Abstract

This integrative literature review aimed to analyze studies about factors associated with the utilization of dental health services by the pediatric population between zero and 15 years old, published between 2006 and 2016 and available in Portuguese, English or Spanish. A survey of articles in the Lilacs and Medline databases was carried out, using the search strategy: (“dental care/utilization” OR “dental health services/utilization”) AND (“child” OR “child, preschool”) AND NOT adult. To analyze the methodological quality, the adapted Critical Appraisal Skill Programme (CASP) and the Agency for Healthcare and Research and Quality (AHRQ) were used. The following predictors of use of dental health services stood out: factors associated with children or adolescents (age, frequency of tooth brushing, chronic conditions), caregivers (schooling, perception of child's dental health, perceived oral health needs), dentists (availability at night and on the weekends) and follow up of oral health by the family health team. These are inherent factors for the planning of oral health policies or programs for the pediatric population. However, these factors vary according to the context, and therefore, a contextual analysis should be conducted.

Key words
Health services accessibility; Dental health services; Child; Adolescent

Introduction

The utilization of health services is the core of health care operations, resulting from the interaction between the behavior of the users and the professionals who conduct them within this system. It is also related to access (the act of entering, entrance) and accessibility (quality of what is accessible)¹1. Souza LF, Chaves SCL. Política nacional de saúde bucal: acessibilidade e utilização de serviços odontológicos especializados em um município de médio porte na Bahia. Rev Baiana Saúde Pública 2010; 34(2):371-387.. Among health services, dental health services (DHS) show inequalities related to use. These inequalities could be identified in several countries, regardless of the nature, scope and efficiency of the health systems²2. Szwarcwald CL, Bastos FI, Esteves MAP, Andrade CLT, Paez MS, Medici EV, Derrico M. Desigualdade de renda e situação de saúde: o caso do Rio de Janeiro. Cad Saude Publica 1999; 15(1):15-28..

Children and adolescents are less prone to receiving dental care and, therefore, have unmet oral health care needs³3. Gomes AMM, Thomaz EBAF, Alves MTSSDB, Silva AAM, Silva RA. Fatores associados ao uso dos serviços de saúde bucal: estudo de base populacional em municípios do Maranhão, Brasil. Cien Saude Colet 2014; 19(2):629-640.. Data from the National Household Survey (2008) conducted in Brazil showed that among the 11.7% of the population that have never consulted a dentist, 47.9% were children up to 4 years of age and 36.5% were children and adolescents between 5 and 19 years old⁴4. Instituto Brasileiro de Geografia e Estatística (IBGE). Acesso e Utilização dos Serviços, Condições de Saúde e Fatores de Risco e Proteção à Saúde 2008. Rio de Janeiro: IBGE; 2010..

Factors related to the pediatric population, caregivers and DHS may influence the visit to the dentist⁵5. Núñez L, Icaza G, Contreras V, Correa G, Canales T, Mejía G, Oxman-Martínez J, Moreau J. Factores asociados a la consulta odontológica en niños/as y jóvenes de Talca (Chile) e inmigrantes chilenos de Montreal (Canadá). Gac Sanit 2013; 27(4):344-349.. Therefore, it is of utmost importance that managers and health professionals be familiar with these factors and analyze them carefully when offering dental services, since early interventions during childhood and adolescence may affect adult life and, consequently, reduce inequalities in health⁶6. World Healh Organization (WHO). Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: WHO; 2008..

Studies that evaluate factors that influence the use of DHS are performed in the general population, and are fundamental to provide information for the planning of policies and programs that encourage the utilization of DHS and reduce social injustices. Despite the importance of these services, there are no published studies that gather scientific evidence on factors associated with the utilization of DHS by pediatric patients.

Thus, this study aimed to analyze articles published between 2006 and 2016 on factors associated with the utilization of DHS by the pediatric population between zero and 15 years old, contributing to a discussion based on scientific evidence.

Methods

This is an integrative literature review, which allows the synthesis and critical analysis of scientific knowledge on a particular topic or guiding question, contributing to evidence-based health practice⁷7. Callahan JL. Constructing a manuscript: Distinguishing integrative literature reviews and conceptual and theory articles. Hum Resour Dev Rev 2010; 9(3):300-304..

The study comprised six methodological steps: 1 - identification of the topic and selection of the guiding question; 2 - establishment of inclusion and exclusion criteria of the studies; 3 - definition of the information to be extracted from the selected studies and their respective categorization; 4 - methodological evaluation of the included studies; 5- interpretation of the results; 6- presentation of the review and synthesis of knowledge⁸8. Torraco RJ. Writing Integrative Literature Reviews: Guidelines and Examples. Hum Resour Dev Rev 2005; 4(3):356-367.^,99. Mendes KDS, Silveira RCDCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Context - Enferm 2008; 17(4):758-764..

For the first step, the following guiding question was constructed: “Which are the factors associated with the utilization of DHS by the pediatric population between zero and 15 years old?” Subsequently, eligibility criteria for the articles were established by searching the LILACS (Latin American and Caribbean Health Sciences Literature) and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases between March and April 2016. The articles were independently selected by two reviewers, considering the following sequence to verify eligibility: titles, abstracts and full text articles were read. In case of discrepancies, reviewers resolved these by consensus.

The inclusion criteria were: articles on factors associated with the utilization of DHS by pediatric patients between zero and 15 years old, published between 2006 and 2016, and available in Portuguese, English or Spanish. There were no restrictions on the study design. The exclusion criteria were: duplicate studies in databases and publications not available in full. The articles were searched with descriptors indexed at the Health Science Descriptors (DeCS) and the Medical Subject Headings (MeSH) – “dental care” and “dental health services” – associated to the qualifier “utilization” and the descriptors “child”, “child, preschool” and “adult”. The Boolean operators were: OR, AND and AND NOT (NOT for MEDLINE). The search strategy used was (“dental care/utilization” OR “dental health services/utilization”) AND (“child” OR “child, preschool”) AND NOT adult.

