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Comparison of Factors Affecting Perceived and Objective Dental Needs
J Dent Hyg Sci 2019;19:147-53
Published online September 30, 2019;  https://doi.org/10.17135/jdhs.2019.19.3.147
© 2019 Korean Society of Dental Hygiene Science.

Eunsuk Ahn1 , Ji-Hyoung Han2 , Ki-Eun Kim1,†

1Department of Dental Hygiene, Daejeon Institute of Science and Technology, Daejeon 35408, 
2Department of Dental Hygiene, Suwon Science College, Hwaseong 18516, Korea
Correspondence to: Ki-Eun Kim, https://orcid.org/0000-0002-5989-9503 Department of Dental Hygiene, Daejeon Institute of Science and Technology, 100 Hyecheon-ro, Seo-gu, Daejeon 35408, Korea
Tel: +82-42-580-6449, Fax: +82-42-580-6301, E-mail: hsun0405@naver.com
Received April 24, 2019; Revised July 24, 2019; Accepted July 31, 2019.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background:

With increased interest in oral health, several efforts have been made to improve oral health conditions. To achieve this, needs for oral health must be precisely determined and accurately measured. Therefore, factors influencing both objective unmet dental needs, which were determined by experts, and perceived unmet dental needs, which were determined by patients, were examined in this study.

Methods:

Responses of 17,735 respondents aged greater than 19 years from the Korean National Health and Nutrition Survey collected using the fifth (2010∼2012) rotation sample survey were analyzed. Based on the information collected from the survey and dental examination, we determined the associations between the independent (sex and socioeconomic level) and dependent variables using a chi-squared test. Moreover, ordinal logistic regression analyses on multiple categorical values were performed using perceived and objective dental needs as the dependent variables.

Results:

Generally, factors influencing both perceived and objective dental needs were similar. These included sex, household income, educational level, private insurance, and subjective oral health status. However, the high-income groups had lesser perceived and objective dental needs compared to the low-income groups. Furthermore, factors such as sex, educational level, and marital status had different influence on both needs.

Conclusion:

Generally, factors that affect perceived and objective dental needs were similar. To minimize unmet dental needs, factors influencing both perceived and objective dental needs should be examined for a broad dental insurance coverage, and efforts to prevent oral diseases are also required.

Keywords : Objective needs, Oral health, Perceived needs, Unmet needs
Introduction

Generally, unmet needs refer to needs and/or healthcare services that are not timely and properly provided and performed, representing one of the problems of the healthcare system1). Unmet needs are divided into objective dental needs and perceived dental needs depending on the appraising subjects2). Objective needs are needs assessed by healthcare professionals, while perceived dental needs, referred to as medical wants, indicate the subjective dental needs that the patients themselves perceive3). It is possible that in assessing the unmet needs based on the needs perceived by the patients themselves, bias in the process of remembering and reporting experiences by the patients and questions on whether subjective assessment can assure an objective assessment may be observed1), with the patients’ subjective evaluation and recognition influencing the utilization of healthcare services and treatment compliance.

Particularly, oral health is significantly related to systemic health, and oral diseases, if improperly and untimely treated, lead to worsening of the disease and expensive treatment. Subsequently, economic burden increases. Nevertheless, low utilization rate of dental services and unmet dental needs have been consistently observed worldwide4-8).

Recently, there have been studies conducted that examine the unmet dental needs, with studies reporting the unmet dental needs for specific groups such as children in the low-income group, children with disabilities, youth, and workers9-12) or studies determining the factors affecting unmet dental needs6,9,10). Only socioeconomic factors such as income or employment status and status of private insurance and dental fear were considered the causes of unmet dental needs, and studies that confirm the difference between subjective dental needs and objective dental needs in unmet dental care were not conducted.

Consequently, this study aimed to confirm the difference between objective dental needs (need) and perceived dental needs (want) in the unmet dental care and to determine the factors that influence objective dental needs and perceived dental needs in Korean adults using the materials of the Fifth Korean National Health and Nutrition Survey. This way, this study was able to widely determine the unmet dental needs and recommend an increased access to dental care services to reduce the unmet dental needs.

