Cancer is one of the most common chronic non communicable diseases with an overall incidence of 17 per 100,000 female individuals in Iran [1]. Due to higher awareness about cancer, systematic screening programs, and new treatments strategies, the survival of cancer patients increased and more than 58% of female patients with breast cancer survive 10 years after diagnosis [2]. Exposure to chemotherapy and/or radiation therapy leads to mucositis, hypofunction of salivary glands which consequently increase dental caries [3]. Besides, a considerable number of cancer survivors are exposed to a heavy economic burden imposed by the disease [4].
Recent evidence highlights cancer survivors’ crucial need for accessible and affordable preventive OHC services. The situation grows even worse in less developed and developing countries where OHC utilisation is significantly low even among the normal population. Research conducted on OHC utilisation among Iranian adults shows that factors, such as being covered by an insurance policy, job status, level of education, SES, and psychologic health affect utilisation of OHC services [5-9].
According to the literature, there could be an association between oral health and SES among adults [10-12]. A systematic review evaluating the effects of socio-economic factors on dental caries among adults reported that a higher proportion of people of low SES experienced more severe dental caries in a population [10]. Another systematic review indicated the same results and, reported that the recent association could be stronger in developed countries [11].
To the best of the authors’ knowledge, there is no study conducted on oral health and utilisation of OHC services in female cancer survivors in Iran. Thus, the current study aims to evaluate the effects of SES on OHC utilisation and dental health among female cancer survivors in southern Iran.
Materials and Methods
This cross-sectional study was conducted on female cancer survivors having attended Shiraz cancer clinics at Shiraz, Iran, from June 2019 to October 2019, after approval by the Ethics Committee (approval number: IR.SUMS.MED.REC.1399.160) of Shiraz University of Medical Sciences. Written informed consent forms were obtained from all participants in this study.
Inclusion criteria: Female cancer survivors older than 18 years, who were able to consciously participate in the study, were included.
Exclusion criteria: Those patients with less than six months and/or over 60 months of cancer diagnosis as well as edentulous patients were excluded.
Sample size calculation: Stratified cluster sampling was employed at different public and private cancer care centres. The study sample size was calculated using Cochran’s sample size formula [13]:
where e: Desired level of precision; p: Estimated proportion of the population; q: 1-p.
By assuming the prevalence of OHC utilisation at 4.67%, with the hypothesis of a 10% decrease in OHC utilisation among cancer survivors, and with the precision value of 0.05, the total sample size was estimated 200 [9].
Data collection was conducted in a single face-to-face interview and an oral examination. The interviews were conducted in a private room for each participant. Three interviewers were selected among senior dental students, who were trained in an educational meeting managed by a highly competent dentist. Next, all of them participated in a role-play interview.
The data on OHC utilisation were collected using the Iranian National Healthcare Utilisation Questionnaire (version 2015) which was designed, standardised, and used by the National Institute of Health Research (NIHR) [14] [Annexure-1]. Data on SES among individuals were gathered through a Persian questionnaire on socio-economic determinants [15] [Annexure-2]. Variables assessed in the current study included SES, education level, age, job status, place of residence (urban/rural), number of months passed from initial diagnosis of cancer, history of head and/or neck radiation therapy, multiple co-morbidities, polypharmacy, anxiety, depression, oral hygiene behaviours (oral hygiene frequency, use of a toothbrush, toothpaste, dental floss, mouth wash, and sugar consumption), cancer treatments (surgery, chemotherapy, and radiation therapy), and the history of smoking. Anxiety and depression was assessed through Hospital Anxiety and Depression Scale (HADS) questionnaire. SES was categorised into four quartiles including low, low-middle, middle-high, and high. The cut-offs were selected according to the Interquartile Range (IQR) of the studied sample (n=200) [16]. Therefore, each group of the SES, included twenty-five percent (n=50) of the participants.
