6: Service considerations a report from the Adult Dental Health Survey 2009

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2 The NHS Information Centre is England s central, authoritative source of health and social care information. Acting as a hub for high quality, national, comparative data, we deliver information for local decision makers, to improve the quality and efficiency of care. Author(s): John Morris, Victoria Chenery, Gail Douglas, Elizabeth Treasure Editor(s): Ian O Sullivan Responsible Statistician: Phil Cooke, Section Head, Dental and Eye Care Team Version:.0 Date of Publication: 4 th March 0 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

4 Contents Introduction 5 Key findings 6 6. Dental attendance patterns 7 Introduction Usual reason for attendance Frequency of dental attendance Change in frequency of attendance Time since last visit to the dentist 0 6. Dental services Introduction 6.. Type of service Cost of dental treatment Reported reason for use of NHS or private dental care Reasons for non-attendance Dental treatment received 9 Introduction Treatment received during most recent course of treatment Lifetime treatment history 6.4 Relationship with dental practice 3 Introduction Length of time at the dental practice Dental practice ratings 3 Conclusion 5 Notes and References 6 Tables 7 4 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

5 Introduction Substantial changes have been made to how dental health services are provided in the United Kingdom since the previous Adult Dental Health Survey (ADHS) in 998. For example guidance has been issued on how an appropriate recall interval might be determined for individual patients and, in England and Wales, there have been significant changes to the nature of NHS patient charges. As well as these, a new contract was agreed with NHS dentists in 006. As a consequence these changes may reflect on how regularly adults attend for dental check-ups, the services they access and their views of the service they are provided with. This report from the 009 Adult Dental Health Survey (ADHS) considers adults use of and interactions with all types of dental health services in England, Wales and Northern Ireland. This includes information on what motivates them to attend the dentist, how regularly they attend, the type of service they used at their most recent visit, their experiences of NHS and private dentistry, and also their relationship with the dentist and dental health practitioners at their most recent visit. The report presents estimates by socio-demographic factors including age, sex, country, Strategic Health Authority (SHA) and the socio-economic classification of the household. All of the Tables are to be found at the back of the report. Full background and methodological details for the survey, including response and clinical examination conversion rates can be found in Foundation report: Adult Dental Health Survey 009. A glossary of all clinical terms can also be found in this report. Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 5

6 Key findings Almost two-thirds (6 per cent) of dentate adults said that the usual reason they attended the dentist is for a regular check-up. Furthermore, 0 per cent said that they attended for an occasional check-up, 7 per cent said that they attended when having trouble with their teeth, and per cent said that they never attended the dentist. Overall half of all dentate adults (50 per cent) reported that they attended the dentist at least once every six months; per cent indicated that they attended at least once a year; and a further 6 per cent once every two years. Fifty-five per cent of dentate adults said they went to the dentist about the same as they did five years ago, 7 per cent said that they visit less often and 8 per cent reported visiting the dentist more often than they did five years ago. Seventy-one per cent of dentate adults had received NHS care at their last completed course of dental treatment: 45 per cent of all dentate adults said they paid for this care and 5 per cent said it was free. Private dental care was reported by 7 per cent and very few dentate adults ( per cent) reported receiving mixed NHS and private care. The most frequently cited reasons for using NHS dental services were affordability (63 per cent) and location (3 per cent), although 0 per cent of adults indicated that the recommendation of family or friends was the reason, and a further 6 per cent said because of the better quality of care. Eighty-five per cent of adults rated the practice they had attended most recently as good or very good, for length of time waiting for routine appointments. Similarly, the vast majority of adults (87 per cent) indicated that their dental practice was good or very good in terms of the length of time waiting for an urgent appointment, however just over half (53 per cent) said that their practice was good or very good at providing evening and/or weekend appointments. 6 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

7 6. Dental attendance patterns Introduction Since the first ADHS in 968, a question has been included asking participants to indicate if they attend the dentist for a regular check-up, an occasional check-up or only when they are having trouble with their teeth. This question aims to identify the usual reason why the individual attends the dentist and as such is considered to reflect motivation towards attending rather than the frequency of attendance. How often individuals attend the dentist is also an important consideration, although not necessarily related to a person s usual reason for attendance, and estimates of the frequency of attendance will also be discussed. 6.. Usual reason for attendance Table 6.. demonstrates that almost two-thirds (6 per cent) of dentate adults said that the usual reason they attend the dentist is for a regular check-up. Furthermore, 0 per cent said that they attend for an occasional check-up, 7 per cent said that they attend when having trouble with their teeth, and per cent said that they never attend the dentist. The proportion of dentate adults saying that they attend for a regular check-up was lowest among those adults aged 5 to 34 years (44 per cent) and highest among those aged 65 to 74 (76 per cent). There was a general pattern of more attendance for a regular check-up as dentate adults got older; the reverse pattern can be seen among adults who attend for all other reasons. Figure 6.. and Table 6.. Figure 6.. Dental attendance pattern by age 00% 80% 60% 40% Never been to the dentist Only with trouble Occasionally Regularly 0% 0% and over Age Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 7