For the methodological analysis of the included articles, the following instruments were applied: 1) an instrument adapted from the Critical Appraisal Skill Programme (CASP)¹⁰10. Toledo MM, Takahashi RF, De-La-Torre-Ugarte-Guanilo MC. Elementos de vulnerabilidade individual de adolescentes ao HIV/AIDS. Rev Bras Enferm 2011; 64(2):370-375. and 2) Agency for Healthcare and Research and Quality (AHRQ)¹¹11. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Searching for the evidence behind EMS. Am J Nurs 2010; 110(5):41-47.. The adapted CASP has 10 items in the scoring: 1) clear and justifiable objective; 2) adequate methodology; 3) presentation and discussion of theoretical and methodological procedures; 4) adequate selection of sample; 5) detailed data collection; 6) relationship between researcher and researched; 7) preserved ethical aspects; 8) rigorous and substantiated analysis of data; 9) presentation and discussion of the results and 10) contributions, limitations and indications of new research questions. For each item, the value 0 (zero) or 1 (one) is assigned, and the final result is the sum of the scores, with a maximum score of 10 points. The selected articles were classified according to the scores: level A – 6 to 10 points (good methodological quality and reduced bias) or level B – at least 5 points (satisfactory methodological quality, but with increased risk of bias).

The AHRQ classifies studies in seven levels according to the level of evidence: I) systematic review or meta-analysis; II) randomized controlled trials; III) controlled trials without randomization; IV) case-control and cohort studies; V) systematic reviews of descriptive and qualitative studies; VI) single descriptive or qualitative study; and VII) opinion of authorities and/or report of expert committees.

Results

Of the 307 articles found, 158 did not meet the inclusion criterion for “year of publication”, 2 for “language” and 126 for the “guiding question”, amounting to 21 articles. Of these, 4 (2 duplicates and 2 were not available in full) were excluded, for a total of 17 articles in the final sample (Figure 1). Major information on the final sample is summarized in Chart 1.

Most of the articles (58.9%) investigated factors associated with the utilization of DHS in preschoolers (2-5 years) and/or schoolchildren (6-12 years), followed by 3 articles (17.6%) with infants (zero to 23 months) and preschoolers, and 2 (11.7%) with schoolchildren and adolescents (13-15 years). Also, 1 (5.9%) article included the age group of preschoolers to adolescents and 1 (5.9%) of infants to adolescents. Of the total, 2 (11.7%) investigated children and/or adolescents with chronic conditions. The main factors associated with the utilization of DHS included: maternal level of education, family income, health insurance plan, age, unmet oral health needs, frequency of tooth brushing, and parental perception of child's oral health. Additionally, contextual factors related to the dentist and to the systemic health status of the pediatric population should be pointed out (Chart 1).

Regarding the language, 10 articles (58.9%) were published in English, 5 (29.4%) in Spanish and 2 (11.7%) in Portuguese. Also, 14 articles (82.4%) were found in international journals and 3 (17.6%) in national journals. Regarding the year of publication, most articles were published in 2012 (29.4%), followed by 2008 (17.6%). The countries of origin of the study included Mexico (35.2%), Brazil (23.5%), Spain and the United States (11.8% each) and Belgium, Canada and Nicaragua (5.9% each).

After reading the studies in full, 15 (88.2%) were classified as level A and two (11.8%) as level B, according to the adapted CASP. According to the AHRQ, 14 articles (82.4%) were classified as level of evidence VI (cross-sectional studies) and 3 (17.6%) as level IV (2 cohort studies and one case-control study).

Discussion

The studies included in this review suggested that demographic, socioeconomic, parental, behavioral, contextual and well as factors related to the dentist and oral and/or systemic health status were associated with the utilization of DHS by the pediatric population between zero and 15 years old.

Demographic and socioeconomic factors

Age was the major demographic factor related to the utilization of DHS by the population between zero and 12 years old. The articles evaluated this factor among infants, preschoolers and schoolchildren in Mexico¹²12. Jiménez-Gayosso S, Medina-Solis C, Lara-Carrillo E, Scougal-Vilchis RJ, Rosa-Santillana R, Márquez-Rodríguez S, Mendoza-Rodríguez M, Navarrete-Hernández JJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal (USSB) alguna vez en la vida por escolares mexicanos de 6-12 años de edad. Gac Med Mex 2015; 151:27-33.^,1818. Vallejos-Sánchez AA, Medina-Solís CE, Minaya-Sánchez M, Villalobos-Rodelo JJ, Márquez-Corona ML, Islas-Granillo H, Maupomé G. Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children. Eur J Paediatr Dent 2012; 13(4):307-310.^,2222. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286.^,2323. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631.^,2828. Nicopoulos M, Brennan MT, Kent ML, Brickhouse TH, Rogers MK, Fox PC, Lockhart PB. Oral health needs and barriers to dental care in hospitalized children. Spec Care Dentist 2007; 27(5):206-211., Brazil¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60.^,2525. Kramer PF, Ardenghi TM, Ferreira S, Fischer LA, Cardoso L, Feldens CA. Use of dental services by preschool children in Canela, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008; 24(1):150-156. and Spain¹⁵15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124. and confirmed a greater probability of using DHS with increasing age. Lapresa and Barbero¹⁵15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124. observed that of 601 Spanish 2-year-old children, only 24 had gone to the dentist and of 459 5-year-old children, 181 used DHS. A Brazilian study by Machry et al.¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60. with children aged 1 to 5 years showed that the youngest (1 to 2 years) showed higher probability of having never visited the dentist.