In this study, dental caries was assessed in female cancer survivors using decayed teeth (DT), missing teeth (MT), filled teeth (FT), and decayed mobile filled teeth (DMFT) indices [17]. All dental examinations were conducted by a general dentist based on the World Health Organisation (WHO) method of measurement [18], i.e., the examination of all permanent teeth, including wisdom teeth for dental caries using a metallic periodontal probe {Community Periodontal Index (CPI) probe} as well as a plane mouth mirror.
Statistical Analysis
Pearson’s Chi-squared test, the independent samples t-test, binary logistic regression, and Poisson regression were used for statistical analyses. Furthermore, p-values <0.05 was considered statistically significant, and all analyses were performed using International Business Management (IBM) SPSS Statistics 24.0 (Armonk, NY: IBM Corp.). To investigate the associated variables to the dental visits within the previous year, First the independent variables like education, age, number of months passed from initial diagnosis, multimorbidity, polypharmacy, SES, place of residence, job status, type of cancer, history of surgery, chemotherapy, radiation therapy, smoking, oral hygiene, anxiety, depression, and self-report health state, were put in the model and then backward elimination technique was used to fit logistic regression and calculate adjusted Odds Ratio (OR). The associated variables of dental indices i.e. DMFT, DT, MT, and FT were examined through the Poisson regression modelling by application of robust technique for estimation of standard errors for regression coefficients; and the Prevalence Ratio (PR) with 95% confidence interval was measured.
Results
Two hundred female cancer survivors were included, among whom 146 (73%) were breast cancer survivors. The other most frequent types of cancers in patients involved 15 (7.5%) endometrial cancers, 8 (4%) cervical cancers, 8 (4%) colon cancers, and 7 (3.5%) brain tumours and 16 (8%) other cancers. The median (IQR) age was 49 (41, 55) years. Out of 200, 135 (68%) were educated up to a high school diploma and 169 (85%) were housewives (had no job). A number of 75 (38%) suffered from depression and 92 (46%) suffered from anxiety [Table/Fig-1].
Dental health and oral healthcare utilisation according to participants’ characteristics.
| Factors | n (%) | Median (IQR) | Seek for dental services |
|---|
| DMFT | p-value* | Decayed Teeth (DT) | p-value* | Missing Teeth (MT) | p-value* | Filled Teeth (FT) | p-value* | n (%) | p-value^ |
|---|
| SES |
| Low | 50 (25) | 15 (9, 18) | 0.9 | 3 (1, 5) | 0.6 | 6 (2, 10) | 0.01 | 2 (0, 5) | 0.001 | 22 (11) | 0.2 |
| Low-Middle | 50 (25) | 13 (8, 19) | 3 (1, 5) | 3 (1, 8) | 3 (0, 9) | 33 (16.5) |
| Middle-High | 50 (25) | 14 (10, 17) | 3 (2, 5) | 3 (2, 6) | 5 (2, 8) | 30 (15) |