8 Previous Adult Dental Health Surveys have reported that women are more likely than men to report that they attend the dentist for a regular check-up and the present survey confirmed this; 68 per cent of women said they attend for a regular check-up compared with 54 per cent of men. Similarly, a smaller proportion of women than men said that they attend only when having trouble with their teeth, per cent of women compared with 3 per cent of men. Less than 50 per cent of dentate men in all age groups up to 44 years said that they attend for a regular check-up whereas in all age groups above 44 years at least 60 per cent of men attend for a regular check-up. Among dentate women, the age group with the lowest proportion saying that they attend for a regular check-up was the 5 to 34 year olds, 54 per cent of women in this age group said they attend for a regular check-up. Finally, at least 30 per cent of men in all age groups up to 54 years said that they attend the dentist only when they have trouble with their teeth, whereas this reason for attending was only provided by over 30 per cent of women in the youngest age group (6 to 4 years). The difference between men and women was not constant with age; for regular attendance the difference was much higher in the 5-54 year old age groups than in the younger and older age groups. Tables 6.. and 6.. At least 60 per cent of dentate adults in England, Wales and Northern Ireland said that they attend the dentist for a regular check-up. There were no significant differences between the three countries, however there were between the English SHAs, specifically in the proportion of dentate adults who said that they attend the dentist for a regular check-up; the highest rate was in South Central SHA (69 per cent) and the lowest was in London SHA (44 per cent). In all other SHAs self-reported regular attendance for a check-up was above 60 per cent. Conversely the highest proportion of dentate adults reporting that they attend the dentist occasionally or only when having trouble with their teeth was in London; 7 per cent of dentate adults in London said they attend for an occasional check up only, and 35 per cent said that they attend only when having trouble with their teeth or dentures. There was also a socio-economic gradient observed in the proportion of dentate adults reporting that they attend for a regular check-up. The highest rate of regular attendance for a check-up was reported by dentate adults from managerial and professional occupation households (66 per cent) and the lowest by dentate adults from routine and manual occupation households (55 per cent). Table 6.. Table 6..3 show changes in dental attendance over time in England. The proportion of dentate adults attending the dentist for a regular check-up increased between 978 and 009 from 44 per cent in 978 to 6 per cent in 009. Table Frequency of dental attendance Self-reporting attendance for a regular check-up does not necessarily relate to attending at a particular frequency and consequently all dentate adults who had ever been to a dentist were asked how often they went to the dentist. Response options included at least every six months, at least once a year, at least once every two years, less frequently than every two years, and only when having trouble with teeth and/or dentures. Guidance from the National Institute for Health and Clinical Excellence recommends that all adults, depending 8 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

9 on their risk category, have dental recalls between three months and two years, therefore all dentate adults should attend the dentist at least once in any two year period. Overall half of all dentate adults (50 per cent) reported that they attended the dentist at least once every six months and a further per cent indicated that they attended at least once a year. Six per cent said they attended once every two years and a further 0 per cent less often than every two years. The remaining 3 per cent of dentate adults said that they only attended when they were having trouble with their teeth. In terms of attending at the maximum recommended interval, over three-quarters of dentate adults (77 per cent) indicated that they were attending with this degree of frequency. Although it is not possible to discuss these estimates in relation to individuals clinical risk, and it therefore remains possible that a large number of dentate adults are not attending as frequently as they should be, it is encouraging that the vast majority of dentate adults are going to the dentist at least every two years. Tables 6..4 and 6..5 Table 6..4 indicates that a smaller proportion of dentate adults in age groups up to 44 years reported attending every six months than adults in those age groups above 44 years (except for those aged 85 and above). For example between 38 and 48 per cent of adults in age groups up to 44 years old attended every six months, compared with between 55 and 59 per cent in age groups between 45 to 74. It is also clear from this table that a greater proportion of women said they went to the dentist at least every six months (55 per cent) than men (45 per cent). Women were also more likely than men to say that they attended at least every two years (8 per cent compared with 7 per cent). Tables 6..4 and 6..5 Frequency of dental attendance varied between the three countries with 59 per cent of dentate adults in Wales reporting that they attended every six months, compared with 54 per cent of dentate adults in Northern Ireland and 49 per cent in England. However when frequency of dental attendance was considered in terms of attending at least every two years, there were no significant differences between England, Wales and Northern Ireland. Within England, at least 50 per cent of dentate adults from all SHAs except Yorkshire and the Humber, London and the South West reported attending at least every six months. In Yorkshire and the Humber and the South West just under half of all dentate adults said they attended every six months (49 and 48 per cent respectively), however in London it was less than two-fifths (39 per cent). In all SHAs, over 70 per cent of dentate adults indicated that they attended at the minimum recommended frequency. Although there was a 0 percentage point difference between the highest South Central (8 per cent) and the lowest Yorkshire and the Humber (7 per cent) the difference was not statistically significant. Tables 6..4 and 6..5 Frequency of attendance also varied by the socio-economic classification of the respondent s household. For example, 53 per cent of dentate adults from professional and managerial occupation households reported attending the dentist at least once every six months compared with 46 per cent of adults from routine and manual occupational households. The reverse pattern was observed when considering adults who only attend when having trouble with their teeth; 8 per cent of adults from routine and manual occupation households go to the dentist only when having trouble with their teeth compared with 9 per cent of adults from managerial and professional occupation households. The Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 9

