DENTAL HEALTH BEHAVIOUR AND SATISFACTION WITH DENTAL CARE AMONG 35–44 YEARS AGED LITHUANIAN UNIVERSITY EMPLOYEES

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY

Žana Sakalauskienė

DENTAL HEALTH BEHAVIOUR

AND SATISFACTION WITH DENTAL

CARE AMONG 35–44 YEARS AGED

LITHUANIAN UNIVERSITY

EMPLOYEES

Doctoral Dissertation Biomedical Sciences, Odontology (07B) Kaunas, 2013

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2 Disertation is defended extramurally

Scientific Consultant

Prof. Dr. Vita Mačiulskienė (Lithuanian University of Health Sciences, Biomedical Sciences, Odontology – 07B)

The dissertation will be defended at the Odontology Research Council of Lithuanian University of Health Sciences

Chairman

Prof. Dr. Antanas Šidlauskas (Lithuanian University of Health Sciences, Biomedical Sciences, Odontology – 07B)

Members:

Prof. Dr. Vytautė Pečiulienė (Institute of Odontology, Vilnius University, Biomedical Sciences, Odontology – 07B)

Prof. Dr. Alina Pūrienė (Institute of Odontology, Vilnius University, Biomedical Sciences, Odontology – 07B)

Assoc. Prof. Dr. Gailutė Bernotienė (Lithuanian University of Health Sciences, Biomedical Sciences, Public Health –09B)

Prof. Dr. Jorma Virtanen (Institute of Dentistry, University of Oulu, Finland, Biomedical Sciences, Odontology – 07B)

The dissertation will be defended at the open session of the Odontology Research Council at Museum of the History of Lithuanian Medicine and Pharmacy on the 28th of June 2013 at 13:00.

Address: Rotušės 28, LT-44279 Kaunas, Lithuania

Review of the dissertation is available in the Library of Lithuanian Uni-versity of Health Sciences.

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LIETUVOS SVEIKATOS MOKSLŲ UNIVERSITETAS MEDICINOS AKADEMIJA

Žana Sakalauskienė

LIETUVOS UNIVERSITETŲ

35–

44 METŲ AMŽIAUS DARBUOTOJŲ

DANTŲ PRIEŽIŪROS ELGSENA IR

NUOMONĖ APIE TEIKIAMĄ

ODONTOLOGINĘ PAGALBĄ

Daktaro disertacija Biomedicinos mokslai,

Odontologija (07B)

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4 Disertacija ginama eksternu.

Mokslinė konsultantė

prof. dr. Vita Mačiulskienė (Lietuvos sveikatos mokslų universitetas, biomedicinos mokslai, odontologija – 07B)

Disertacija ginama Lietuvos sveikatos mokslų universiteto Odontologijos mokslo krypties taryboje:

Pirmininkas

prof. dr. Antanas Šidlauskas (Lietuvos sveikatos mokslų universitetas, biomedicinos mokslai, odontologija – 07B)

Nariai:

prof. dr. Vytautė Pečiulienė (Vilniaus universiteto Odontologijos institutas, biomedicinos mokslai, odontologija – 07B)

prof. dr. Alina Pūrienė (Vilniaus universiteto Odontologijos institutas, biomedicinos mokslai, odontologija – 07B)

doc. dr. Gailutė Bernotienė (Lietuvos sveikatos mokslų universitetas, biomedicinos mokslai, visuomenės sveikata – 09B)

prof. dr. Jorma Virtanen (Oulu universiteto Odontologijos institutas, Suomija; biomedicinos mokslai, odontologija – 07B)

Disertacija ginama viešame Odontologijos mokslo krypties tarybos posė-dyje 2013 m. birželio 28 d. 13 val. Lietuvos medicinos ir farmacijos istorijos muziejuje.

Adresas: Rotušės a. 28, LT-44279 Kaunas, Lietuva

Disertaciją galima peržiūrėti Lietuvos sveikatos mokslų universiteto bib-liotekoje.

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ABBREVIATIONS

CI Confidence intervals

CPI Community periodonal index DAI Dental aesthetic index

DHB Dental health behaviour

DMFT Decayed, missing, and filled permanent teeth DSQ Dental Satisfaction Questionnaire

OHB Oral health behaviour OR Odds ratio

SD Standard deviation

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INTRODUCTION

The WHO prepared the list of the global oral health goals to be achieved by the year 2020 among those are the objectives to develop acces-sible cost-effective oral health care systems for the prevention and control of dental diseases and to develop oral health programmes that will empower people to control determinants of their oral health (Hobdell 2003). An increased knowledge about development and management of dental diseases emphasizes the important role of the oral health behaviour in preventing or arresting dental caries and periodontal diseases (Löe 2000; Teng et al. 2003; Sanders et al. 2006).

Dental health behaviour (DHB) can be described as self-care – dental hygiene habits, and professional care – dental attendance. Getting indivi-duals to brush their teeth, together with regular visits to dental professionals for reinforcement, is believed to be the core pattern for the prevention of dental diseases (Löe 2000; Teng et al. 2003; Sanders et al. 2006).

The ways of dental health service delivery vary in different countries, from well-organised and planned public health care systems to private practice based services. Since Lithuania’s re-declaration of independence in 1990, Lithuanian dental health care has been undergoing the transition from a government-based, strictly planned and controlled heavily subsidized system to one based on private ownership and partly or fully charged dental services. In the former USSR, free dental care, with the exception of pros-thetic treatment, was accessible to all citizens at public clinics (Balčiūnienė 1998; WHO 2000). Under the new circumstances, dentistry has become one of the fastest growing private sectors in the Lithuanian health care system (WHO 2000). These changes are likely to affect the utilization of dental services, especially in the lower socioeconomic groups of the population, and may widen dental health inequalities in the future. In this situation evaluation of patients’ DHB and assessment of factors related to it could be helpful in development of effective oral health promotion programmes.

Dental treatment to the big extent has to be conducted with the patients’ cooperation to be successful. Satisfied patients are mostly regular visitors likely complying with prescribed preventive and treatment regimens (Arnbjerg et al. 1992; Liddell and Locker 1992; Butters and Willis 2000; Sgan-Cohen et al. 2004). Patient satisfaction with dental care studies may be useful for evaluation of dental care providers and services as well as for understanding and predicting patients’ behaviour (Newsome and Wright 1999). As satisfied patients are more cooperative with the dentist, it is likely that these individuals will be willing to follow dental health-related

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mendations. In this situation, higher levels of satisfaction may be helpful in improvement of DHB. Knowledge about satisfaction with dental care among adults in Lithuania is very limited. Some data is published briefly describing a study on patients’ opinions about public and private dental ser-vices as well as general satisfaction with dental care in Lithuania (Pūrienė et al. 2008).

The dental health status of the Lithuanian adult population is rather poor (Skudutytė et al. 2000). Very few studies evaluating dental status among adults in Lithuania demonstrated that a majority of the adult population in Lithuania is in need of dental treatment and prevention (Skudutytė et al. 2000; Vyšniauskaitė et al. 2005). During the past decade the only study measuring caries experience among 35–44-years old Lithuanians in 2000 (Skudutytė et al. 2000) found high DMFT values (17.2) in the population of this group of age.

Limited information is available on the DHB and attitudes among Lit-huanian adults. Only few studies provided an overview of the DHB situation of the adult population in Lithuania indicating weak regular dental self-care practices and low utilization of dental services (Petersen et al. 2000; Aleksejūnienė et al. 2000, 2002).

