ABSTRACT

OBJECTIVE

Measure the prevalence of use of dental services in the previous year and associated factors among 31-year-old adults from a birth cohort of 1982.

METHODS

This is a cross-sectional study that analyzed a birth cohort of 1982 from the city of Pelotas. In 1997, a systematic sample of 27% of the city’s census sectors was defined and all households in these sectors were visited, where 1,076 15-year-old adolescents were interviewed. For the oral health studies, 900 of these individuals were randomly selected and followed up at 24 and 31 years of age. The study used data collected from 523 individuals in 2013 (at 31 years old). The outcome was visit to the dentist (use of dental services) in the previous year. Demographic factors (sex), socioeconomic factors (income, education), and oral health factors (reason and type of service, self-perception of oral health, dental pain and caries experience - DMFT) were used as independent variables. Prevalence ratios were estimated using Poisson regression.

RESULTS

The prevalence of use of dental services in the previous year was 55.3% (95%CI: 51.0–59.5%). In the adjusted analysis, the reason and type of service, self-perception of oral health, and DMFT were associated with the outcome. A stronger association was found with use of dental services in individuals who visited for prevention and used the private service, who were satisfied with their oral health, and who had more caries experiences.

CONCLUSION

55.3% of the cohort sample used dental services in the previous year. Individuals who visited the dentist of private service for preventive reasons, who were very satisfied with their oral health, used these services in a higher proportion. In addition, a higher DMFT index also led to higher use of services.

Dental Care; Dental Health Services; Disparities in Health Care; Adults

INTRODUCTION

Around 3.5 billion people in the world have oral diseases, with caries being the most prevalent. According to the Global Burden of Disease Study, 2.3 billion people have permanent teeth affected by caries¹1. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018 Nov;392(10159):1789-858. https://doi.org/10.1016/S0140-6736(18)32279-7
https://doi.org/10.1016/S0140-6736(18)32... ,²2. World Health Organization. Oral health. Geneva: World Health Organization; 2022 [cited 2022 Jul 20]. Available from: https://www.who.int/news-room/fact-sheets/detail/oral-health
https://www.who.int/news-room/fact-sheet... . A strong relation was observed between the oral conditions of the population and their socioeconomic situation³3. Peres MA, Macpherson LM, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet. 2019 Jul;394(10194):249-60. https://doi.org/10.1016/S0140-6736(19)31146-8
https://doi.org/10.1016/S0140-6736(19)31... . Oral diseases are an indicator of inequalities and health problems in the population, as they affect marginalized people in society in a different way. Lifestyle and type of work are part of these determinants and include elements such as housing, working conditions, support and access to health³3. Peres MA, Macpherson LM, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet. 2019 Jul;394(10194):249-60. https://doi.org/10.1016/S0140-6736(19)31146-8
https://doi.org/10.1016/S0140-6736(19)31... . In Brazil, in the last national oral health survey, adults aged from 35 to 44 years had caries experience, with an average of 16.75 affected teeth. Missing teeth accounted for around 44.7% of the index in this age group. Also, among adults and elderly people, missing teeth due to caries was the most prevalent problem⁴4. Ministério da Saúde (BR). Brasil SB. 2010: Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2014..