10 socio-economic gradient was also apparent when attendance was considered in terms of the recommended minimum frequency of attendance; a greater proportion of adults from managerial and professional occupation households attended (8 per cent) than from routine and manual occupation households (70 per cent). Tables 6..4 and Change in frequency of attendance To ascertain changes in dental attendance frequency over time, all dentate adults, except those who reported never going to the dentist, were asked if they visited the dentist more, less or about the same as they did five years ago. Fifty-five per cent of adults said they went to the dentist about the same as they did five years ago, 7 per cent said that they visit less often and 8 per cent reported visiting the dentist more often now than they did five years ago. The proportion of dentate adults reporting that they attended as frequently as they did five years ago varied between age-groups; for example 68 per cent of 75 to 84 year olds said they visit the dentist about the same as they did five years ago compared with 44 per cent of 5 to 34 year olds. Table 6..6 In terms of less frequent attendance, a greater proportion of younger adults said that they attended less often than they did five years ago, than older adults; for example, 4 per cent of adults aged 6 to 4 said that they didn t go to the dentist as regularly as they did compared with 3 per cent of adults aged 5 to 34, and around per cent of adults in all other age groups up to 74 years. Table 6..6 There were no significant differences in the proportions of dentate adults in England, Wales and Northern Ireland or in different English SHAs saying that they attended the dentist about the same or less often than they used to attend. Finally, there were differences between dentate adults from different socio-economically classified households; 57 per cent of dentate adults from managerial and professional occupation households said that they visit the dentist about the same as they did five years ago, compared with 5 per cent of dentate adults from routine and manual occupation households. Conversely, a greater proportion of dentate adults from routine and manual occupation households said that they attended less often than they did five years ago (30 per cent) compared with adults from managerial and professional occupation households (4 per cent) Table Time since last visit to the dentist Section 6.. looked at how often dentate adults generally went to the dentist. This section looks specifically at how long it had been since dentate adults last visit to the dentist. The majority of adults (56 per cent) reported having been to the dentist in the previous six months, with a further 7 per cent indicating that they had attended between six and twelve months previously and 9 per cent between one and two years before. Table 6..8 demonstrates that 8 per cent of dentate adults attended the dentist in the previous two years and have therefore met the minimum criteria suggested in the NICE guidance for 0 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

11 dental attendance. This does not mean that all of these adults have attended as regularly as they ought to. Individual risk profiles and recommended frequency of attendance vary from individual to individual, however this overall estimate can be viewed as a broad indicator of adults attending in line with the recommendations. Tables 6..7 and 6..8 Table 6..8 demonstrates that the proportion of dentate adults who said that they had attended the dentist in the two years prior to being interviewed on the survey was highest amongst adults aged 65 to 74 years (87 per cent) and lowest among adults aged 5 to 34 years (76 per cent). The rate of attendance within the two years prior to interview broadly increased in a linear manner possibly partly reflecting the increasing need for dental treatment and care as people age. This table also demonstrated that there was a significant difference between men and women in the proportion who had reported attending the dentist in the two years before being interviewed; 78 per cent of dentate men said they had attended in the previous two years compared with 87 per cent of dentate women. Table 6..8 Attendance across all three countries in the previous two years was above 80 per cent, as it was in all SHAs with the exception of Yorkshire and the Humber SHA. There was a 7 percentage point difference between the proportion of dentate adults from managerial and professional occupation households (85 per cent) and dentate adults from routine and manual occupation households (78 per cent). Table 6..8 In summary, nearly two-thirds of dentate adults reported attending for regular check-ups and over three-quarters attended at least once in the previous two years. Although the proportion of adults who report attending regularly has increased substantially in Wales and Northern Ireland since the 998 ADHS, the rate of improvement seems to have slowed in England and there remain substantial differences between social groups. Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