In Lithuania dental health promotion programmes exist for children only. Adult population oriented dental health promotion programmes have not been established in Lithuania. Activities to improve adults’ dental health habits have mostly been by promotional actions of the companies producing dental hygiene products. The consequences on adults’ dental health behaviour are disappointing: preventive habits such as tooth brushing and check-up based dental visiting are at a rather poor level among Lithuanian adults (Vyšniauskaitė et al. 2005; Grabauskas at al. 2009, 2011; Sakalauskienė et al. 2011).

Comprehensive information on the DHB and perception of the dental care as well as the factors related to it would be helpful for planning and quality assessment of dental health services as well as for development of the dental health promotion programmes for the adult population in Lithuania.

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AIMS AND TASKS OF THE RESEARCH

Aim of the study

The general aim of the present study was to evaluate factors related to dental health behaviour and satisfaction with dental care among 35–44 years old university employees in Lithuania.

Objectives of the study:

1. To assess main determinants of dental hygiene habits.

2. To evaluate dental attendance patterns and factors related to it. 3. To evaluate dental health attitudes and knowledge, and their role in

dental health behaviour.

4. To describe self-assessed dental health status and it‘s relation to dental health behaviour.

5. To evaluate satisfaction with dental care based on the experience from the most recent dental visit and it‘s role in dental health beha-viour.

DESCRIPTION OF THE NOVELTY AND PRACTICAL

SIGNIFICANCE OF THE RESEARCH

Limited information is available on the dental health behaviour as well as on satisfaction with dental care among Lithuanian adults. Dental care satisfaction among adults has not been assessed in Lithuania. Over the last decade of the XX century, Lithuanian dental health care has been under-going the transition from a government-based, strictly controlled and hea-vily subsidized system to one based on private ownership. These changes are likely to affect the utilization of dental services, and may increase dental health inequalities in the future. In this situation evaluation of patients’ dental health behaviour and assessment of factors related to it could be helpful in development of effective oral health promotion programmes.

This study shows systematic information on the dental health behaviour and satisfaction with dental care as well as factors related to it among specific sample of adults in Lithuania – 35–44 years old university employees. This data may serve as a baseline for the future evaluation and development of dental health promotion programmes for the adult population in Lithuania.

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1 . LITERATURE REVIEW

1.1. Organization of dental health care for adults in Lithuania Dental health care in Lithuania is still in transition. Until 1990, under former Soviet Union regulations, dental health care was responsibility of the state. All citizens were eligible to free dental care at public clinics, except for prosthetic treatment being free of charge for pensioners and school-children only (Petersen et al. 2000). In 1991, a consumer survey revealed that only 7% of respondents were satisfied with the health sector’s per-formance in Lithuania. At the same time, 80% expressed a desire for reforms. There were a number of criticisms of the previous health system. Unofficial payments were common. The health sector paid too little atten-tion to primary health care or health promoatten-tion. Salaries of professsionals were low, and private practice was not allowed. Alongside this, there were inequities in service provision, with special health services for the “no-menclature” and for workers in certain industries (WHO 2000).

The health care reforms in Lithuania can be seen as an interaction between efforts to change the Soviet health system and to adapt the health system to a rapidly changing social environment (WHO 2000). Law on Dental care, regulating dental health services, was launched in 1996 in Lithuania (Lithuanian law on dental care).

According to Lithuanian Dental Chamber report in 2012, there were 2974 registered dentists-general practitioners (81% of whom were women) and 477 dental hygienists in Lithuania (Lithuanian Dental Chamber, Report 2008-2012). In 2004, after Lithuania became a member of European Union, dental professionals became free to move to other EU countries to practice dentistry. During the period of year 2004–2011, about 4% of dental profess-sionals officially declared their leave. The number of dentists per 10 000 inhabitants vary significantly within the country, from 0–5 to 15 and more, depending on region (Lithuanian Dental Chamber, Report 2008–2012).

Dental health services are provided in both public and private sectors in Lithuania. Vast majority of the registered dental clinics belong to private sector (87%), mainly consisting of small practices with one to two dentists working.

Dental health expenses may be reimbursed from different sources: mandatory health insurance funds, supplemental health insurance funds, state or municipal funds, and by patients themselves. Only essential dental health care services are provided free of charge. The national health insurance system offers free of charge dental services for children and

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teenagers under age of 18 years, and for disabled adults. Retired inhabitants should receive prosthetic treatment free of charge, but in fact it is very limited due to the lack of financial resources. Adult dental care in the public sector is partly funded by reimbursement from public insurance and partly paid by the patient. In the private sector patients are expected to pay all the expenses (Widström 2004). In 2010, dental health services were reimbursed by 157.8 million litas, which is 0.17 of GDP (reports by Lithuanian Dental Chamber, Ministry of Health and Ministry of Finance of the Republic of Lithuania).

In Lithuania dental health promotion programmes exist for school-children only. Adult population oriented dental health promotion programmes have not been established in Lithuania.

Lithuania has been ranked by the World Bank (2011) as an upper-middle-income economy country.

1.2. Dental health behaviour

Dental health is an important component of general health and essen-tial for individuals’ well-being, as recognised by WHO (Petersen 2003). Several studies performed during the past decade demonstrated substantial improvement in the dental health of children and adult populations in some countries. This improvement was caused by many reasons such as better socioeconomic conditions and education as well as increased interest to maintain good dental health, also development of modern preventive and therapeutic services and implementation of new concepts of dental health promotion (Löe 2000). In addition, life style of individuals and DHB has direct impact on improvement of dental health. Many studies demonstrated that DHB, such as dental hygiene habits and check-up based dental attendance play a significant role in preventing and controlling dental disea-ses inside the community (Axelsson et al. 1991; Löe 2000; Richards and Ameen 2002; Kressin et al. 2003; Teng et al. 2003; Watt and Marinho 2005; Sanders et al. 2006). Therefore main recommendations for dental health behaviour include practicing of dental hygiene habits such as tooth brushing with fluoridated toothpaste and visiting of dental professionals in sufficient time periods (Bratthall et al. 1996; Brothwell et al. 1998; Löe 2000).

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1.2.1. Dental self care - dental hygiene habits

Association between dental plaque and dental diseases, such as dental caries, gingivitis and periodontal disease is clearly recognised (Christersson et al. 1991; Cancro and Fischman 1995). The natural physiological forces, such as saliva and movements of tongue and cheeks are insufficient to remove dental plaque from dental surfaces thus use of mechanical dental hygiene devices is strongly recommended by dental professionals to keep dental and periodontal health throughout the life (Chestnutt et al. 1998; Kressin et al. 2003; Marsh 2005; Thomas and Nakaishi 2006). Big variety of mechanical cleaning means, such as toothbrushes of various designs, dental floss, chew sticks and tools for inter-dental cleaning are available for plaque removal today.

