Australian Dental Journal

Australian Dental Journal The official journal of the Australian Dental Association DATA WATCH Australian Dental Journal 2012; 57: 1 5 doi: 10.1111/j.1834-7819.2012.01697.x The avoidance and delaying of dental visits in Australia Australian Research Centre for Population Oral Health, The University of Adelaide, South Australia. INTRODUCTION Access to dental services is generally regarded as a necessary condition for achieving population-level oral health and well-being. 1 While there is no officially endorsed ideal dental visiting frequency in Australia, the American Dental Association recommends that adults see a dentist at least once every six months, and this is based on the belief that dentists cannot only treat existing problems but that regular dental visits are necessary for the maintenance of healthy gums and teeth. In Australia, almost two-thirds of dentate adults report having visited the dentist in the last 12 months, while over 80% report having visited in the past two years. 2 Given that Australia operates a primarily private dental system, the cost of purchasing care can have an appreciable effect on determining dental visiting patterns. In 2008, just over one-third of all Australian dentate adults claimed that they avoided or delayed visiting a dental professional because of cost. 3 Whether or not people have dental insurance can also affect use of dental services. Dental insurance mitigates the potential barrier of upfront costs, meaning insured people visit the dentist more regularly than uninsured people. 2 Conversely, approximately twice the percentage of uninsured dentate people avoid visiting the dentist due to cost (45.9%) than do insured people (22.9%). 3 Another possible reason for why some people avoid dental visiting is anxiety and fear. Approximately 16% of Australian adults have high dental fear. 4 Research has consistently demonstrated that dental fear is not only related to poorer oral health 5,6 but also to reduced dental visiting. 7 10 People who are afraid to visit the dentist are also more likely to cancel dental appointments or to not show up on the day of a scheduled appointment. While there is strong evidence that the cost of seeing a dentist and dental anxiety are barriers to receiving care, there is less information available on what other reasons might lead to people avoiding or delaying dental visiting. One possible further factor may be patient apathy. An early study in the UK found that over one-third of dentate adults responded I can t be bothered really as a reason for putting off dental visiting. 11 Dental indifference has been found to be associated with poorer oral health and non-attendance, 12 as well as usually visiting for a problem rather than a check-up. 13 However, few studies have actually asked people if they avoid going to the dentist and what the reason for their avoidance or delay might be. This article presents self-reported information on avoiding or delaying dental visiting and the reasons given for this avoidance. Further, avoidance and reasons are examined by several patient characteristics including past dental experiences. METHODS The research was nested within the larger 2008 National Dental Telephone Interview Survey (NDTIS), a computer-assisted telephone interview (CATI) study of a representative sample of the Australian population. The Australian Research Centre for Population Oral Health (ARCPOH) has conducted six rounds of the NDTIS since 1994 and achieved a response rate of 59.4% in 2008. On completion of their telephone interview, interviewees aged 18+ years old (dentate and edentulous) were invited to have a self-complete questionnaire posted to them. A random 25% of available adults completing the NDTIS were posted a questionnaire containing items related to dental avoidance, dental anxiety and fear, and aversive experiences. All participants were asked: Do you avoid visiting the dentist or do you visit the dentist less often than you believe you need to?. People who responded that this was the case were then asked to indicate possible reasons for their avoidance or delay of dental visiting, with options being: lack of time too busy, cost too expensive, do not like dentists, inconvenient to get to, fear or anxiety, just don t get around to it, or other reason. Participants were capable of indicating more than one possible reason if applicable. Potentially anxiety-inducing aspects of dentistry were measured using the stimulus module of the Index of Dental Anxiety and Fear (IDAF-4C + ). 14 The stimulus module (IDAF-S) contains 10 items, related to several of the most common concerns about going to the dentist: painful or uncomfortable procedures, feeling ª 2012 Australian Dental Association 1