12 6. Dental services Introduction The reported use of NHS and private dental services is explored in this section, along with any reported difficulty in accessing services and reasons for non-attendance. This helps to build a picture of demand for NHS and private dental healthcare services and ascertain the number and complexity of dental treatments being carried out in England, Wales and Northern Ireland today. More specifically, the discussion that follows covers the way that adults utilised NHS dental services at their most recent course of dental treatment and explores the reasons why they accessed different types of dental services. The main focus was on how those dentate adults interacted with dental services however some estimates are presented for edentate adults also. A discussion of the accessibility of NHS dental services for all adults, since the changes to the NHS dental contract is presented in the report in this series Access and barriers to care: a report from the Adult Dental Health Survey 009. Barriers to accessibility are also discussed in that report. Most dental care in England, Wales and Northern Ireland is provided by NHS and private primary care services. The majority of adults who access NHS dental care are required to pay set charges as a contribution to the costs of that care. Some adults receive completely free NHS dental treatment if they are aged 6 or 7, are aged 8 and in full time education, or are pregnant or have had a baby in the months before treatment starts, or are an NHS inpatient and the treatment is carried out by the hospital dentist, or are an NHS Hospital Dental Service outpatient or if they or their partner are in receipt of certain income based benefits or they are named on a valid NHS tax credit exemption or HC certificate. Some adults may opt to receive a mixture of NHS and private dental care from their dentist. Not all dentists will offer NHS dental care and those that do may not have capacity to offer this to new patients. Some patients will have seen their dentist move from NHS to private arrangements in their lifetime but will have opted to remain with that particular dentist or dental practice and receive private care from that time onwards, others may have opted to move to a NHS dentist or desire to do so. Patients are free to change dentist at any time and do not have to return to the same dentist for subsequent courses of treatment. To ensure that respondents were not in the middle of a course of treatment, for which they could reasonably attend both for NHS and private dental services, all of the questions covering access to dental services were asked in relation to the respondent s last completed course of treatment. Asking about last completed course of treatment also ensured that respondents were able to provide details of all the specific treatments they had received, and to evaluate their experience in its totality. Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

13 6.. Type of service All dentate adults were asked about the type of dental service that they had used for their last completed course of treatment. The pre-coded answer options were: private dental care, NHS dental care that you paid for, NHS dental care that was free, NHS dental care followed by additional private dental care or some other type of care. Paid for NHS dental care was the most commonly reported type of dental care received, with 45 per cent of dentate adults receiving their last completed course of treatment in this way. Private dental care was reported by 7 per cent and free NHS care by 5 per cent of all dentate adults during their last completed course of treatment; very few respondents ( per cent) reported receiving mixed NHS and private care. It is clear from these results that for the majority of dentate adults (7 per cent) the NHS is the primary provider of dental health services. Table 6.. Type of service used varied by age with a greater proportion of older than younger adults using private dental treatment; 33 per cent of adults aged 55 to 64 and 65 to 74 said that their last completed course of dental treatment was provided by a private dentist, compared with 7 per cent of adults aged 6 to 4. Conversely, a greater proportion of younger adults reported that they had received free NHS dental care at their last visit. Receipt of free NHS dental care was highest among adults aged 6 to 4 (53 per cent) and lowest among adults aged 55 to 64 (4 per cent). The high rate among 6 to 4 year olds is to be expected as 6 and 7 year olds receive free dental treatment on the NHS. Although there are variations between age groups, in all age groups the vast majority of dentate adults had seen an NHS dentist. However, as can be seen in Figure 6.. there was a very clear gradient (decreasing) in use of an NHS dentist (whether paid for or free) as age increased; 8 per cent of 6 to 4 year olds had some type of NHS treatment compared with 56 per cent of adults aged 85 and above. Table 6.. and Figure 6.. Figure 6.. Percentage receiving NHS care at last completed course of treatment (free or paid for) by age Percentage and over Age Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 3