Tooth brushing is one of the most effective, inexpensive and easy methods of dental plaque removal (Ashley 2001). However, wide variations exist in toothbrush design, brushing technique, brushing time and frequency of brushing (Cancro and Fischman 1995; Löe 2000). Studies on the asso-ciation between tooth brushing frequency and state of oral hygiene as well as incidence of dental diseases are controversial and still scarce. Early reports from 1973–1974 on frequency of dental plaque removal confirmed that longer than one to two days periods between cleanings are insufficient in maintaining gingival health (Lang et al. 1973; Kelner et al. 1974). Later research indicated that an increase in the daily frequency of brushing the teeth reduces the plaque accumulation and dental diseases (Cancro and Fischman 1995). On the other hand, too aggressive tooth brushing will promote gingival recession and may cause tooth abrasion. Brushing teeth twice daily is the current recommendation in many countries (Chestnutt et al. 1995; Brothwell et al. 1998; Ashley 2001; Kressin et al. 2003). Another important factor related to toothbrushing is the use of fluoride toothpaste. Questionnaire survey evaluating opinions of dental caries experts from different countries found that majority of experts agree that most important factor for caries decline during the past decades in many countries was use of fluoride toothpaste (Bratthall et al. 1996). Research on dental hygiene habits show that during past 30 years dental hygiene has improved and that in the industrialized countries vast majority of the population brush their teeth more than once a day (Saxer and Yankell 1997). Nation-wide surveys from Western European countries show 61%–74% of adult individuals reported brushing their teeth more than once a day (Table 1.2.1). These figures dramatically differ from the results of Lithuanian survey where only 39% of adults indicated brushing their teeth more than once a day (Table

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1.2.1). The Lithuanian rates are more similar to those in the neighboring Baltic countries Estonia and Latvia (Table 1.2.1).

Table 1.2.1. Percentages of adults brushing their teeth more than once a day by gender, according to nationwide surveys

Country, year of study publication _(years)Age n Tooth brushing more than once a day (%)

United Kingdom (Brandock 2001 et al.) • Total • Women • Men 16–55+ 5281 n.a. n.a. 74 83 64 Denmark (Christensen et al. 2003)

• Total • Women • Men 16–65+ 3509 1783 1726 68 77 59 Finland (Suominen-Taipale et al. 2008)

• Total • Women • Men 30–65+ 5595 n.a. n.a. 61 76 45 Estonia (Kasmel et al. 1999)

• Total • Women • Men 16–64 1311 745 566 45 57 30 Latvia (Pudele et al. 2007)

• Total • Women • Men 15–64 1566 897 669 43 53 31 Lithuania (Grabauskas et al. 2007)

• Total • Women • Men 20–64 1671 989 682 39 50 23

It was observed that inter-proximal areas of dentition form signify-cantly greater amounts of plaque (DeVore et al. 1990). However, tooth brushing alone leaves proximal and inter-dental areas of the tooth untreated being able to clean only the accessible surfaces of the tooth, excluding pits and fissures (Löe 2000). Therefore, focus on inter-dental cleaning is of high importance in prevention of dental diseases. Big variety of tools for inter-dental cleaning including inter-dental floss and tape, wooden toothpicks, inter-dental brushes and other mechanical and electrical devices exists today.

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Several studies, investigating effectiveness of various inter-dental cleaning tools, revealed that these devices generally help to remove significantly more plaque than tooth brushing alone (Lobene et al. 1982; Mauriello et al. 1987; Barton and Abelson 1987; Kiger et al. 1991). However, none of these devices appeared to be very popular, probably because they are not easy to use and they should be selected individually, most of them require consi-derable time, instruction how to use, and motivation (Löe 2000). Reports of using tools for inter-dental cleaning are low: only 15% and 10% of adults from one district in Netherlands (Kalsbeek et al. 2000), and 28% and 11% of adults in nationwide sample in Denmark (Christensen et al. 2003) re-ported using toothpick and dental floss, respectively, on daily basis. The only study among the representative sample of 35–44 years old adults from Lithuania in 2000 revealed that using wooden toothpick reported 57%, plastic toothpick – 14% and dental floss – 23% of the respondents, not indi-cating frequency of the usage (Petersen et al. 2000).

It was demonstrated by many studies from various countries that im-portant determinants affecting dental hygiene habits, such as tooth brushing frequency and inter-dental cleaning are gender (Murtomaa and Metsäniitty 1994; Payne and Locker 1996; Sakki et al. 1998; Christensen et al. 2003; Tada and Hanada 2004; Maes et al. 2006; Suominen-Taipale et al. 2008; Artnik et al. 2008), socio-economic factors (Murtomaa and Metsäniitty 1994; Paunio 1994; Sakki et al. 1998; Tada and Matsukubo 2003; Artnik et al. 2008), education (Paunio 1994; Payne and Locker 1996; Christensen et al. 2003; Artnik et al. 2008), preventive dental attendance (Paunio 1994; Christensen et al. 2003) as well as favourable attitudes and believes about dental health (Savolainen et al. 2005; Riley et al. 2006), gender being the strongest one. Clear gender differences are observed in reporting of tooth brushing more than once a day from the surveys of various countries (Table 1.2.1). It has been shown previously that women exhibit better oral self-care than men do (Murtomaa 1979; Søgaard et al. 1991; Murtomaa and Metsä-niitty 1994). It was noted by the researchers that these aspects should be considered when planning intensive population-directed strategies for dental health education in order to improve the dental hygiene practices of the entire population, in particular among the individuals of the risk groups (Christensen et al. 2003; Artnik et al. 2008; Rimondini et al. 2001; Bran-dock et al. 2001; Payne and Locker 1996).

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1.2.2. Professional dental care - dental attendance

Individuals have increasingly been required to take responsibility for their own dental health lately. Besides improvement of preventive dental hygiene habits, seeking of the professional dental care is of high importance. It is generally assumed that regular dental attendance has a positive effect on dental health (Scully 1995; Murray 1996; Nuttall 1997; Kelly et al. 2000; Bullock et al. 2001; Richards and Ameen 2002). Dental attendance could be described by individuals’ experiences of the most recent as well as habitual dental attendance. To assess individuals’ dental attendance, indicators such as time period since and reason for the most recent dental visit and reason as well as frequency for the habitual dental attendance, are used (Murtomaa and Metsäniitty 1994; Vyšniauskaitė and Vehkalahti 2006; Nuttal 1997; Vargas et al. 2003; Stahlnacke 2005 et al.; Kosteniuk and D’Arcy 2006; Bayat et al. 2006). When talking about frequency of dental visits, the in-dividual need should be considered – high risk individuals will require more frequent attendance in comparison with low risk disease group. According to the literature on dental attendance, there is contradictory data on recom-mendations and value of dental attendance frequency (Murray 1996; Kay 1999). Activity of the dental disease for majority of individuals depends on their DHB (Axelsson et al. 1991; Löe 2000; Richards and Ameen 2002; Teng et al. 2003; Kressin et al. 2003; Watt and Marinho 2005; Sanders et al. 2006). The effectiveness of routine six monthly examinations to improve oral health was questioned by researchers, based on epidemiological data (Sheiham 1977). It was suggested later that dental visits every six months were only advisable if a preventive approach to care was adopted by the dentist (Elderton 1985). It was considered generally that a dentist is the best person to advice frequency of dental visits, based on the individual assessment of the disease risk (Kay 1999). Study from Finland evaluating check-up intervals among the sample of patients under 18 years old found that for the patients with the higher caries indices dentists proposed shorter average check-up intervals, however dentists' ability to differentiate between patients by caries indices varied widely. Researchers concluded that in order to optimise the use of dental care resources, more emphasis should be placed on selection of individual check-up intervals by encouraging dentists to differentiate between the patients (Helminen and Vehkalahti 2002).

Studies from industrialized countries show that the use of dental ser-vices among adults obviously increased during recent decades (Suominen-Taipale et al. 2000; Nuttall et al. 2001; Vargas et al. 2003; Petersen et al. 2004; Osterberg et al. 1998). According to the results of surveys in a num-ber of countries, from 62% to 87% of various groups of the adult samples

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report preventive check-ups as the most common reason for their habitual dental attendance (Pavi et al. 1995; Schwarz 1996; Kelly et al. 2000; Nuttall et al. 2001; Suominen-Taipale et al. 2008). Percentages of adults reporting preventive check-up as the most common reason for their habitual dental attendance in United Kingdom, Denmark, Finland and Canada are presented in table 1.2.2.