ARCPOH embarrassed or ashamed, not being in control of what is happening, feeling sick, queasy or disgusted, numbness caused by the anaesthetic, not knowing what the dentist is going to do, the cost of dental treatment, needles or injections, gagging or choking, and having an unsympathetic or unkind dentist. Possible responses ranged from not at all (1) to very much (5) and, for the sake of analyses, responses from somewhat (3) to very much were taken to indicate the presence of anxiety. Participants were also asked whether they had previously had any of several possible experiences when visiting a dentist: intense or sharp pain, considerable discomfort, felt like gagging, fainted or felt light-headed or a personal problem with the dentist. Additional information, including the participant s age and gender and socioeconomic characteristics, was obtained from the NDTIS CATI. Weighting of the data was used to account for differing sampling probabilities due to the sampling design and adjust the age and gender characteristics for capital and rest-of-state stratum across all states and territories to estimates made available by the Australia Bureau of Statistics Census. Response frequencies for dental avoidance and reasons for avoidance were analysed by selected demographic, socioeconomic and visiting characteristics, as well as by anxiety-eliciting dental stimuli and aversive dental experiences. RESULTS A total of 1511 Australian adults were approached to participate in the nested survey and there were 1083 respondents (response rate = 71.7%). After weighting the data, the mean age of the sample was 44.7 years (SD = 18.3) and 51.3% were female. Just over two-thirds (67.1%) of people indicated that they avoided going to the dentist or went to the dentist less often than they felt they needed to (Fig. 1). When asked why they avoided going to the dentist, 67.6% of those who avoided or delayed visiting (45.4% of the entire sample) rated the cost or expense of going to the Fig. 1 Frequency of avoiding going to the dentist and reasons for avoidance. Fig. 2 Frequency distribution of the number of reasons given by participants for avoiding or delaying going to a dentist. dentist as a reason, which was more than twice as high as the next most commonly cited reasons, lack of time (30.3%; 20.3% of the entire sample) and just not getting around to it (31.9%; 21.3% of the entire sample). Less commonly cited reasons were not liking the dentist (18.1%; 12.1% of the entire sample), dental anxiety and fear (17.8%; 12.0% of the entire sample) and the inconvenience of getting to the dentist (8.5%; 5.7% of the entire sample). Just over one-half of surveyed adults provided two or more reasons for avoiding or delaying going to the dentist (Fig. 2). One in five adults gave three or more reasons. In general, the various reasons were independent of one another. However, there were significant associations between people who avoided due to fear and those who avoided because they did not like going (Kendall s tau = 0.45, p < 0.001). Also, there was an association between avoiding due to lack of time and avoiding due to the perceived inconvenience of going to the dentist (Kendall s tau = 0.21, p < 0.001). Finally, people who avoided due to cost were significantly less likely to avoid due to just not getting around to it (Kendall s tau = )0.26, p < 0.001). Differences in avoiding going to the dentist and reasons for dental avoidance by demographic, socioeconomic and visiting characteristics are shown in Table 1. While males and females did not differ overall in dental avoidance, of those people who did avoid going to the dentist females were more likely to avoid the dentist because they did not like dentists while males were more likely to avoid going because of apathy or indifference. Adults aged 25 39 were significantly more likely to avoid going to the dentist than were other age groups, and were more likely to avoid going to the dentist because of lack of time (35.1%) and cost (61.5%). However, avoidance due to not getting around to it was greater for younger age groups, while avoidance due to lack of convenience and anxiety and fear was lowest for 18 24-year-olds. Household income was also significantly associated with dental avoidance, with avoidance due to lack of time, inconvenience and not getting around to it being most common for people with the highest income. 2 ª 2012 Australian Dental Association