14 Differences between England, Wales and Northern Ireland were also apparent. A smaller proportion of dentate adults in Northern Ireland said that they had received private dental care at their last completed course of treatment, 6 per cent compared with 7 per cent in England and 9 per cent in Wales. Just over half (5 per cent) of dentate adults in Northern Ireland said that they paid for their NHS treatment whereas 46 per cent in England and 37 per cent in Wales respectively said that they did. Receipt of free NHS dental care also varied significantly between the three countries with 33 per cent of dentate adults in Wales reporting that they had received free NHS dental care at their last completed course of treatment compared with 9 per cent of adults in Northern Ireland and 4 per cent in England. Type of service received at last completed course of treatment also varied between English SHAs; 40 per cent of dentate adults in South Central SHA said that they had attended a private dentist for their last completed course of treatment, compared with 8 per cent in the North East. The majority of dentate adults in each SHA had received either paid for or free NHS treatment at their last completed course of treatment, however this ranged from 80 per cent of adults in the North East to 56 per cent of adults in South Central. The SHA with the highest self-reported rate of attendance for free NHS dental care at most recent completed course of treatment was Yorkshire and the Humber (3 per cent) and the lowest was South Central (4 per cent). The four SHAs with the lowest use of NHS services occurred in the four SHAs representing southern England (London, South East Coast, South Central and South West). Table 6.. There was also a clear gradient in use of the different types of service by socio-economic classification of the household. Thirty-five per cent of dentate adults from managerial and professional occupation households reported private dental care for their last completed course of dental treatment, compared with 9 per cent of adults from routine and manual occupation households. Conversely, 3 per cent of those in managerial and professional households, and 37 per cent of those in routine and manual households reported receiving free NHS dental care. Nevertheless, the majority of dentate adults from all three socioeconomic classifications of the household had seen an NHS dentist at their last completed course of treatment, whether they paid for this service or not. Table 6.. As for dentate adults, the majority of edentate adults either went to an NHS dentist that they paid for (37 per cent) or was free (39 per cent). Just under one-fifth (8 per cent) indicated that they received private dental care at their last completed course of treatment. Table 4 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

15 Table Type of dental care received during last completed course of treatment: edentate adults Edentate adults Type of dental care England, Wales and Northern Ireland: 009 All % Private 8 Paid for NHS dental care 37 Free NHS dental care 39 NHS and private care 0 Other Not sure 5 Unweighted Base 750 Weighted Base (000s),499 Excludes those who reported never attending the dentist or who had had their last course of treatment abroad. Includes respondents who said they were treated in a dental hospital. 6.. Cost of dental treatment All dentate adults, whether they attended privately or went to an NHS dentist, were asked about the cost of their last completed course of dental treatment. Those who said they have their treatment paid by a Dental Plan or private health insurance schemes (e.g. DenPlan), were excluded from this analysis as their answer related to how much the scheme costs per month and not the dental treatment cost. Overall, one-third (33 per cent) reported paying nothing and a further 4 per cent reported paying between one and twenty pounds. Table 6.. Older dentate adults were less likely to report obtaining free care and were more likely to report paying greater sums; 9 per cent of dentate adults aged 55 to 64 reported paying over 00 for their last course of treatment compared with 3 per cent of dentate adults aged 6 to 4 years. A greater proportion of women reported that they paid nothing for their last completed course of dental treatment than men, 35 per cent compared with 30 per cent. Table 6.. A greater proportion of dentate adults from Wales said they had received free care (44 per cent) than adults in England (3 per cent); in Northern Ireland 39 per cent of dentate adults said they had received free dental care. Within England, the proportion of dentate adults in South Central SHA reporting receiving free care (0 percent) was about half that in Yorkshire and the Humber SHA (4 per cent). Finally, dentate adults from routine and manual occupation households were more likely to say that their last completed course of dental treatment cost them nothing (45 per cent) compared with dentate adults from managerial and professional occupation households (0 per cent). Table 6.. Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 5

16 Only a small minority of dentate adults ( per cent) indicated that the cost of their dental care and treatment was covered by a pre-payment plan or insurance scheme. There were some small variations by age, country and household socio-economic classification. For example, 8 per cent of 55 to 64 year olds said that they had some form of dental insurance compared with 5 per cent of respondents aged 6 to 4, and 7 per cent of respondents aged 5 to 34. In Wales, 8 per cent of dentate people have dental insurance compared with per cent in England and 9 per cent in Northern Ireland. Finally, 5 per cent of dentate adults in managerial and professional occupation households have dental insurance, compared with only 9 per cent in routine and manual occupational households. Table Reported reason for use of NHS or private dental care Adults who reported that their last completed course of dental treatment was provided under NHS arrangements were asked why they had decided to use NHS services. Respondents could give more than one reason. The most frequently cited reasons by dentate adults were affordability (63 per cent) and location (3 per cent), although 0 per cent of dentate adults indicated that the recommendation of family or friends was the reason, and a further 6 per cent said because of the better quality of care. Table 6..4 and Figure 6.. Figure 6.. Reason for using NHS dental care: dentate adults No reason More types of treatment available Shorter waiting times Lack of availability of private dentists Better quality of care Dentist only sees NHS patients Reputation/ recommendation Location Affordability Percentage As for dentate adults, the majority of edentate adults cited affordability (55 per cent) as the reason they went to an NHS dentist. Fourteen per cent mentioned location and 0 per cent of edentate adults indicated that their dentist only sees NHS patients. Table 6 Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

