annual education expenses, just as they were more likely to report that they brush their teeth only once a day (OR = 1.7) or less than once a day (OR = 1.9), (Table 2).
Students who reported that their last visit to the dentist was due to symptoms were more likely to be daily smokers (OR = 1.2), to have a father without income (OR = 1.4); to attend a school with lower tuition and fees (OR = 1.4); and to report a poor oral health status (OR = 2.9), (Table 2).
This study has demonstrated that a substantial proportion of students in this population have never visited a dentist, and that the reason for visiting a dentist is often related to the presence of symptoms. Although it is possible that the reason for never having visited a dentist is to be found in the absence of symptoms, our findings on the socio-economic and oral health behavioral profile of the non-attendees suggest that this interpretation is fallacious. A more plausible explanation for the observations is that economic barriers may prevent a large portion of Chilean adolescents with tangible dental care needs from seeking professional help. Some of the association reported may seem relatively small, however small risks among a large number of people may generate many cases; while a few people with high risk may not do so .
The use of self-reported social indicators and self-reported data on dental visits in this study could be seen as a weakness. However, previous studies have shown that adolescents are able to supply valid and reliable information on their parents' socioeconomic position [32–34]; and a study conducted among adults indicate that self-reported data on dental care habits are accurate .
The health care needs of socioeconomically deprived Chilean adolescents are thought to be covered by the public system [19–21], and it may seem surprising that dental attendance patterns are strongly associated with social position even in a population that is offered public dental care free of charge for those in the lower end of the social hierarchy. However, this may in part reflect the effect of additional factors such as negative beliefs about dentists ; lack of knowledge, and cultural and parental values about the importance of oral health [9, 37]; limited access to transportation to and from the health care centers; and the extent to which these health care services are really available. Hence, there are many observations of the public health care system being unable to cope with the current demands for treatment.
Considerably more adolescents in this study population have never visited a dentist or have attended more than one year ago than what has been reported previously for a US American adolescent population . The percentage of subjects who reported their last dental visit being due to symptoms appears to be comparable with that reported for US American and Scottish adolescent populations [9, 13].
Our results corroborate previous reports on the role of social inequalities in dental attendance patterns among adolescents [4, 9–11, 13]. This result strengthens the idea that free access to health care does not guarantee dental care provision among the young, the findings of a study revealing significant ethnic disparities in the utilization of dental services among US American children and adolescents even among Medicaid-eligible subjects points to the same direction .
Girls were more likely to visit frequently the dentist than did boys and were more likely to consult the dentist because of symptoms. These results, though not new [8–13], raise questions in connection with the results of previous analyses showing that girls have fewer remaining teeth than do boys in this study population . A plausible explanation for this finding is that visiting a dentist with symptoms increases the probability of tooth extractions because "the reason for seeking dental treatment care influences the treatment likely to be received" . This agrees with the results of a previous study showing that children and young adolescents who consulted a dentist because of symptoms were likely to have more teeth missing in later adolescence than were asymptomatic dental attendants, despite a similar number of decayed or filled teeth for both groups at baseline .
Our finding of an association between daily smoking and symptom-related dental visits corroborates previous findings on the relationship between smoking and dental attendance patterns , but a plausible explanation for the association is missing. It is known that smoking is associated with several other unhealthy behaviors indicating an unhealthy lifestyle , and smoking may just be a marker of an environment characterized by health undermining living conditions and an unhealthy lifestyle. This interpretation is corroborated by the association observed between infrequent tooth brushing and infrequent dental visits, and infrequent tooth brushing and having never visited a dentist. Hence, it is well-known that a considerable portion of Chilean adolescents cannot pay for dental visits or even a personal toothbrush . The fact that the students with poor dental attendance patterns were more likely to report their oral health status as poor suggests the existence of substantial unmet dental care needs in this adolescent population.
The results of the study demonstrate the existence of gender, as well as considerable socioeconomic and behavioral differences in the frequency of, and reasons for dental visits in this adolescent population. Self-perceived oral health status is strongly associated with the frequency of dental visits and the reasons for attendance. The findings of this study indicate that a major impact on dental attendance patterns requires political decisions aiming to reduce social inequalities.
The study was partially supported by a grant from the Danish Medical Research Council, which played no role in the study design, in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Colgate-Palmolive, Chile, is kindly thanked for the donation of 10,000 toothbrushes to be given to the participating students.
