DOI: 10.1590/1413-81232018235.

20422016 1561

Factors associated with the utilization of dental health services

REVIEW
by the pediatric population: an integrative review

Davi Silva Carvalho Curi 1

Andreia Cristina Leal Figueiredo 2
Silvia Regina Jamelli 1

Abstract This integrative literature review aimed

to analyze studies about factors associated with
the utilization of dental health services by the pe-
diatric population between zero and 15 years old,
published between 2006 and 2016 and available
in Portuguese, English or Spanish. A survey of
articles in the Lilacs and Medline databases was
carried out, using the search strategy: (“dental
care/utilization” OR “dental health services/uti-
lization”) AND (“child” OR “child, preschool”)
AND NOT adult. To analyze the methodological
quality, the adapted Critical Appraisal Skill Pro-
gramme (CASP) and the Agency for Healthcare
and Research and Quality (AHRQ) were used.
The following predictors of use of dental health
services stood out: factors associated with children
or adolescents (age, frequency of tooth brushing,
chronic conditions), caregivers (schooling, percep-
tion of child’s dental health, perceived oral health
needs), dentists (availability at night and on the
weekends) and follow up of oral health by the
family health team. These are inherent factors for
the planning of oral health policies or programs
Centro de Ciências da for the pediatric population. However, these fac-
Saúde, Universidade Federal tors vary according to the context, and therefore, a
de Pernambuco. Av. Prof. contextual analysis should be conducted.
Moraes Rego 1235, Cidade
Universitária. 50670-901 Key words Health services accessibility, Dental
Recife PE Brasil. health services, Child, Adolescent
curidavi@gmail.com
2
Faculdade de Odontologia,
Universidade Federal da
Bahia. Salvador BA Brasil.
1562
Curi DSC et al.

Introduction The study comprised six methodological

steps: 1 - identification of the topic and selec-
The utilization of health services is the core of tion of the guiding question; 2 - establishment
health care operations, resulting from the inter- of inclusion and exclusion criteria of the studies;
action between the behavior of the users and the 3 - definition of the information to be extract-
professionals who conduct them within this sys- ed from the selected studies and their respective
tem. It is also related to access (the act of enter- categorization; 4 - methodological evaluation of
ing, entrance) and accessibility (quality of what is the included studies; 5- interpretation of the re-
accessible)1. Among health services, dental health sults; 6- presentation of the review and synthesis
services (DHS) show inequalities related to use. of knowledge8,9.
These inequalities could be identified in several For the first step, the following guiding ques-
countries, regardless of the nature, scope and ef- tion was constructed: “Which are the factors
ficiency of the health systems2. associated with the utilization of DHS by the
Children and adolescents are less prone to pediatric population between zero and 15 years
receiving dental care and, therefore, have unmet old?” Subsequently, eligibility criteria for the ar-
oral health care needs3. Data from the National ticles were established by searching the LILACS
Household Survey (2008) conducted in Brazil (Latin American and Caribbean Health Sciences
showed that among the 11.7% of the population Literature) and MEDLINE (Medical Literature
that have never consulted a dentist, 47.9% were Analysis and Retrieval System Online) databases
children up to 4 years of age and 36.5% were chil- between March and April 2016. The articles were
dren and adolescents between 5 and 19 years old4. independently selected by two reviewers, consid-
Factors related to the pediatric population, ering the following sequence to verify eligibility:
caregivers and DHS may influence the visit to the titles, abstracts and full text articles were read. In
dentist5. Therefore, it is of utmost importance case of discrepancies, reviewers resolved these by
that managers and health professionals be famil- consensus.
iar with these factors and analyze them carefully The inclusion criteria were: articles on fac-
when offering dental services, since early inter- tors associated with the utilization of DHS by
ventions during childhood and adolescence may pediatric patients between zero and 15 years old,
affect adult life and, consequently, reduce in- published between 2006 and 2016, and available
equalities in health6. in Portuguese, English or Spanish. There were
Studies that evaluate factors that influence the no restrictions on the study design. The exclu-
use of DHS are performed in the general popu- sion criteria were: duplicate studies in databases
lation, and are fundamental to provide informa- and publications not available in full. The arti-
tion for the planning of policies and programs cles were searched with descriptors indexed at
that encourage the utilization of DHS and reduce the Health Science Descriptors (DeCS) and the
social injustices. Despite the importance of these Medical Subject Headings (MeSH) – “dental
services, there are no published studies that gath- care” and “dental health services” – associated
er scientific evidence on factors associated with to the qualifier “utilization” and the descriptors
the utilization of DHS by pediatric patients. “child”, “child, preschool” and “adult”. The Bool-
Thus, this study aimed to analyze articles ean operators were: OR, AND and AND NOT
published between 2006 and 2016 on factors as- (NOT for MEDLINE). The search strategy used
sociated with the utilization of DHS by the pedi- was (“dental care/utilization” OR “dental health
atric population between zero and 15 years old, services/utilization”) AND (“child” OR “child,
contributing to a discussion based on scientific preschool”) AND NOT adult.
evidence. For the methodological analysis of the in-
cluded articles, the following instruments were
applied: 1) an instrument adapted from the Crit-
Methods ical Appraisal Skill Programme (CASP)10 and 2)
Agency for Healthcare and Research and Qual-
This is an integrative literature review, which al- ity (AHRQ)11. The adapted CASP has 10 items
lows the synthesis and critical analysis of scien- in the scoring: 1) clear and justifiable objective;
tific knowledge on a particular topic or guiding 2) adequate methodology; 3) presentation and
question, contributing to evidence-based health discussion of theoretical and methodological
practice7. procedures; 4) adequate selection of sample; 5)
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Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