Table 1.2.2. Percentages of adults reporting preventive check-up as the most common reason for their habitual dental attendance according to the surveys

Country, year of study and

publication Age (years) n

Preventive check-up as the reason for

habitual dental attendance (%)

United Kingdom nationwide survey 1998 (Nuttal et al. 2001) • Total • Women • Men 35–44 16–55+ 16–55+ 1095 2870 2398 62 66 52 Denmark nationwide survey 2000

(Petersen et al. 2004) • Total • Women • Men 35–44 2999 n.a. n.a. 87 n.a. n.a. Finland nationwide survey 2000

(Suominen-Taipale et al. 2008) • Total • Women • Men 30–75+ 5656 n.a. n.a. 57 64 50 Canada, North York representative

municipality sample, survey 1992 (Payne and Locker 1996)

• Total • Women • Men 18–65+ 976 n.a. n.a. 69 71 68

No nationwide studies evaluating habitual dental attendance patterns among adults in Lithuania were performed recently, only some data related to the most recent dental visiting is available (Petersen et al. 2000; Alek-sejunienė et al. 2000; Grabauskas et al. 2007, 2009, 2011). Time since the most recent dental visit, as reported by Lithuanian adults, seems to be si-milar as indicated in the studies from neighboring countries, such as Latvia, Estonia and Finland (Table 1.2.3.). Clear difference appears in reporting

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Table 1.2.3. Percentages of adults reporting most recent dental visit within 12 months and preventive reason for their most recent dental visits, according to nationwide surveys

Country, year of study publication _{(years) n}Age

Most recent dental visit within 12 months (%) Preventive check-up as the reason for most recent dental visit (%)

Lithuania (Grabauskas et al. 2007) • Total • Women • Men 20–64 1680 986 694 66 74 55 26 30 19 Estonia (Kasmel et al. 1999)

• Total • Women • Men 16–64 1321 749 572 60 68 51 n.a. n.a. n.a. Latvia (Pudele et al. 2007)

• Total • Women • Men 15–64 1538 881 657 63 67 50 n.a. n.a. n.a. Finland nationwide survey 2000

(Suominen-Taipale at al. 2008) • Total • Women • Men 30– 75+ 5656 n.a. n.a 62 68 56 n.a. n.a. n.a. Sweden nationwide survey 1999

(Kronström et al. 2002) • Total • Women • Men 55–69 453 n.a. n.a 82 n.a. n.a n.a. n.a. n.a. Denmark nationwide survey 1999

(Kronström et al. 2002) • Total • Women • Men 45–69 826 n.a. n.a 87 n.a. n.a n.a. n.a. n.a. United Kingdom nationwide survey

1998 (Kelly et al. 2000) • Total • Women • Men 16– 75+ 5281 n.a. n.a. 71 77 65 63 n.a. n.a. United States nationwide survey 1999

(Vargas et al. 2003) • Total • Women • Men 35–54 n.a. n.a. n.a. 68 n.a. n.a. n.a. n.a. n.a.

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reason for the most recent dental visit between Lithuanian and UK adults – in UK many more adults indicated preventive reason for their most recent dental visit (Table 1.2.3.).

Despite the trend of increased dental attendance habits in many coun-tries significant inequalities in dental health care utilization remain between socioeconomic groups inside the populations (Stahlnacke et al. 2005; Var-gas et al. 2003). Dental attendance is multi-factorial phenomenon. It has been shown that dental attendance habits are affected by a range of factors, such as gender, marital status, level of education and income, urbanization, cultural aspects, dental health attitudes and knowledge, as well as the orga-nization of dental services. Many studies confirmed that women, cohabiting individuals with higher levels of education and income, urban residents practiced preventive check-up based dental attendance more often (Ter Horst and De Wit 1993; Pavi et al. 1995; Zakrevska 1996; Schwarz 1996; Osterberg et al. 1998; Tomar et al. 1998; Suominen-Taipale et al. 2000; Nuttal et al. 2001; Scheutz and Heidmann 2001; Slater 2001; Kronström et al. 2002; Roberts-Thomson and Stewart 2003; Petersen et al. 2004; Stahl-nacke et al. 2005; Sanders et al. 2006; Bayat et al. 2006; Kosteniuk and D’Arcy 2006). Researchers conclude, that these results highlight the con-tinuing perception among the significant part of the population that dental visit is needed only in case of trouble, rather than opportunity for prevention and detection of the disease at early stage, and may lead to inequalities of dental health inside the population (Tomar et al. 1998).

A comprehensive review of the literature, made by E. Pavi and co-workers in 1995, confirmed that social inequalities were linked to the type, frequency and pattern of dental service utilization (Pavi et al. 1995). Results of many studies from 1975 to 1995 demonstrated stable association between socio-economic status and dental visiting behaviour (Pavi at al. 1995). The comprehensive study concluded that the barriers to dental attendance among low socioeconomic groups were determined by the subtle and powerful influences found within cultures (Pavi et al. 1995).

Besides gender and socioeconomic factors, organization of dental ser-vices has influence on dental attendance of the population. Reimbursement system as well as accessibility of a dental office affects utilization of dental care especially among deprived groups of individuals (Suominen-Taipale and Widström 2000; Nuttall et al. 2001; Bagewitz et al. 2002; Kronström et al. 2002; Chattopadhyay et al. 2003; Holm-Pedersen et al. 2005; Kosteniuk and D’Arcy 2006). Several studies showed that individuals with dental insurance had significantly more dental visits, particularly check-up based (Tomar et al. 1998; Brennan et al. 2000; Chattopadhyay et al. 2003; Bayat et al. 2006). Cost of the dental treatment is one of the reasons for not seeking

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dental care despite recognizing a need (Chattopadhyay et al. 2003; Nuttall et al. 2001; Bagewitz et al. 2002). In addition, dental attendance depends on availability of dental services, number of dentists in population as well as activity of recall system, implemented by the dentists (Suominen-Taipale and Widström 2000). It was admitted that higher dentist/population ratio and implementation of the recall system had positive impact on dental atten-dance (Murtomaa 1983; Suominen-Taipale and Widström 2000; Schouten et al. 2006).

Many studies indicated that dental attendance was strongly associated with self-reported dental status. The subjects reporting fewer lost teeth or those being satisfied with their dental condition more often indicate a preventive check-up based dental attendance (Muromaa and Metsäniitty 1994; Schwarz 1996; Osterberg et al. 1998; Tomar et al. 1998; Suominen-Taipale et al. 2000; Scheutz and Heidmann 2001; Bagewitz et al. 2002; Kronström et al. 2002; Petersen et al. 2004). Perceived need is one of the most important predictors for use of both medical and dental services. Non-users most often report no need for care (Tennstedt et al. 1994). Meanwhile, studies on dental attendance have certain limitations when it comes to draw-ing clear conclusion concerndraw-ing cause and effect – whether maintenance of natural dentition may be attributed to regular dental visiting, or whether loss of teeth is the reason for lack in dental attendance (Petersen et al. 2004). An interesting finding was reported by the study comparing utilization of dental services among middle-aged people in Sweden and Denmark – more frequent use of dental services among Danes despite their poorer dental conditions compared to Swedes was observed (Kronström et al. 2002). Researchers admitted that explanation of these results by the different insurance systems in both countries, still remained contradictory. In their opinion, this finding illustrates complexity of the relation between dental care utilization and dental health condition, calling for more comprehensive analysis (Kronström et al. 2002).