17 Table Reason for using NHS dental care during last visit: edentate adults Edentate adults Reasons for using NHS dental care England, Wales and Northern Ireland: 009 All Percentage who said Affordability 55 Location 4 Dentist only sees NHS patients 0 Reputation/ recommendation 7 Better quality of care 5 Lack of availability of private dentists Shorter waiting times More types of treatment available No reason 4 Unweighted Base 570 Weighted Base (000s),893 Edentate adults who received NHS treatment excluding those who reported never attending the dentist or who had had their last course of treatment abroad. When dentate adults who had reported using private dental care were asked what had made them use this type of service the two most frequently cited reasons were because their NHS dentist had gone private (4 per cent) and because they were unable to get an NHS dentist (3 per cent). Again respondents could give more than one reason. A further 8 per cent of dentate adults said that they went to a private dentist because the quality of care was better. There were some differences between countries in terms of the explanations adults provided for choosing private dentists. For example, in Northern Ireland and Wales 53 per cent of dentate adults said that the reason they had gone to a private dentists was because their NHS dentist had gone private, this compares with 40 per cent of adults in England. However, 9 per cent of adults in England said that one of the reasons they went to a private dentist was because of the better quality of care; this compares with 0 per cent in both Wales and Northern Ireland. In England there were much larger differences between adults in the SHAs regarding the reasons they gave for going to a private dentist. For example, 56 per cent of adults in the West Midlands SHA said that their NHS dentist going private was one of the main reasons why they went to a private dentist for their last completed course of treatment, compared with 3 per cent of adults in the London SHA. Table 6..5 Those adults who said that they had been to a private dentist at their last visit were asked what would encourage them to use an NHS dentist. Just under two-fifths (38 per cent) of dentate adults said that they would consider going to an NHS dentist if they could find one in their local area. A larger proportion of adults in Wales who had been to the dentist privately (54 per cent) indicated that local availability would encourage them to use NHS dental care, compared with 46 per cent in Northern Ireland, and 37 per cent in England. Finally, just over one-fifth ( per cent) of all adults who had seen a private dentist at their last visit indicated that there was nothing that would encourage them to use an NHS dentist. This indicates that improvements in access to NHS dental care could lead to a sizeable proportion of private patients choosing NHS dental care and also suggests that people s choosing of private Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 7

18 dental care is driven more by lack of access to NHS dental care rather than other considerations. Table Reasons for non-attendance Given that NICE guidelines suggest that as a minimum (depending on clinical risk) all adults should see the dentist every two years it is important to understand why some adults have not been to a dentist within this time frame. The distribution of responses suggests that for any individual there are a number of factors which impact on them not having been to the dentist within the previous two years. The most common response, given by two-fifths of dentate adults (40 per cent), was that they felt that there was nothing wrong with their teeth and that they did not feel a need to go. Twenty five per cent of those who had not attended a dentist in the last years (4 per cent of all dentate adults) said it was because they could not find one or their dentist had gone private. Men were more likely than women to say that they felt there was nothing wrong with their teeth (45 per cent compared with 3 per cent). Table 6..7 A greater proportion of dentate adults in Northern Ireland (48 per cent) said that they had not been to the dentist in the previous two years because they felt there was no need for them to attend the dentist compared with dentate adults in England (40 per cent) and Wales (7 per cent). In Wales, the most frequently mentioned reason for not attending in the previous two years was an inability to find an NHS dentist or that the dentist had gone private, 3 per cent of dentate adults indicating that this was one of the reasons for their non-attendance. In England 5 per cent of adults highlighted this as a reason for the non-attendance and in Northern Ireland 0 per cent of adults said this was a factor. Table Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