According to the American Dental Association⁵5. Oralhealth. American Dental Association statement on regular dental visits. Nov 2013 [cited 2022 Jul 20]. Available from: https://www.ada.org/en/press-room/news-releases/2013-archive/june/american-dental-association-statement-on-regular-dental-visits
https://www.ada.org/en/press-room/news-r... , to maintain good oral health, it is recommended to visit the dentist regularly, with the interval between visits determined by the dentist according to the patient’s needs and history. Visiting the dentist frequently is important to prevent toothache, periodontal diseases, mouth cancer, missing teeth, among other problems⁵5. Oralhealth. American Dental Association statement on regular dental visits. Nov 2013 [cited 2022 Jul 20]. Available from: https://www.ada.org/en/press-room/news-releases/2013-archive/june/american-dental-association-statement-on-regular-dental-visits
https://www.ada.org/en/press-room/news-r... . Several studies conducted around the world have reported some patterns in the association of use of dental services and sociodemographic and oral health variables. In Europe, in countries such as the United Kingdom, Finland, and Ireland, women with higher income and higher educational level are positively associated with use of dental services⁶6. Guiney H, Woods N, Whelton H, Morgan K. Predictors of utilisation of dental care services in a nationally representative sample of adults. Community Dent Health. 2011 Dec;28(4):269-73.. In the United States and Colombia, people who reported good oral health were also more associated with recent use of dental services⁹9. Christian B, Chattopadhyay A, Kingman A, Boroumand S, Adams A, Garcia I. Oral health care services utilisation in the adult US population: Medical Expenditure Panel Survey 2006. Community Dent Health. 2013 Sep;30(3):161-7.,¹⁰10. Agudelo-Suárez A, Vivares-Builes A, Posada-López A, Sánchez-Patiño D, Meneses-Gómez J. Use of Oral Health Services in elderly population in Colombia: paradoxes and controversies. Int J Odontostomatol. 2015;9(1):5-11. https://doi.org/10.4067/S0718-381X2015000100001
https://doi.org/10.4067/S0718-381X201500... . On the other hand, use of dental services was lower in China when compared to other places in the world. In this country, only 20.1% of adults visited the dentist in the year prior to the study and the most prevalent reason was curative treatment¹¹11. Cheng ML, Xu MR, Xie YY, Gao XL, Wu HJ, Wang X, et al. Utilisation of oral health services and economic burden of oral diseases in China. Chin J Dent Res. 2018;21(4):275-84. https://doi.org/10.3290/j.cjdr.a41086
https://doi.org/10.3290/j.cjdr.a41086... . Nigeria also presented lower prevalence rates, as only 26.4% of individuals reported using the service at least once before the study, 54.9% of which for curative treatment¹²12. Olusile AO, Adeniyi AA, Orebanjo O. Self-rated oral health status, oral health service utilization, and oral hygiene practices among adult Nigerians. BMC Oral Health. 2014 Nov;14(1):140. https://doi.org/10.1186/1472-6831-14-140
https://doi.org/10.1186/1472-6831-14-140... . Finally, in Paraguay, 11% of people reported visiting the dentist once a year and 64% only seek dental care only when required; that is, prevention is a service used by a minority¹³13. Caballero-García C, Espínola-Verdún PA, Domínguez-González DD, Martínez-Benítez GG, Figueredo-Palacios S, Fernández-Cáceres AM, et al. Oral health and dental health service use. Memorias Instituto Investig Cien Salud. 2017;15(3):57-63. https://doi.org/10.18004/mem.iics/1812-9528/2017.015(03)57-063
https://doi.org/10.18004/mem.iics/1812-9... .

In 1998, the National Household Sample Survey (PNAD) reported low use of dental services and divergence between higher and lower income groups regarding the use of such services¹⁴14. Barros AJD, Bertoldi AD. Desigualdades na utilização e no acesso a serviços odontológicos: uma avaliação em nível nacional. Cienc Saúde Coletiva. 2002;7(4):709-17 https://doi.org/10.1590/S1413-81232002000400008
https://doi.org/10.1590/S1413-8123200200... . However, according to the 2003 and 2008 PNAD, such use increased and issues in service access decreased in this two-year period. More than 89 million people saw a dentist in the 12 months prior to the study, which corresponded to 44.4%. The highest rates of use of dental services in the previous year were observed in the South and Southeast regions of Brazil (51.9% and 48.3%, respectively) and the lowest were in the North and Northeast regions (34.4% and 37.5%, respectively)¹⁵15. Peres KG, Peres MA, Boing AF, Bertoldi AD, Bastos JL, Barros AJ. Redução das desigualdades sociais na utilização de serviços odontológicos no Brasil entre 1998 e 2008. Rev Saúde Pública. 2012;46(2):250-8. https://doi.org/10.1590/S0034-89102012000200007
https://doi.org/10.1590/S0034-8910201200... ,¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde, 2013: acesso e utilização dos serviços de saúde, acidentes e violências: Brasil, grandes regiões e unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2015.. However, unequal use persists in different groups of society, such as people of low income and educational level¹⁷17. Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: a multilevel analysis. PLoS One. 2018 Feb;13(2):e0192771. https://doi.org/10.1371/journal.pone.0192771
https://doi.org/10.1371/journal.pone.019... ,¹⁸18. Silva JV, Oliveira AG. Individual and contextual factors associated to the self-perception of oral health in Brazilian adults. Rev Saúde Pública. 2018 Apr;52:29. https://doi.org/10.11606/S1518-8787.2018052000361
https://doi.org/10.11606/S1518-8787.2018... .

This study aimed to assess the prevalence of visits to the dentist (use of dental services) in the last 12 months among adults from a cohort of live births.

