Dental Service Utilization by Europeans Aged 50 Plus

8/13/2019 Dental Service Utilization by Europeans Aged 50 Plus

1/12

In recent years, population aging has receivedincreasing attention from health policy and clinicaldecision makers (1, 2). This is mainly because of economic considerations that identify populationaging as one factor that explains the steady rise indental(3,4)andhealthcare(5,6)expenditures.Othercauses frequently cited include advancing medicalinnovation (7) and the epidemiological shift fromacute to chronicdiseases (8). Despite the relevance of dental service utilization by populations aged50 years or over to health service and workforceplanning (9), there is little comparative evidenceregarding the utilization of dental services by thisdemographicgroupacrossEuropeancountries.Suchinformation may, however, enable a better under-standing of the extent to which different socioeco-nomic, cultural, and institutional settings shape theutilization of dental services by persons aged50 years and over, as well as provide guidance to

decision makers in dental services regarding thisdemographic group.

To the best of our knowledge,differences betweenEuropean countries in the dental attendance of theproportionofthepopulationaged50plushavenever been investigated. The purposes of this study weretherefore to describe variations in the utilization of dental services by persons aged 50+ from differentEuropean countries and to identify the extent towhich such variations are attributable to differencesin oral health need and in accessibility of dental care.

MethodsDatasetThe analysis presented here is based on cross-sectional data from Wave 2 of the Surveyof Health, Ageing, and Retirement in Europe

Community Dent Oral Epidemiol 2012; 40: 164174 All rights reserved

2011 John Wiley & Sons A/S

Dental service utilization byEuropeans aged 50 plusListl S, Moran V, Maurer J, Faggion CM Jr. Dental service utilization byEuropeans aged 50 plus. Community Dent Oral Epidemiol 2012; 40: 164174.

2011 John Wiley & Sons A S

Abstract Objectives: To describe variations in the utilization of dental services by persons aged 50+ from 14 European countries and to identify the extent towhich such variations are attributable to differences in oral health need and inaccessibility of dental care. Methods: We use data from the Survey of Health,Ageing, and Retirement in Europe (SHARE Waves 2 and 3) and estimate aseries of multivariate logistic regression models to analyze variations in dentalservice utilization (overall dental attendance, preventive treatment and oroperative treatment, dental attendance in early life years) Results: Overalldental attendance and incidence of solely preventive treatment arecomparatively high in the Netherlands, Sweden, Denmark, Germany, andSwitzerland. In contrast, overall dental attendance is relatively low in Spain,Italy, France, Greece, Poland, and Ireland. Moreover, a high incidence of solelyoperative treatment is observed in Austria, Italy, and France, whereas in theNetherlands, Sweden, Denmark, Switzerland, and Ireland, the incidence of solely operative treatment is comparably low. By and large, these variationspersist even when controlling for cross-country differences in oral health needand in accessibility of dental care. Conclusions: In comparison with otherEuropean regions, there is a tendency toward more frequent and preventivedental treatment of the elderly populations residing in Scandinavia andWestern Europe. Such utilization patterns appear only partially attributable todifferences in need for and accessibility of dental care.

Stefan Listl 1,2 , Valerie Moran 3 , Ju rgen Maurer 4 andClovis M. Faggion Jr 5

1 Department of Conservative Dentistry,University of Heidelberg, Heidelberg,Germany, 2 Mannheim Research Institute forthe Economics of Aging (MEA), Universityof Mannheim, Mannheim, Germany, 3 HealthDivision, Employment, Labour and SocialAffairs Directorate, Organisation forEconomic Co-operation and Development(OECD), Paris, France, 4 University of Lausanne, Institute of Health Economics andManagement (IEMS), Lausanne,Switzwerland, 5 Department of Prosthodontics, University of Heidelberg,Heidelberg, Germany

Key words: dental services research; Europe;geriatrics; public policy; utilization

Stefan Listl, Department of ConservativeDentistry, University of Heidelberg, ImNeuenheimer Feld 400, Heidelberg Baden-Wu rttemberg, 69120 Heidelberg, Germany.Tel.: +49 621 181 1863Fax: +49 621 181 1863e-mail: [email protected]

Submitted 10 August 2010;accepted 1 August 2011

164 doi: 10.1111/j.1600-0528.2011.00639.x


2/12

(SHARE). In addition, we rely on SHARELIFE the third wave of SHARE that provides retrospec-tive information on early life conditions of SHAREparticipants. Wave 2 data of SHARE were collectedduring 20062007, while SHARELIFE data werecollected during 20082009. A detailed descriptionof the process of data collection is available on the

SHARE webpage (see http://www.share-project.org). The survey is modeled closely after the USHealth and Retirement Study (HRS) and is the rstEuropean dataset to combine extensive cross-national information on socioeconomic status,health, and family conditions of the populationaged 50 or older. SHARE contains information on arepresentative sample of about 34 000 individualsfrom 23 000 households in 14 countries. Despitecountries such as Norway, Finland, Portugal, andLuxembourg not yet being included in SHARE, thesurvey presents a snapshot of Europes economic,social, institutional, and cultural diversity fromScandinavia to the Mediterranean. In addition, thelarge degree of harmonization of the SHAREquestionnaire and sample design makes SHAREan ideal resource for comparative analysis of health care use among older Europeans (10).