- Zimmer-Gembeck MJ, Alexander T, Nystrom RJ: Adolescents report their need for and use of health care services. J Adolesc Health. 1997, 21: 388-399. 10.1016/S1054-139X(97)00167-5.View ArticlePubMedGoogle Scholar
- Lieu TA, Newacheck PW, McManus MA: Race, ethnicity, and access to ambulatory care among US adolescents. Am J Public Health. 1993, 83: 960-965.View ArticlePubMedPubMed CentralGoogle Scholar
- Monheit AC, Cunningham PJ: Children without health insurance. Future Child. 1992, 2: 154-170. 10.2307/1602567.View ArticleGoogle Scholar
- Ryan SA, Millstein SG, Greene B, Irwin CE: Utilization of ambulatory health services by urban adolescents. J Adolesc Health. 1996, 18: 192-202. 10.1016/1054-139X(95)00100-7.View ArticlePubMedGoogle Scholar
- Newacheck PW, Brindis CD, Cart CU, Marchi K, Irwin CE: Adolescent health insurance coverage: recent changes and access to care. Pediatrics. 1999, 104: 195-202. 10.1542/peds.104.2.195.View ArticlePubMedGoogle Scholar
- McBroome K, Damiano PC, Willard JC: Impact of the Iowa S-SCHIP program on access to dental care for adolescents. Pediatr Dent. 2005, 27: 47-53.PubMedGoogle Scholar
- Hawley GM, Davies RM: Documented dental attendance patterns during childhood and adolescence. Br Dent J. 1996, 180: 145-148. 10.1038/sj.bdj.4809003.View ArticlePubMedGoogle Scholar
- Dasanayake AP, Li Y, Wadhawan S, Kirk K, Bronstein J, Childers NK: Disparities in dental service utilization among Alabama Medicaid children. Community Dent Oral Epidemiol. 2002, 30: 369-376. 10.1034/j.1600-0528.2002.00001.x.View ArticlePubMedGoogle Scholar
- Attwood D, West P, Blinkhorn AS: Factors associated with the dental visiting habits of adolescents in the west of Scotland. Community Dent Health. 1993, 10: 365-373.PubMedGoogle Scholar
- Honkala E, Kuusela S, Rimpelä A, Rimpelä M, Jokela J: Dental services utilization between 1977 and 1995 by Finnish adolescents of different socioeconomic levels. Community Dent Oral Epidemiol. 1997, 25: 385-390. 10.1111/j.1600-0528.1997.tb01727.x.View ArticlePubMedGoogle Scholar
- Okullo I, Åstrøm AN, Haugejorden O: Social inequalities in oral health and in use of oral health care services among adolescents in Uganda. Int J Paediatr Dent. 2004, 14: 326-335. 10.1111/j.1365-263X.2004.00568.x.View ArticlePubMedGoogle Scholar
- Skaret E, Raadal M, Kvale G, Berg E: Gender-based differences in factors related to non-utilization of dental care in young Norwegians. A longitudinal study. Eur J Oral Sci. 2003, 111: 377-382. 10.1034/j.1600-0722.2003.00072.x.View ArticlePubMedGoogle Scholar
- Yu SM, Bellamy HA, Schwalberg RH, Drum MA: Factors associated with use of preventive dental and health services among U.S. adolescents. J Adolesc Health. 2001, 29: 395-405. 10.1016/S1054-139X(01)00252-X.View ArticlePubMedGoogle Scholar
- Aday LA, Forthofer RN: A profile of black and hispanic subgroups' access to dental care: findings from the national health interview survey. J Public Health Dent. 1992, 52: 210-215.View ArticlePubMedGoogle Scholar
- Edelstein BL, Manski RJ, Moeller JF: Pediatric dental visits during 1996: An analysis of the federal Medical Expenditure Panel Survey. Pediatr Dent. 2000, 22: 17-20.PubMedGoogle Scholar
- Hughes DC, Duderstadt KG, Soobader MJ, Newacheck PW: Disparities in children's use of Oral Health Services. Public Health Rep. 2005, 120: 455-462.PubMedPubMed CentralGoogle Scholar
- Watson MR, Manski RJ, Macek MD: The impact of income on children's and adolescents' preventive dental visits. J Am Dent Assoc. 2001, 132: 1580-1587.View ArticlePubMedGoogle Scholar
- Östberg AL, Halling A, Lindblad U: A gender perspective of self-perceived oral health in adolescents: associations with attitudes and behaviours. Community Dent Health. 2001, 18: 110-116.PubMedGoogle Scholar
- Resultados de la encuesta de caracterización socioeconómica nacional (CASEN 2000). 2002, Santiago, Chile, Ministerio de Planificación y Cooperación División Social, [http://www.mideplan.cl]