Dental attendance to some extent could be influenced by dental prac-tice related factors, such as private or public type of dental care. Evidence of this data remains scant. It has been suggested that private dentists more frequently considered the opinion of their patients, were more actively involved in oral health promotion or provided even better treatment quality (Barsby et al. 1995; Forss and Widström 1996; John et al. 1997). Despite the difference in perceived dental health between private and public dental service users, this difference is more likely to be attributed to socio-demo-graphic factors and regular use of services rather than payment method (McGrath and Bedi 2003).

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1.3. Dental health knowledge and attitudes

Dental health attitudes are associated with patients' satisfaction with dental care, compliance with prescribed regimens, and use of professional dental health care services, practicing of preventive dental self-care habits at home and consequently on dental health condition (Mataki 2000; Riley and Gilbert 2005; Riley et al. 2006). Many studies reported that dental health related attitudes of individual were linked to his dental health status (Tennstedt et al. 1994; Ahlberg et al. 1996; Steele et al. 1996; Unell et al. 1999; Riley et al. 2006) and dental attendance habits (Tennstedt at al. 1994; Ahlberg et al. 1996; Riley et al. 2006). As reported previously, one of the common reasons for not visiting a dentist was „no reason to go to“, demons-trating an attitude of seeking for the dental care only in case of trouble. Such a negative attitude toward dental health and prevention of dental diseases may be an important barrier for regular check-up based dental attendance (Steele et al. 1996; Tomar et al. 1998; Chattopadhyay et al. 2003).

Dental health attitudes develop and change with age and lifestyle of the individual. Understanding how health behaviours evolve, develop and are modified, allows the dental health professional to take actions when people attempt to modify their dental health care attitudes (Freeman 1999).

For development of positive dental health attitudes, experiences of the first dental visits, DHB habits of the parents as well as dentist-patients relationship is very important (Attwood et al. 1993; Kinirons and McCabe 1995; Riley and Gilbert 2005). It was observed that visits to the dentist in early childhood appeared to be associated with several positive attitudes and beliefs about the importance and effectiveness of dental care. Early expe-riences with the dentist may serve in development of the positive attitudes that promote the use of dental services and improve dental health. It was suggested for the dental health policy makers to educate parents about importance of early dental visits in order to develop positive dental health attitudes from childhood (Riley and Gilbert 2005).

Dental health attitudes could be modified by the dental health know-ledge. Several studies demonstrated that better dental health knowledge is related to the improvement of preventive DHB among adults (Keogh and Linden 1991; Stewart et al. 1996; Steele et al. 1996; Barrieshi-Nusair et al. 2006). Efforts to encourage people to adopt health practices rely on persuasive health education. One of the models, known as „knowledge, attitudes, practices“ (KAP), is based on the belief that increasing a know-ledge of individual will prompt a behaviour change. However, this model has its weaknesses, because motivation usually comes from sources other

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than, or in addition to, factual knowledge, as was noticed by researchers (WHO 2012).

Dentist and the dental team appear to be the most important source of dental health care knowledge (Hugoson et al. 2005). Information about dental care patients partly receive via advertisements and media as well as from friends and relatives. However, as observed earlier, not always contact with the dentist was associated with clear understanding of the preventive dental care methods and, in addition, negative perception of the dentist was expressed (Keogh and Linden 1991). It was admitted by the researchers that it is important aim to establish dentists and their staff as health educators.

Dental health attitudes and knowledge of the individuals have been evaluated by asking them to answer the questions (Keogh and Linden 1991; Unell et al. 1999; Hugoson et al. 2005) or assess the statements on dental health attitudes and knowledge (Riley and Gilbert 2005, Riley et al. 2006; Schouten et al. 2006; Ostberg et al. 1999). Examples of the questions and statements, related to knowledge of and attitudes to dental health, used by researchers are presented in tables 1.3.1. and 1.3.2. Several instruments as-sessing dental health knowledge and attitudes, such as Dental Health Know-ledge Questionnaire (Stewart et al. 1996), Duch Dental Attitudes Ques-tionnaire (Hoogstraten and Broers 1987; Bos et al. 2003; Schouten et al. 2006), Hiroshima University-Dental Behaviour Inventory (Kawamura et al. 2000) or Dental Checker (Kawamura and Iwamoto 1999) with the different number of content items for evaluation were developed. However, as noticed by the researchers, there were many difficulties in assessing dental health knowledge of the populations, possibly because some questions or statements could be unclear and easily misunderstood (Ostberg et al. 1999). On the other hand, knowledge about the involvement of behaviours in disease is seldom certain, and there is disagreement even among experts about the importance of different factors (Bratthall et al. 1996; Kawamura and Iwamoto 1999).

Dental health knowledge and attitudes are affected by a number of factors. It was observed that adult individuals from higher socioeconomic groups as well as with better dental health and retaining natural dentition demonstrate higher dental health knowledge and more positive attitudes to it (Keogh and Linden 1991). Gender is important factor too: females generally have more favourable attitudes on health-related issues and greater interest in their health (Dean 1989; Ostberg et al. 1999). Women tend to visit a dentist more frequently, are more likely to seek preventive dental care and have a more positive attitude towards dental education (Zakrewska 1996). Cultural differences in dental health attitudes were observed in a study

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comparing oral health behaviour between Japanese and Finish dental stu-dents (Kawamura et al. 2000).

Table 1.3.1. Questions related to knowledge of and attitudes to dental health used in a study by Keogh et al (Keogh and Linden 1991)

1. Do you know what dental plaque is?

2. If you had some sweets would it be better for your teeth to eat them all at once or split them up and eat few at several times through the day?

3. Have you ever been given or received any advice or information about looking after your teeth?

4. Have you ever been given or received any advice or information about looking after your gums?

5. Do you think it is an inevitable that most people lose all their natural teeth as they get older?

6. Do you expect to keep some of your remaining teeth for life? 7. Do you think fluoride should be added to the water?

Table 1.3.2. Statements on dental health knowledge and attitudes (Hiro-shima University-Dental Behaviour Inventory) used in a study by Kawa-mura et al (KawaKawa-mura et al. 2000)

1. I don’t worry much about visiting dentist. 2. My gums tend to bleed when I brush my teeth. 3. I worry about the colour of my teeth.

4. I have noticed some white sticky deposites on my teeth. 5. I use a child sized toothbrush.

6. I think I cannot help having false teeth when I’m old. 7. I am bothered by the colour of my gums.

8. I think my teeth are getting worse despite my daily brushing. 9. I brush each of my teeth carefully.

10. I have never been taught professionally how to brush. 11. I think I can clean my teeth well without using toothpaste. 12. I often check my teeth in a mirror after brushing.

13. I worry about having bad breath.

14. It is impossible to prevent gum disease without tooth brushing alone. 15. I put off going to the dentist until I have a toothache.

16. I have used to dye to see how clean my teeth are. 17. I use a toothbrush which has hard bristles.

18. I don’t feel I’ve brushed well unless I brush with strong strokes. 19. I feel I sometimes take too much time to brush my teeth. 20. I have had my dentist tell me that I brush very well.