Measures of utilization, oral health need, andaccessibility of dental servicesUtilization of dental services. In addition to generalrespondents characteristics (age, sex, and subjec-

tive health), SHARE provides information onaccess to dental services and utilization of pre-ventive and or operative treatment. In a rstquestion, SHARE participants were asked toanswer the following question: During the lasttwelve months, have you seen a dentist or a dentalhygienist?

If respondents had answered yes to the abovequestion, more detailed information about thetype of care received was obtained using thefollowing survey item: Was that for routine con-trol or prevention, for treatment, or for both?Based on these questions, we construct severaloutcome variables, i.e. (i) any dental care use; (ii)preventive dental care use only; (iii) operativedental care use only; and (iv) preventive andoperative care use.

Within SHARELIFE, respondents were alsoasked to retrospectively report their access todental care in early life years based on the question:Did you start going regularly to the dentist duringyour childhood (that is, from when you were bornup to and including age 15)? Based on this survey

item, we construct our nal outcome variable, i.e.regular dental care use during childhood.Oral health care need. We use the following twoSHARE questions regarding respondents oralhealth to dene oral health care need: Can you bite and chew on hard foods such as a

rm apple without difculty?

Do you use dentures?As a complement to oral health measures pro-vided by SHARE, we have matched edentulous-ness rates (population proportions of persons withcomplete loss of all natural teeth) from the FDIWorld Dental Federation Oral Health Atlas (seehttp://www.oralhealthatlas.org) to our database.These data are available only at the country level. Accessibility of dental services. SHARE providesseveral measures that can be considered as deter-minants of accessibility of dental services. First,dental insurance coverage reects the extent towhich treatment costs are borne by the individualas opposed to their health insurance. This infor-mation is gathered by asking Who nally pays fordental care? and categorizing the answer intoyourself only, mostly yourself, mostly yourhealth insurance, or your health insurance only.For ease of interpretation, we generated a binarycontrol variable by combining the categories your-self only and mostly yourself and the categoriesmostly your health insurance and your healthinsurance only, respectively.

Second, we treat net monthly family income as afurther determinant of accessing dental services.Such a measure of socioeconomic conditions can berelevant when considering travel costs incurred fordental visits. Our income measure refers to thefollowing SHARE question: To summarize, howmuch was the overall income, after tax, that yourentire household had in an average month in theprevious year? We also regard years of schoolingand number of books in household during child-hood as further socioeconomic determinants of access to dental care at age 50+ or in early lifeyears, respectively. A comprehensive justicationfor using number of books per household as ameasure for socioeconomic status during child-hood can be found elsewhere (11). Finally, dentalvisits can be associated with costs resulting fromtime off work. In particular, individuals who donot participate in the labor force can be consideredto incur little or no costs as caused by loss of earnings through work. In this regard, SHAREprovides information on whether a respondent isunemployed (laid out or out of work, including

165

Dental service use by elderly Europeans


3/12

short-term unemployment) and or retired (retiredfrom own work, including semi-retired, partiallyretired, early retired, and pre-retired).

Estimation strategyIn a rst series of multivariate logistic regressionmodels, we used dental service utilization by

individuals aged 50+ as dependent variables andexplored the extent to which cross-country varia-tions hold robust against different model speci-cation. The latter were dened according to thefollowing control variables:(A) respondents age and sex(B) respondents age and sex and health status and

oral health status(C) respondents age and sex and health status and

oral health status and dental insurance cover-age

(D) respondents age and sex and health status andoral health status and dental insurance cover-age and socioeconomic status

(E) respondents age and sex and health status andoral health status and dental insurance cover-age and socioeconomic status and labor forceparticipation

To examine whether dental attendance patternsin early life years are similar to those found at age50+ (for the same persons), we used retrospectiveinformation on respondents utilization of dentalservice during childhood adolescence (up to age15) as a dependent variable in a second series of multivariate logistic regression models. Based on

the retrospective information available regardingrespondents early life years, we included thefollowing variables as controls:(retro-A) respondents sex(retro-B) respondents sex and subjectively rated

health during childhood(retro-C) respondents sex and subjectively rated

health during childhood and socioeconomic sta-tus during childhoodOur regression models include dummy variable

controls for respondents country of residencewhereby the countries with median dental careuse (see results section) serve as (omitted) referencecategories. This specication suitably allows theidentication of treatment variations relative to themedian. Also note that we treat respondents whosenet monthly family income exceeds 1 000 000 Euroas statistical outliers; we therefore exclude such

Table 1. Dental service utilization at age 50+ and in early life years

Country Any Preventive only Operative only Preventive and Operative Childhood

Austria 50.13% 20.61% 16.09% 13.39% 69.89%(n = 1149) (n = 445)

Germany 75.64% 34.39% 10.02% 31.12% 64.62%(n = 1954) (n = 1077)

Sweden 81.55% 39.85% 11.23% 30.34% 87.19%(n = 2499) (n = 1397)

Netherlands 65.73% 33.62% 5.57% 26.30% 83.90%(n = 2110) (n = 1273)

Spain 25.37% 7.97% 9.85% 7.48% 24.42%(n = 1427) (n = 434)

Italy 36.76% 12.85% 15.13% 8.76% 31.71%(n = 2590) (n = 968)

