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Original Research
Utilization of oral health care services among adults
attending community outreach programs
Umashankar Gangadhariah Kadaluru, Vanishree Mysore Kempraj, Pramila Muddaiah
Department of Public Health
Dentistry, MR Ambedkar Dental
College, Bangalore, India

Received :200511
Review completed :191011
Accepted :101211

ABSTRACT
Introduction: Good oral health is a mirror of overall health and wellbeing. Oral health is
determined by diet, oral hygiene practices, and the pattern of dental visits. Poor oral health
has significant social and economic consequences. Outreach programs conducted by dental
schools offer an opportunity for early diagnosis and treatment, dental health education, and
institution of preventive measures.
Objective: To assess the utilization of oral healthcare services among adults attending outreach
programs.
Materials and Methods: This study included 246 adults aged 1855years attending community
outreach programs in and around Bangalore. Using a questionnaire we collected data on dental
visits, perceived oral health status, reasons for seeking care, and barriers in seeking care.
Statistical significance was assessed using the Chisquare test.
Results: In this sample, 28% had visited the dentist in the last 12months. Males visited dentist
more frequently than females. The main reason for a dental visit was for tooth extraction (11%),
followed by restorative and endodontic treatment 6%. The main barriers to utilization of dental
services were high cost (22%), inability to take time off from child care duties (19.5%), and fear
of the dentist or dental tools (8.5%).
Conclusion: The utilization of dental services in this population was poor. The majority of the
dental visits were for treatment of acute symptoms rather than for preventive care. High cost
was the main barrier to the utilization of dental services. Policies and programs should focus
on these factors to decrease the burden of oral diseases and to improve quality of life among
the socioeconomically disadvantaged.
Key words: Barriers to oral health, dental visit, healthcare utilization, outreach programs

Good oral health helps to ensure overall health and

wellbeing. Poor oral health has significant social and
economic consequences. In the US alone, illnesses related
to oral health result in 6.1 million days of bed disability,
12.7 million days of restricted activity, and 20.5 million
workdays lost each year.[1]
Orodental diseases are emerging as a major public health
problem in developing countries like India. At present, in
Address for correspondence:
Dr.Umashankar GK
Email:drumashankargk@yahoo.com
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DOI:
10.4103/0970-9290.111290

India, there are more than 267 dental schools, producing

approximately 19000 dental graduates per year, and there
are almost 3000 specialists available for providing dental
care. Despite this, even the most basic oral health education
and simple interventions for pain relief and emergency
care for acute infection and trauma is unavailable to the
vast majority of population, especially the rural and urban
poor. In addition, the recent growth in the economy and the
advances in healthcare technology have widened the gap
between the rich and the poor, exacerbating the inequity
in access to oral health care in particular and health care in
general. Despite the deleterious consequences of untreated
oral pathology, inappropriate utilization of dental services
remains a major problem.[2]
Utilization of health care is a complex phenomenon
and multifaceted human behavior. Various theories and
conceptual models have been proposed to explain this
phenomenon. The determinants of oral health care can
be classified as predisposing (sociodemographic factors
like age, sex, occupation, and social network), enabling
Indian Journal of Dental Research, 23(6), 2012

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Utilization of oral health care services in community outreach programs

(transportation, income, and information), and need

(perceived health or professionally assessed illness) factors.[3]
Some studies have suggested that a lack of understanding
of the benefits of good oral health and competing financial
needs exacerbate oral health access disparities among the
poor.[4] Parents who were less educated were more likely to
postpone dental care for their child. Males and females were
reported to utilize dental services equally, and utilization
increased with age. Utilization was also high among the
dentate elderly, with nearly threequarters reporting that
they had visited a dentist within the past year.[46]
Anticipation of painful dental treatment, high dental
charges, long waiting times, and being too busy for a dental
visit were cited as the most important barriers to seeking
dental treatment.[7] Reasons other than sociodemographic
factors have also been cited on occasion, for example, lack
of confidence in the competence of the dentist.[8]
Community outreach programs are an essential part of
public health services, helping health professionals reach
the weaker sections of the society for delivery of basic oral
health services. It provides an unmatched opportunity for
research. With better understanding of why people use or do
not use the services, the programs can be tailored to address
the felt needs of the community.[9]
Studies focusing on oral health care service utilization
are meager in Indian populations. Hence, we have made
an attempt to assess the utilization of oral health services
by adults attending community outreach programs in and
around Bangalore.