| High | 50 (25) | 13 (10, 16) | 2.5 (1, 4) | 1 (0, 6) | 7 (3, 11) | 29 (14.5) |
| Education |
| Illiterate | 16 (8) | 17 (12, 19) | 0.1 | 4 (1, 6) | 0.7 | 10(5, 16) | <0.001 | 0 (0, 5) | 0.001 | 6 (3) | 0.2 |
| Up to Diploma | 135 (67.5) | 13 (9, 18) | 3 (1, 5) | 4 (1, 8) | 4 (1, 8) | 81 (40.5) |
| Diploma and more | 49 (24.5) | 12 (9, 16) | 3 (1, 5) | 1 (0, 5) | 6 (3, 10) | 27 (13.5) |
| Age (year) |
| 18-34 | 13 (6.5) | 11 (10, 16) | <0.001 | 5 (2, 8) | 0.06 | 0 (0, 2) | <0.001 | 6 (2, 11) | 0.4 | 8 (4) | 0.3 |
| 35-44 | 55 (27.5) | 11 (7, 14) | 2 (1, 5) | 2 (1, 6) | 4 (0, 8) | 32 (16) |
| 45-54 | 74 (37) | 14 (10, 18) | 3 (2, 5) | 4 (1, 9) | 4 (0, 9) | 38 (19) |
| 55 and more | 58 (29) | 16 (11, 19) | 3 (0.7, 5) | 5 (3, 10) | 5 (2, 8) | 36 (18) |
| Job |
| Yes | 31 (15.5) | 12 (8, 15) | 0.05 | 3 (1, 4) | 0.4 | 2 (0, 3) | 0.004 | 6 (3, 9) | 0.2 | 6 (3, 9) | 1.0 |
| No | 169 (84.5) | 14 (9, 18) | 3 (1, 5) | 4 (1, 9) | 4 (1, 8) | 4 (1, 8) |
| Inhabitancy |
| Metropolitan | 100 (50) | 13 (9, 18) | 0.6 | 2.5 (1, 4) | 0.07 | 3 (1, 7) | 0.9 | 5 (2, 9) | 0.7 | 64 (32) | 0.6 |
| Other | 100 (50) | 13 (9, 17) | 3 (2, 6) | 3 (1, 9) | 3 (0, 8) | 50 (25) |
| Duration of cancer (month) |
| Up to 6 | 29 (14.5) | 11 (9, 14) | 0.05 | 3 (1, 4) | 0.06 | 2 (0, 6) | 0.09 | 3 (1, 9) | 0.8 | 14 (7) | 0.4 |
| 7-12 | 48 (24) | 14 (9, 17) | 3 (2, 6) | 3 (1, 7) | 4 (1, 8) | 24 (12) |
| 13-36 | 58 (29) | 13 (8, 17) | 2 (1, 4) | 3 (1, 9) | 3 (1, 8) | 37 (18.5) |
| 37 and more | 65 (32.5) | 15 (11, 19) | 2 (1, 5) | 5 (1, 9) | 5 (1, 9) | 39 (19.5) |
| Head and Neck radiation therapy |
| Yes | 46 (23) | 15 (8,18) | 0.7 | 3 (2, 6) | 0.006 | 3 (1, 9) | 0.9 | 4 (0, 7) | 0.2 | 28 (14) | 0.6 |
| No | 154 (77) | 13 (9, 17) | 3 (1, 5) | 3 (1, 7) | 4 (1, 8) | 86 (43) |
| Co-morbidities |
| Zero | 100 (50) | 13 (9, 16) | 0.006 | 3 (2, 5) | 0.5 | 3 (1, 6) | 0.001 | 5 (1, 8) | 0.6 | 58 (29) | 0.6 |
| One | 64 (32) | 12 (9, 17) | 2 (1, 5) | 3 (1, 7) | 4 (1, 8) | 38 (19) |
| Two and more | 36 (18) | 17 (11, 21) | 3(1, 6) | 7 (3, 14) | 3 (0, 8) | 18 (9) |
| Depression |
| Yes | 75 (37.5) | 14 (11, 19) | 0.003 | 3 (2, 6) | 0.004 | 5 (2, 10) | 0.006 | 3 (0, 8) | 0.2 | 51 (25.5) | 0.01 |
| No | 125 (62.5) | 12 (8, 16) | 2 (1, 4) | 3 (1, 6) | 4 (2, 8) | 63 (31.5) |
| Anxiety |
| Yes | 92 (46) | 14 (9, 18) | 0.5 | 3 (1, 5) | 0.2 | 4 (1, 8) | 0.8 | 4 (0, 9) | 0.7 | 58 (29) | 0.1 |
| No | 108 (54) | 13 (9, 16) | 2 (1, 5) | 3 (1, 7) | 4 (1, 8) | 56 (28) |
Independent sample t-test; ^: Pearson’s chi-squared test; bold p-values are significant; DMFT: Decayed missing filled teeth
The median (IQR) of the MT among four groups of SES from Low to High was 6 (2, 10), 3 (1, 8), 3 (2, 6) and 1 (0, 6) respectively (p=0.01); and also, for FT, it was 2 (0, 5), 3 (0, 9), 5 (2, 8) and 7 (3, 11) in respect (p=0.001) [Table/Fig-1].