The main reasons for the association between age and use are the cumulative effect of oral problems as the child's age increases as well as the lack of parental awareness of the importance of early preventive dental health care¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60.^,2525. Kramer PF, Ardenghi TM, Ferreira S, Fischer LA, Cardoso L, Feldens CA. Use of dental services by preschool children in Canela, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008; 24(1):150-156.^,2929. Ardenghi TM, Vargas-Ferreira F, Piovesan C, Mendes FM. Age of first dental visit and predictors for oral healthcare utilisation in preschool children. Oral Health Prev Dent 2012; 10(1):17-27.. Another reason is the poor parents' perception of the child's need for oral health, followed by a visit to the dentist only after the presence of oral problems or the appearance of symptoms, such as toothache³⁰30. Goettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD. Children's use of dental services: Influence of maternal dental anxiety, attendance pattern, and perception of children's quality of life. Community Dent Oral Epidemiol 2012; 40:451-458.. In this context, a Mexican study by Villalobos-Rodelo et al.²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286. with students aged 6 to 12 years concluded that older children (10-12 years old) were more likely to go to the dentist due to dental pain than younger ones. The authors suggested that teeth of older children are exposed to cariogenic challenges for a longer period of time, increasing the likelihood of having more advanced stages of carious lesions³¹31. Villalobos-Rodelo JJ, Medina-Solís CE, Maupomé G, Vallejos-Sánchez AA, Lau-Rojo L, de León-Viedas MV. Socioeconomic and sociodemographic variables associated with oral hygiene status in Mexican schoolchildren aged 6 to 12 years. J Periodontol 2007; 78(5):816-822. and consequently, of using curative DHS.

The sex of the child was also associated with the utilization of DHS²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286.^,2525. Kramer PF, Ardenghi TM, Ferreira S, Fischer LA, Cardoso L, Feldens CA. Use of dental services by preschool children in Canela, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008; 24(1):150-156.^,2626. Medina-Solis CE, Maupomé G, del Socorro HM, Pérez-Núñez R, Avila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. J Public Health Dent 2008; 68(1):39-45.. In the Brazilian study by Kramer et al.²⁵25. Kramer PF, Ardenghi TM, Ferreira S, Fischer LA, Cardoso L, Feldens CA. Use of dental services by preschool children in Canela, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008; 24(1):150-156. with children between zero and 5 years old, girls were more likely to use the services than boys, in compliance with Medina-Solís et al.'s findings²⁶26. Medina-Solis CE, Maupomé G, del Socorro HM, Pérez-Núñez R, Avila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. J Public Health Dent 2008; 68(1):39-45. with Mexican schoolchildren. However, a study by Villalobos-Rodelo et al.²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286. reported different results, showing that boys from public schools used more DHS than girls. These discrepancies may be influenced by the decision of the persons responsible for seeking and using DHS²⁵25. Kramer PF, Ardenghi TM, Ferreira S, Fischer LA, Cardoso L, Feldens CA. Use of dental services by preschool children in Canela, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008; 24(1):150-156.. Therefore, parental factors can directly influence the association between the child's sex and the visit to the dentist.

Only one study¹⁴14. Leroy R, Bogaerts K, Hoppenbrouwers K, Martens LC, Declerck D. Dental attendance in preschool children - A prospective study. Int J Paediatr Dent 2013; 23(2):84-93. reported that first-born children were less likely to visit the dentist earlier than non-first-born children. According to the authors, parents tend to take their younger children to the dentist with their first-born child. However, this association should be carefully analyzed because the social background³²32. Bourdieu P. Razões Práticas: Sobre a teoria da ação. Campinas: Papirus Editora; 2008. of the parents, according to the different types of capital accumulated throughout life, can influence the early use of preventive DHS regardless of whether or not the child is a first-born. Thus, parents who have accumulated greater cultural, social, and economic capital³³33. Chaves SCL, Vieira-da-Silva LM. Inequalities in oral health practices and social space: An exploratory qualitative study. Health Policy 2008; 86(1):119-128. tend to have a better perception of their children's oral health and may take them to the dentist earlier.