MATERIALS AND METHODS

Study setting

To extend oral health services to the poor and needy,

the Department of Public Health Dentistry, MRADC
(Mathrushri Ramabhai Ambedkar Dental College and
Hospital) conducts regular outreach programs with the help
of various voluntary organizations. Parinaam Foundation,
one such organization, in strategic partnership with Ujjivan
Financial Services Ltd., a Non Banking Financial Company,
provides a full range of financial services to urban and rural
economicallyactive poor women. As part of their healthcare
activities, Parinaam Foundation regularly organizes health
camps (including ophthalmology, ENT, and dental camps)
on Sundays for their members in and around Bangalore. Four
such health camps were conducted over a 2month period,
one each in Lingarajpuram and Kodigihalli in Bangalore,
Maddur taluk of Mandya district, and Ramnagar district.
These health camps were the setting for this study.
In these health camps, participants receive a complete
physical examination by a team of physicians. The
Indian Journal of Dental Research, 23(6), 2012

Kadaluru, etal.

Venkateshwara Eye Hospital provides free vision screening,

while the faculty and postgraduate students from the
MRADC provide free dental examinations as well as basic
treatment services like extraction, permanent restorations,
and oral prophylaxis, in a mobile dental unit meant for these
programs. When further treatment is necessary, the patient
is referred to the appropriate hospital (network hospitals for
Ujjivan members or the nearest government hospital). All
services are offered free of charge.

Subjects

In all, 606 Ujjivan members participated in these health

camps. Of these 342 attended the camp for dental care, and
246 of them gave consent for the interview.

Data collection and survey instrument

The data regarding the utilization of dental health services

were obtained using a questionnaire. Data was collected on
perceived oral health status, number of visits to the dentist
in the last 12months, reasons for the visit (e.g.dental
examination, tooth restoration, dental cleaning, tooth
extraction, having a prosthesis made, and aching tooth or
gums). The reasons for not visiting the dentist included, for
example, high cost of treatment, inconvenient consulting
hours, fear of the dentist/dental tools, ignorance regarding
where to go, lack of transportation, language barrier, long
waiting time, and inability to take time off child care duties.
Information on sociodemographic variables like age, gender,
and education was also obtained for the purpose of the study.
The investigators were given a brief training on administering
the questionnaire in the local language after obtaining
informed consent from each participant. The questionnaire
was administered by facetoface interview. This study was
approved by MRADC ethical review committee.

Statistical analysis

Statistical analysis was done using SPSS, version 19.0

(Statistical Package for Social Sciences). The independent
variables were age, gender, and educational qualification,
and the dependent variables were the dental visiting pattern,
perceived oral health status, and perceived felt need. The
quantitative values were expressed as means ( standard
deviation) and qualitative values as percentages. The
Chisquare test was used to detect difference in distribution
of dental service utilization for age sex education and
perceived oral health. The statistical significance level was
fixed at P 0.05.

RESULTS
Overall, 246 adult participants were interviewed, of
whom 216 (87.80%) were females. The mean age was
34.59.66years. Atotal of 28% (69/246) participants had
visited the dentist in the last 12months. Males were found

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Kadaluru, etal.

Utilization of oral health care services in community outreach programs

to be more likely than females to visit the dentist, with 40%

(12/30) of the males in this study saying that they had visited
the dentist in the last 12months. It was also observed that
52.2% (36) of participants above the age of 35 years had
visited the dentist in the past 12months compared to their
younger agegroup47.8% (33). However, these differences
were not statistically significant [Table1] (P > 0.05). Level
of education did not have any impact on the dental visit
pattern. The main reason for a dental visit was extraction
of the tooth (11%; 27 subjects) followed by restoration and
endodontic treatment (6%; 15 subjects) and cleaning of teeth
(3.7%; 9 subjects) [Table1].
The primary reason for not seeking care was the high cost
of dental treatment (22%; 54 subjects). Among the female
subjects, 19.5% (48), said that they had not visited the
dentist because it was difficult to take time off from child
care duties [Table2].
Among the responders, 67.1% (165 participants) perceived
their oral health as poor. Of those above 35years of age,
79.5% (105) perceived their oral health as poor. As the level
of education increased, fewer number of subjects perceived
their oral health status as poor. The Chisquare test showed
that these differences were statistically significant (P < 0.05)
[Table3].

DISCUSSION
The present study provides an excellent opportunity to
understand the pattern of utilization of oral health care by
people attending outreach programs.