METHODS

Cohort of Live Births of 1982 – Pelotas, RS

In 1997, 1,079 participants were identified from the 1982 birth cohort by analyzing 70 census sectors out of a total of 259 in the city of Pelotas, RS, where the individuals were interviewed. For oral health studies, a random subsample of these 1,079 participants was selected with 900 individuals (ESB-97). The purpose of these studies was to identify the main oral diseases reported throughout life, assess the socioeconomic situation with oral health problems, and investigate the behaviors of individuals in relation to oral health. Follow-up was performed at 15 (n = 888), 24 (n = 720), and 31 years of age¹⁹19. Peres KG, Peres MA, Demarco FF, Gigante DP, Horta BL, Menezes AM, et al. A saúde bucal nas coortes de nascimentos de Pelotas, RS, Brasil. Rev Bras Epidemiol. 2014 Mar;17(1):281-4. https://doi.org/10.1590/1415-790X201400010022
https://doi.org/10.1590/1415-790X2014000... . This sample was sufficient to estimate the prevalence rates of unknown outcomes with 50% prevalence, margin of error of 5 percentage points, and 95% confidence intervals (95%CI)²⁰20. Seerig LM, Nascimento GG, Peres MA, Horta BL, Demarco FF. Acúmulo de risco decorrente da pobreza e perda dentária aos 31 anos, coorte de nascidos vivos de 1982, Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública. 2020;36(8):):e00167619. https://doi.org/10.1590/0102-311X00167619
https://doi.org/10.1590/0102-311X0016761... . Figure 1 shows a flowchart illustrating general and oral health follow-up performed with the 1982 cohort over the years²¹21. Nascimento GG, Peres MA, Mittinty MN, Peres KG, Do LG, Horta BL, et al. Diet-induced overweight and obesity and periodontitis risk: an application of the parametric G-Formula in the 1982 Pelotas Birth Cohort. Am J Epidemiol. 2017 Mar;185(6):442-51. https://doi.org/10.1093/aje/kww187
https://doi.org/10.1093/aje/kww187... .

Individuals participating in the ESB-97 were contacted (n = 888) in 2013 for the follow-up at 31 years of age and, of these, 539 were interviewed and examined. In this follow-up, oral hygiene habits, use of dental services, toothache in the last six months, and some oral problems were investigated. The sample from this follow-up was used in our study, with a cross-section of these data. Six dentists received theoretical and practical training and were calibrated to perform the exams, with the level of agreement measured by the Kappa coefficient, with 0.65 as the lowest value in our study. In the calibration process, 20 individuals of similar age, but not belonging to the cohort, were examined. Follow-up examinations were performed at the homes of participants. For quality control, 15% of the telephone interviews were repeated²⁰20. Seerig LM, Nascimento GG, Peres MA, Horta BL, Demarco FF. Acúmulo de risco decorrente da pobreza e perda dentária aos 31 anos, coorte de nascidos vivos de 1982, Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública. 2020;36(8):):e00167619. https://doi.org/10.1590/0102-311X00167619
https://doi.org/10.1590/0102-311X0016761... ,²²22. Chisini LA, Collares K, Bastos JL, Peres KG, Peres MA, Horta BL, et al. Skin color affect the replacement of amalgam for composite in posterior restorations: a birth-cohort study. Braz Oral Res. 2019 Jul;33:e54. https://doi.org/10.1590/1807-3107bor-2019.vol33.0054
https://doi.org/10.1590/1807-3107bor-201... . More details about the method of oral health studies with the cohort can be found in previous publications¹⁹19. Peres KG, Peres MA, Demarco FF, Gigante DP, Horta BL, Menezes AM, et al. A saúde bucal nas coortes de nascimentos de Pelotas, RS, Brasil. Rev Bras Epidemiol. 2014 Mar;17(1):281-4. https://doi.org/10.1590/1415-790X201400010022
https://doi.org/10.1590/1415-790X2014000... .

Outcome

To guide this study, the following question was proposed: “When was your last visit to a dentist?” The response categories were: “one year or less,” “between one and two years,” and “more than two years.” It was adapted to: “Did you see the dentist in the last year? (12 months prior to the visit)”, with yes or no answers.

Explanation

The outcome was described according to sociodemographic characteristics, such as the sex (male and female), skin color (white, black/brown, other), education (years of study), and income (in income quintiles).