Regarding socioeconomic factors, the socioeconomic status of the family was associated to the utilization of DHS by the population between zero and 15 years old. Studies showed that children and adolescents with low socioeconomic status were less likely to visit the dentist¹²12. Jiménez-Gayosso S, Medina-Solis C, Lara-Carrillo E, Scougal-Vilchis RJ, Rosa-Santillana R, Márquez-Rodríguez S, Mendoza-Rodríguez M, Navarrete-Hernández JJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal (USSB) alguna vez en la vida por escolares mexicanos de 6-12 años de edad. Gac Med Mex 2015; 151:27-33.^,1515. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124.^,2020. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396.^,2323. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631.^,2626. Medina-Solis CE, Maupomé G, del Socorro HM, Pérez-Núñez R, Avila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. J Public Health Dent 2008; 68(1):39-45.^,2828. Nicopoulos M, Brennan MT, Kent ML, Brickhouse TH, Rogers MK, Fox PC, Lockhart PB. Oral health needs and barriers to dental care in hospitalized children. Spec Care Dentist 2007; 27(5):206-211. or more likely to use DHS due to dental pain²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286.. These findings suggest socioeconomic inequalities that may result from structural barriers to public services, i.e., these services have more demand than supply. This prompts individuals to seek the private sector, who are confronted with economic barriers, such as the costs of treatments²³23. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631.. Moreover, socioeconomic inequalities can be explained by Bourdieu's sociological theory³²32. Bourdieu P. Razões Práticas: Sobre a teoria da ação. Campinas: Papirus Editora; 2008., where caregivers with greater accumulation of cultural, economic and social capitals mediated by habitus tend to have a better perception of oral health in children or adolescents, dental care practices and utilization of DHS³³33. Chaves SCL, Vieira-da-Silva LM. Inequalities in oral health practices and social space: An exploratory qualitative study. Health Policy 2008; 86(1):119-128.^,3434. Abel T. Cultural capital and social inequality in health. J Epidemiol Community Health 2008; 62:e13.. According to Cruz³⁵35. Cruz DN. Desigualdades na utilização de serviços odontológico: posição e tomadas de posição no espaço social [tese]. Salvador: Universidade Federal da Bahia; 2015., habitus is the product of the agent's position within the social space and mediates the need for health and the factors that facilitate the utilization of DHS. Thus, although parents have economic resources, universal coverage and access to DHS, their dispositions (perceiving, feeling, acting, and thinking)³⁶36. Thiry-Cherques HR. Pierre Bourdieu: a teoria na prática. Rev Adm Pública 2006; 40(1):27-53. may anticipate or postpone their children's use of DHS³⁵35. Cruz DN. Desigualdades na utilização de serviços odontológico: posição e tomadas de posição no espaço social [tese]. Salvador: Universidade Federal da Bahia; 2015..

Most of the studies assessed the socioeconomic status using variables such as maternal and/or paternal schooling and family income¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60.

14. Leroy R, Bogaerts K, Hoppenbrouwers K, Martens LC, Declerck D. Dental attendance in preschool children - A prospective study. Int J Paediatr Dent 2013; 23(2):84-93.

15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124.

16. Pontigo-Loyola AP, Medina-Solís CE, Márquez-Corona ML, Vallejos-Sánchez AA, Minaya-Sánchez M, Escoffié-Ramírez M, Maupomé G. Influencia de variables predisponentes, facilitadoras y de necesidades sobre la utilización de servicios de salud bucal en adolescentes mexicanos en un medio semirrural. Gac Med Mex 2012; 148(3):218-226.

17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18.^-1818. Vallejos-Sánchez AA, Medina-Solís CE, Minaya-Sánchez M, Villalobos-Rodelo JJ, Márquez-Corona ML, Islas-Granillo H, Maupomé G. Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children. Eur J Paediatr Dent 2012; 13(4):307-310.^,2424. Noro LRA, Roncalli AG, Mendes Júnior FIR, Lima KC. A utilização de serviços odontológicos entre crianças e fatores associados em Sobral, Ceará, Brasil Use of dental care by children and associated factors in Sobral, Ceará, Brazil. Cad Saude Publica 2008; 24(7):1509-1516.. A study conducted by Lapresa and Barbero¹⁵15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124. with preschool children showed that lower maternal schooling was associated with lower probability of using DHS. According to the authors, the number of years the mother attended school will eventually have greater impact on their children's oral health than paternal schooling. However, this statement should be interpreted carefully because some children and adolescents are looked after by people other than the mothers. Therefore, a caregiver is an individual with direct kinship and is also responsible for coordinating the resources required by the child or adolescent³⁷37. Cassis SVA, Karnakis T, Moraes TA, Curiati JAE, Quadrante ACR, Magaldi RM. Correlação Entre O Estresse Do Cuidador E As Características Clínicas do paciente portador De Demência. Rev Assoc Med Bras 2007; 53(6):497-501.^,3838. Mensorio MS, Kohlsdorf M, Junior ALC. Cuidadores de crianças e adolescentes com leucemia: análise de estratégias de enfrentamento. Psicol em Rev 2009; 15(1):158-176.. Their level of education can influence the utilization of DHS. In this sense, a Mexican study by Pontigo-Loyola et al.¹⁶16. Pontigo-Loyola AP, Medina-Solís CE, Márquez-Corona ML, Vallejos-Sánchez AA, Minaya-Sánchez M, Escoffié-Ramírez M, Maupomé G. Influencia de variables predisponentes, facilitadoras y de necesidades sobre la utilización de servicios de salud bucal en adolescentes mexicanos en un medio semirrural. Gac Med Mex 2012; 148(3):218-226. showed that adolescents aged 12 to 15 years with parents with higher level of education showed great probability of using DHS.

Regarding family income, a Brazilian study by Machry et al.¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60. showed that 1- to 5-year-old children in a lower-income family are more likely to use curative DHS. Also, an American study by Tellen et al.¹⁷17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18. showed that family income was a predictor of the increase in the number of planned visits to the dentist of 4- to 8-year-old children. Essentially, the caregiver's level of education and family income are interconnected, and the former can generate the latter. In other words, education gives access to a specific occupation and, therefore, to a certain level of income, and this may influence access to health care³⁹39. Kawachi I, Adler NE, Dow WH. Money, schooling, and health: Mechanisms and causal evidence. Ann N Y Acad Sci 2010; 1186:56-68..

Another socioeconomic factor was the possession of private health insurance plan. Two studies²³23. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631.^,2424. Noro LRA, Roncalli AG, Mendes Júnior FIR, Lima KC. A utilização de serviços odontológicos entre crianças e fatores associados em Sobral, Ceará, Brasil Use of dental care by children and associated factors in Sobral, Ceará, Brazil. Cad Saude Publica 2008; 24(7):1509-1516. showed that children and adolescents with health insurance (public or private) were more likely to use DHS. A Mexican study carried out by Villalobos-Rodelo et al.²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286. showed that schoolchildren who did not have a health insurance plan presented higher probability of using DHS due to dental pain. This can be explained by the fact that children who do not have a health insurance plan are usually from families with low socioeconomic status, therefore, with greater unmet oral health needs⁴⁰40. Kumar S, Tadakamadla J, Kroon J, Johnson NW. Impact of parent-related factors on dental caries in the permanent dentition of 6-12-year-old children: A systematic review. J Dent 2016; 46:1-11..

