The current study shows that the frequency of dentist visits is low in both middle-aged and elderly populations in northeast China. The frequencies of middle-aged (82.3 %) and elderly (80.3 %) residents of northeast China who did not visit dentist in the past year were much higher than in comparable populations in south China (20.9–76.0 %) [25, 26] and in other developed countries (28.6–49.7 %) [23, 32, 33]. The high burden of oral disease and limited oral health care resources in China are preventing the dental care needs of elderly individuals from being adequately met [34], particularly in the central region of northeast China. Although northeast China, which bridges the Northeast Economic Zone and the Greater Bohai Economic Zone, is considered one of the key political, economic, and cultural centers of the nation, the data presented here indicate that both oral health status and oral health awareness in this region are low.
The perceived need for dentist visits in middle-aged populations was higher than in elderly populations, and higher in urban areas than in rural areas. Furthermore, the frequency of regular oral health checkup and periodontal treatment was higher in urban areas than in the rural areas. However, usage of oral health care service was generally low in both middle-aged and elderly populations in northeast China, and the rate of dental care visits was low. While 60–70 % of the subjects chose the option that “there is a need for dental care visit,” less than 20 % had visited a dentist during the past year. Less than 10 % of these chose periodontal treatment, while most of underwent tooth extraction or received fillings or inlays. These results reflect a substantial discrepancy between the needs and demands of oral health care service in middle-aged and elderly people in northeast China.
With regard to the reasons for dental care visits, due to a lack of basic oral health knowledge, we found that individuals had a generally high assessment of their oral health status compared to the mean level reported in previous studies [29, 30]. Approximately half of middle-aged and elderly people thought that there was no problem with their teeth, and there was therefore no need to visit a dentist. Moreover, less than 7 % of these individuals actively followed regular oral health checkup and took preventive measures, while more than 80 % of them visited dentists only when they had acute or chronic toothache. Furthermore, compared with residents of urban areas, more middle-aged people in rural areas reported a perceived absence of severe oral diseases or a lack of time as reasons not to visit dentists. Indeed, most middle-aged people in rural areas typically choose passive measures (self-medication, tolerance, etc.) because they consider their oral diseases to be not severe. In contrast, although the number of middle-aged people in urban areas who followed regular oral health checkup was similarly limited, these individuals reported visiting dentists in a relatively timely manner upon the onset of toothache symptoms. Reasons for these results, which are similar to those of previous studies [35–37], include differences in income level between rural and urban areas, and imbalances in the distribution of oral health care resources [38].
Consistent with the lack of coverage of rural areas by the traditional reimbursement system in China, and the fact that the new social health insurance system was in its early stages in rural areas during the study period, the majority of participants living in rural areas obtained dental care at their own expense. Whereas health insurance covered a certain proportion of dental care visits in urban areas, there were limits to such coverage and, which is likely why most participants living in urban areas also paid for their own dental care. Economic status is an important constraint on dental care-seeking behavior: 30–40 % of middle-aged and elderly participants could likely not afford dental care, even when it was definitely required. Accordingly, as they did not seek dental care services, the need for dental care is not reflected by demand, which compromises the use of the existing, limited oral health care resources [34, 39].
With regard to choices of dental care clinics, there was a significant difference between rural and urban areas in both the middle-aged and elderly groups. The results of this study show that most people who live in rural areas went to private clinics for their dental care. Our recent study [40] found a total of 1518 private clinics in central northeast China, accounting for 74.88 % of oral health resources. Most of these clinics are inexpensive, convenient, have no time limit for treatment, and are distributed in communities and villages and, as such, are emerging as the preferred choice for dental care in middle-aged and elderly individuals. These features are of great importance for people of limited financial means living in rural areas. However, the technical strength of such clinics is relatively weak; for example, only 33.2 % of their staff are registered as dentists, and only 42.5 % have a college degree [40], indicating a need for improved management and continuing education in these clinics [26]. The results of the present study also show that fewer people went to provincial comprehensive hospitals and dental specialized hospitals above the county level, particularly in rural areas. The relatively high expense could be an important factor restricting the participants from seeking dental care at such hospitals. In addition, these hospitals are generally located in city centers, and their service duration is limited, making it inconvenient for people who seek dental care service. The advantages of these hospitals include their advanced dental specialists with solid training and sophisticated treatment techniques. We suggest that such oral health resources should be better developed and utilized. For instance, these hospitals can allocate specialists and transfer technologies to community clinics, which will help bridge the gap between the needs and demands of dental care to improve oral health in northeast China.
Consistent with the findings of Lundegren et al. [12], the results of this study show that education levels are positively associated with tooth brushing frequency. Participants with higher educational levels reported brushing their teeth more often. Moreover, consistent with the data of Chaves et al. [41], the frequency of high income individuals who had never visited dentists was significantly lower than in lower income individuals. After educational level and income had been included in the logistic regression equation, however, there was no significant influence on the frequency of dental care visits. These data indicate that although education level and income influence the frequency of dental care visits, they cannot be considered as determinative factors of such visits. In contrast, education levels in central China are significantly correlated with oral health-related quality of life [28]. In addition to geographic disparities with other parts of the country, including differences in region and lifestyle, northeast China has, since the 1930s, been a prominent economic mega-region in China. In the years since the reformation and opening up and the accompanying changes in the economic system, the development of this region has gradually lagged behind the economically developed coastal regions. The restrictions that the lack of economic development in northeast China have placed upon lifestyle and culture in this region [42] have attenuated the overall impact of education level and income on dental care-seeking behavior.
Consistent with findings from previous studies [25, 32, 36, 37], the results presented here show that rural residence is a significant impediment to dental care-seeking behavior in middle-aged and elderly people. This phenomenon has a variety of explanations. First, as observed in this study, middle-aged and elderly people living in urban areas report greater access to oral health information than those living in rural areas. Greater access to oral health knowledge not only increases an individual’s awareness of oral health care, but can also improve the perception of a person’s need for dental care [24]. Second, health insurance coverage is higher in urban areas compared to rural areas. In rural areas, most of the middle-aged and the elderly participants obtained dental care at their own expense, suggesting that the low coverage of dental health insurance directly affects dental care-seeking behavior in this population. Because most rural residents have lower incomes than urban residents, they may not be able to afford such visits, which hampers the intent to seek dental care services. Finally, the availability of health services could also affect dental care-seeking behavior [37, 43]. In parallel with the rapid development of urban economies, the demand for oral health care is increasing among urban residents, and disparities in the allocation of oral health resources between urban and rural areas are increasing. Our previous study [44] showed that urban areas in central northeast China have eight times as many dentists as rural areas, and that the vast majority of oral health institutions and dental manpower services were located in cities. As a consequence, rural oral health services cannot meet the oral health needs of the majority of rural residents, which in turn limits active dental care-seeking behavior among middle-aged and elderly people in rural areas.
There are several limitations of the present study. First, information bias may be present, as all the data collected were self-reported by the participants, with no objective measures of oral health status provided by medical or experimental examination. Second, stratified random sampling was used to obtain the sample in the present study, thus members of the same family may have been included. Members from the same family are likely to share similar health behaviors, which could also introduce bias. Third, the degree of the variability in the urban areas may not be comparable with that in the rural areas; however, no data were available regarding these differences, which could bias the results. Finally, other sociodemographic factors, including smoking, weekly low alcohol consumption, body mass index > 25 mg/kg2, and fear of dental care, have been recently suggested as possible determinants of dental care-seeking behavior [10, 32]. Unfortunately, these data were not collected in the current study. We will address these limitations in future studies.