Use of dental services was also described according to oral health characteristics: toothache in the last six months (yes or no), reason of visit (preventive or curative), and type of service (public or private/health plan); in addition to self-perception of oral health (very satisfied/satisfied or neither satisfied/nor dissatisfied/dissatisfied/very dissatisfied); and mean index of decayed, missing, or filled teeth (DMFT) collected in the clinical examination.

Data Analysis

The theoretical pattern used in the analysis of variables was based on the model proposed by Andersen³⁴34. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995 Mar;36(1):1-10. https://doi.org/10.2307/2137284
https://doi.org/10.2307/2137284... . The socioeconomic and demographic variables are at the most distal level of this study, such as sex, income, education, and skin color. The factors related to the individual’s health beliefs are at the intermediate level, which define the actions in relation to health services, such as the type of service and the reason of the last visit. Finally, oral health conditions are considered at the most proximal level, which, in this study, were: pain in the last 6 months, self-perception of oral health, and caries experience.

Data were analyzed using Stata 14.2 statistical software. A descriptive analysis was performed with absolute and relative frequencies of all variables, based on the model illustrated in Figure 2 described above. Bivariate and multivariate Poisson regressions with robust variance were performed to test the association between use of dental services in the previous year and other covariates, respecting the hierarchical model. Variables of the first level were inserted in the regression, variables with p > 0.2 were removed, and the level was processed again until all variables presented p > 0.2; then variables of the second level and then variables of the third level were inserted using the same logic. Prevalence ratio (PR) and respective 95% confidence intervals were estimated. The significance level considered was 5% for all statistical tests.

Ethical Aspects

This study was approved by the Ethics Committee of the Faculdade de Medicina at the Universidade Federal de Pelotas (UFPel). All participants signed an informed consent form and had the guarantee of data confidentiality²³23. Barros FC, Victora CG, Horta BL, Gigante DP. Metodologia do estudo da coorte de nascimentos de 1982 a 2004-5, Pelotas, RS. Rev Saude Publica. 2008;42 suppl 2:7-15. https://doi.org/10.1590/S0034-89102008000900003
https://doi.org/10.1590/S0034-8910200800... .

RESULTS

Sample of Adults

Of all 523 individuals in the sample, most were white (78.6%), with an average income of BRL 3,118.77 (± 2,825.13), and mean education of 11.5 years (± 3.99). Among all participants, 55.3% had visited the dentist in the previous year. Regarding the type of service and reason of the last visit, most used the private service (77.1%) for curative reasons (66.4%).

Regarding pain, 31.2% felt it in the last six months. DMFT was 7.1, and most of them were dissatisfied or indifferent (54.6%) in relation to self-perception of oral health. Table 1 shows sample details.

Use of Dental Services in the Previous Year

In the crude analysis, the factors that were positively associated with use of dental services in the previous year were sex (female individuals), higher income, and higher levels of education. Regarding oral health, the factors with a significant association were: seeing a dentist for preventive reasons, using the private service, and having a good self-perception of oral health. Finally, those with a higher DMFT index showed a stronger association with use of dental services in the previous year.

In the adjusted analysis for possible confounders, the following factors were associated with the outcome: reason and type of service in the last visit, self-perception of oral health, and DMFT. The prevalence of visits in the previous year was 79% higher among individuals who used the private service when compared to those who used the public service, and 26% higher among those who visited a dentist for preventive reasons when compared to those who visited for curative reasons. Individuals who perceived their oral health satisfactorily had a 27% higher prevalence of visits than those who were indifferent or dissatisfied regarding their oral health. Finally, people with more caries experiences had a higher prevalence of visits to the dentist in the previous year, with prevalence increasing 3% for every decayed, missing, or filled decayed tooth. Table 2 shows the crude and adjusted analyses.