Dental visits

The results from the study show that utilization of

the dental service among adults attending outreach
program was very low (28%). This is concordant with
reports from China (20%) and Spain (34.3%). [3,10] In
contrast, dental service utilization is high in developed
countries, with figures of 75% in the US, 61% in the
Danish adult population, 47% in the UK, 56% in Finland,
and 43% in Singapore. Health insurance which covers
dental services in these countries can be speculated
for the high utilization, which is nonexistent in India.
Insurance schemes either at micro level or at macro
level for oral health services for our population should
be considered.[1014]
The present study showed no significant difference in the
pattern of dental visits between different agegroups. However,
there was a tendency for increased visits in the elderly
agegroup, which is similar to the findings in the report from
China. However, other studies have shown the opposite trend
in the dental visit pattern.[15] The reasons for such trends are still

Table1: Distribution of study subjects according to dental visits and reason for seeking care
No n

Gender
Men
Women
Age
<35Years
>35Years
Education
Primary
Secondary
College
Total

Dental visit
Yes n P value

Reason for seeking care

Dental
Tooth
cleaning
extraction
n
%
n
%

Dental
examination
n
%

Restoration/
Endodontic
n
%
06
09

20
4.2

03
06

10
2.8

03
24

Prosthesis
made
n
%

Aching
tooth/gums
n
%

10
11.1

09

4.2

06

2.8

06

4.5

03
03
06

2.2
6.7
2.4

18
159

12
57

P>.05

03

81
96

33
36

P>.05

03

2.6

06
09

5.3
6.8

06
03

5.3
2.3

12
15

10.5
11.4

06
03

2.3

42
105
30
177

24
30
15
69

P>.05

9.1

6.7
1.2

4.5
6.7
6.7
6

06

03
03

03
09
03
15

03
09

6.7
3.7

09
15
03
27

13.6
11.1
6.7
11

06
03

9.1
2.2

09

3.7

1.3

Table2: Distribution of study subjects according to felt need and reasons for not seeking care
Felt need
No Yes n
n
Gender
Men
Women
Age
<35Years
>35Years
Education
Primary
Secondary
College
Total

High Cost

Lack of
time/Hours
n
%

Reasons for not seeking care

Fear of dentist/Dental
Lack of
tools
transportation
n
%
n
%

Needed
child care
n
%

Any other

15
96

15
120

6
48

20
22.2

1.4

21

9.7

1.4

09
39

30
18.1

06

2.8

42
69

69
66

30
24

26.3
18.2

03

2.3

15
06

13.2
4.5

2.3

21
27

18.4
20.5

03
03

2.6
2.3

36
66
09
111

30
69
36
135

6
42
6
54

9.1
31.1
13.3
22

03

03

2.2

1.2

12
03
06
21

18.2
2.2
13.3
8.5

4.5

1.2

09
21
18
48

13.6
15.6
40
19.5

06
06

13.3
2.4

Indian Journal of Dental Research, 23(6), 2012

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Utilization of oral health care services in community outreach programs

Assessment of barrier of health service utilization

Table3: Distribution of study subjects according to

perceived oral health
Perceived oral health status
Poor
Good
n
%
n
%
Gender
Male
Female
Age
<35years
>35years
Education
Primary
Secondary
College
Total

Pvalue

21
144

70.0
66.7

9
72

30.0
33.3

P>.05

60
105

52.6
79.5

54
27

47.4
20.5

P<.05

54
87
24
165

81.8
64.4
53.3
67.1

12
48
21
81

18.2
35.6
46.7
32.9

P<.05

not clear but it can be speculated that the elderly perceive their
health status to be poor compared to younger subjects.
Since Ujjivan members are females, the percentage of female
participants was high in this study. The number of dental
visits of these females was less than that of males. This is
because, in our population, females are largely dependent
on other family members, and decisions regarding matters
such as visits to the dentists are made by others. On the other
hand, women in Western countries are twice as likely as
men to use oral healthcare services due to the higher illness
perception, higher health consciousness, and greater social
role of women in the West. [8,11]
Though previous studies have shown a positive association
of education with dental visits, the present study did not
show any impact of education on dental visits. It appears that
awareness regarding oral health is low in our population,
irrespective of the level of education.[8]

Reasons of health care utilization

The majority of the dental visits by the participants were for

tooth extractions or treatment of acute symptoms. This was
similar to the study done in Southern China, where the three
most common treatments received in the subjects last dental
visits were fillings, extractions, and dental prosthesis.[15] The
data from Western studies suggests the main reasons for oral
care were dental examination (44.4%), tooth restoration
(35.0%), and dental cleaning (32.1%).[8] Similarly, among
Finnish adults, 43% of subjects visited the dentist for a
dental examination.[12,13]
The reasons for the poor utilization of dental services
seen in this study could be: the existing preventive dental
health services, both through the public and the private
sector, has failed to reach this population; and the choices
for health care are largely determined and conditioned by
the social environment in which the individual lives and
works. There is no policy or program in our country which
focuses in improving the social conditions that determine
this behavior.[16]
Indian Journal of Dental Research, 23(6), 2012

Kadaluru, etal.