Only Villalobos-Rodelo et al.²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286. related the type of school with the utilization of DHS, and observed that children from public schools were more likely to use DHS due to dental pain in comparison to children from private schools. Usually, caregivers of public school children have lower levels of education⁴¹41. Freire MDCM, Reis SCGB, Gonçalves MM, Balbo PL, Leles CR. Oral health in 12 year-old students from public and private schools in the city of Goiânia, Brazil. Rev Panam salud publica 2010; 28(2):86-91., tend to have poor perception of the child's oral health⁴²42. Castilho ARF, Mialhe FL, Barbosa T, Puppin-Rontani RM. Influence of family environment on children's oral health: a systematic review. J Pediatr 2013; 89(2):116-123. and will eventually seek dental care in advanced stages of oral diseases. However, in other contexts, the school can be notably perceived as a place to establish oral care practices³⁵35. Cruz DN. Desigualdades na utilização de serviços odontológico: posição e tomadas de posição no espaço social [tese]. Salvador: Universidade Federal da Bahia; 2015..

Parental factors

Mother's perception¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60. about the child's dental care and a positive maternal attitude¹⁸18. Vallejos-Sánchez AA, Medina-Solís CE, Minaya-Sánchez M, Villalobos-Rodelo JJ, Márquez-Corona ML, Islas-Granillo H, Maupomé G. Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children. Eur J Paediatr Dent 2012; 13(4):307-310. towards it were related to the use of DHS in infants, preschoolers and schoolchildren. A Brazilian study by Machry et al.¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60. showed that 1- to 5-year-old children whose parents had an inadequate perception of the child's oral health were more likely to use curative DHS. The authors pointed out that “poor” perception implies greater oral health needs of the child, and this is essential to measure the need for dental care³⁰30. Goettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD. Children's use of dental services: Influence of maternal dental anxiety, attendance pattern, and perception of children's quality of life. Community Dent Oral Epidemiol 2012; 40:451-458.. A Mexican study by Vallejos-Sánchez et al.¹⁸18. Vallejos-Sánchez AA, Medina-Solís CE, Minaya-Sánchez M, Villalobos-Rodelo JJ, Márquez-Corona ML, Islas-Granillo H, Maupomé G. Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children. Eur J Paediatr Dent 2012; 13(4):307-310. showed that schoolchildren whose mothers had a positive attitude towards their child's oral health were more likely to use DHS. The authors highlighted the relationship of this variable with the frequency of brushing, i.e., among preschoolers and schoolchildren, the frequency usually depends on the mother⁴³43. Khadri FA, Gopinath VK, Hector MP, Davenport ES. How pre-school children learn to brush their teeth in Sharjah, United Arab Emirates. Int J Pediatr Dent 2010; 20(3):230-234.. It is also noteworthy that according to Andersen and Davison⁴⁴44. Andersen RM, Davidson PL. Improving Access to Care in America: Individual and Contextual Indicators. In: Kominski GF, editor. Changing the U.S. health care system: key issues in health services policy and management. San Francisco: John Wiley & Sons Inc.; 2007. p. 3-31., attitude towards health services is an important predictor of DHS use.

Two other parental factors related to the utilization of DHS were parents' use¹⁴14. Leroy R, Bogaerts K, Hoppenbrouwers K, Martens LC, Declerck D. Dental attendance in preschool children - A prospective study. Int J Paediatr Dent 2013; 23(2):84-93. and mothers' awareness of the importance of preventive dental care¹⁷17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18.. A prospective cohort study conducted by Leroy et al.¹⁴14. Leroy R, Bogaerts K, Hoppenbrouwers K, Martens LC, Declerck D. Dental attendance in preschool children - A prospective study. Int J Paediatr Dent 2013; 23(2):84-93. followed up on Belgian children from birth to age 5, and showed that recent use of DHS by parents implied that children were more likely to have visited the dentist earlier. Parents with a regular source of dental care may have a better perception of their children's oral health⁴⁵45. D, Spiekerman C, Milgrom P. Linking mother access to dental care and child oral health. Community Dent Oral Epidemiol 2009; 37(5):381-390., and therefore take them to the dentist earlier. In this sense, a study by Tellen et al.¹⁷17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18. with 4- to 8-year-old children living in Hispanic American communities in Chicago (USA) suggested that the children whose mothers had improved awareness of the importance of preventive dental care for their children had a better chance of visiting the dentist early and regularly. Therefore, it is worth mentioning that in order to increase the frequency of early use of DHS by children, attention should be paid to the parents who do not use these services regularly¹⁴14. Leroy R, Bogaerts K, Hoppenbrouwers K, Martens LC, Declerck D. Dental attendance in preschool children - A prospective study. Int J Paediatr Dent 2013; 23(2):84-93.. Ultimately, dentists play a key role in oral health promotion and prevention of aggravation⁴⁶46. Reis WG, Scherer MDDA, Carcereri DL. O trabalho do Cirurgião-Dentista na Atenção Primária à Saúde: entre o prescrito e o real. Saúde em Debate 2015; 39(104):56-64., being the link between caregivers and children.

