Introduction
Oral diseases are among the most prevalent noncommunicable diseases, affecting approximately half of the people (3.5 billion individuals) worldwide while being mainly preventable. An estimated 2.5 billion persons have untreated tooth decay [
1]. The health of deciduous teeth is intimately tied to the healthy eruption of permanent teeth, the child’s nutritional intake, and the child’s growth [
2]. During the primary teeth stage, dental caries is the most prevalent oral disease [
3]. Dental problems affect children’s chewing and eating, enunciation, facial development, and even their mental health as adults [
4]. The dental status of a five-year-old child is critical, as this age coincides with the beginning stages of mixed dentition [
5]. According to the findings of the fourth national oral health epidemiological survey conducted in China in 2017, the prevalence of early childhood caries (ECC) in 5-year-olds reached 71.9% [
6].
Utilization of oral health services refers to residents’ actual use of oral health services, as well as the quantity and efficacy of oral health services provided by dental institutions to residents. It can indirectly reflect the importance that residents place on oral diseases and the level of oral health care service development [
7]. It is generally accepted that children have access to oral health services in most countries. Since its inception in 1921, the School Dental Service (SDS) of New Zealand has investigated novel strategies for improvement, and children’s dental health has steadily improved since the 1980s [
8]. In the United States, 94% of children who have been to the dentist for the first time continue to receive regular checkups [
9]. The Fourth National Oral Health Epidemiology Survey in China provides potential predictive factors related to sourcing dental services among children, such as feeding method, initiation time of tooth brushing, and usage of fluoride toothpaste [
10]. In Beijing, China, 45.5% of preschool children aged 2 to 6 years utilized oral services within 12 months [
11].
Guizhou Province is located in the western region of China and is an economically undeveloped, mountainous province [
12,
13]. In addition, Guizhou is a province with people of different ethnicities, including Miao, Gelao, and Buyi individuals [
14]. However, Guizhou does not have as many medical resources as other southern Chinese provinces [
15].
China is investigating relevant policies to lower medical costs and lighten the financial burden [
16]. Reducing the financial cost of health care requires improved basic health insurance support, and it is important to include oral health services for children. It is worth noting that the utilization of oral health services for children in China is still low at present in some parts of China [
10]. However, this has not been previously reported in Guizhou. Hence, to verify this claim and to explore the importance of including oral health services for children in basic public health coverage, the study aimed to conduct an epidemiological survey on the utilization of oral health services for children and related factors. For this purpose, this survey selected five-year-old children in Guizhou Province, China, and conducted a survey on them.
Several of the explanations for the significance of our findings include the following. First, the present study fills a gap in the investigation of oral health care utilization among Chinese 5-year-olds in Guizhou Province. Second, since provincial trends are not balanced across regions in China, the results of this study can be compared with those of other regions (e.g., Beijing, etc.) so that researchers can easily identify regional differences, determine their causes, and propose solutions. In addition, the local basic insurance for children does not cover dental services, and those who need dental services must bear all the costs themselves, which reduces the utilization of dental services to a certain extent and places a greater burden on preventive dental work and dentists.
In the current analysis, relevant variables were selected using the Andersen Behavioral Model as a guiding framework [
17,
18]. In this investigation, we hypothesized before conducting the study that several factors might contribute to underutilization of oral health services among children in Guizhou, China, including feeding method, use of fluoride toothpaste, history of toothache and parents’ knowledge of oral health. Our study assessed these factors as independent variables.
Discussion
Oral health, especially in children, is currently a medical challenge. This is due to the consumption of a variety of sugary foods and poor oral habits, which can have a negative impact on general and mental health [
1]. The oral health of a population may be worsen by low visit rates and financial burden. Our 2019–2020 study examined oral health service utilization and associated factors among 5-year-olds in Guizhou Province.
The results of this study showed that the utilization of oral health services for children in Guizhou province was 20.5% (including dmft 4.43, caries rate 72.2%, and untreated caries 98.3%). This could be attributed to the fact that the average cost of a dental visit was higher in rural areas and for girls. Moreover, logistic regression analysis showed that dental caries ≥ 6 teeth, a history of toothache, starting toothbrushing at less than 3 years of age, and limited parental knowledge were the most important factors impacting dental visits.
A ten-year examination of Brazilian preschoolers revealed that the average dmft had decreased from 1.88 to 2006 to 0.99 in 2016 and that up to 78% of children had reached caries-free status [
25]. In Germany, the prevalence and incidence of caries among children aged 5 were 26.2% and 0.9 ± 2.0 dmft, respectively, in 2015 [
26]. In this study, from 2019 to 2020, 5-year-olds in Guizhou Province in China had a dmft of 4.43 and a caries rate of 72.2%. However, the study conducted by this group from 2015 to 2016 revealed that the prevalence of dental caries in children aged 3–5 in Guizhou was 63.1%, and the mean dmft of ECC in children aged 3–5 in Guizhou province was 3.32 [
27]. From these numbers, it is clear that the dental caries of 5-year-olds in Guizhou are much higher than those in other nations, even greater than the survey results provided from four years ago, and that action needs to be taken by the local medical administration and dentists.