France 48.39% 15.25% 22.81% 9.77% 59.78%(n = 2327) (n = 1176)

Denmark 80.43% 47.62% 3.93% 28.74% 77.56%(n = 2310) (n = 1631)

Greece 38.50% 10.30% 14.53% 13.63% 42.31%(n = 1774) (n = 527)

Switzerland 73.37% 33.50% 9.15% 30.34% 84.78%(n = 1164) (n = 782)

Belgium 49.69% 19.57% 13.28% 16.81% 54.35%(n = 2604) (n = 1369)

Czechia 53.72% 17.52% 13.17% 22.85% 93.43%(n = 2059) (n = 1156)

Poland 23.76% 3.12% 13.54% 7.07% 73.92%(n = 2176) (n = 648)

Ireland 40.90% 22.34% 8.16% 10.17% (n = 841)

N = 26 984 N = 12 883

, No information available.

166

Listl et al.


4/12

observations in our analysis to prevent bias in oursample 1 . All data analyses were carried out usingthe software package STATA SE 10.1 (StataCorp,College Station, TX, USA).

ResultsDental care utilization of older Europeans:cross-country comparisonsTable 1 shows the incidence rates of dental treat-ment by respondents country of residence, whichreveals substantial differences in dental care utili-

zation rates of older persons across differentEuropean countries. For example, almost 82% of Swedish respondents but only about 24% of Polishrespondents report having seen a dentist within thepast year. According to these univariate variationsin the utilization of dental services, Table 2 ranksrespondents countries according to treatmentincidence by both overall and type of treatment.By way of example, Table 2 shows that Denmarkhas a comparably high incidence of preventive butrelatively low incidence of operative treatment.Moreover, Table 2 shows the countries that areranked either lower or upper median in all fourcolumns which represent different dental careutilization patterns at older ages.

Table 2 also ranks study populations accordingto respective proportions of regular access to dentalservices during childhood adolescence. As high-

lighted in Table 1, there are considerable cross-country variations in dental utilization during earlylife years. Czechia ranks highest with a probabilityof about 93% of having regularly accessed dentalservices during childhood adolescence, whereasSpain ranks lowest with a probability of about 24%.

Oral health care need and accessibility of dentalservices: cross-country comparisonsDescriptive statistics for oral health status anddental insurance coverage are given in Table 3.Descriptive statistics for all other control variablesare presented in Table 4. Because of their specialimportance for the analysis at hand, oral healthstatus and dental insurance coverage are reportedseparately and in more detail by country. In termsof oral health care need, edentulous rates vary between 15% (Austria) and 61% (the Netherlands);denture wearing varies between 13% (Sweden) and61% (Austria); the highest chewing ability is foundin Sweden (92%), and the lowest in Poland (67%).Note that levels of denture wearing and propor-tions of edentulous persons do not necessarily needto correspond to each other because rates of

noncompensated complete tooth loss may differ between countries (12). In terms of accessibility of dental services, the fraction of the populationwhose dental care is mostly or fully paid by healthinsurance varies between 90% (Germany) and 9%(Switzerland).

Findings from regression analysisDental service utilization at ages 50+. Table 5 showsodds ratios for variations in dental attendance byrespondents country of residence (relative to the

Table 2. Countries ranked by incidence of dental attendance

Any Preventive only Operative only Preventive and Operative Childhood

Sweden (HI) Denmark (HI) France (HI) Germany (HI) Czechia (HI)Denmark Sweden Austria Switzerland SwedenGermany Germany Italy Sweden SwitzerlandSwitzerland The Netherlands Greece Denmark The NetherlandsThe Netherlands Switzerland Poland The Netherlands DenmarkCzechia Ireland Belgium Czechia PolandAustria (UM) Austria (UM) Czechia (UM) Belgium (UM) Austria a (UM)Belgium (LM) Belgium (LM) Sweden (LM) Greece (LM) Austria a (LM)France Czechia Germany Austria GermanyIreland France Spain Ireland FranceGreece Italy Switzerland France BelgiumItaly Greece Ireland Italy GreeceSpain Spain The Netherlands Spain ItalyPoland (LI) Poland (LI) Denmark (LI) Poland (LI) Spain (LI)

HI: highest incidence; UM: upper median; LM: lower median; LI: lowest incidence; a Because of missing information forIreland, Austria represents the only median.

1 As a robustness check, we have also run our regressionanalysis without excluding observations with a netmonthly family income above 1 000 000 Euro andobtained similar results.

167



5/12

median, i.e. Belgium and Austria). The differentmodel specications in columns (A) to (E) illustratethat the model specication inuences the magni-tude of some parameter estimates for cross-countrydifferences in dental attendance. In particular, theadditional inclusion of respondents health andsocioeconomic status as well as insurance coverageleads to alterations in parameter estimates forcountries such as Sweden, Denmark, and Switzer-land. Statistical (non)signicance and sign of

parameter estimates (above, equal, or below 1)hold robust across almost all different modelspecications. The coefcients for France are onlystatistically signicant in model specications (B)to (E). Table 5 identies a median level of dentalattendance in Belgium, Austria, and Czechia (rel-ative to the other countries). The level of dentalattendance is statistically signicantly above themedian in the Netherlands, Sweden, Denmark,Germany, and Switzerland. Moreover, the level of