Avoidance and delaying of dental visits in Australia Table 1. Dental avoidance and reasons by sociodemographic, socioeconomic and dental visiting characteristics Reason for avoidance (%) Characteristic Avoid going to the dentist (%) Lack of time Cost Don t like dentists Not convenient Fear or anxiety Don t get around to it Gender n.s. n.s. n.s. ** n.s. n.s. *** Male 67.6 21.3 43.5 9.5 5.5 10.6 27.3 Female 66.8 19.5 47.4 14.6 5.9 13.2 15.8 Age (years) *** *** *** * n.s. *** *** 18 24 55.1 24.4 25.9 7.4 5.4 3.9 33.7 25 39 81.4 35.1 61.5 10.3 7.6 14.5 24.8 40 64 66.6 16.8 47.7 14.9 5.4 13.1 17.5 65+ 61.5 3.2 39.6 13.4 4.3 15.0 12.3 Income (per annum) * *** ** n.s. ** * n.s. <$30K 70.7 5.3 53.2 12.8 5.3 16.0 14.4 $30K <$60K 62.5 16.1 49.4 10.2 2.7 7.8 22.7 $60K <$90K 73.6 21.5 50.0 13.4 5.3 14.6 22.4 $90K+ 65.3 32.5 38.9 11.0 9.4 10.3 23.2 Level of education n.s. *** n.s. * *** n.s. *** Year 10 70.4 7.0 51.4 16.7 3.8 14.5 23.7 Year 12 70.5 27.0 42.6 12.7 11.0 10.5 29.5 Certificate diploma 62.6 17.0 41.9 12.6 2.8 12.9 17.5 Undergraduate 66.7 26.0 46.6 6.3 4.7 9.4 22.0 Postgraduate 76.6 36.4 56.6 13.2 10.4 13.2 9.1 LOTE n.s. ** n.s. n.s. * n.s. *** No 66.9 30.1 48.5 11.1 1.5 16.9 8.1 Yes 67.2 19.0 45.0 12.2 6.3 11.3 23.2 Visiting frequency *** *** *** *** * *** *** 2+ per year 34.1 6.8 19.2 6.8 4.4 4.4 9.6 1 per year 63.3 28.0 45.4 8.6 4.0 9.0 16.4 1 per 2 years 89.7 26.0 57.8 18.5 5.8 10.9 33.5 <1 per 2 years 82.4 20.5 56.4 16.2 8.9 21.1 24.8 ANOVA: *p < 0.05, **p < 0.01, ***p < 0.001. Avoidance due to cost was lowest for people with the highest income while avoidance due to anxiety and fear was lowest for people with a household income of $30,001 $60,000. While level of education was not related overall to avoiding going to the dentist, people with postgraduate educations were over five times more likely than those with a Year 10 education to claim that lack of time was a reason for their dental avoidance, but almost three times less likely than those with a Year 10 or Year 12 education to state that not getting around to going to the dentist was their reason for avoidance. People who spoke a language other than English (LOTE) at home were less likely to endorse lack of time, but more likely to endorse inconvenience and indifference as reasons for not going to the dentist. As might be expected, there was a strong association between visiting frequency and deliberate avoidance of going to the dentist or going less than a person believed they needed to. However, while people with decreased visiting frequency had greater endorsement of every possible reason for avoidance, the nature of the associations were different for the different reasons. Those people who avoided or delayed going to the dentist expressed more anxiety across all 10 potentially concerning aspects of going to the dentist than did people who did not avoid dental visits (Fig. 3). Fig. 3 Percentage of people somewhat to very much anxious about various visit factors by avoidance non-avoidance. Anxieties were from 0.3 to 2.8 times more prevalent for people who avoided the dentist than for those who did not, and all differences were statistically significant except for numbness caused by the anaesthetic. Participants were asked if any of five different possible aversive experiences had happened to them. In general, there were few differences in the percentage of people who had previously had aversive experiences between those people who avoided and those who did not avoid dental visits (Fig. 4). The only significant difference was that a higher percentage of people who avoided the dentist had experienced intense or sharp ª 2012 Australian Dental Association 3