detailed data collection; 6) relationship between study; and VII) opinion of authorities and/or re-
researcher and researched; 7) preserved ethical port of expert committees.
aspects; 8) rigorous and substantiated analysis
of data; 9) presentation and discussion of the
results and 10) contributions, limitations and Results
indications of new research questions. For each
item, the value 0 (zero) or 1 (one) is assigned, and Of the 307 articles found, 158 did not meet the
the final result is the sum of the scores, with a inclusion criterion for “year of publication”, 2 for
maximum score of 10 points. The selected arti- “language” and 126 for the “guiding question”,
cles were classified according to the scores: level amounting to 21 articles. Of these, 4 (2 duplicates
A – 6 to 10 points (good methodological quality and 2 were not available in full) were excluded,
and reduced bias) or level B – at least 5 points for a total of 17 articles in the final sample (Fig-
(satisfactory methodological quality, but with in- ure 1). Major information on the final sample is
creased risk of bias). summarized in Chart 1.
The AHRQ classifies studies in seven levels Most of the articles (58.9%) investigated fac-
according to the level of evidence: I) systematic tors associated with the utilization of DHS in
review or meta-analysis; II) randomized con- preschoolers (2-5 years) and/or schoolchildren
trolled trials; III) controlled trials without ran- (6-12 years), followed by 3 articles (17.6%) with
domization; IV) case-control and cohort studies; infants (zero to 23 months) and preschoolers,
V) systematic reviews of descriptive and qualita- and 2 (11.7%) with schoolchildren and adoles-
tive studies; VI) single descriptive or qualitative cents (13-15 years). Also, 1 (5.9%) article includ-

307 articles found

13 Lilacs
294 Medline

Did not meet the inclusion criterion

year of publication (02 Lilacs and 156 Medline)

194 articles

Did not meet the inclusion criterion

language (0 Lilacs and 02 Medline)

147 articles

Did not meet the inclusion criterion

answered guiding question (08 Lilacs and 118 Medline)

21 articles

Met the inclusion criteria

duplicates (0 Lilacs and 2 Medline)
studies not found in full (0 Lilacs and 02 Medline)

17 selected articles
03 Lilacs
14 Medline

Figure 1. Flowchart with final sample.

1564
Curi DSC et al.

Chart 1. Description of literature and levels of evidence, according to adapted CASP and AHRQ, for each study of the final
sample of this review. Recife-PE, 2016.

Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Jimenéz- Mexico Cross- 1404 To determine Increasing age and A VI
Gayosso et sectional schoolchildren the prevalence higher socioeconomic
al., 201512 between 06 and and existence of status of
12 years old socioeconomic schoolchildren were
inequalities in associated with the
the utilization of utilization of DHS.
DHS in Pachuca,
Hidalgo, Mexico.
Machry et Brazil Cross- 478 children To evaluate Younger children (01 A VI
al., 201313 sectional between 01 and relationships and 02 years old) who
05 years old between did not brush their
socioeconomic teeth regularly or
and psychosocial whose mothers had
factors and the less than 08 years of
utilization of DHS schooling were more
by children in likely to have never
the city of Santa gone to the dentist. In
Maria, Rio Grande addition, children of
do Sul, Brazil. low-income families,
with dental caries, or
mothers with poor
perception of their
child's oral health had
a higher probability
of using curative
DHS compared to
preventive ones.
Leroy et al., Belgium Retrospective- 1057 children at To investigate Children who were A IV
201314 Cohort birth, 587 at the the proportion not first-born, who
age of 03 and of visits to the had mothers with
699 at the age dentist in children higher levels of
of 05 aged 03 and 05 education, and whose
years; to describe parents recently
the experience of visited the dentist
parents about their were more likely
children’s first visit to have visited the
to dentist at the dentist at a younger
age of 03 and 05; age.
factors associated
with early use of
DHS.
it continues