Table 3. Descriptive statistics of control variables for oral health care need and dental insurance coverage at age 50+

Country Edentulous Dentures Able to chew Dental insurance

Austria (%) 15.00 61.01 79.57 86.92Germany (%) 23.00 49.80 80.98 89.78Sweden (%) 16.00 13.41 92.40 15.70Netherlands (%) 61.00 46.35 85.40 81.04Spain (%) 31.00 39.69 78.39 22.41Italy (%) 44.00 32.97 73.66 12.71France (%) 16.00 33.26 78.96 77.65Denmark (%) 27.00 27.43 81.65 34.06Greece (%) 25.00 27.15 80.18 27.46Switzerland (%) 14.00 30.47 88.07 8.79Belgium (%) 41.00 54.74 74.85 84.42Czechia (%) 34.00 43.90 70.82 69.53Poland (%) 35.00 56.27 67.16 65.24Ireland (%) 48.00 54.99 80.19 45.04N 27 060 27 012 27 008 26 390

Table 4. Descriptive statistics of general demographic characteristics, socioeconomic status, and labor force participation

Variables Mean proportion (SD), % N

Age 66.54 (10.11) 33 763Female 55.04 33 812Subjective health is

excellent 9.01 33 684very good 18.78 33 684good 36.92 33 684fair 24.63 33 684poor 10.60 33 684

Subjective health during childhood was excellent 35.21 26 181was very good 33.68 26 181was good 22.86 26 181

was fair 5.74 26 181was poor 2.10 26 181varied a great deal (spontaneous) 0.40 26 181

Net monthly household income (EUR) 4818.97 (18342.07) 27 060Years of schooling 10.51 (4.28) 33 239Number of books in household during childhood

none or very few (010 books) 44.17 18 738enough to ll one shelf (1125 books) 22.17 18 738enough to ll one bookcase (26100 books) 20.80 18 738enough to ll two bookcases (101200 books) 6.47 18 738enough to ll two or more bookcases (more than 200 books) 6.39 18 738

Unemployed 2.71 27 060Retired 52.29 27 060

168

Listl et al.


6/12

dental attendance is statistically signicantly belowthe median in Spain, Italy, France, Greece, Poland,and Ireland. Figure 1 illustrates the geographicaldistribution of these ndings on basis of the oddsratios in Table 5.

Table 6 shows odds ratios for variations insolely preventive dental treatment according torespondents country of residence (relative to themedian, i.e. Belgium and Austria). Similar toTable 5, the different model specications in col-umns (A) to (E) illustrate that the model speci-cation inuences the magnitude of someparameter estimates for cross-country differences.

In particular, the additional inclusion of respon-dents health status and insurance coverage lead toalterations in parameter estimates for countriessuch as Sweden, Denmark, and Switzerland.Again, statistical signicance and sign of param-eter estimates (above, equal, or below 1) holdrobust across different model specications. Ta- ble 6 thus identies that utilization of preventivedental treatment is at a median level in Belgium,Austria, and Ireland (relative to the other coun-tries). The level of preventive treatment is statis-tically signicantly above the median in theNetherlands, Sweden, Denmark, Germany, andSwitzerland. Moreover, the level of dental atten-dance is statistically signicantly below the med-ian in Spain, Italy, France, Greece, Czechia, andPoland. These ndings are also shown in Fig. 2,which shows the levels of solely preventive dentaltreatment in the countries under study on the basisof the odds ratios in Table 6.

Table 7 shows the odds ratios for variations insolely operative dental treatment according torespondents country of residence (relative to the

median, i.e. Czechia and Sweden). The differentmodel specications in columns (A) to (E) illus-trate that the control for potential confoundersinuences the statistical signicance of only someparameter estimates for cross-country differences:the inclusion of additional control variables leadsto alterations in signicance for Germany, Italy,Greece, and Switzerland. For other countries, sta-tistical (non)signicance of parameter estimates

Table 5. Regression results for dental attendance (odds ratios relative to the median)

(A) (B) (C) (D) (E)

The Netherlands 1.844 (0.106)*** 1.891 (0.187) *** 1.977 (0.199) *** 2.765 (0.288) *** 2.724 (0.285) ***Sweden 4.953 (0.311)*** 3.300 (0.267)*** 2.916 (0.249)*** 2.317 (0.208)*** 2.351 (0.211)***Denmark 4.170 (0.264)*** 3.389 (0.227)*** 3.145 (0.217)*** 2.490 (0.177)*** 2.506 (0.178)***Germany 3.213 (0.204)*** 3.197 (0.226)*** 3.211 (0.229)*** 2.365 (0.177)*** 2.406 (0.180)***Italy 0.570 (0.030)*** 0.510 (0.032)*** 0.431 (0.029)*** 0.589 (0.042)*** 0.576 (0.041)***France 0.911 (0.049) 0.759 (0.056)*** 0.756 (0.056)*** 0.561 (0.045)*** 0.567 (0.045)***Greece 0.597 (0.036)*** 0.464 (0.031)*** 0.406 (0.028)*** 0.418 (0.030)*** 0.423 (0.031)***Switzerland 2.854 (0.217)*** 2.194 (0.207)*** 1.797 (0.179)*** 1.370 (0.144)** 1.416 (0.149)***Czechia 1.116 (0.063) 1.106 (0.064) 1.103 (0.065) 1.008 (0.060) 0.976 (0.058)Poland 0.283 (0.017)*** 0.323 (0.020)*** 0.320 (0.020)*** 0.339 (0.022)*** 0.331 (0.022)***Spain 0.347 (0.024)*** 0.308 (0.022)*** 0.269 (0.020)*** 0.323 (0.026)*** 0.331 (0.026)***Ireland 0.653 (0.052)*** 0.640 (0.058)*** 0.591 (0.055)*** 0.648 (0.061)*** 0.651 (0.061)***N 26950 26930 26327 26026 26026

Standard errors in parentheses.*P < 0.05, **P < 0.01, ***P < 0.001.