- Chile. Ley 19.378 publicada en Diario Oficial de la República de Chile el 13.04. 1995Google Scholar
- Chile. Ley 18.469 publicada en Diario Oficial de la República de Chile el 23.11. 1985Google Scholar
- Chile. Ley 18.933 publicada en Diario Oficial de la República de Chile el 09.03. 1990Google Scholar
- Lopez R, Fernández O, Jara G, Baelum V: Epidemiology of clinical attachment loss in adolescents. J Periodontol. 2001, 72: 1666-1674. 10.1902/jop.2001.72.12.1666.View ArticlePubMedGoogle Scholar
- Lopez R, Fernández O, Jara G, Baelum V: Epidemiology of necrotizing ulcerative gingival lesions in adolescents. J Periodont Res. 2002, 37: 439-444. 10.1034/j.1600-0765.2002.01377.x.View ArticlePubMedGoogle Scholar
- 1999, Santiago, Chile, División de Planificación y Presupuesto. Ministerio de Educación, Chile, [http://www.mineduc.cl/]Cobertura de atención en los niveles de educación parvularia, básica y media, según región, año 1998. Ministerio de Educación de Chile,Estadísticas del Sistema Educacional de Chile,
- Gahlinger PM, Abramson JH: Computer programs for epidemiologic analysis. PEPI 2. 1995, Stone Mountain, GA, USD, Inc.Google Scholar
- Lopez R, Fernández O, Baelum V: Social gradients in periodontal disease among adolescents. Community Dent Oral Epidemiol. 2006, 34: 184-196. 10.1111/j.1600-0528.2006.00271.x.View ArticlePubMedGoogle Scholar
- Lopez R, Baelum V: Gender differences in tooth loss among Chilean adolescents: Socioeconomic and behavioral correlates. Acta Odontol Scand. 2006, 64: 169-176. 10.1080/00016350500514824.View ArticlePubMedGoogle Scholar
- Hosmer DW, Lemeshow S: Wiley series in probability and statistics. Applied logistic regression. 2000, New York, John Wiley & Sons, 1-373. 2ndView ArticleGoogle Scholar
- StataCorp., stat: StataCorp. Statistical Software: Release 9.0. 2005, College Station, TX, Stata CorporationGoogle Scholar
- Rose G: The strategy of preventive medicine. 1992, Oxford, Oxford University Press, 1-138. 1stGoogle Scholar
- Lien N, Friestad C, Klepp KI: Adolescents' proxy reports of parents' socioeconomic status: How valid are they?. J Epidemiol Community Health. 2001, 55: 731-737. 10.1136/jech.55.10.731.View ArticlePubMedPubMed CentralGoogle Scholar
- Wardle J, Robb K, Johnson F: Assessing socioeconomic status in adolescents: the validity of a home affluence scale. J Epidemiol Community Health. 2002, 56: 595-599. 10.1136/jech.56.8.595.View ArticlePubMedPubMed CentralGoogle Scholar
- Goodman E, Adler NE, Kawachi I, Frazier AL, Huang B, Colditz GA: Adolescents' perceptions of social status: development and evaluation of a new indicator. Pediatrics. 2001, 108: E31-10.1542/peds.108.2.e31.View ArticlePubMedGoogle Scholar
- Gilbert GH, Rose JS, Shelton BJ: A prospective study of the validity of data on self-reported dental visits. Community Dent Oral Epidemiol. 2002, 30: 352-362. 10.1034/j.1600-0528.2002.00062.x.View ArticlePubMedGoogle Scholar
- Skaret E, Raadal M, Kvale G, Berg E: Factors related to missed and cancelled dental apointments among adolescents in Norway. Eur J Oral Sci. 2000, 108: 175-183. 10.1034/j.1600-0722.2000.108003175.x.View ArticlePubMedGoogle Scholar
- Scott G, Brodeur JM, Olivier M, Benigeri M: Parental factors associated with regular use of dental services by second-year secondary school students in Quebec. J Can Dent Assoc. 2002, 68: 604-608.PubMedGoogle Scholar
- AIHW Dental Statistics and Research Unit.University of Adelaide.: Oral health and access to dental care - the gap between the 'deprived' and the 'privileged' in Australia. 2001, Australia, AIHW Dental Statistics and Research Unit. University of Adelaide, 1-4.Google Scholar
- Hawley GM, Holloway PJ, Davies RM: Dental health status associated with documented dental attendance patterns in adolescents. Community Dent Health. 1997, 14: 22-24.PubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6831/7/4/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.