ARCPOH Fig. 4 Percentages of people who have had aversive experiences by avoidance non-avoidance. pain (46.5%) than had those people who did not avoid going to the dentist (39.4%), Pearson chisquare = 4.76, p = 0.029. DISCUSSION Avoiding going to the dentist was very frequent, with just over two-thirds of people avoiding the dentist or visiting less often than they felt they needed to. The main reason for dental avoidance was cost, but one in five people cited lack of time and not getting around to it as factors, while approximately one in eight cited not liking going to the dentist or dental anxiety and fear as reasons for avoidance. Avoidance and reasons for avoidance varied across several sociodemographic, socioeconomic and visiting characteristics. The finding that just over two-thirds of those people surveyed indicated that they intentionally delayed seeking dental care is of concern. Presumably, many of those people who do not avoid visiting either visit regularly or feel no need to visit the dentist. Of those who do avoid going to the dentist, approximately 18% do so due to fear or anxiety. Many people did not consider going to the dentist to be worth making time for, with just over 30% of those people who avoided or delayed going to the dentist citing lack of time as well as not getting around to it as reasons. By far the biggest reason, however, was due to the cost of dental treatment, representing 67.6% of those who avoided going to the dentist or 45.4% of all people. This finding is higher than findings out of the National Survey of Adult Oral Health (NSAOH) which found that 30% of Australians aged 15+ years old either avoided or delayed going to a dental professional due to cost. 15 However, the figure reported in the NSAOH would have significantly underestimated total avoidance due to cost because it restricted the relevant time period to only the previous 12 months. The high percentage of people avoiding due to cost found in this study fits with the finding that anxiety regarding the cost of dental treatment was the single biggest concern related to going to the dentist. Approximately 65% of all people stated that they were at least somewhat anxious about the cost associated with making a dental visit. This is despite approximately 56% of the dentate Australian adult population having dental insurance. 2 This study also found differences in dental avoidance across a number of individual-level characteristics, including gender, age, income, education, speaking a language other than English and dental visiting frequency. People with the highest household income appear to face perceived barriers related to being time poor, being more likely to avoid dental visits due to lack of time, inconvenience, and not getting around to it. As might be expected, however, higher income was also significantly associated with lower percentages avoiding due to the cost of dental treatment. In terms of associations with age, avoidance due to fear or anxiety was most commonly reported by older individuals while avoidance due to not getting around to it was most commonly reported by the youngest age group. Avoidance due to cost was most commonly reported by younger adults aged 25 39-year-olds. It was perhaps not surprising that people who visited the dentist less frequently were most likely to indicate that they intentionally avoided or delayed going to the dentist. Nonetheless, the finding that over 80% of people who visit less than once every two years do so intentionally should be of concern to dental professionals. Cost is clearly a factor, with approximately 57% of those who visit no more than once every two years citing cost as a reason for dental avoidance, compared to less than 20% of those people who visit two or more times a year. However, other important barriers to receiving dental care were perceived lack of time, apathy, fear or anxiety, and not liking dentists. Another finding of note is that those people who avoided or delayed visiting the dentist did not have many more aversive dental experiences than did those people who did not avoid or delay dental visiting. This is consistent with the idea that it is not negative experiences per se, but perceptions of the dentist, which are the most important determinants of dental fear and avoidance. 16 However, those people who avoided going to the dentist had significantly greater anxiety relating to possible pain, feelings of embarrassment or shame, lack of control, feeling queasy, nauseated or disgusted, not knowing what the dentist was going to do, receiving injections, having personal problems with the dentist and the cost of dental treatment. This represents an appreciable list of possible barriers to overcome in order to increase dental visiting among those who go to the dentist less often than they feel they need to. This research indicates that almost two-thirds of Australian adults actively avoid or delay visiting the dentist. The reasons behind this avoidance are multifactorial, but predominantly relate to the perceived barriers of cost and anxiety, as well as a general apathy towards dental visiting. In particular, perceptions of the 4 ª 2012 Australian Dental Association