Fig. 1. Dental attendance by Europeans aged 50 andabove. Figure is based on results from Table 5, model

specication (E).

169



7/12

(above, equal, or below 1) holds robust acrossdifferent model specications. Overall, Table 7identies that the utilization of just operativedental treatment is at a median level in Czechia,Sweden, Germany, Italy, Belgium, and Poland(relative to the other countries). The level of isolated operative treatment is statistically signi-cantly above the median in Austria, France, and

Greece, whereas it is below the median in theNetherlands, Spain, Denmark, Switzerland, andIreland. These ndings are also shown in Fig. 3,which illustrates geographical variations in solelyoperative dental treatment in Europe on the basisof odds ratios in Table 7.

Table 8 shows the odds ratios for variations incontemporaneous preventive and operative dentaltreatment according to respondents country of residence (relative to the median, i.e. Greece andBelgium). Different model specications in col-umns (A) to (E) illustrate that the control forpotential confounders inuences the magnitude of

some parameter estimates for cross-country differ-ences. In particular, the additional inclusion of respondents health status and insurance coveragelead to alterations in parameter estimates forSweden, Switzerland, and Austria. Again, statisti-cal signicance and sign of parameter estimates(above, equal, or below 1) hold robust across mostmodel specications, exceptions being found forAustria, France, and the Netherlands. Table 8 thusidenties that contemporaneous utilization of pre-ventive and operative dental treatment is at amedian level in Greece, Belgium, France, and theNetherlands. It is statistically signicantly abovethe median in Sweden, Denmark, Germany, Aus-tria, Switzerland, and Czechia, whereas it is belowthe median in Spain, Italy, Poland, and Ireland.These ndings are also shown in Fig. 4, whichillustrates contemporaneous levels of preventiveand operative dental treatment on the basis of oddsratios in Table 8.Dental service utilization in early life years. Table 9shows odds ratios for variations in dental atten-dance during childhood and adolescence (up to age

Table 6. Regression results for preventive only (odds ratios relative to the median)

(A) (B) (C) (D) (E)

The Netherlands 1.971 (0.122)*** 2.022 (0.235)*** 1.961 (0.230)*** 2.267 (0.272)*** 2.250 (0.270)**Sweden 2.761 (0.161)*** 1.947 (0.164)*** 2.065 (0.184)*** 1.846 (0.171)*** 1.876 (0.175)*Denmark 3.611 (0.213)*** 2.976 (0.190)*** 3.071 (0.202)*** 2.736 (0.186)*** 2.761 (0.188)*Germany 2.114 (0.134)*** 2.083 (0.152)*** 2.071 (0.151)*** 1.789 (0.136)*** 1.811 (0.138)*Italy 0.592 (0.043)*** 0.571 (0.047)*** 0.598 (0.052)*** 0.686 (0.061)*** 0.678 (0.061)*France 0.712 (0.050)*** 0.627 (0.058)*** 0.635 (0.059)*** 0.550 (0.054)*** 0.555 (0.054)*Greece 0.451 (0.040)*** 0.365 (0.034)*** 0.382 (0.037)*** 0.388 (0.038)*** 0.393 (0.039)*Switzerland 2.020 (0.151)*** 1.555 (0.157)*** 1.692 (0.182)*** 1.463 (0.164)*** 1.503 (0.169)**Czechia 0.831 (0.059)** 0.859 (0.062)* 0.866 (0.063)* 0.838 (0.062)* 0.822 (0.061)**Poland 0.124 (0.016)*** 0.152 (0.020)*** 0.153 (0.020)*** 0.159 (0.021)*** 0.157 (0.021)*Spain 0.358 (0.038)*** 0.341 (0.037)*** 0.363 (0.040)*** 0.397 (0.045)*** 0.405 (0.046)*Ireland 1.124 (0.104) 1.092 (0.118) 1.099 (0.120) 1.147 (0.125) 1.154 (0.126)N 27 023 26 962 26 339 26 037 26 037


Fig. 2. Preventive dental visits by Europeans aged 50and above. Figure is based on results from Table 6,model specication (E).

170

Listl et al.


8/12

15). For most countries, sign and signicance of parameter estimates are robust across differentmodel specications. However, the additionalinclusion of socioeconomic status changes signi-cance for Denmark and Germany: while the intro-duction of the socioeconomic control variable leadsto a nonsignicant odds ratio in Denmark, it resultsin the signicance of the parameter estimate for

Germany. This indicates that socioeconomic statusduring childhood is an important determinant of access to dental care and is also reinforced bychanges in the size of parameter estimates whencomparing model specications with withoutinclusion of socioeconomic status as a control(see, e.g. Sweden, the Netherlands, and Switzer-land). According to Table 9 and factoring in socio-economic status as a control, countries with amedian level of childhood dental attendance areAustria, Denmark, and Poland. Countries with anabove-median attendance level are the Nether-lands, Sweden, Switzerland, and Czechia. Finally,

countries with below-median levels of childhooddental attendance include Germany, Italy, France,Greece, Spain, and Belgium.