ed the age group of preschoolers to adolescents health needs, frequency of tooth brushing, and
and 1 (5.9%) of infants to adolescents. Of the parental perception of child’s oral health. Addi-
total, 2 (11.7%) investigated children and/or tionally, contextual factors related to the dentist
adolescents with chronic conditions. The main and to the systemic health status of the pediatric
factors associated with the utilization of DHS population should be pointed out (Chart 1).
included: maternal level of education, family Regarding the language, 10 articles (58.9%)
income, health insurance plan, age, unmet oral were published in English, 5 (29.4%) in Spanish
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Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Lapresa Spain Cross- 2172 children To know the Increasing age, A VI
e Sanz- sectional between 02 and prevalence of frequency of daily
Barbero, 05 years old the utilization of tooth brushing
201215 DHS, to quantify and presence of
and analyze oral diseases were
the existence of associated with a
variability among higher probability
the autonomous of using DHS.
communities, Families with low
and to identify socioeconomic
the variables status, measured by
associated with the both social class and
utilization of DHS maternal schooling,
by the preschoolers were associated with
in Spain. a lower probability of
using DHS.
Pontigo- Mexico Cross- 1538 To identify factors Children whose A VI
Loyola et sectional adolescents that influence the parents had higher
al., 201216 between 12 and utilization of DHS levels of education
15 years old by old Mexican and had at least one
adolescents from tooth with dental
three localities in caries favored the
the municipality of utilization of DHS.
Tula de Allende.
Tellen et United Cross- 320 children To assess Predictors of age B VI
al., 201217 States of sectional between 04 and predictors of for the first visit to
America 08 years old utilization of the dentist were:
DHS by Hispanic- mother´s awareness
American of the importance
children in three of preventive care.
neighborhoods in Predictors of the
the city of Chicago. increase in the
number of planned
visits to the dentist
were: family income
and availability of the
professional on the
weekends. Predictors
of the decision to
return to the same
dentist included:
weekly availability
of the dentist at
night; satisfactory
communication
among dentist,
mother and child, and
mother´s awareness
of the importance of
preventive care.
it continues
1566
Curi DSC et al.

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Vallejos- Mexico Cross- 1373 To determine the Higher level of B VI
Sánchez et sectional schoolchildren sociodemographic, education, positive
al., 201218 between 06 and maternal and maternal attitude
12 years old treatment needs about the importance
associated with of child´s oral health,
the utilization of moderate and high
DHS by school- levels of dental caries
age children severity, increased
in Campeche, schoolchildren age
Mexico. and frequency of
dental brushing were
associated with DHS
use.
Chi e United Retrospective- 25993 children To assess the Children with A IV
Raklios, States of Cohort with chronical utilization of severe, endocrine,
201219 America conditions, DHS by children craniofacial or
between 03 with chronic hematological
and 14 years diseases enrolled neurological
old, enrolled in in Medicaid and to conditions were
Medicaid from identify subgroups at increased risk
Iowa during of children with of not using DHS
11 months or chronic diseases compared to other
longer less likely to use chronic disease
these services. subgroups. On the
other hand, children
with respiratory,
musculoskeletal,
digestive or ear, nose
and throat conditions
presented a lower risk
of not using DHS in
comparison to other
subgroups of chronic
diseases.
it continues