This study revealed that the high cost of oral health care,
and fear of dentists or dental tools were the major barriers
for seeking oral health care. This was true for all age group
and educational status where as time needed for child care
was the major barrier for female subjects. Similar results
were observed in a study from Southern China, with
financial difficulty and fear of the dentist being barriers
for receiving dental care.[15] In the present study, we did
not examine the association between income and other
dependent variables as all the study participants were from
economically disadvantaged backgrounds, with monthly
incomes of less than Rs. 5000.
It is important to remove the barrier of high cost of health
care by conducting free health camps, which have proved
to be effective in screening for diseases and for providing
preventive care. Afree referral can also be provided to the
participants in these camps when necessary.

Perception of oral health status

This study suggests that as age increased, positive perception

of oral health decreased. Also noted was that as the
education level increased, the perception of good oral
health increased.
Community outreach programs provide an opportunity
for investigating issues among groups of people who
do not utilize dental services, which should help in
understanding the barriers to accessing dental care in
these populations.

Limitations of the study

The measures of perceived dental care need were subjective,

as they were based on the individuals conception of dental
health and illness. Thus, dental health perceptions may not
only depend on ones sensitivity to signs and symptoms of
disease but may also be influenced by ones knowledge of
dental health.
Selfreports of utilization of services has a considerable
degree of inaccuracy, with a net tendency to overestimate
the actual number of visits. It seems advisable to assess
the validity of studies based on this measure of utilization
carefully.

CONCLUSION
Utilization of oral health care is an indicator of oral health
behavior, with underlying social determinants. Since high cost
is one of the main barriers to utilization of oral health care,
social and economic upliftment through policies addressing
the issues of sickness and rehabilitation benefits, maternity
and child benefits, unemployment benefits, housing policies,
healthcare facilities, and women empowerment is crucial for
the successful delivery of oral health services.

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Utilization of oral health care services in community outreach programs

REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.

9.

DHHS. Oral health in America: Areport of the Surgeon General. [http://

www.surgeongeneral.gov/library/oralhealth/] website NIH Publication
no.0047132000.
Nanda Kishor KM. Public health implications of oral health -inequity
in India. J Adv Dent Res 2010;I:OnlineISSN (22294120).
Pizzaro V, Ferrer M. The utilization of dental care services according
to health insurance coverage in catalonia spain. Community Dent Oral
Epidemiol 2009;37:7884.
Vargas CM, Ronzio CR. Disparities in Early Childhood Caries. BMC Oral
Health 2006;6(Suppl1):S3. doi:10.1186/147268316S1S3.
Olson DG, Levy RL, Evans CA, Olson SK. Enhancement of High
Risk Childrens Utilization of Dental Services. Am J Public Health
1981;71:6314.
Warren JJ, Cowen HJ, Watkins CM, Hand JS. Dental caries prevalence
and dental care utilization among the very old. JAm Dent Assoc
2000;131;15719.
Bamise CT, Bada TA, Bamise FO, Ogunbodede EO. Dental Care
Utilization and Satisfaction of Residential University Students. Libyan
J Med 2008;3:1403. AOP: 080601.
SnchezGarca S, de la FuenteHernndez J, JurezCedillo T, Mendoza
JM. Oral health service utilization by elderly beneficiaries of the
Mexican Institute of Social Security in Mxico City. BMC Health Serv
Res 2007;7:211.
Vidal A, Nye N. Lessons from the community outreach partnership

10.
11.
12.
13.
14.
15.
16.

Kadaluru, etal.
center program. U.S. Washington, DC: Department of Housing and
Urban Development Office of Policy Development and Research; 2002.
Brown LJ, Lazar V. Dental care utilization: How saturated is the patient
market? J Am Dent Assoc 1999;130:57380.
Petersen PE. Dental visits and selfassessment of dental health
status in the adult Danish population. Scand J Prim Health Care
1984;2:16773.
McGrath C, Bedi R, Dhawan N. Factors influencing older peoples
self reported use of dental services in the UK. Gerodontology
1999;16:97102.
Murtomaa H. Utilization of dental services by Finnish adults in 1971
and 1980. Acta Odontol Scand 1983;41:6570.
Lo GL. The use of dental services by adult Singaporeans. Singapore
Dent J 1993;18:225.
Lo EC, Lin HC, Wang ZJ, Wong MC, Schwarz E. Utilization of dental
services in Southern China. JDent Res 2001;80:1471. http://jdr.sagepub.
com/content/80/5/1471.
Watt RG. From victim blaming to upstream action: Tackling the
social determinants of oral health inequalities. Community Dent Oral
Epidemiol 2007;35:111.

How to cite this article: Kadaluru UG, Kempraj VM, Muddaiah P. Utilization
of oral health care services among adults attending community outreach
programs. Indian J Dent Res 2012;23:841-2.
Source of Support: Nil, Conflict of Interest: None declared.

Indian Journal of Dental Research, 23(6), 2012