Materials and Methods

1. Materials

This study used the materials from the Korean National Health and Nutrition Survey using the fifth (2010∼2012) rotation sample survey. The average participation rate in the study over the past 3 years was 80%, comprising 3,800 households from the 192 sampling areas each year with data of all the household members over the age of 1 year in the sampled households13). It includes comprehensive information, such as disease morbidity, healthcare utilization, and demographic and socioeconomic characteristics of the subjects in the study. This study was performed to analyze 17,735 adults aged greater than 19 years who had received an oral examination.

2. Variables

Despite the need for dental treatment, individuals who do not want to receive dental treatment was defined as a perceived dental need. In this case, actual needs (needs or objective dental needs) based on medical diagnosis and subjective dental needs (wants or perceived dental needs) can be distinguished, depending on the patients who require dental care.

In this study, objective dental need is reclassified according to the extent of treatment needed as assessed during oral examination of the teeth into the following: “unneeded of treatment,” “dental conservative treatment needs,” “dental prosthetic treatment needs,” and “extraction needs.” In assessing the patients’ perceived dental needs, the following question was asked: “Haven’t you ever been given dental treatment for 1 year lately in spite of thinking that you needed dental care?,” with a “yes” or “no” answer (Table 1). Regarding the variables considered to be factors that influence dental treatment needs, sex and age were considered as the demographic variables, and region, equivalent income, educational level, marital status, and status of private insurance were considered as the socioeconomic variables.

Descriptive Variables

 Classification  Detail
Dependent variable
 Perceived needs 0=no, 1=yes
 Objective needs 0=treatment unneeded
1=dentist conservation treatment needs
2=dental prosthetic treatment needs
3=teeth extraction needs
Independent variable
 Sex 1=male, 2=female
 Age (y) 1= 19~44, 2= 45~64, 3= 65 or older
 Region 1=urban, 2=rural
 Household income 1=low, 2=mid-low, 3=mid-upper, 4=upper
 Educational attainments 1=elementary or less, 2=middle school, 3=high school, 4=college or more
 Marital status 1=living together, 2=living apart, 3=bereavement, 4=divorce, 5=unmarried
 Private insurance 1=yes, 2=no
 Subjective oral health 1=very good, 2=good, 3=medium, 4=poor, 5=very poor
 Regular oral examination 1=yes, 2=no


3. Data analysis

Descriptive statistics were generated to describe the prevalence of perceived (or objective) needs and subjective dental needs for oral health. We determined the associations between the independent and dependent variables using a chi-squared test. Moreover, multiple logistic regression analysis was performed to determine the factors affecting perceived dental needs, with the following two answers: “yes” or “no.” Ordinal logistic regression analysis was performed to determine the variables affecting objective dental needs, which had the following multiple categorical values: “unneeded of treatment,” “dental conservative treatment needs,” “dental prosthetic treatment needs,” and “extraction needs.” Stata version 11.0 (Stata Co., College Station, TX, USA) was used to perform all the statistical analyses, and p<0.05 was="" considered="" significant="" p="">

Results

1. Comparison between perceived and objective dental needs

Tables 2 and 3 summarize the results regarding the association between perceived dental needs and objective dental needs based on the patients’ general characteristics. In the case of perceived dental needs, lower income and worse subjective status of oral health without oral examinations but with private insurance were statistically significant (p<0.001). While in the case of objective dental needs, it was statistically confirmed that there was a significantly lower need for dental treatment in urban areas (80.11%) than in rural areas (19.89%) (p<0.001).