DISCUSSION

The prevalence of use of dental services in the previous year in this study was 55.3% (95%CI: 51.0–59.5%), a little higher than the rate reported in the literature for the age group studied. In the 2010 National Oral Health Survey, this number was 49.1% for the country in general and in the 2013 National Health Survey (PNS), 44.4%⁴4. Ministério da Saúde (BR). Brasil SB. 2010: Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2014.. In the same report, Rio Grande do Sul had a proportion of 52.7%, higher than the national rate. In Pelotas, a population-based study was conducted in 2006, in which the prevalence of use of dental services in the previous year was 50.9%, but this study also included adolescents and elderly individuals, in addition to adults²⁴24. Araújo CS, Lima RC, Peres MA, Barros AJ. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... . Data from our study confirm the epidemiological profile described in other studies with adults from the region where Pelotas is located⁷7. Al-Haboubi M, Klass C, Jones K, Bernabé E, Gallagher JE. Inequalities in the use of dental services among adults in inner South East London. Eur J Oral Sci. 2013 Jun;121(3 Pt 1):176-81. https://doi.org/10.1111/eos.12043
https://doi.org/10.1111/eos.12043... ,¹⁰10. Agudelo-Suárez A, Vivares-Builes A, Posada-López A, Sánchez-Patiño D, Meneses-Gómez J. Use of Oral Health Services in elderly population in Colombia: paradoxes and controversies. Int J Odontostomatol. 2015;9(1):5-11. https://doi.org/10.4067/S0718-381X2015000100001
https://doi.org/10.4067/S0718-381X201500... ,²⁴24. Araújo CS, Lima RC, Peres MA, Barros AJ. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... .

White women, with higher income and education level, are more associated with the use of dental services in the literature, but these associations were not significant in our study. Herkrath et al.¹⁷17. Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: a multilevel analysis. PLoS One. 2018 Feb;13(2):e0192771. https://doi.org/10.1371/journal.pone.0192771
https://doi.org/10.1371/journal.pone.019... used data from the 2013 PNS and presented similar results to those in the literature: people with higher education were associated with more recent use of services than those with lower educational level. In general, women are associated with more frequent use of dental services than men¹⁶16. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde, 2013: acesso e utilização dos serviços de saúde, acidentes e violências: Brasil, grandes regiões e unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2015.,²⁴24. Araújo CS, Lima RC, Peres MA, Barros AJ. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... ,²⁵25. Camargo MB, Dumith SC, Barros AJ. Uso regular de serviços odontológicos entre adultos: padrões de utilização e tipos de serviços. Cad Saúde Pública. 2009 Sep;25(9):1894-906. https://doi.org/10.1590/S0102-311X2009000900004
https://doi.org/10.1590/S0102-311X200900... . The occupation level shows higher proportions of men than women, which may explain this characteristic²⁷27. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013., as men find more trouble visiting the dentist during working hours²⁸28. Ministério da Saúde (BR). Secretaria de Atnção à Saude. Departamento de Atenção Básica. Diretrizes da Política Nacional de Saúde Bucal: apresentação. Brasília, DF: Ministério da Saúde; 2004 [cited 20 julho 2022]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_brasil_sorridente.htm
https://bvsms.saude.gov.br/bvs/publicaco... ,²⁹29. Sampaio DM, Cruz LMFS. Perfil de utilização dos serviços odontológicos públicos e privados pela população adulta brasileira. Rev Bras Pesq Saúde. 2014 jul-set;16(3):14-22. https://doi.org/10.21722/rbps.v16i3.10146
https://doi.org/10.21722/rbps.v16i3.1014... . The potential lack of association between education and use of dental services could be linked with two factors: 1) average education of 11.5 years, i.e., it is a relatively educated sample; 2) the sample size may have been insufficient to detect potential associations, which is also a factor for the lack of association for sex, skin color, and income.

Regarding the type and reason for using the dental service, private service was the most common type and preventive service was the most frequent reason. The prevalence of use was 80% higher in the private service when compared to public services. In a study about the use of medical and dental services in the previous year, which used PNAD data from 1998, 2003, and 2008, as well as data from the 2013 PNS, a trend was observed towards an increase in services over the years among individuals with or without a private health plan, but individuals with a health plan had higher percentage of use of services in all years, that is, adults with a health plan had a higher chance of using services in all years analyzed³⁰30. Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saúde Pública. 2018;34(4):34. https://doi.org/10.1590/0102-311x00052017
https://doi.org/10.1590/0102-311x0005201... . Income influences the type of service, and people who use public services find it more difficult to pay for other services. Barros and Bertoldi¹⁴14. Barros AJD, Bertoldi AD. Desigualdades na utilização e no acesso a serviços odontológicos: uma avaliação em nível nacional. Cienc Saúde Coletiva. 2002;7(4):709-17 https://doi.org/10.1590/S1413-81232002000400008
https://doi.org/10.1590/S1413-8123200200... highlight that the adult population is historically neglected, without priority in general health care in public services.