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Data on dental health knowledge and attitudes to it among adults in Lithuania are scarce. The only study that included some aspects of dental health attitudes and knowledge was conducted in Lithuania in 1997/1998 among a representative sample of 34–45 years and 65–74 years age adults, and provided an overview of the OHB of the respondents. A relatively high level of dental health knowledge and attitudes among the study subjects was demonstrated when evaluating the statements. However some aspects of knowledge appeared surprisingly low, for instance 56% of the participants indicated that they did not know about any effect of fluoride in prevention of dental caries (Petersen et al. 2000). In addition, more than half of the subjects in the group of 35–44 year old adults demonstrated inadequate or no dental health knowledge, and negative or not stated attitude to dentists (Aleksejūnienė et al. 2000).

1.4. Self-assesed dental health

Importance of the oral health for individuals’ wellbeing was empha-sized by WHO (Petersen 2003). Dental disease is still a major public health problem in high income countries and the burden of oral disease is growing in many low and middle income countries (Pettersen 2009). Although overall improvements in oral health have occurred in many developed countries over the past 30 years, oral health inequalities still exist among low income and socially disadvantaged groups inside the populations (Pettersen 2008).

Oral health status of the individuals traditionally is assessed by a den-tist, with the help of reliable clinical measures, such as DMFT index (de-cayed, missing, filled teeth), CPI (Community periodonal index), DAI (Den-tal aesthetic index) or others, based on strictly defined criteria and using specific instruments and supplies (WHO 1997). According to the findings treatment needs are determined and recommendations for the patient appointed by the dental professional.

Recently, a number of studies focused on self-assessment of the oral health status offering variety of measures for it. Subjects of the numerous studies were asked to indicate the number of teeth lost or left, or replaced (Palmqvist et al. 2000; Suominen-Taipale et al. 2001; Bagevitz et al. 2002; Kronström et al. 2002; Christensen et al. 2003; McGrath and Bedi 2003; Petersen et al. 2004; Cunha-Cruz et al. 2004; Savolainen et al. 2005; San-ders et al. 2006), assuming this as reliable data for assessment of their dental status. Other studies measured dental health of the participants by offering for their evaluation questions and statements about experienced dental discomforts and symptoms (Newton et al. 2000; Hjern et al. 2001; Taani

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2002; Heft et al. 2003) or asking to assess their dental condition, or to indicate their satisfaction with it (Kawamura and Iwamoto 1999; Bradnock et al. 2001; Scheutz and Heidmann 2001; Afonso-Souza at al. 2007). Some studies used both – clinical indices and self-reported assessment of dental health status (Unell et al. 1999; Riley and Gilbert 2005; Riley et al. 2006). Further more, sociodental indicators were introduced to broaden the narrow focus that had emerged within oral epidemiology, which emphasized only the clinical parameters of disease, and therefore failed to document the full impact of oral disorders within populations (Slade et al. 1998). On this basis special instruments for self-assessment of oral health status and its impact on individuals’ wellbeing were developed and used by the researchers, such as Subjective Oral Health Status Indicators (Richards and Ameen 2002), Oral Health Impact profile, The Dental Impact Profile, Geriatric Oral Health Assessment Index and others (Slade et al. 1998).

A number of studies demonstrated evidence of relationship between self-assessment of dental status and socioeconomic characteristics as well as preventive DHB. Those individuals reporting better dental status or greater satisfaction with their dentition appear to belong to higher socioeconomic groups of the populations (Petersen 1983; Berset et al. 1996; Palmqvist et al. 2000; Hjern et al. 2001; Krustrup and Petersen 2007; Afonso-Souza et al. 2007,) and demonstrating better preventive DHB (Petersen 1983; Berset et al. 1996; Hjern at al. 2001; Richards and Ameen 2002; Cunha-Cruz et al. 2004; Sanders et al. 2006; Afonso-Souza et al. 2007; Krustrup and Petersen 2007).

Systematic information on dental health of adults in Lithuania is missing. Few studies more than 10 years ago evaluated dental health status of adult Lithuanians’ using clinical indices (Skudutytė et al. 2000; Alekse-junienė et al. 2000; AlekseAlekse-junienė et al. 2002) as well as offering statements (Aleksejunienė et al. 2000; Petersen et al. 2000) for self-assessment of individuals’ dental health. Health behaviour surveys among Lithuanian adult population included question on self-reported number of teeth lost (Gra-bauskas et al. 2005, 2007, 2009, 2011). Dental health status of Lithuanian adult population is rather poor in comparison with industrialised countries by clinical indices as well as self-reported number of teeth (Table 1.4.1., 1.4.2).

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Table 1.4.1. DMFT index among adult Lithuanians and among adults in the other countries

Country DMFT The year of survey, population, publication

Lithuania 14.2 17.2

1984 nation-wide survey of 35–44 year old adults (WHO, Country profiles on oral health in Europe, 1991)

1997/1998 nation-wide survey of 35–44 year old dentate adults (Skudutytė et al.)

Denmark 16.7 2000-2001 nation-wide survey of 35–44 year old dentate adults (Krustrup and Petersen 2007)

Norway 19.9 14.8

1984 survey of 35 years old Oslo residents

1993 survey of 35 years old Oslo residents (Berset et al. 1996) UK 17.5

15.7

1978, nation-wide survey, 25–34 year old adults

1988, nation-wide survey, 25–34 year old adults (Downer 1996)

Table 1.4.2. Self-reported number of lost teeth among adult Lithuanians and among adults in the other countries

Country Number of _{teeth lost} Percentages of reporting subjects (%)

The year of survey, population, publication Lithuania None 1–5 6–10 10> Edentate 16.4/19.8 49.1/46.7 16.6/16.8 15.3/14.0 2.6/2.6 2004/2010 nation-wide surveys of 20–65 years old adults (n=1791/1965) (Grabauskas et al. 2005/2011) Estonia None 1–5 6–10 10> Edentate 19.6 48.1 18.1 12.1 2.1

1998 nation-wide survey of 16–64 years old adults (n=1315) (Kasmel et al. 1999)

Denmark ≤12 13–22 22> Edentate 80 7 5 8

2000 nation-wide survey of 16–75+ years old adults (n=16659) (Petersen et al. 2004)

UK ≤12 13–22 22> 70 10 20

Nation-wide survey of 16–64+ year old adults (McGrath and Bedi 2003)

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1.5. Patients‘ satisfaction with dental care

Concern about the doctor-patient relationship was documented as far back as Hippocrates (Kress 1988) and continues to receive considerable attention in the fields of medicine in recent times (Grytten et al. 2009). During past decades in a number of countries the researchers in dentistry as well as dental practitioners have been concerned with investigating patient-dentists relationship and patients satisfaction with dental care in particular, as dental treatment to the big extent has to be conducted with the patients’ cooperation to be successful (Murtomaa and masalin 1982; Abrams et al. 1986; Crall and Morris 1988; Arnbjerg et al. 1992; Liddell and Locker 1992; Lahti et al. 1995; Croucher et al. 1997; Hancock et al. 1999; Chu and Lo 1999; Tuominen and Tuominen 1998; Mataki 2000; Yoshida and Mataki 2002; Sondell et al. 2002; Schouten et al. 2003; Anderson et al. 2005; Bedi et al. 2005; Skaret et al. 2005; Milgrom et al. 2008; Ohrn et al. 2008; Mussard et al. 2008; Njio et al. 2008; Kikwilu et al. 2009; Sun et al. 2010). In dentistry, evaluation of dentist-patient relationship has been focused mainly on description of the patients’ satisfaction with dental care and dentist (Ayer 1982). Patient satisfaction has been widely recognised as the principle measure of dental care quality (Kress 1988). Studies on patients’ satisfaction with dental care may be useful to assess dental care providers and services as well as to understand or to predict patients’ behaviour (Newsome and Wright 1999; Chu and Lo 1999). Satisfied patients are mostly regular visitors likely complying with prescribed preventive and treatment regimens (Arnbjerg et al. 1992; Liddell and Locker 1992; Al-brecht and Hoogstraten 1998; Butters and Willis 2000; Sgan-Cohen et al. 2004).