Relation between General Characteristics and Perceived Dental Needs (n=17,735)

 Classification No Yes p-value
Sex
 Male 4,932 (43.70) 2,586 (40.10) <0.000
 Female 6,354 (56.30) 3,863 (59.90)
Age (y)
 19~44 4,557 (40.38) 3,041 (47.15) <0.000
 45~64 3,747 (33.20) 2,143 (33.23)
 65 or older 2,982 (26.42) 1,265 (19.62)
Region
 Urban 8,943 (79.24) 5,100 (79.08) 0.803
 Rural 2,343 (20.76) 1,349 (20.92)
Household income
 Low 2,684 (24.07) 1,634 (25.56) 0.006
 Mid-low 2,787 (24.99) 1,593 (24.92)
 Mid-upper 2,771 (24.85) 1,639 (25.64)
 Upper 2,910 (26.09) 1,527 (23.89)
Educational attainments
 Elementary or less 3,016 (26.78) 1,551 (24.12) 0.001
 Middle school 1,229 (10.91)  700 (10.89)
 High school 3,684 (32.71) 2,195 (34.14)
 College or more 3,335 (29.61) 1,984 (30.86)
Marital status
 Living together 8,419 (74.65) 4,661 (72.30) <0.000
 Living apart  59 (0.52)  41 (0.64)
 Bereavement 1,066 (9.45)  579 (8.98)
 Divorce 243 (2.15) 215 (3.33)
 Unmarried 1,491 (13.22) 951 (14.75)
Private Insurance
 Yes 7,822 (70.16) 4,584 (71.95) 0.012
 No 3,327 (29.84) 1,787 (28.05)
Subjective oral health
 Very good 171 (1.54) 33 (0.52) <0.000
 Good 1,757 (15.78) 356 (5.60)
 Medium 5,042 (45.27) 1,927 (30.30)
 Poor 3,539 (31.78) 3,159 (49.68)
 Very poor 628 (5.64) 884 (13.90)
Regular oral examination
 No 8,111 (72.83) 5,100 (80.21) <0.000
 Yes 3,026 (27.17) 1,258 (19.79)

Values are presented as n (%).

p-values by chi-square test.


Relations between General Characteristics and Objective Dental Needs (n=17,735)

 Classification 0 1 2 3 p-value
Sex
 Male 4,925 (40.11) 950 (43.03) 305 (44.20) 1,456 (51.56) <0.000
 Female 7,353 (59.89) 1,258 (56.97) 385 (55.80) 1,368 (48.44)
Age (y)
 19~44 4,909 (39.98) 1,242 (56.25) 278 (40.29) 1,180 (41.78) <0.000
 45~64 4,196 (34.17) 662 (29.98) 249 (36.09) 809 (28.65)
 65 or older 3,173 (25.84) 304 (13.77) 163 (23.62) 835 (29.57)
Region
 Urban 9,836 (80.11) 1,674 (75.82) 541 (78.41) 2,154 (76.27) <0.000
 Rural 2,442 (19.89) 534 (24.18) 149 (21.59) 670 (23.73)
Household income
 Low 2,933 (24.20) 473 (21.62) 195 (28.68) 843 (30.32) <0.000
 Mid-low 3,071 (25.34) 558 (25.50) 149 (21.91) 653 (23.49)
 Mid-upper 2,931 (24.18) 585 (26.74) 187 (27.50) 752 (27.05)
 Upper 3,186 (26.28) 572 (26.14) 149 (21.91) 532 (19.14)
Educational attainments
 Elementary or less 3,138 (26.22) 397 (18.46) 180 (26.99) 821 (30.37) <0.000
 Middle school 1,293 (10.81) 232 (10.79) 84 (12.59) 298 (11.02)
 High school 3,857 (32.23) 838 (38.96) 222 (33.28) 880 (32.56)
 College or more 3,678 (30.74) 684 (31.80) 181 (27.14) 704 (26.05)
Marital status
 Living together 9,155 (74.68) 1,590 (72.08) 499 (72.42) 1,981 (70.32) <0.000
 Living apart 64 (0.52) 14 (0.63) 5 (0.73) 24 (0.85)
 Bereavement 1,240 (10.12) 118 (5.35) 77 (11.18) 309 (10.97)
 Divorce 286 (2.33) 60 (2.72) 16 (2.32) 101 (3.59)
 Unmarried 1,514 (12.35) 424 (19.22) 92 (13.35) 402 (14.27)
Private insurance
 Yes 8,573 (70.78) 1,658 (75.85) 462 (68.04) 1,736 (62.45) <0.000
 No 3,540 (29.22) 528 (24.15) 217 (31.96) 1,044 (37.55)
Subjective oral health
 Very good 162 (1.32) 26 (1.18) 4 (0.58) 15 (0.53) <0.000
 Good 1,718 (14.01) 208 (9.44) 49 (7.12) 194 (6.88)
 Medium 5,303 (43.23) 869 (39.43) 192 (27.91) 781 (27.71)
 Poor 4,270 (34.81) 924 (41.92) 350 (50.87) 1,354 (48.05)
 Very poor 813 (6.63) 177 (8.03) 93 (13.52) 474 (16.82)
Regular oral examination
 No 8,904 (73.66) 1,723 (79.44) 500 (73.96) 2,237 (81.52) <0.000
 Yes 3,184 (26.34) 446 (20.56) 176 (26.04) 507 (18.48)