Behavioral factors

The frequency of tooth brushing was the major factor related to the utilization of DHS by the population between 1 and 15 years old. The articles evaluated this factor in infants, preschoolers, schoolchildren and adolescents in Mexico¹⁸18. Vallejos-Sánchez AA, Medina-Solís CE, Minaya-Sánchez M, Villalobos-Rodelo JJ, Márquez-Corona ML, Islas-Granillo H, Maupomé G. Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children. Eur J Paediatr Dent 2012; 13(4):307-310.^,2323. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631.^,2828. Nicopoulos M, Brennan MT, Kent ML, Brickhouse TH, Rogers MK, Fox PC, Lockhart PB. Oral health needs and barriers to dental care in hospitalized children. Spec Care Dentist 2007; 27(5):206-211., Brazil¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60., Nicaragua²⁶26. Medina-Solis CE, Maupomé G, del Socorro HM, Pérez-Núñez R, Avila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. J Public Health Dent 2008; 68(1):39-45. and Spain¹⁵15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124.^,2020. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396. and concluded that individuals who brushed their teeth regularly, especially 3 times a day, showed greater chances of using mainly preventive DHS²³23. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631.. Also, lower age at onset of tooth brushing (< 2 years)²³23. Medina-Solís CE, Villalobos-Rodelo JJ, Márquez-Corona ML, Vallejos-Sánchez AA, Portillo-Núñez CL, Casanova-Rosado AJ. Desigualdades socioeconómicas en la utilización de servicios de salud bucal: estudio en escolares mexicanos de 6 a 12 años de edad. Cad Saude Publica 2009; 25(12):2621-2631. and low consumption of sugary soft drinks²⁰20. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396. increased the likelihood of visiting the dentist.

Notably, these are cross-sectional studies and, consequently, reverse causality may occur, i.e., because children and adolescents use DHS, they may have started brushing their teeth earlier and regularly and consumed less sugary soft drinks. Also, the influence of parental factors on the behavior of this population plays an important part. Therefore, educational approaches with parents and children are essential to increase the practice of healthy oral habits⁴²42. Castilho ARF, Mialhe FL, Barbosa T, Puppin-Rontani RM. Influence of family environment on children's oral health: a systematic review. J Pediatr 2013; 89(2):116-123., reducing the use of curative DHS.

Factors related to oral and/or systemic health status

Perceived oral health need was the main factor related to the utilization of DHS by the population between 1 and 15 years old. The articles evaluated this factor among infants, preschoolers, schoolchildren and adolescents in Spain¹⁵15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124.^,2020. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396., Mexico¹⁶16. Pontigo-Loyola AP, Medina-Solís CE, Márquez-Corona ML, Vallejos-Sánchez AA, Minaya-Sánchez M, Escoffié-Ramírez M, Maupomé G. Influencia de variables predisponentes, facilitadoras y de necesidades sobre la utilización de servicios de salud bucal en adolescentes mexicanos en un medio semirrural. Gac Med Mex 2012; 148(3):218-226.^,1818. Vallejos-Sánchez AA, Medina-Solís CE, Minaya-Sánchez M, Villalobos-Rodelo JJ, Márquez-Corona ML, Islas-Granillo H, Maupomé G. Maternal characteristics and treatment needs as predictors of dental health services utilisation among Mexican school children. Eur J Paediatr Dent 2012; 13(4):307-310.^,2222. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286.^,2828. Nicopoulos M, Brennan MT, Kent ML, Brickhouse TH, Rogers MK, Fox PC, Lockhart PB. Oral health needs and barriers to dental care in hospitalized children. Spec Care Dentist 2007; 27(5):206-211., Brazil¹³13. Machry RV, Tuchtenhagen S, Agostini BA, Silva Teixeira CR, Piovesan C, Mendes FM, Ardenghi TM. Socioeconomic and psychosocial predictors of dental healthcare use among Brazilian preschool children. BMC Oral Health 2013; 13:60.^,2121. Baldani MH, Mendes YBE, Lawder JA, Lara AP, Rodrigues MM, Antunes JL. Inequalities in dental services utilization among Brazilian low-income children: The role of individual determinants. J Public Health Dent 2011; 71(1):46-53. and Nicaragua²⁶26. Medina-Solis CE, Maupomé G, del Socorro HM, Pérez-Núñez R, Avila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. J Public Health Dent 2008; 68(1):39-45. and concluded that people with oral health needs perceived by caregivers or evaluated by the dentist presented greater chance to use DHS, especially curative DHS²⁶26. Medina-Solis CE, Maupomé G, del Socorro HM, Pérez-Núñez R, Avila-Burgos L, Lamadrid-Figueroa H. Dental health services utilization and associated factors in children 6 to 12 years old in a low-income country. J Public Health Dent 2008; 68(1):39-45.. The main reasons reported included: severity and number of decayed teeth, presence of dental pain²²22. Villalobos-Rodelo JJ, Medina-Solis CE, Maupomé G, Lamadrid-Figueroa H, Casanova-Rosado AJ, Casanova-Rosado JF, Márquez-Corona ML. Dental Needs and Socioeconomic Status Associated with Utilization of Dental Services in the Presence of Dental Pain: A Case-Control Study in Children. J Orofac Pain 2010; 24(3):279-286. and caregivers' poor awareness of the importance of deciduous dentition.

It should be pointed out that according to the Andersen and Newman's model⁴⁷47. Andersen R, Newman JF. Societal and individual determinants of medical care utilisation in the United States. Milbank Mem Fund Q Health Soc 1973; 51(1):95-124., health care need is the most proximal determinant of use of health services, i.e., greater health needs would imply greater prediction of DHS use. Additionally, perceived oral health needs can be explained by social structure and awareness towards health, being an important predictor of the demand for health care and adherence to treatment⁴⁸48. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995; 36(1):1-10.. In this review, only two studies assessed the needs of perceived oral health¹⁵15. Lapresa LB, Sanz-Barbero B. Variables asociadas al uso de los servicios de salud bucodental por la problación preescolar en españa: Un análisis de la encuesta nacional de salud. Rev Esp Salud Pública 2012; 86(1):115-124.^,2020. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396. and, therefore, more research is needed including this issue.