Satisfaction in self-perception of oral health is often associated with a higher frequency of visits to the dentist. Among the 31-year-old individuals in this study, use of dental services was 26% higher among those who were satisfied with their own oral health when compared to those feeling indifferent or dissatisfied with it. Self-perception is a factor based on health belief, which influences the use of dental services. Individual who considers their oral health as good or very good are the same individuals associated with more frequent use¹⁷17. Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: a multilevel analysis. PLoS One. 2018 Feb;13(2):e0192771. https://doi.org/10.1371/journal.pone.0192771
https://doi.org/10.1371/journal.pone.019... ,²⁴24. Araújo CS, Lima RC, Peres MA, Barros AJ. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... .

The DMFT index was also associated with more frequent use, with the prevalence of use increasing 3% for every decayed, missing or filled tooth. Missing tooth was one of the factors associated with the use of services in the study by Herkrath et al.¹⁷17. Herkrath FJ, Vettore MV, Werneck GL. Contextual and individual factors associated with dental services utilisation by Brazilian adults: a multilevel analysis. PLoS One. 2018 Feb;13(2):e0192771. https://doi.org/10.1371/journal.pone.0192771
https://doi.org/10.1371/journal.pone.019... in 2018. Few studies have been conducted addressing the association between use and the DMFT index in adults. Most studies on this topic involve populations of children and adolescents. Provision of health services, together with the perception of treatment need, can define the use of dental services³³33. Pinheiro RS, Torres TZG. Uso de serviços odontológicos entre os Estados do Brasil. Cienc Saúde Coletiva.2006 dez;11(4):999-1010. https://doi.org/10.1590/S1413-81232006000400021
https://doi.org/10.1590/S1413-8123200600... . Therefore, just visiting the dentist may not result in a decrease in oral problems²⁴24. Araújo CS, Lima RC, Peres MA, Barros AJ. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... . Possibly people with higher DMFT index went to the dentist because they needed a treatment, i.e., because they had more caries experience, although in our study, recent use was more associated with preventive than curative reasons. The most immediate cause for using health services is the individual’s perception of his or her own need for treatment³¹31. Baldani MH, Brito WH, Lawder JA, Mendes YB, Silva FF, Antunes JL. Determinantes individuais da utilização de serviços odontológicos por adultos e idosos de baixa renda. Rev Bras Epidemiol. 2010 Mar;13(1):150-62. https://doi.org/10.1590/S1415-790X2010000100014
https://doi.org/10.1590/S1415-790X201000... ,³⁴34. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995 Mar;36(1):1-10. https://doi.org/10.2307/2137284
https://doi.org/10.2307/2137284... and, in the general population, this perception is related to the symptoms and social and functional problems resulting from oral diseases²⁴24. Araújo CS, Lima RC, Peres MA, Barros AJ. Utilização de serviços odontológicos e fatores associados: um estudo de base populacional no Sul do Brasil. Cad Saúde Pública. 2009;25(5):1063-72. https://doi.org/10.1590/S0102-311X2009000500013
https://doi.org/10.1590/S0102-311X200900... .

One of the strong points of this study was the association of clinical examination with sociodemographic variables and use of dental services in the previous year in adults. When studying this population, questionnaires are usually developed about factors related to the use of services, but they often do not cover the clinical examination. Study limitations include its design, because despite being a cohort study, it is a cross-sectional analysis. Also, the outcome was analyzed through self-report, which may overestimate data, considering that visiting a dentist is a socially acceptable behavior.

Another aspect is that, although the Andersen’s model was used, not all variables were used because some had not been collected. This study analyzed a subsample from a cohort of 1982, assessing the oral health of 888 individuals aged 15 years. In the follow-up at 31 years (2013), 523 individuals were evaluated regarding the outcome, which corresponded to almost 60% of the initial subsample. This reduced sample size may have been the cause of absent association with some variables, due to lower power. However, the sample analyzed at age 31 has similar characteristics to the sample evaluated at age 15, considering demographic and socioeconomic factors, and that the subsample of oral health has characteristics of the entire cohort (data not shown).

People who visited a dentist for curative reasons, in the public service, who were indifferent or dissatisfied with their oral health, and had fewer caries experiences were the ones who used dental services with the lowest frequency. People who use public services and are dissatisfied with their oral health need new social actions to support existing policies and include disadvantaged groups. Our study shows public dental services should be expanded to enable access to dental treatment for vulnerable groups with lower oral health indicators. Considering the impact of social inequality on oral health, strategies to expand access for disadvantaged groups are critical for improving oral health indicators.

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