Avoidance and delaying of dental visits in Australia cost of going to the dentist stand out as the primary reason why people avoid or delay visiting. Approximately 45% of all adults claimed that they avoided or delayed dental visits because of the associated cost or because it was considered too expensive. However, approximately one-half of adults avoid for more than one reason and avoidance was also related to a large number of possible concerns relating to attending a dentist. The results indicate that numerous barriers, real or perceived, need to be overcome in order to meet existing unmet needs. ACKNOWLEDGEMENTS This report was produced by Jason Armfield. The study was funded by a grant from the Australian Dental Research Foundation and the National Dental Telephone Interview Survey was supported by the Australian Government Department of Health and Ageing. REFERENCES 1. Australian Health Ministers Advisory Council (AHMAC). Steering Committee for National Planning for Oral Health. Oral health of Australians: national planning for oral health improvement. Adelaide: South Australian Department of Human Services, 2001. 2. Chrisopolous S, Beckwith K, Harford J. Oral health and dental care in Australia: key facts and figures 2011. AIHW Cat. no. DEN 214. Canberra: Australian Institute of Health and Welfare, 2011. 3. Harford JE, Ellershaw AC, Spencer AJ. Trends in access to dental care among Australian adults 1994 2008. Dental Statistics and Research Series No. 55. AIHW Cat. no. DEN 204. Canberra: Australian Institute of Health and Welfare, 2011. 4. Armfield JM. The extent and nature of dental anxiety and phobia in Australia. Aust Dent J 2010;55:368 377. 5. Schuller AA, Willumsen T, Holst D. Are there differences in oral health and oral health behavior between individuals with high and low dental fear? Community Dent Oral Epidemiol 2003;31: 116 121. 6. Armfield JM, Slade GD, Spencer AJ. Dental fear and adult oral health in Australia. Community Dent Oral Epidemiol 2009;37:220 230. 7. Armfield JM, Stewart J, Spencer AJ. Dental fear in Australia: who s afraid of the dentist? Aust Dent J 2006;51:78 85. 8. Armfield JM, Spencer AJ, Stewart J. The vicious cycle of dental fear: the interplay between oral health, oral health care utilization and dental fear. BMC Oral Health 2007;7:1. 9. Enkling N, Marwinski G, Johren P. Dental anxiety in a representative sample of residents of a large German city. Clin Oral Investig 2006;10:84 91. 10. Pohjola V, Lahti S, Vehkalahti MM, Tolvanen M, Hausen H. Association between dental fear and dental attendance among adults in Finland. Acta Odontol Scand 2007;65:224 230. 11. Todd JE, Walker AM, Dodd P. Adult dental health. Volume 2. United Kingdom. 1978. London: Her Majesty s Stationery Office, 1982. 12. Nuttall NM. Initial development of a scale to measure dental indifference. Community Dent Oral Epidemiol 1996;24:112 116. 13. Jamieson LM, Thomson WM. The dental neglect and dental indifference scales compared. Community Dent Oral Epidemiol 2002;30:168 175. 14. Armfield JM. Development and psychometric evaluation of the Index of Dental Anxiety and Fear (IDAF-4C + ). Psych Assess 2010;22:279 287. 15. Slade GD, Spencer AJ, Roberts-Thomson KF, eds. Australia s dental generations. The National Survey of Adult Oral Health 2004 06. AIHW cat. no. DEN 165. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 34), 2007. 16. Armfield JM, Slade GD, Spencer AJ. Cognitive vulnerability and dental fear. BMC Oral Health 2008;8:2. Address for correspondence: Dr Jason Armfield Australian Research Centre for Population Oral Health School of Dentistry Faculty of Health Sciences The University of Adelaide Adelaide SA 5005 Email: jason.armfield@adelaide.edu.au ª 2012 Australian Dental Association 5