Only two studies¹⁹19. Chi DL, Raklios N. The relationship between body system-based chronic conditions and dental utilization for Medicaid-enrolled children: a retrospective cohort study. BMC Oral Health 2012; 12:28.^,2727. Medina-Solís CE, Maupomé G, Avila-Burgos L, Hijar-Medina M, Segovia-Villanueva A, Pérez-Núñez R. Factors influencing the use of dental health services by preschool children in Mexico. Pediatr Dent 2006; 28(3):285-292. suggested the association of children with chronic diseases with the utilization of DHS. In the Canadian study by Nicopoulos et al.²⁷27. Medina-Solís CE, Maupomé G, Avila-Burgos L, Hijar-Medina M, Segovia-Villanueva A, Pérez-Núñez R. Factors influencing the use of dental health services by preschool children in Mexico. Pediatr Dent 2006; 28(3):285-292. with hospitalized children aged 3 to 12 years, those with chronic conditions (oncological, hepatic, renal, congenital heart disease, immunosuppression, among others) showed lower chances of using DHS due to medical barriers than children with acute conditions. According to the authors, the major medical barriers included: recurrent hospitalizations, dentist's reluctance to treat this population and pancytopenia. An American study conducted by Chi and Raklios¹⁹19. Chi DL, Raklios N. The relationship between body system-based chronic conditions and dental utilization for Medicaid-enrolled children: a retrospective cohort study. BMC Oral Health 2012; 12:28. with children and adolescents aged 3 to 14 years with chronic conditions revealed that the individuals with neurological, endocrine, craniofacial or hematological conditions used less DHS than those with other chronic conditions. The authors attributed this fact to the behavioral characteristics of the caregiver, such as high level of stress in relation to the systemic health needs of this population and approach to oral health as a lower priority.

Importantly, individuals with greater vulnerability are more affected by oral health morbidities, showing greater accumulation of needs⁴⁹49. Peres MA, Iser BPM, Boing AF, Yokota RTC, Malta RC, Peres KG. Desigualdades no acesso e na utilização de serviços odontológicos no Brasil: análise do Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL 2009). Cad Saude Publica 2012; 28(Supl.):90-100., as well as they seem to have more restricted access to DHS⁵⁰50. Institute of Medicine and National Research Council (IMNRC). Improving access to oral health care for vulnerable and underserved populations. Washington: IMNRC; 2011.^,5151. The Canadian Academy of Health Sciences (CAHS). Improving access to oral health care for vulnerable people living in Canada. Ottawa: CAHS; 2005.. Thus, this group should be considered when proposing oral health policies aiming at ensuring health equity.

Factors related to the dentist

Only one study¹⁷17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18. observed an association between factors related to the dentist and the utilization of DHS in evaluating predictors of use by 4- to 8-year-old children in three Hispanic-American neighborhoods of Chicago, USA. The authors found that the dentist's availability at night or on the weekends increases the number of planned visits to the dentist as well as returns visits. Possibly, these factors facilitate the use of DHS because the dentist is available in shifts and days in which caregivers are usually not working¹⁷17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18.. However, in other contexts, such as the Family Health Strategy (FHS) in Brazil, the dentist does not work at night or on the weekends, posing difficulties for children whose caregivers work during the week⁵²52. Andrade RTS, Silva UA. O acesso dos trabalhadores aos serviços odontológicos na rede SUS: uma reflexão crítica. Rev Bras Pesqui em Saúde 2010; 12(4):45-51.. Therefore, this issue should be addressed when proposing public oral health policies.

Moreover, an important factor for returning to the dentist was the satisfactory communication among professionals, mothers and children¹⁷17. Telleen S, Rhee Kim YO, Chavez N, Barrett RE, Hall W, Gajendra S. Access to oral health services for urban low-income Latino children: Social ecological influences. J Public Health Dent 2012; 72(1):8-18., with focus on the importance of the command of language, since the population of his study was composed of immigrants from Latin American countries. However, it is important to point out that non-verbal communication, humanization of care and bonding are important strategies for a satisfactory relationship among dentists, caregivers and children⁵³53. Ferreira JMS, Aragão AKR, Colares V. Técnicas de controle do comportamento do paciente infantil: Revisão de literatura. Pesqui Bras Odontopediatria Clin Integr 2009; 9(2):247-251.^,5454. Coriolano-Marinus MWL, Andrade RS, Ruiz-Moreno L, Lima LS. Comunicação entre trabalhadores de saúde e usuários no cuidado à criança menor de dois anos no contexto de uma unidade de saúde da família. Interface (Botucatu) 2015; 19(53):311-324..