Values are presented as n (%).

p-values by chi-square test.

0: unneeded of treatment, 1: dental conservative treatment needs, 2: dental prosthetic treatment needs, 3: extraction needs.



2. Factors affecting subjective and objective dental needs

The result of determining the variables affecting perceived dental needs and objective dental needs is shown in Table 4. The perceived and objective dental needs were 1.03 times and 1.15 times higher, respectively, for people who live in rural areas than those who live in urban areas (p<0.01). Moreover, the high-income groups had lesser perceived and objective dental needs compared to the low-income groups. Regarding educational level, patients who were college graduates or who had advanced degrees had 1.18 times higher perceived dental needs and 0.77 times lower objective dental needs compared to patients with elementary school or lower educational level. Patients who did not undergo oral examination for 1 year had a higher perceived and objective dental need compared to patients who underwent oral examination for 1 year (p<0.01).

Factors Affecting Perceived and Objective Dental Needs

Classification Perceived dental needsa Objective dental needsb

OR (95% CI) OR (95% CI)
Sex
 Male - -
 Female 1.185 (1.105~1.271) 0.690 (0.645~0.739)
Age (y)
 19~44 - -
 45~64 0.749 (0.683~0.822) 0.632 (0.576~0.694)
 65 or older 0.458 (0.401~0.523) 0.501 (0.440~0.570)
Region
 Urban - -
 Rural 1.028 (0.944~1.120) 1.148 (1.057~1.246)
Household income
 Low - -
 Mid-low 0.883 (0.800~0.975) 0.848 (0.770~0.934)
 Mid-upper 0.912 (0.828~1.005) 0.958 (0.872~1.052)
 Upper 0.809 (0.729~0.897) 0.758 (0.685~0.840)
Educational attainments
 Elementary or less - -
 Middle school 1.101 (0.970~1.250) 0.971 (0.858~1.099)
 High school 1.073 (0.959~1.200) 0.878 (0.786~0.980)
 College or more 1.177 (1.039~1.334) 0.774 (0.684~0.876)
Marital status
 Living together - -
 Living apart 1.235 (0.799~1.907) 1.511 (1.002~2.279)
 Bereavement 1.148 (1.006~1.309) 1.064 (0.932~1.216)
 Divorce 1.363 (1.109~1.675) 1.322 (1.083~1.613)
 Unmarried 0.982 (0.883~1.091) 1.135 (1.026~1.256)
Private Insurance
 Yes - -
 No 1.085 (0.991~1.186) 1.207 (1.107~1.317)
Subjective oral health
 Very good - -
 Good 1.037 (0.697~1.544) 0.936 (0.658~1.333)
 Medium 1.868 (1.271~2.743) 1.249 (0.888~1.756)
 Poor 4.704 (3.205~6.905) 2.307 (1.642~3.242)
 Very poor 7.782 (5.243~11.551) 3.666 (2.581~5.206)
Regular oral examination
 No - -
 Yes 0.627 (0.578~0.680) 0.742 (0.685~0.804)

OR: odds ratio, CI: confidence interval, -: reference.