Satisfaction as a subject has been studied from the different points of view, in sociology, in psychology, in marketing and in health care. Number of studies has been done mainly in the field of consumer satisfaction. Today dental health care is consumer driven. Dental patients are better-informed consumers of dental services then they have been in the past. This situation has forced dental professionals to respond to the personal needs of the patients. Dental patient satisfaction surveys could be helpful in receiving feedback from the patients and determining the status of the relationship between dental team and the patient (Haisch 2000). Use of a well designed instrument is helpful in getting feedback from the patient and obtaining meaningful information for the policy makers as well as dental practitioners. However, consumer and patient satisfaction cannot be measured in the same manner (Carr-Hill 1992; Williams 1994). There is no generally accepted theoretical definition of the concept of the patient satisfaction (Baker 1997;

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Newsome and Wright 1999; Sitzia and Wood 1997). Conceptual model for satisfaction with dental care was constructed by Ståhlnacke (Ståhlnacke 2007) to be used as theoretical framework for the analyses (Fig. 1.5.1).

Fig. 1.5.1. Theoretical model in the analysis of satisfaction with dental care

(Ståhlnacke 2007)

Many studies evaluated satisfaction of various patient groups with their dental care (Kress and Shulman 1997), trying to assess factors that motivate patients to seek for dental treatment. In questionnaire studies satisfaction with dental care has been evaluated in various dimensions, such as technical competence of the dentist, his/her personality and organisation of the surgery (Murtomaa and Masalin 1982), financial aspects (Koslowsky et al. 1974), interpersonal aspects of care, accessibility/convenience, treat-ment–related pain and fear and general satisfaction (Corah et al. 1984). The results seem to demonstrate the importance of the dentists’ personal characteristics and interpersonal skills in forming patient’s image of him no

Patient satisfaction with dental care

Dental care factors Recent care experience Past care experiences General health factors

Expectation disconfirmation Zone of tolerance Attribution duty/culpability

– Care organization – Accesibility – Visit specialist – Visit hygienist – Cost for care – Travel time – Waiting time – Information – Time last visit – Regular attender – Reception – Anxiety – Unpleasant – Pain – School dentist – Frightening experience – Utilization habits – Attitudes – Perceived general health – Smoking – Perceived oral health – Dental appearance – Dental trouble – Toothache – Dentures – Gender – Marital status – Ethnicity – Residence – Work factors – Education Oral health factors Socio-economic factors

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less then his professional skills. In addition, patients often pointed out the lack of understandable explanation given by the dentist about their dental health status, what dentist is going to do and why (Abrams et al. 1986; Crall and Morris 1988; Golletz et al. 1995; Kress et al. 1973; Al-Mudaf et al. 2002; Hakeberg et al. 2000; Karydis et al. 2001; Kelly et al. 2000). As was shown before, various groups of patients differ in their expectations and preferences for dental treatment. Patient’s response to health care delivery, including satisfaction, commitment to prescribed regiments, and utilization of services is closely related to how the patient perceives the quality of the provider-patient relationship (Mataki 2000).

Patient satisfaction is a multidimensional concept. The dimensions of dental care satisfaction comprise distinguishable features of care that influ-ence attitudes toward providers and services. Technical, interpersonal, ac-cessibility, convenience, financial and other different aspects of dental care can be identified, depending on instrument developed by researchers (Da-vies and Ware 1982). Surveys on satisfaction with dental care, mostly tar-geting to evaluate attitudes towards dental services have been using multi-item mainly self-administered instruments assumed as reliable enough for group comparisons (Davies and Ware 1982). After comprehensive analysis of surveys on satisfaction with dental and medical health care Davies and Ware developed Dental Satisfaction Questionnaire (DSQ), covering quality of care (interpersonal and technical), accessibility (financial and non-financial), availability, convenience, continuity, efficacy/outcomes, general satisfaction and pain management. 19-item DSQ was designed for self-ad-ministration by individuals 14 and more years old, and requires an average of about 5 minutes to complete (Davies and Ware 1982) (Table 1.5.1).

Some studies have used original (Goletz et al. 1995, Mascarenhas 2001; Skaret et al. 2004, 2005) or modified versions (Chapko et al. 1985; Badner et al. 1992; Tuominen and Tuominen 1998; Chu and Lo 1999; Milgrom et al. 2008) of the Dental Satisfaction Questionnaire (DSQ), others have created their own tools (Croucher et al. 1997; Butters and Willis 2000; Gurdal et al. 2000; Karydis et al. 2001; Yoshida and Mataki 2002; Al-Mudaf et al. 2003; Sgan-Cohen et al. 2004; Sur et al. 2004; Bedi et al. 2005; Schouten et al. 2003; Mussard et al. 2008; Stahlnacke et al. 2007; Bayat et al. 2010) for assessment of satisfaction with dental care. Besides the DSQ, few other instruments were developed and used by researchers to measure patients’ satisfaction with dental care, such as Dental Visit Satisfaction Scale (Corah et al. 1984; Liddell and Locker 1992; Stouthard et al. 1992; Hakeberg et al. 2000; Sun et al. 2010), Patient Satisfaction with Out-of-hours Care instrument (Anderson et al. 2005) or Survey Tool for Ortho-dontic Patient Satisfaction (Njio et al. 2008).

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Table 1.5.1. Abbreviated item content and content category of Dental Satisfaction Questionnaire (DSQ) by Davies and Ware (Davies and Ware 1982)

Item Abbreviated Content Content category

1. Dental care could be better General 2. Dentist check everything Technical 3. Fees too high Financial 4. Avoid dentist because painful Pain 5. Wait long time at dentist’s office Access 6. Dentists treat patients with respect Interpersonal 7. Enough dentists around here Availability 8. Dentists should reduce pain Pain

9. Dental care conveniently located Convenience 10. Dentists avoid unnecessary expenses Financial 11. Dentists not thorough Technical 12. See same dentist Continuity 13. Hard to get appointment Access 14. Dentists relieve most problems Outcomes

15 Office hours good Access 16. Dentists explain what they do and cost Interpersonal 17. Keep people from problems with teeth Prevention 18. Dentists’ office modern Technical 19. Not concerned about pain Pain

The search for causes of patient satisfaction with dental care identified three impact aspects that seem to make difference: subjective treatment experience that creates positive or negative feelings, patients’ characteristics on how they view dental care, and nature of practice or the doctor (Kress 1988). Reviews of the studies noticed that office atmosphere, both physical and psychological, convenience and access, costs, and perceived quality are the general issues to which dental patients generally respond and that influence the extent to which they feel satisfied with dental care. Inves-tigation on patient-related factors has found that women, individuals with higher income, and better educated people appear to be more satisfied with dental services. Literature review showed that patients of private and

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smaller sized clinics with modern equipment and female dentist reported being more satisfied with dental care. Importance of interpersonal factors for satisfaction with dental care, even as having influence in assessment of dentists’ technical competence was emphasised as well (Kress 1988).