Contextual factors related to dental care

Two Brazilian studies²¹21. Baldani MH, Mendes YBE, Lawder JA, Lara AP, Rodrigues MM, Antunes JL. Inequalities in dental services utilization among Brazilian low-income children: The role of individual determinants. J Public Health Dent 2011; 71(1):46-53.^,2424. Noro LRA, Roncalli AG, Mendes Júnior FIR, Lima KC. A utilização de serviços odontológicos entre crianças e fatores associados em Sobral, Ceará, Brasil Use of dental care by children and associated factors in Sobral, Ceará, Brazil. Cad Saude Publica 2008; 24(7):1509-1516. and one Spanish study²⁰20. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396. showed that contextual factors are related to the utilization of DHS. A study by Noro et al.²⁴24. Noro LRA, Roncalli AG, Mendes Júnior FIR, Lima KC. A utilização de serviços odontológicos entre crianças e fatores associados em Sobral, Ceará, Brasil Use of dental care by children and associated factors in Sobral, Ceará, Brazil. Cad Saude Publica 2008; 24(7):1509-1516. observed that 5- to 9-year-old children whose households did not receive visits from a community health agent (CHA) were more likely to use DHS. According to the authors, most visited households by CHAs are those where children's caregivers showed greater needs for follow-up due to systemic diseases or situations of social vulnerability, rendering them unable to articulate child health care, such as dental care. At the same time, it is important to point out how challenging it is for Brazilian dentists to work according to the FHS guidelines due to the historical influences of the Flexner's model, their conceptions of FHS and the autonomy provided by this model. As a consequence, consultations will take place exclusively at a dental practice⁴⁶46. Reis WG, Scherer MDDA, Carcereri DL. O trabalho do Cirurgião-Dentista na Atenção Primária à Saúde: entre o prescrito e o real. Saúde em Debate 2015; 39(104):56-64.. Therefore, equity, as a perspective of expanding access to DHS, should be considered in the construction of oral health policies.

In contrast to Noro et al.'s findings²⁴24. Noro LRA, Roncalli AG, Mendes Júnior FIR, Lima KC. A utilização de serviços odontológicos entre crianças e fatores associados em Sobral, Ceará, Brasil Use of dental care by children and associated factors in Sobral, Ceará, Brazil. Cad Saude Publica 2008; 24(7):1509-1516., Baldani et al.²¹21. Baldani MH, Mendes YBE, Lawder JA, Lara AP, Rodrigues MM, Antunes JL. Inequalities in dental services utilization among Brazilian low-income children: The role of individual determinants. J Public Health Dent 2011; 71(1):46-53. showed that children and adolescents between zero and 14 years old followed up by the family health team were more likely to visit the dentist. This demonstrates the longitudinality of dental care and the existence of a bond between users and staff⁴⁶46. Reis WG, Scherer MDDA, Carcereri DL. O trabalho do Cirurgião-Dentista na Atenção Primária à Saúde: entre o prescrito e o real. Saúde em Debate 2015; 39(104):56-64.^,5555. Scherer MDDA, Pires D, Schwartz Y. Trabalho coletivo: um desafio para a gestão em saúde. Rev Saude Publica 2009; 43(4):721-725..

Lapresa and Barbero²⁰20. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396. showed that having a Children's Dental Care Plan in a Spanish autonomous community for more than 10 years increased the probability of DHS use by the population between 6 and 15 years old. Spain is divided into autonomous communities, with varied health system coverage and financing mechanisms. The Children's Dental Care Plan caters to the population between 6 and 15 years of age, offering urgent restorative and preventive treatment in the permanent and preventive dentition, as well as exodontia in the deciduous dentition, not including restorative treatment here²⁰20. Lapresa LB, Barbero BS. Análisis multinivel del uso de servicios de salud bucodental por población infantojuvenil. Gac Sanit 2011; 25(5):391-396.. The authors report that although this assistance model is consolidated, the socioeconomic gradient is still present and does not vary between the autonomous communities. This means that parents or caregivers who have higher socioeconomic status, as well as accumulated cultural capital, tend to have better perception of child oral health and, therefore, seek DHS³⁴34. Abel T. Cultural capital and social inequality in health. J Epidemiol Community Health 2008; 62:e13..

Final considerations

The studies of this review show that demographic, socioeconomic, parental, behavioral and contextual factors as well as those related to the dentist and to the oral and/or systemic health status are associated with the utilization of DHS by the pediatric population between zero and 15 years old. Predictors of DHS use include: factors related to children or adolescents (age, frequency of tooth brushing, chronic conditions), caregivers (schooling, perception of the child's oral health, perceived oral health needs), dentists (availability at night or on the weekends) and follow-up of oral health by the family health team.

Nevertheless, it is important to emphasize that most studies are cross-sectional; therefore, it is difficult to establish a causal relationship. Also, the studies used questionnaires, and memory bias is likely to occur. Therefore, longitudinal studies should be conducted to clarify causality and minimization of bias. Research on the utilization of DHS in pediatric patients with chronic diseases should be further conducted, comparing them to healthy individuals of the same age group, as this field has not been thoroughly explored.

In this review, most of the studies used the Andersen Behavioral Model⁴⁷47. Andersen R, Newman JF. Societal and individual determinants of medical care utilisation in the United States. Milbank Mem Fund Q Health Soc 1973; 51(1):95-124. to establish which conditions facilitate or hinder the utilization of DHS. However, they did not explain the reasons for inequalities. Thus, comprehensive research based on Bourdieu's³²32. Bourdieu P. Razões Práticas: Sobre a teoria da ação. Campinas: Papirus Editora; 2008. sociological theory should be carried out. Moreover, the Andersen Behavioral Model was developed to analyze the use of US private health services and should be carefully interpreted, since the studies of this review applied this model in contexts which are different from those in the USA.

Ultimately, the articles were written in different countries, which have different health care systems. In this sense, it can be pointed out that factors related to the use of DHS by children and adolescents may vary according to the context in which the research is performed. Therefore, for the planning of oral health policies or programs for the pediatric population, an exploratory research should be conducted according to the context in which the actions are to be carried out. Also, increasing supply of DHS alone is not able to guarantee better utilization of dental health services and reduce inequalities between vulnerable groups. A sociological analysis of these services should be carried out following Bourdieu's model³²32. Bourdieu P. Razões Práticas: Sobre a teoria da ação. Campinas: Papirus Editora; 2008..

References

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