By multilple logistic regression.

By ordinal logistic regression.


Discussion

This study aimed to distinguish between perceived dental needs and objective dental needs based on the unmet dental needs for adults and to determine the factors influencing perceived and objective dental needs.

Several factors that influence perceived and objective dental needs were determined. These included sex, individual income, educational level, status of private insurance, and subjective oral health status. According to sex, females showed higher perceived dental needs than males. On the contrary, males had higher objective dental needs than females. These results show that females are more concerned about their oral health than males, and women’s higher perceived dental needs indicate that they fully utilize dental care services. Both perceived dental needs and objective dental needs decreased as age increased. In the unmet healthcare needs, the highest perceived dental needs were observed in patients in their 20s to 40s, with dental needs decreasing with increasing age14). Thus, unmet dental needs should be reduced by performing preventive treatment such as using fluoride (e.g., water or salt fluoridation) and conducting repetitive oral health education regarding oral health and its cost-effectiveness even to children.

Particularly, objective dental needs in rural areas are slightly higher than in urban areas. Neighborhood socioeconomic status poses several risks on health15). People living in areas that lack diverse social infrastructures may have difficulty accessing health care because of insufficient healthcare facilities and healthcare personnel in their area16). Unmet dental needs of adults and children6) who live in rural areas are higher than those in urban areas because of regional vulnerabilities17). Perceived dental needs and objective dental needs of the low-income groups were 1.20 times and 1.25 times higher than the high-income groups, respectively. That is, as income level increases, unmet dental needs significantly decrease4-6,18). Consistent to the results of the study by Kim et al.4), in the low-income groups, inability to undergo dental care due to financial constraints can be considered as objective dental needs. Patients who were college graduates or had advanced degrees had higher perceived dental needs and lower objective dental needs than those patients with elementary school or less educational level. It is considered that educational level has significant effects on the knowledge, attitudes, and behaviors on oral health. The higher the level of education, the higher the interest on oral health. That is, it appears that patients with higher educational level had higher perceived dental needs and lower objective dental needs due to regular oral examination resulting in early treatment than patients with lower educational level. Moreover, oral health education should be repeatedly conducted to individuals with low educational level as it affects the oral health of children and young people4).

Regarding marital status, individuals living with a spouse showed the lowest objective dental needs among all the marital statuses. Generally, married individuals are healthier than the unmarried individuals because the interest or caring for a spouse influences him or her to keep sound and healthy19). The result of the study based on the National Health Interview Survey suggests that married individuals are economically richer compared to unmarried individuals10). Objective dental needs were higher in individuals with private insurance than in individuals with no private insurance. However, this study was not able to determine the effect of private insurance on the perceived dental needs of the individuals. However, in some studies, unmet dental needs of subjects without private insurance were higher (odds ratio, 1.6∼3.5) than the unmet dental needs of subjects with private insurance4,19). It is thought that such a difference resulted from not specifying the information on private insurance used for dental care in this study. Hence, determining the subjects with private dental insurance to assure the availability of private dental insurance scheme is required in future studies.

According to this study, generally, the factors influencing perceived dental needs and objective dental needs were similar. In conclusion, efforts to strengthen dental health insurance and to prevent oral diseases have to be continued to reduce the unmet dental needs. Hence, it is necessary to improve the knowledge and attitudes of the individuals by providing proper information on the need for dental care and implementing the appropriate oral care to the medical consumers20). Maintaining good health is not just an individual effort but a collaboration with the nation and society that recognize their co-responsibility and implement strategies and efforts to maintain the individuals’ health. Improvement in policies should be established to provide timely and appropriate healthcare services for the individuals. Using the oral health projects in schools, which is considered the most efficient strategy to improve an individual’s knowledge, attitudes, and behaviors on oral health, we suggest that dental health rooms should be established in elementary schools to improve oral health education and preventive treatment.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

The study was reviewed and approved by the Institutional Review Board of Eulji University (Seongnam, Korea), which also approved the secondary data analysis (approval No. EUIRB2016-32).

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