According to the Chinese Fourth National Oral Epidemiological Survey, the overall dental visit rate for children aged 5 in China is 25.4%, and the attendance rate in the last 12 months is 19.2% [
10]. In this study, at age 5, the rate of dental appointments for children in Guizhou province was 20.5%, and the attendance rate in the last 12 months was 14.0%. Guizhou Province, unlike other developed provinces in China (e.g., 21.5% for children in Guangdong Province and 15.63% for children in Zhejiang Province), has a relatively low incidence of 5-year-olds seeing the dentist in the previous 12 months [
28,
29].
Caries is the most common form of oral illness in children and the leading cause of dental visits [
30]. This survey showed that 98.3% of open cavities were not filled. In addition, the cost of a dental appointment for a 5-year-old child in Guizhou province was 633.19 Chinese Yuan, almost entirely self-pay, which is more than 413.65 Chinese Yuan nationally [
10]. The aforementioned demonstrates that 5-year-olds in Guizhou Province have low utilization of oral health services and a significant economic burden of oral diseases.
At the age of 5, dental caries rates are higher among rural children than among urban children, so rural children ought to have a higher attendance rate. However, the difference between rural and urban children is not statistically significant, likely due to a lack of oral health care services in rural areas, consequently, some rural children might skip a consultation or treatment. Some children’s parents choose to travel to urban areas for oral care services. Considering travel time and road and hotel expenses, the majority of rural children will have a single treatment for multiple teeth or complete the entire treatment at once, resulting in a higher cost. We assume that this is the reason that there is no difference in attendance between rural and urban areas but that there is a difference in cost, although further investigation is needed.
In this study, a multifactor logistic regression study revealed that dental caries ≥ 6, a history of toothache for the past 12 months, age of starting to brush teeth before 3 years, and inadequate parents’ knowledge of oral health were the most influential factors in the utilization of oral health services. The high dental visit rate of children with dental caries ≥ 6 cavities and a history of toothache within the last 12 months suggests that the utilization of dental services for 5-year-olds in Guizhou Province continues to be demand-driven. In addition, children at this age are in the early phases of mixed dentition, and the growth of permanent teeth, such as the first molars, can be associated with dental pain [
31], hence increasing the need for dental consultations.
A 5-year-old youngster with more than six teeth with cavities is deemed to have severe underage caries [
32]. It takes a long time for caries to reach a painful stage, and this study indicated that many parents would only take their children for treatment if caries had reached a severe stage, indicating that the actual need for dental care is significantly higher than the demand for dental visits [
11]. There is one possible explanation for the higher dental visits of children’s parents who begin brushing their teeth before the age of three. This is similar to this group’s previous study in that children who brush more frequently have higher caries rates [
27]. The caries rate was higher among children who began brushing their teeth before the age of three (73.2%) than among children who began brushing their teeth after three (71.7%). It can be inferred that some of the children who started brushing their teeth under the age of three may have already developed caries before their parents chose to brush their teeth or seek medical attention. Parents are primarily responsible for the oral health of their newborns and early children, and a lack of parental health knowledge is associated with a deterioration in the oral health status of children and an increase in their likelihood of seeking medical assistance [
33].
Ultimately, comparing the current results of oral status of 5-year-olds and policies regarding other countries or regions [
34‐
36], passive attendance is a key characteristic of 5-year-old children’s utilization of oral health services in Guizhou province and that a shift from a passive to an active attitude is a direction in which to work. According to the draft Global Oral Health Action Plan (2023–2030), by 2030, 75% of the global population will be covered by essential oral health care services to ensure progress towards Universal Health Coverage (UHC) for oral health [
37]. UHC indicates that all individuals and communities have access to essential, high-quality health services that meet their needs and that they can use without experiencing financial hardship [
37]. In recent years, the Lancet has published article proposals for incorporating basic oral health services and necessary oral care packages into universal health programs [
38]. Although children in Guizhou, China, are largely covered by basic health insurance, children’s oral health care is not included. The fact that children’s oral health treatments are completely self-funded by their parents may contribute to the low dental visit rate. Children of this age group in the region require a high level of dental care to reduce dental caries.
Three suggestions can be made to improve the utilization of oral services for preschool children in Guizhou province. First, oral health education for pregnant women and young parents should be enhanced so that they are concerned about dental health and recognize the need for regular checkups. Second, the system of oral health consultation services based in kindergartens needs be expanded so that oral health issues can be diagnosed and treated on campus. Third, it is proposed that the government cover the expense of dental services for children in basic health insurance to reduce the financial burden of oral problems on families.
Limitations: this study harbors several limitations that should be acknowledged. First and foremost, a considerable limitation is the use of cross-sectional study design, which precludes the ability to establish causality between the associated factors and utilization of oral health services. Moreover, the study was confined to 5-year-old preschoolers in Guizhou Province. This geographical and age limitation may prevent the generalizability of the findings to other regions or age groups. In addition, reliance on self-reported data from parents and grandparents, could introduce recall bias, influencing the accuracy of the data. Additionally, the reasons why 5-year-old females had a higher expenditure on dental visits in the past 12 months weren’t fully explored, warranting further research.
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