and 2 (11.7%) in Portuguese. Also, 14 articles 3 (17.6%) as level IV (2 cohort studies and one
(82.4%) were found in international journals case-control study).
and 3 (17.6%) in national journals. Regarding the
year of publication, most articles were published
in 2012 (29.4%), followed by 2008 (17.6%). The Discussion
countries of origin of the study included Mexico
(35.2%), Brazil (23.5%), Spain and the United The studies included in this review suggested
States (11.8% each) and Belgium, Canada and that demographic, socioeconomic, parental, be-
Nicaragua (5.9% each). havioral, contextual and well as factors related to
After reading the studies in full, 15 (88.2%) the dentist and oral and/or systemic health sta-
were classified as level A and two (11.8%) as level tus were associated with the utilization of DHS
B, according to the adapted CASP. According to by the pediatric population between zero and 15
the AHRQ, 14 articles (82.4%) were classified as years old.
level of evidence VI (cross-sectional studies) and
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Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Lapresa e Spain Cross- 5441 children To identify Individual variables A VI
Barbero, sectional and adolescents individual and associated with
201120 between 06 contextual greater probability
and15 years old variables of using DHS were:
associated with presence of perceived
the utilization of oral diseases and
DHS by children frequency of tooth
and adolescents in brushing. Variables
Spain. associated with a
lower probability
of use were: high or
moderate intake of
sugary soft drinks and
lower socioeconomic
status of the family.
From the contextual
variables, having
a dental insurance
plan (Children´s
Dental Care Plan),
established in
the autonomous
community over
10 years ago, was
associated with a
greater probability of
using DHS.
Baldani et Brazil Cross- 350 children To evaluate Absence of perception A VI
al., 201121 sectional and adolescents the individual about child´s dental
between zero determinants care needs decreased
and 14 years that influence the chances of using
old the utilization of DHS. Follow-up
DHS by a low- by the FHP team
income pediatric increased the
population living likelihood of use.
in areas served by
the Family Health
Program (FHP)
in a large city in
southern Brazil.
it continues

Demographic and socioeconomic factors bero15 observed that of 601 Spanish 2-year-old
children, only 24 had gone to the dentist and of
Age was the major demographic factor relat- 459 5-year-old children, 181 used DHS. A Brazil-
ed to the utilization of DHS by the population ian study by Machry et al.13 with children aged 1
between zero and 12 years old. The articles evalu- to 5 years showed that the youngest (1 to 2 years)
ated this factor among infants, preschoolers and showed higher probability of having never visit-
schoolchildren in Mexico12,18,22,23,28, Brazil13,25 and ed the dentist.
Spain15 and confirmed a greater probability of The main reasons for the association be-
using DHS with increasing age. Lapresa and Bar- tween age and use are the cumulative effect of
1568
Curi DSC et al.

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Villalobos- Mexico Case-Control 379 cases To identify the CSchoolchildren A IV
Rodelo et (schoolchildren effect of unmet with moderate (04 to
al., 201022 between 6 and dental treatment 06 teeth affected by
12 years old needs and caries), high (07 to
who used DHS socioeconomic 09) and very high (>
in the last year and demographic 09) needs were more
due to dental variables on likely to have visited
pain) and 1137 patterns of the dentist due to
controls dental visits due dental pain than those
to toothache in with low needs (zero
schoolchildren to 03). Schoolchildren
aged 06 to 12 years. who had no health
insurance plan or
were older (10 to
12 years old) were
more likely to have
visited the dentist
due to dental pain
than those who had
a health insurance
(public or private)
or were younger
(06 to 09 years old),
respectively. Boys
from public schools
had a 70% chance of
having gone to the
dentist due to dental
pain than those from
private schools. The
probability of visiting
the dentist due to
dental pain in girls
in public schools was
28%, when compared
to those attending
private schools.
it continues

oral problems as the child´s age increases as well due to dental pain than younger ones. The au-
as the lack of parental awareness of the impor- thors suggested that teeth of older children are
tance of early preventive dental health care13,25,29. exposed to cariogenic challenges for a longer pe-
Another reason is the poor parents’ perception riod of time, increasing the likelihood of having
of the child’s need for oral health, followed by a more advanced stages of carious lesions31 and
visit to the dentist only after the presence of oral consequently, of using curative DHS.
problems or the appearance of symptoms, such The sex of the child was also associated with
as toothache30. In this context, a Mexican study the utilization of DHS22,25,26. In the Brazilian study
by Villalobos-Rodelo et al.22 with students aged 6 by Kramer et al.25 with children between zero and
to 12 years concluded that older children (10-12 5 years old, girls were more likely to use the ser-
years old) were more likely to go to the dentist vices than boys, in compliance with Medina-Solís
 1569

Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Medina- Mexico Cross- 3048 To evaluate The following factors A VI
Solís et al., sectional schoolchildren the association facilitated the use
200923 between 06 and between of DHS: higher
12 years old socioeconomic socioeconomic status,
indicators and health insurance and
the utilization ofincreased age. Also,
DHS, according to higher frequency
the type of service
and lower age of
used (preventive onset of tooth
or curative), in brushing increased
children from the possibility
Navolato, Sinaloa,of using DHS,
Mexico. especially preventive
services, regardless
of socioeconomic
status and health
needs. Individuals
with higher clinically
evaluated health
needs used more
curative DHS.
Noro et al., Brazil Cross- 3425 children To analyze the High influence of A VI
200824 sectional between 05 and utilization of DHS socioeconomic status
09 years old by children in on the utilization of
the municipality DHS. Children who
of Sobral, Ceará, had a health insurance
Brazil, relating it plan were more likely
to socioeconomic to use these services.
factors and the use In addition, children
of health services. whose mothers
had lower levels of
education showed
greater difficulty of
using DHS. Regarding
the consumption of
health services, the
lack of home visits by
a community health
worker showed as
a protection factor,
i.e., the households
that did not receive
their visit were more
likely to have access to
dental treatment.
it continues

et al.´s findings26 with Mexican schoolchildren. public schools used more DHS than girls. These
However, a study by Villalobos-Rodelo et al.22 re- discrepancies may be influenced by the decision
ported different results, showing that boys from of the persons responsible for seeking and using
1570
Curi DSC et al.

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Kramer et Brazil Cross- 1092 children To verify the Relationship between A VI
al., 200825 sectional between zero prevalence age of the child and
and 05 years of preschool utilization of DHS.
old children who have As age increased,
consulted with the the frequency of
dental surgeon and children who went
the age at which to the dental surgeon
the first dental increased. In addition,
appointment was female children
performed in a were more likely to
representative use DHS than male
sample of children.
preschool children
from the city
of Canela, Rio
Grande do Sul,
Brazil.
Medina- Nicaragua Cross- 1400 To determine Older girls or A VI
Solís et al., sectional schoolchildren factors associated schoolchildren (> 08
200826 between 06 and with the utilization years old) were more
12 years old of DHS in likely to use DHS.
schoolchildren in Those with a higher
León, Nicaragua. socioeconomic status
were more likely to
use both curative
and preventive DHS.
Those who brushed
their teeth at least
once a day were
more likely to use
preventive services.
Evaluated oral health
needs were positively
associated with the
use of DHS, especially
curative services.
it continues

DHS25. Therefore, parental factors can directly the early use of preventive DHS regardless of
influence the association between the child’s sex whether or not the child is a first-born. Thus,
and the visit to the dentist. parents who have accumulated greater cultural,
Only one study14 reported that first-born social, and economic capital33 tend to have a bet-
children were less likely to visit the dentist ear- ter perception of their children’s oral health and
lier than non-first-born children. According to may take them to the dentist earlier.
the authors, parents tend to take their younger Regarding socioeconomic factors, the socio-
children to the dentist with their first-born child. economic status of the family was associated to
However, this association should be carefully the utilization of DHS by the population between
analyzed because the social background32 of the zero and 15 years old. Studies showed that chil-
parents, according to the different types of cap- dren and adolescents with low socioeconomic
ital accumulated throughout life, can influence status were less likely to visit the dentist12,15,20,23,26,28
 1571

Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

Chart 1. continuation
Evidence
Author, Evidence
Country Study Design Sample Objective Major findings (adapted
year AHRQ
CAPS)
Nicopoulos Canada Cross- 120 patients To assess the Children with chronic A VI
et al., sectional between 03 and prevalence of oral conditions were less
200728 12 years old health needs and likely to use DHS due
barriers in the to medical barriers
utilization of DHS than those with acute
in hospitalized conditions. The
children with main barriers were:
chronic or acute hospitalization, denial
medical conditions of treatment and low
blood count.
Medina- Mexico Cross- 1303 children To identify factors Facilitating factors A VI
Solís et al., sectional between 03 and associated with the for the use of DHS
200627 06 years old utilization of DHS were: older children
in children from (05 to 06 years old);
10 public schools moderate and high
participating in need of evaluated
an oral health oral health; greater
program in frequency of tooth
Campeche, brushing; families
Mexico. with a higher
socioeconomic status.
DHS = Dental Health Services.