19 6.3 Dental treatment received Introduction The next section considers the dental treatment that dentate adults report receiving at their last completed course of treatment and over the course of their lifetime. Monitoring lifetime dental treatment is important as demands for future dental services reflect, in part, the maintenance requirements of the population Treatment received during most recent course of treatment The number of dental visits required to complete a course of treatment can be regarded as an indication of the extent or complexity of patient needs. Just under two-thirds (65 per cent) of dentate adults reported completing their most recent course of treatment in just one visit; with the exception of adults aged 45 to 54, and 55 to 64, at least 65 per cent of adults in all other age groups required just one visit. Twenty-five per cent of 6 to 4 year olds required more than one visit at their last completed course of dental treatment rising with increasing age up to a peak of 4 per cent among adults aged 45 to 54, before falling back as adults got older. This should be seen in the context of the complexity of clinical needs at different age groups which shows a very similar pattern (see Complexity and maintenance a report from the Adult Dental Health Survey 009). A smaller proportion of adults in Northern Ireland required one visit only to complete their last course of treatment (55 per cent) compared with adults from England (65 per cent) and Wales (73 per cent), indicating a generally higher level of need. There were also differences between adults in the different English SHAs, ranging from 57 per cent in London SHA to 7 per cent in the West Midlands SHA. Table 6.3. In terms of treatment received during the most recent completed course of dental treatment, the majority (90 per cent) of dentate adults reported receiving a check-up. Half of adults (50 per cent) indicated that they had had their teeth scaled and polished, and 46 per cent said that they had received advice on how to look after their teeth such as diet or oral hygiene advice. For a more detailed discussion of dental hygiene advice see Preventive behaviour and risks to oral health a report from the Adult Dental Health Survey 009. Table 6.3. There were differences between dentate adults in England, Wales and Northern Ireland in terms of the treatments they reported having at their most recent completed course of treatment. For example 7 per cent of adults in England and 5 per cent in Wales said that they had seen a dental hygienist at their last completed course of dental treatment, compared with 7 per cent of adults in Northern Ireland. In addition, a smaller proportion of adults in Wales reported having been given advice on looking after their teeth by their dentist (35 per cent) than in Northern Ireland (4 per cent) and England (47 per cent). A greater proportion of adults in Northern Ireland reported having x-rays (4 per cent) and fillings (45 per cent) than adults in Wales (8 and 7 per cent respectively) and England (34 and 8 per cent respectively) which might indicate a greater level of disease in Northern Ireland patients attending the dentist. Table Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 9

20 Finally, there were variations between dentate adults from different household socioeconomic classification in terms of the treatment(s) they received during their last completed course of treatment. For example, 54 per cent of dentate adults from managerial and professional occupation households reported having a scale and polish compared with 49 per cent of dentate adults from intermediate occupation households and 46 per cent of dentate adults from routine and manual occupation households. Similarly, there were differences between dentate adults from these different household socio-economic groups in terms of the proportions reporting that they had seen a dental hygienist at their last completed course of treatment; per cent of dentate adults from managerial and professional occupation households reported seeing the hygienist at the last completed course of treatment compared with 7 per cent of dentate adults from intermediate occupation households and per cent of dentate adults from routine and manual occupation households. Table Those adults who paid for their last completed course of treatment or had the cost covered by a pre-payment plan or insurance scheme were asked to rate the care they received in terms of value for money. Almost two-thirds (65 per cent) of adults indicated that they felt the care they received was good or very good value for money, per cent felt that it was fair, and per cent that it was poor/very poor. Older adults tended to be more positive about their last completed course of treatment in terms of value for money; 73 per cent of adults aged 75 to 84 said their care was good or very good value for money compared with 56 per cent of adults aged 6 to 4. Adults in Wales were more positive about their care than adults in England and Northern Ireland; 74 per cent of adults who had paid for their last course of treatment (or had some form of insurance) said that it was good or very good value for money, compared with 65 per cent of adults in England and Northern Ireland. Table The findings of the 998 ADH survey illustrated that having a scale and polish was the most frequently mentioned treatment by dentate adults (check-up was not included as a response option on the 998 ADHS questionnaire) and when the same response categories were compared between 998 and 009, having a scale and polish was still the most frequently mentioned. The proportion of dentate adults in England indicating that they had a scale and polish at their last completed course of treatment has, however, fallen (from 59 to 50 per cent). Conversely, the proportion of adults reporting that they had an x-ray at their last completed course of dental treatment increased. Table and Figure Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