DiscussionBased on the cross-sectional data (SHARE wave 2),this study describes variations in 1-year incidenceof dental attendance as well as of preventiveand or operative dental treatment of Europeansaged above 50 years with respect to country of residence. Our ndings suggest median levels of dental attendance in Belgium, Austria, and Cze-chia, above-median levels of dental attendance inthe Netherlands, Sweden, Denmark, Germany, andSwitzerland as well as below-median levels of dental attendance in Spain, Italy, France, Greece,Poland, and Ireland. Furthermore, our results showthat solely preventive treatment occurs at medianlevels in Belgium, Austria, and Ireland. In theNetherlands, Sweden, Denmark, Germany, andSwitzerland, preventive treatment is delivered

Table 7. Regression results for operative only (odds ratios relative to the median)

(A) (B) (C) (D) (E)

The Netherlands 0.422 (0.044)*** 0.347 (0.074)*** 0.275 (0.060)*** 0.284 (0.062)*** 0.299 (0.066)***Spain 0.810 (0.081)* 0.767 (0.080)* 0.661 (0.071)*** 0.713 (0.080)** 0.732 (0.082)**Denmark 0.294 (0.034)*** 0.294 (0.035)*** 0.282 (0.033)*** 0.277 (0.033)*** 0.280 (0.033)***Germany 0.808 (0.071)* 0.797 (0.071)* 0.904 (0.083) 0.887 (0.082) 0.886 (0.082)Italy 1.299 (0.093)*** 1.151 (0.140) 0.832 (0.109) 0.890 (0.119) 0.912 (0.123)France 2.136 (0.143)*** 2.221 (0.181)*** 2.728 (0.238)*** 2.714 (0.237)*** 2.700 (0.236)***Greece 1.229 (0.100)* 1.230 (0.100)* 1.145 (0.095) 1.200 (0.101)* 1.219 (0.103)*Switzerland 0.731 (0.081)** 0.793 (0.099) 0.756 (0.095)* 0.736 (0.094)* 0.740 (0.094)*Belgium 1.111 (0.082) 1.000 (0.111) 0.917 (0.104) 0.921 (0.104) 0.939 (0.107)Poland 1.124 (0.087) 0.994 (0.093) 0.989 (0.094) 1.018 (0.097) 1.022 (0.098)Austria 1.412 (0.130)*** 1.460 (0.156)*** 1.830 (0.206)*** 2.100 (0.243)*** 2.077 (0.240)***Ireland 0.641 (0.086)*** 0.569 (0.102)** 0.452 (0.083)*** 0.459 (0.085)*** 0.477 (0.089)***N 27 023 26 962 26 339 26 037 26 037


Fig. 3. Operative dental visits by Europeans aged 50 andabove. Figure is based on results from Table 7, modelspecication (E).

171



9/12

more frequently, whereas in Spain, Italy, France,Greece, Czechia, and Poland, it takes place lessoften. Solely operative treatment occurs at medianlevels in Belgium, Germany, Czechia, Poland,Sweden, and Italy. Increased levels of operativetreatment are observed in Austria and France,whereas lower levels are found in Spain, Ireland,Switzerland, Denmark, and the Netherlands. Fi-nally, simultaneous occurrence of preventive and

operative dental treatment within the past year isclassied as median for Greece, France, the Neth-erlands, and Belgium. In Sweden, Denmark, Ger-many, Switzerland, Austria, and Czechia, relativelyhigh levels of both preventative and operativetreatment are found, whereas comparatively lowlevels are evident in Spain, Italy, Poland, andIreland.

The aforesaid ndings suggest considerablecross-country variations in dental service utiliza-tion. In particular, there appears to be a tendencytoward more frequent and preventive dentaltreatment for populations aged 50 years or over

residing in Scandinavia and Western Europe [asdened by the United Nations (13)] in compar-ison with other European regions. Interestingly,this pattern stands in contrast to general healthcare use as measured by the overall number of doctor visits, which is considerably higher inSouthern Europe compared with Scandinavia andSwitzerland (14). Our ndings point to largecross-country differences in dental care utilization by older Europeans, and these can only partially be explained by cross-country differences inoral health care need and accessibility of dentalcare.