or more likely to use DHS due to dental pain22. preschool children showed that lower maternal
These findings suggest socioeconomic inequal- schooling was associated with lower probabil-
ities that may result from structural barriers to ity of using DHS. According to the authors, the
public services, i.e., these services have more de- number of years the mother attended school will
mand than supply. This prompts individuals to eventually have greater impact on their children´s
seek the private sector, who are confronted with oral health than paternal schooling. However, this
economic barriers, such as the costs of treat- statement should be interpreted carefully because
ments23. Moreover, socioeconomic inequalities some children and adolescents are looked after
can be explained by Bourdieu’s sociological theo- by people other than the mothers. Therefore, a
ry32, where caregivers with greater accumulation caregiver is an individual with direct kinship and
of cultural, economic and social capitals medi- is also responsible for coordinating the resources
ated by habitus tend to have a better perception required by the child or adolescent37,38. Their level
of oral health in children or adolescents, dental of education can influence the utilization of DHS.
care practices and utilization of DHS33,34. Accord- In this sense, a Mexican study by Pontigo-Loyola
ing to Cruz35, habitus is the product of the agent’s et al.16 showed that adolescents aged 12 to 15
position within the social space and mediates the years with parents with higher level of education
need for health and the factors that facilitate the showed great probability of using DHS.
utilization of DHS. Thus, although parents have Regarding family income, a Brazilian study
economic resources, universal coverage and ac- by Machry et al.13 showed that 1- to 5-year-old
cess to DHS, their dispositions (perceiving, feel- children in a lower-income family are more like-
ing, acting, and thinking)36 may anticipate or ly to use curative DHS. Also, an American study
postpone their children´s use of DHS35. by Tellen et al.17 showed that family income was
Most of the studies assessed the socioeconom- a predictor of the increase in the number of
ic status using variables such as maternal and/or planned visits to the dentist of 4- to 8-year-old
paternal schooling and family income13-18,24. A children. Essentially, the caregiver’s level of ed-
study conducted by Lapresa and Barbero15 with ucation and family income are interconnected,
1572
Curi DSC et al.

and the former can generate the latter. In other awareness of the importance of preventive den-
words, education gives access to a specific occu- tal care17. A prospective cohort study conducted
pation and, therefore, to a certain level of income, by Leroy et al.14 followed up on Belgian children
and this may influence access to health care39. from birth to age 5, and showed that recent use of
Another socioeconomic factor was the pos- DHS by parents implied that children were more
session of private health insurance plan. Two likely to have visited the dentist earlier. Parents
studies23,24 showed that children and adolescents with a regular source of dental care may have a
with health insurance (public or private) were better perception of their children’s oral health45,
more likely to use DHS. A Mexican study car- and therefore take them to the dentist earlier.
ried out by Villalobos-Rodelo et al.22 showed that In this sense, a study by Tellen et al.17 with 4- to
schoolchildren who did not have a health insur- 8-year-old children living in Hispanic Ameri-
ance plan presented higher probability of using can communities in Chicago (USA) suggested
DHS due to dental pain. This can be explained that the children whose mothers had improved
by the fact that children who do not have a health awareness of the importance of preventive den-
insurance plan are usually from families with low tal care for their children had a better chance of
socioeconomic status, therefore, with greater un- visiting the dentist early and regularly. Therefore,
met oral health needs40. it is worth mentioning that in order to increase
Only Villalobos-Rodelo et al.22 related the the frequency of early use of DHS by children, at-
type of school with the utilization of DHS, and tention should be paid to the parents who do not
observed that children from public schools were use these services regularly14. Ultimately, dentists
more likely to use DHS due to dental pain in play a key role in oral health promotion and pre-
comparison to children from private schools. vention of aggravation46, being the link between
Usually, caregivers of public school children have caregivers and children.
lower levels of education41, tend to have poor
perception of the child’s oral health42 and will Behavioral factors
eventually seek dental care in advanced stages
of oral diseases. However, in other contexts, the The frequency of tooth brushing was the ma-
school can be notably perceived as a place to es- jor factor related to the utilization of DHS by the
tablish oral care practices35. population between 1 and 15 years old. The arti-
cles evaluated this factor in infants, preschoolers,
Parental factors schoolchildren and adolescents in Mexico18,23,28,
Brazil13, Nicaragua26 and Spain15,20 and conclud-
Mother´s perception13 about the child´s den- ed that individuals who brushed their teeth reg-
tal care and a positive maternal attitude18 towards ularly, especially 3 times a day, showed greater
it were related to the use of DHS in infants, pre- chances of using mainly preventive DHS23. Also,
schoolers and schoolchildren. A Brazilian study lower age at onset of tooth brushing (< 2 years)23
by Machry et al.13 showed that 1- to 5-year-old and low consumption of sugary soft drinks20 in-
children whose parents had an inadequate per- creased the likelihood of visiting the dentist.
ception of the child’s oral health were more likely Notably, these are cross-sectional studies
to use curative DHS. The authors pointed out and, consequently, reverse causality may occur,
that “poor” perception implies greater oral health i.e., because children and adolescents use DHS,
needs of the child, and this is essential to measure they may have started brushing their teeth ear-
the need for dental care30. A Mexican study by lier and regularly and consumed less sugary soft
Vallejos-Sánchez et al.18 showed that schoolchil- drinks. Also, the influence of parental factors on
dren whose mothers had a positive attitude to- the behavior of this population plays an import-
wards their child’s oral health were more likely to ant part. Therefore, educational approaches with
use DHS. The authors highlighted the relation- parents and children are essential to increase the
ship of this variable with the frequency of brush- practice of healthy oral habits42, reducing the use
ing, i.e., among preschoolers and schoolchildren, of curative DHS.
the frequency usually depends on the mother43.
It is also noteworthy that according to Andersen Factors related to oral and/or systemic
and Davison44, attitude towards health services is health status
an important predictor of DHS use.
Two other parental factors related to the uti- Perceived oral health need was the main fac-
lization of DHS were parents’ use14 and mothers’ tor related to the utilization of DHS by the pop-
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Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