Numerous later studies investigating determinants of satisfaction with dental care confirmed that it is affected by previously mentioned factors, such as background characteristics of the patient (Yoshida and Mataki 2002; Skaret et al. 2005; Kikwilu et al. 2009), practice type (Milgrom et al. 2008; Skaret et al. 2005), dentists’ gender (Sondell et al. 2002), and communi-cation abilities of a dentist (Butters and Willis 2000; Gurdal et al. 2000; Sondell et al. 2002; Al-Mudaf et al. 2003; Schouten et al. 2003; Kikwilu et al. 2009; Bayat et al. 2010), the latter one being most important when leading to the conclusion to emphasise the importance of teaching dentists interpersonal skills as a way to encourage use of dental services.

All the studies mentioned above were carried out in the countries that significantly differ by social, cultural and economical aspects in comparison with Lithuania’s situation. Nearly no studies on dental care satisfaction have been performed in Lithuania, neither there were any studies to identify factors that can be used to predict DHB, treatment motivation, decision making in order to provide complete dental treatment and to follow dentist’s recommendations after the treatment. Attempts to assess patients attitudes to the dentist as well as satisfaction with the treatment costs were made in a group of Lithuanian 35–44 years old adults by Aleksejuniene and co-workers, showing it relation to socioeconomic factors and tooth brushing habits (Aleksejūnienė et al. 2002; Petersen et al. 2000). Only one article briefly describing data on patients’ opinions about private and public dental care in Lithuania was published by Pūrienė and co-workers, concluding that patients are generally satisfied with public and private dental care services, less satisfied appeared to be those visiting both sectors (Pūrienė et al. 2008).

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2. MATERIALS AND METHODS

2.1. General description of the study (Study design)

The present study was conducted at the Clinic of Dental and Oral Pathology (Kaunas University of Medicine, Faculty of Odontology) in coo-peration with Institute of Dentistry (University of Helsinki, Finland).

A pilot study designed to test the questionnaire was carried out on 53 adult patients attending the dental clinics of the Faculty of Odontology, Kaunas University of Medicine in 2004 (Sakalauskiene et al. 2005). Based on the results of the pilot study, final questionnaire was developed.

A cross-sectional questionnaire survey was conducted among the university employees anonymously from March to June 2005 (Sakalaus-kienė et al. 2009). All present employees between 35 and 44 years of age (n=862; 629 were female) according to the lists provided by the human resources departments of the participating universities received a personally addressed envelope with the questionnaire and invitation letter, signed by the authors, explaining the study design and encouraging them to respond. They were asked to complete the questionnaire voluntary and to return it anonymously to an indicated address (office/officer at the university) within two weeks.

The self-administered questionnaire inquired about the dental hygiene habits, most recent dental visit and habitual dental attendance, dental health knowledge and attitudes, self-assessed dental health and appearance, recently experienced symptoms and discomforts related to dental problems, and satisfaction with dental care, based on the experiences of the most recent dental visit.

Kaunas Regional Committee of Ethics for Biomedical Research (Lit-huania) granted its permission to conduct the present study in December 2003.

2.2. Study population

The target population comprised middle-aged (35- to 44-year-old) university employees in Lithuania. One university from each of four university cities was invited to participate on the basis of having no medical profile, size and willingness to cooperate. Four university cities exist in Lithuania – Vilnius, Kaunas, Klaipėda and Šiauliai. Two of them – Klaipėda and Šiauliai, have one university each, both were invited to participate.

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From the other two cities, universities of the similar size and teaching profile were selected to be invited to the study.

University cities in Lithuania differ by a number of the dentists per 10000 inhabitants (Report of Lithuanian Dental Chamber 2012, Lithuanian Statistics 2012) (Table 2.1.1).

Table 2.2.1. University cities in Lithuania by a number of the dentists per 10000 inhabitants (Report of Lithuanian Dental Chamber 2012, Lithuanian Statistics 2012)

University city (region) Number of inhabitants_{(‘000) 2006–2012} ₁₀_{,000 inhabitants in the region}Number of dentists per

Vilnius (Vilnius region) 542‘–523‘ 15+ Kaunas (Kaunas region) 361‘–311‘ 15+ Klaipėda (Klaipėda region) 187‘–160‘ 10–14.9 Šiauliai (Šiauliai region) 129‘–108‘ 7–9.9

University employees aged 35–44 years were considered as an educated group representing highest level of DHB as well as the most financially stable part of the population in the country. All present emp-loyees between 35 and 44 years of age (n=862; 629 were female) according to the lists provided by the human resources departments of the participating universities were invited to participate in the study.

A total of 553 (64%) questionnaires were returned and evaluated. The mean age of respondents was 40.11 years (SD, 3.19); the mean age of women and men was 40.10 (SD, 3.15) and 40.15 (SD, 3.36), respectively. Response rates between the universities showed no differences. Original study sample by university and response is presented in Table 2.2.2.

The respondents’ age, gender, marital status, education and income served as background information.

Distribution by gender of the study subjects, according to their back-ground characteristics is presented in Table 2.2.3. Distribution by gender in the original sample: 24% – men, 76 % – women. Information about other background characteristics of original sample was not available because of survey anonymity.

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Table 2.2.2. Original study population by university and response

Vilnius1 _Kaunas2 _Klaipėda3 _Šiauliai4

Number of employees according

the HR department list (n) 262 190 226 211 Unreachable (not working any

more, left the country temporary, maternity leave, etc.) (n)

7 11 5 4 Questionnaires distributed (n) 255 179 221 207 Response (n, %) 170 (67%) 113 (63%) 143 (65%) 146 (71%) Total responded 572 (66%)

Excluded form the analysis – didin’t indicate the age (n)

19 Final sample used for analysis / response rate (n, %)

553 (64%)

1_{Vilnius Pedagogical University (one of few universities in the city).} 2_{Vytautas Magnus University (one of few universities in the city).} 3_{Klaipėda University (only one university in the city).}

4

Šiauliai University (only one university in the city).

Table 2.2.3. Distribution by gender of the 35- to 44-year-old university employees in Lithuania, according to their background information

Characteristic All subjects n=553 % Women n=439 (79%) % Men n=114 (21%) % Marital status Cohabiting Single 72 28 70 30 77 23 p=0.150 Education University _{Less than university} 82 ₁₈ 83 ₁₇ 78 ₂₂

p=0.238 City of residence Vilnius Kaunas Klaipėda Šiauliai 30 20 24 26 29 19 26 26 32 18 25 25 p=0.307 Income Above average Average Below average 23 39 38 40 40 20 32 32 34 p=0.003 Statistical evaluation by the Chi-square test for differences according gender.

DENTAL HEALTH BEHAVIOUR AND SATISFACTION WITH DENTAL CARE AMONG 35–44 YEARS AGED LITHUANIAN UNIVERSITY EMPLOYEES

Žana Sakalauskienė

DENTAL HEALTH BEHAVIOUR

AND SATISFACTION WITH DENTAL

CARE AMONG 35–44 YEARS AGED

LITHUANIAN UNIVERSITY

EMPLOYEES

Žana Sakalauskienė

LIETUVOS UNIVERSITETŲ

35–

44 METŲ AMŽIAUS DARBUOTOJŲ

DANTŲ PRIEŽIŪROS ELGSENA IR

NUOMONĖ APIE TEIKIAMĄ

ODONTOLOGINĘ PAGALBĄ

TABLE OF CONTENTS

ABBREVIATIONS

INTRODUCTION

AIMS AND TASKS OF THE RESEARCH

DESCRIPTION OF THE NOVELTY AND PRACTICAL

SIGNIFICANCE OF THE RESEARCH

1

. LITERATURE REVIEW

2.

MATERIALS AND METHODS