On the one hand, dental attendance patternsmay be established in early life years and thus befairly stable over the lifecourse. In this regard, thepresent study provides some, albeit mixed, evi-dence on the basis of SHARELIFE: when compar-ing historical dental care utilization rates duringchildhood adolescence and with contemporane-ous use rates at ages 50 and older, differences indental attendance show a similar pattern for themajority of countries. However, some countries

Table 8. Regression results for preventive and operative (odds ratios relative to the median)

(A) (B) (C) (D) (E)

The Netherlands 1.890 (0.123)*** 1.002 (0.157) 0.849 (0.135) 1.088 (0.176) 1.091 (0.177)Sweden 2.453(0.149)*** 3.311 (0.402)*** 3.584 (0.438)*** 2.923 (0.364)*** 2.930 (0.365)*Denmark 2.161 (0.135)*** 2.444 (0.189)*** 2.518 (0.195)*** 2.100 (0.168)*** 2.104 (0.168)*Germany 2.478 (0.160)*** 3.445 (0.323)*** 3.998 (0.394)*** 3.197 (0.323)*** 3.214 (0.326)*Italy 0.525 (0.043)*** 0.391 (0.037)*** 0.317 (0.032)*** 0.402 (0.042)*** 0.395 (0.041)*France 0.581 (0.047)*** 0.890 (0.118) 1.101 (0.152) 0.869 (0.123) 0.863 (0.122)Austria 0.869 (0.084) 1.533 (0.227)** 1.914 (0.294)*** 1.787 (0.282)*** 1.751 (0.277)**Switzerland 2.398 (0.184)*** 3.789 (0.528)*** 3.907 (0.545)*** 3.188 (0.454)*** 3.234 (0.462)**Czechia 1.590 (0.107)*** 1.638 (0.112)*** 1.712 (0.119)*** 1.598 (0.112)*** 1.546 (0.109)*Poland 0.403 (0.038)*** 0.440 (0.042)*** 0.456 (0.044)*** 0.472 (0.045)*** 0.461 (0.044)*Spain 0.463 (0.051)*** 0.488 (0.055)*** 0.459 (0.052)*** 0.526 (0.060)*** 0.537 (0.062)*Ireland 0.606 (0.074)*** 0.462 (0.065)*** 0.389 (0.056)*** 0.420 (0.061)*** 0.424 (0.062)*N 27023 26962 26339 26037 26037


Fig. 4. Preventive and operative dental visits by Euro-peans aged 50 and above. Figure is based on results from

Table 8, model specication (E).

172

Listl et al.


10/12

(Germany, Belgium, Czechia, Poland, and Den-mark) rank differently in early life years than theydo at age 50+. Despite these exceptions, socioeco-

nomic conditions during childhood seem to have agenerally great impact on dental attendance inearly life years. Future research will likely seek todetermine the precise impact of socioeconomicconditions in early life on dental utilization acrossthe life cycle.

On the other hand, the dental attendance pat-terns highlighted by our study could also be caused by several other factors such as different institu-tional or cultural settings within various Europeancountries. Previous evidence suggests that there arelarge variations between European regions andcountries regarding underuse of dental care overthe life cycle and that a huge proportion of suchvariations can be explained by differences in dentalmanpower (15). There could also exist differentattitudes toward oral well-being and the awarenessof benets received from regular dental attendance.It has, e.g. been proposed that psychosocial factorssuch as self-esteem may be an important determi-nant of oral health behavior (16). Moreover, earlierresearch has identied distinct particularities in theuse of dental services in comparison with other

medical services: most notably, the number of routine dental visits decreases with age, whereas itusually rises for general health services (14). Futureresearch is thus encouraged to examine the preciseextent to which cross-country differences in dentalservice utilization are attributable to differences ininstitutional, cultural, psychosocial, or other cir-cumstances.

Some limitations of our study should be noted.First, our analysis represents an analysis of cross-sectional data and thus does not have a causal

interpretation (17). In the future, additional wavesof SHARE will enable to better investigate causalrelationships between oral health needs, health

care accessibility, and utilization of dental services.Second, the control variables for oral health statusthat were available for our study may be consid-ered proxy variables only. In particular, bivariateinformation about denture wearing and chewingability as well as edentulism rates measured at thecountry level and on the basis of different epide-miological investigations may cause some inaccu-racy in our results. Third, the data used are survey based and thus may be prone to recall bias (18).Nevertheless, as there is currently no comparablesource of administrative data available, SHAREprovides a unique opportunity for cross-countrycomparisons of treatment utilization.

In conclusion, this study is the rst to investigatevariations in dental utilization of the populationaged 50 years and over of 14 European countries.Our ndings suggest considerable cross-countryvariations in overall dental attendance as well aspreventive and or operative treatment. Speci-cally, there is a tendency toward more frequentand preventive dental treatment for those aged50 years and over residing in Scandinavia and

Western Europe in comparison with other Euro-pean regions. Yet more research is needed toidentify the exact causes for such differences inthe utilization of dental services.

AcknowledgementsThe authors thank participants of the Oral Session onEpidemiology organized by the Behavioral, Epidemio-logic, and Health Services Research Group and held at

Table 9. Regression results for dental attendance during childhood adolescence (odds ratios relative to the median)

(retro-A) (retro-B) (retro-C)

The Netherlands 2.318 (0.299)*** 2.327 (0.300)*** 1.992 (0.262)***Sweden 3.019 (0.396)*** 2.998 (0.393)*** 2.261 (0.304)***Denmark 1.532 (0.183)*** 1.517 (0.182)*** 1.084 (0.134)Germany 0.808 (0.098) 0.812 (0.099) 0.675 (0.085)**Italy 0.202 (0.025)*** 0.200 (0.025)*** 0.234 (0.030)***France 0.648 (0.077)*** 0.648 (0.077)*** 0.587 (0.072)***Greece 0.319 (0.043)*** 0.314 (0.043)*** 0.317 (0.044)***Switzerland 2.456 (0.353)*** 2.457 (0.353)*** 1.948 (0.287)***Czechia 6.237 (0.983)*** 6.222 (0.981)*** 4.973 (0.798)***Poland 1.215 (0.166) 1.214 (0.166) 1.259 (0.176)Spain 0.140 (0.021)*** 0.139 (0.021)*** 0.136 (0.021)***Belgium 0.520 (0.061)*** 0.518 (0.061)*** 0.457 (0.055)***N 12 883 12 883 12 788