21 Figure 6.3. Treatment received at last visit, England: Percentage Teeth scaled and polished Teeth filled X-ray Teeth extracted Crown fitted Abscess treated Denture fitted Denture repaired 6.3. Lifetime treatment history The dental treatment that an adult may have received over their lifetime may not be apparent from an examination of their mouths. For example teeth that had once been restored may have been extracted and some treatments may not leave any obvious sign of their provision. In order to get a complete picture of patients' experience of treatment it is therefore necessary to ask patients to recall treatment they have received in their lifetime. The responses may reflect both differing experience of treatment and also differing recollections of treatment which may have occurred many years previously. The most commonly reported treatment was fillings with 87 per cent of all adults reporting that they had had at least one over the course of their lifetime. Table presents lifetime treatment history by age-group. Older adults will clearly have a longer treatment history than younger people and therefore the prevalence of reported treatments or other interventions will therefore rise with age, although older adults may also be more likely to forget some of the treatments they had over the course of their lifetime. As anticipated a smaller proportion of adults aged 6 to 4 reported they had received almost all treatments and interventions than adults in all other age groups. For example, 66 per cent of 6 to 4 year olds reported that they had received a filling at some point in their life time, compared with 97 per cent of adults aged 45 to 54. Similarly, 46 per cent of 6 to 4 year olds reported having an extraction compared with 97 per cent of adults aged 85 and older. There were only minor differences between men and women in their reported lifetime treatment history, with the exception of wisdom teeth removal; 46 per cent of women said they had a wisdom tooth extracted compared with 37 per cent of men. Tables and Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

22 There were a few differences between countries in reported lifetime experience of dental treatment. Forty-two per cent of adults from Northern Ireland reported that they had been sedated during dental treatment in the past compared with 30 per cent of adults in England, and per cent in Wales. Adults in Northern Ireland were less likely to say that had visited a dental hygienist than adults in England and in Wales, per cent in Northern Ireland compared with 48 per cent in England and 4 per cent in Wales. However, similar proportions of adults in England, Wales and Northern Ireland reported having had a scale and polish, which suggests that the differences between Northern Ireland, and England and Wales in terms of visiting the dental hygienist reflect differences in how this service is delivered in Northern Ireland. Table Finally, as well as carrying out treatment, dentists are expected to provide patients with dental advice which can include information on giving up smoking, effective brushing, diet and frequency of dental attendance. A comprehensive discussion of the advice given by dentists to their patients is available in the report Preventive behaviour and risks to oral health from the ADHS 009 series. It is however, also relevant to present lifetime experience of professional advice in the present report. The majority of adults (76 per cent) reported receiving advice from a dentist about oral hygiene. Similarly, the majority of adults also reported receiving advice on frequency of attendance (69 per cent) from a dentist over the course of their lifetime. Table Copyright 0, The Health and Social Care Information Centre. All Rights Reserved.

23 6.4 Relationship with dental practice Introduction Dental disease processes are mostly chronic in nature and may require careful monitoring over a long period. The decision to intervene with invasive treatment, rather than continue to monitor, may require fine judgement by the dentist and an appreciation of whether a disease process is active or quiescent may be key in making such a decision. Furthermore, many adults report feeling anxious about dental visits and it is recognised that effective health promotion aimed at changing behaviour is enhanced when there is an ongoing positive relationship between dentist and patient. For all these reasons it is likely to be important that patients have a particular practice where they repeatedly attend for dental care since this is most likely to facilitate effective monitoring and decision making and foster effective dentistpatient relationships. The survey therefore sought to explore the relationship between respondents and dental practices Length of time at the dental practice The vast majority (89 per cent) of all adults who had attended a dentist in the previous two years indicated that they had been to that dental practice before. Although there was some variation between different age groups, at least four-fifths of adults in all age groups who had been to the dentist in the previous two years said that they had been to that dentist before. A smaller proportion of adults aged 5 to 34 (80 per cent) said that they had been before to the dental practice they had attended most recently, compared with adults in all other age groups, possibly reflecting greater mobility among younger adults. Table 6.4. Table 6.4. also shows that a smaller proportion of adults living in the London SHA said that they had been to the dentist they had been to most recently before, than adults in all other SHAs; 8 per cent of adults in London said that they had visited the dental practice in the past compared with 87 per cent of adults in each of the South West and South East Coast SHAs, the two SHAs with the next lowest rates of repeat attendance. Table 6.4. Adults who said that they had previously attended the practice that they had been to in the last two years, were asked how long they had been attending that practice. Table 6.4. shows that over two-thirds (69 per cent) of these adults had been going to that practice for at least five years. There was a general pattern towards a greater proportion of older adults indicating that they had been at the dental practice for five years or more, for example 53 per cent of adults aged 5 to 34 years said that they had been at the same dental practice for five years or more compared with 74 per cent of adults aged 55 to 64 years old, and 78 per cent of adults 75 to 84 years old. Table Dental practice ratings All adults who said that they had been to the dentist in the previous two years were asked to rate the dental practice they last attended on a number of domains including waiting times, explanation of NHS charges, access, quality of care and reputation of the dentist. Copyright 0, The Health and Social Care Information Centre. All Rights Reserved. 3