ulation between 1 and 15 years old. The articles Factors related to the dentist
evaluated this factor among infants, preschoolers,
schoolchildren and adolescents in Spain15,20, Mex- Only one study17 observed an association be-
ico16,18,22,28, Brazil13,21 and Nicaragua26 and conclud- tween factors related to the dentist and the utiliza-
ed that people with oral health needs perceived by tion of DHS in evaluating predictors of use by 4-
caregivers or evaluated by the dentist presented to 8- year-old children in three Hispanic-Ameri-
greater chance to use DHS, especially curative can neighborhoods of Chicago, USA. The authors
DHS26. The main reasons reported included: se- found that the dentist’s availability at night or on
verity and number of decayed teeth, presence of the weekends increases the number of planned
dental pain22 and caregivers´ poor awareness of visits to the dentist as well as returns visits. Possi-
the importance of deciduous dentition. bly, these factors facilitate the use of DHS because
It should be pointed out that according to the dentist is available in shifts and days in which
the Andersen and Newman’s model47, health care caregivers are usually not working17. However, in
need is the most proximal determinant of use of other contexts, such as the Family Health Strategy
health services, i.e., greater health needs would (FHS) in Brazil, the dentist does not work at night
imply greater prediction of DHS use. Addition- or on the weekends, posing difficulties for chil-
ally, perceived oral health needs can be explained dren whose caregivers work during the week52.
by social structure and awareness towards health, Therefore, this issue should be addressed when
being an important predictor of the demand proposing public oral health policies.
for health care and adherence to treatment48. In Moreover, an important factor for returning
this review, only two studies assessed the needs to the dentist was the satisfactory communication
of perceived oral health15,20 and, therefore, more among professionals, mothers and children17,
research is needed including this issue. with focus on the importance of the command
Only two studies19,27 suggested the association of language, since the population of his study was
of children with chronic diseases with the utiliza- composed of immigrants from Latin American
tion of DHS. In the Canadian study by Nicopou- countries. However, it is important to point out
los et al.27 with hospitalized children aged 3 to 12 that non-verbal communication, humanization
years, those with chronic conditions (oncologi- of care and bonding are important strategies for a
cal, hepatic, renal, congenital heart disease, im- satisfactory relationship among dentists, caregiv-
munosuppression, among others) showed lower ers and children53,54.
chances of using DHS due to medical barriers
than children with acute conditions. According to Contextual factors related to dental care
the authors, the major medical barriers included:
recurrent hospitalizations, dentist’s reluctance Two Brazilian studies21,24 and one Spanish
to treat this population and pancytopenia. An study20 showed that contextual factors are relat-
American study conducted by Chi and Raklios19 ed to the utilization of DHS. A study by Noro et
with children and adolescents aged 3 to 14 years al.24 observed that 5- to 9-year-old children whose
with chronic conditions revealed that the indi- households did not receive visits from a com-
viduals with neurological, endocrine, craniofa- munity health agent (CHA) were more likely to
cial or hematological conditions used less DHS use DHS. According to the authors, most visited
than those with other chronic conditions. The households by CHAs are those where children´s
authors attributed this fact to the behavioral caregivers showed greater needs for follow-up
characteristics of the caregiver, such as high level due to systemic diseases or situations of social
of stress in relation to the systemic health needs vulnerability, rendering them unable to articulate
of this population and approach to oral health as child health care, such as dental care. At the same
a lower priority. time, it is important to point out how challenging
Importantly, individuals with greater vulner- it is for Brazilian dentists to work according to the
ability are more affected by oral health morbidi- FHS guidelines due to the historical influences of
ties, showing greater accumulation of needs49, as the Flexner´s model, their conceptions of FHS
well as they seem to have more restricted access and the autonomy provided by this model. As a
to DHS50,51. Thus, this group should be consid- consequence, consultations will take place exclu-
ered when proposing oral health policies aiming sively at a dental practice46. Therefore, equity, as a
at ensuring health equity. perspective of expanding access to DHS, should
be considered in the construction of oral health
policies.
1574
Curi DSC et al.