173



11/12

the 89th General Session of the IADR in San Diego(California) for helpful comments. This paper uses datafrom SHARE Wave 2 (Release 2.3.1, published on July 29,2010) and SHARELIFE (Release 1.0.0, published onNovember 24, 2010). The SHARE SHARELIFE datacollection was primarily funded by the European Com-mission through its 5th and 6th framework programs(project numbers QLK6-CT-2001-00360; RII-CT-2006-062193; CIT5-CT-s005-028857). Additional funding by

the US National Institute on Aging (grant numbers U01AG09740-13S2; P01 AG005842; P01 AG08291; P30 AG12815; Y1-AG-4553-01; OGHA 04-064; R21 AG025169) aswell as by various national sources is gratefully acknowl-edged (see http://www.share-project.org for a full list of funding institutions).

Sources of fundingS.L. and C.M.F. are afliated with the University of Heidelberg. S.L. is also afliated with the MannheimResearch Institute for the Economics of Aging (MEA).For the present research, S.L. was fully funded through apostdoc fellowship awarded by the Medical Faculty atthe University of Heidelberg. He also holds a PhDscholarship by the German National Academic Founda-tion. C.M.F. is partially funded by a postdoctoral fellow-ship from the Medical Faculty of the University of Heidelberg. V.M. is afliated with the OECD and J.M.with the University of Lausanne. While undertaking thepresent research, V.M. and J.M. were fully funded bytheir institutions.

Disclosure of conicts of interestsThe authors declare that there is no conict of interests.The opinions expressed in the paper are those of theauthors alone and not those of the OECD or its membercountries.

References1. United Nations Population Fund. Population ageing

and development: social, health and gender issues.Population and development strategies series. ReportNo. 3. New York: United Nations Population Fund;2002.

2. Harford J. Population ageing and dental care. Com-munity Dent Oral Epidemiol 2009;37:97103.

3. Grytten J. How age inuences expenditure for dentalservices in Norway. Community Dent Oral Epidem-iol 1990;18:2259.

4. Kleinman ER, Harper PR, Gallagher JE. Trends inNHS primary dental care for older people inEngland: implications for the future. Gerodontology2009;26:193201.

5. Reinhardt U. Does the ageing of the population reallydrive the demand for health care? Health Affair2003;22:2739.

6. Caley M, Sidhu K. Estimating the future healthcarecosts of an aging population in the UK: expansion of

morbidity and the need for preventative care. JPublic Health 2011;33:11722. [Epub ahead of print]7. Rettig RA. Medical innovation duels cost contain-

ment. Health Affair 1994;13:727.8. Thrall JH. Prevalence and costs of chronic disease in

a health care system structured for treatment of acuteillness. Radiology 2005;235:912.

9. Brown LJ, Lazar V. Trends in the dental health workforce. J Am Dent Assoc 1999;130:17439.

10. Maurer J. Socioeconomic and health determinants of health care utilization among elderly Europeans: anew look at equity, intensity and responsiveness forten European countries. Mannheim: MannheimResearch Institute for the Economics of Aging;

2007;WP-144-2007.11. Schuetz G, Ursprung H, Woessman L. Educationpolicy and equality of opportunity. Kyklos2008;61:279308.

12. Listl S. Denture wearing by people among the oldersegment of European populations. Int J Prosthodont2011; (forthcoming).

13. United Nations Statistics Division. Standard Countryand Area Codes Classication. Downloaded on April15th 2011 via http://unstats.un.org/unsd/methods/m49/m49regin.htm#europe

14. Santos-Eggimann B, Junod J, Cornaz S. Healthservices utilization in older Europeans. In: Boersch-Supan A, Brugiavini A, Juerges H, Mackenbach J,Siegrist J, Weber G editors. Health, ageing andretirement in Europe rst results from the surveyof health, ageing and retirement in Europe. Mann-heim: MEA, 2005; 13340.

15. Santos-Eggimann B, Cornaz S, Spagnoli J. Lifetimehistory of prevention in European countries: the caseof dental check-ups. In: Boersch-Supan A, Brandt M,Hank K, Schroeder M editors. The individual and thestate. Life courses in Europe. Heidelberg: Springer,2011; 233240.

16. Locker D. Self-esteem and socioeconomic disparitiesin self-perceived oral health. J Public Health Dent2009;69:18.

17. Flanders WD, Lin L, Pirkle JL, Caudill SP. Assessingthe direction of causality in cross-sectional studies.Am J Epidemiol 1992;135:92635.

18. Coughlin SS. Recall bias in epidemiologic studies. J Clin Epidemiol 1990;43:8791.

174

Listl et al.


12/12

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.

Users should refer to the original published version of the material.

Documents

Dental Service Utilization by Europeans Aged 50 Plus