In contrast to Noro et al.´s findings24, Baldani group, as this field has not been thoroughly ex-
et al.21 showed that children and adolescents be- plored.
tween zero and 14 years old followed up by the In this review, most of the studies used the
family health team were more likely to visit the Andersen Behavioral Model47 to establish which
dentist. This demonstrates the longitudinality of conditions facilitate or hinder the utilization of
dental care and the existence of a bond between DHS. However, they did not explain the reasons
users and staff46,55. for inequalities. Thus, comprehensive research
Lapresa and Barbero20 showed that having based on Bourdieu’s32 sociological theory should
a Children´s Dental Care Plan in a Spanish au- be carried out. Moreover, the Andersen Behav-
tonomous community for more than 10 years ioral Model was developed to analyze the use of
increased the probability of DHS use by the pop- US private health services and should be carefully
ulation between 6 and 15 years old. Spain is di- interpreted, since the studies of this review ap-
vided into autonomous communities, with var- plied this model in contexts which are different
ied health system coverage and financing mech- from those in the USA.
anisms. The Children´s Dental Care Plan caters Ultimately, the articles were written in differ-
to the population between 6 and 15 years of age, ent countries, which have different health care
offering urgent restorative and preventive treat- systems. In this sense, it can be pointed out that
ment in the permanent and preventive dentition, factors related to the use of DHS by children and
as well as exodontia in the deciduous dentition, adolescents may vary according to the context in
not including restorative treatment here20.The which the research is performed. Therefore, for
authors report that although this assistance mod- the planning of oral health policies or programs
el is consolidated, the socioeconomic gradient is for the pediatric population, an exploratory re-
still present and does not vary between the au- search should be conducted according to the
tonomous communities. This means that parents context in which the actions are to be carried out.
or caregivers who have higher socioeconomic sta- Also, increasing supply of DHS alone is not able
tus, as well as accumulated cultural capital, tend to guarantee better utilization of dental health
to have better perception of child oral health and, services and reduce inequalities between vulner-
therefore, seek DHS34. able groups. A sociological analysis of these ser-
vices should be carried out following Bourdieu´s
model32.
Final considerations

The studies of this review show that demo-

graphic, socioeconomic, parental, behavioral and
contextual factors as well as those related to the
dentist and to the oral and/or systemic health
status are associated with the utilization of DHS
by the pediatric population between zero and 15
years old. Predictors of DHS use include: factors
related to children or adolescents (age, frequency
of tooth brushing, chronic conditions), caregivers
(schooling, perception of the child’s oral health,
perceived oral health needs), dentists (availability Collaborations
at night or on the weekends) and follow-up of
oral health by the family health team. DSC Curi was responsible for the concept, de-
Nevertheless, it is important to emphasize sign, analysis and interpretation of data, writing
that most studies are cross-sectional; therefore, of the manuscript and critical review, as well as
it is difficult to establish a causal relationship. for the approval of the version to be published.
Also, the studies used questionnaires, and mem- ACL Figueiredo accounted for the concept, de-
ory bias is likely to occur. Therefore, longitudinal sign, analysis and interpretation of data, writing
studies should be conducted to clarify causality of the manuscript and critical review, as well as
and minimization of bias. Research on the utili- for the approval of the version to be published.
zation of DHS in pediatric patients with chronic SR Jamelli was responsible for critical review as
diseases should be further conducted, compar- well as for the approval of the version to be pub-
ing them to healthy individuals of the same age lished.
 1575

Ciência & Saúde Coletiva, 23(5):1561-1576, 2018

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