A number of 179 (90%) participants reported a history of chemotherapy, and 150 (75%) went under radiation therapy. Twenty-three (11.5%) patients had a history of smoking [Table/Fig-2]. The median (IQR) of MT among patients with and without a history of polypharmacy were 6 (3, 19) and 3 (1, 7) in respect (p=0.02). More details on participants’ medical history are available in [Table/Fig-2].
Dental health and oral healthcare utilisation according to the medical history of the study participants.
| Factors | n (%) | Median (IQR) | Seek for dental services |
|---|
| DMFT | p-value* | Decayed Teeth (DT) | p-value* | Missing Teeth (MT) | p-value* | Filled Teeth (FT) | p-value* | n (%) | p-value^ |
|---|
| Surgery |
| Yes | 187 (93.5) | 13 (9, 17) | 0.1 | 3 (1, 5) | 0.1 | 3 (1, 7) | 0.4 | 4 (1, 8) | 1.0 | 107 (53.5) | 1.0 |
| No | 13 (6.5) | 14 (12, 22) | 5 (2, 7) | 6 (2, 11) | 5 (2, 9) | 3.5 (7) |
| Chemotherapy |
| Yes | 179 (89.5) | 13 (9, 18) | 0.7 | 3 (2, 5) | 0.4 | 3 (1, 8) | 0.05 | 4 (1, 8) | 0.03 | 98 (49) | 0.06 |
| No | 21 (11.5) | 12 (8, 17) | 2 (0, 5) | 2 (0, 4) | 7 (2, 12) | 16 (8) |
| Radiation therapy |
| Yes | 150 (75) | 13 (9, 18) | 0.4 | 3 (1, 5) | 1.0 | 3 (1, 9) | 0.2 | 4 (1, 8) | 0.6 | 45 (90) | 0.1 |
| No | 50 (25) | 13 (10, 15) | 3 (1, 5) | 3 (0, 7) | 6 (0, 8) | 12 (24) |
| History of smoking |
| Yes | 23 (11.5) | 11 (7, 16) | 0.05 | 2 (0, 5) | 0.1 | 4 (1, 9) | 0.8 | 2 (0, 5) | 0.07 | 13 (6.5) | 1.000 |
| No | 177 (88.5) | 13 (9, 18) | 3 (2, 5) | 3 (1, 8) | 5 (1, 9) | 101 (50.5) |
| Polypharmacy |
| Yes | 8 (4) | 18 (17, 23) | 0.003 | 2.5 (1, 4) | 0.6 | 6 (3, 19) | 0.02 | 9.5 (0, 17) | 0.2 | 108 (54) | 0.5 |
| No | 192 (96) | 13 (9, 17) | 3 (1, 5) | 3 (1, 7) | 4 (1, 8) | 6 (3) |
*: Independent sample t-test; ^: Pearson’s chi-squared test; bold p-values are significant; DMFT: Decayed missing filled teeth
Of those who participated in this study, 168 (84%) reported cleaning their teeth at least once a day and 162 (81%) stated to use sugar contained foods/drinks, several times a day. The median (IQR) of DT among patients who used toothbrushes and those who did not were 3 (1, 5) and 5 (2, 7) respectively (p=0.006). Detailed information about patients’ oral hygiene habits is depicted in [Table/Fig-3].
Dental health and oral healthcare utilisation according to oral health behaviours of the study participants.
| Factors | n (%) | Median (IQR) | Seek for dental services |
|---|
| DMFT | p-value* | Decayed Teeth (DT) | p-value* | Missing Teeth (MT) | p-value* | Filled Teeth (FT) | p-value* | n (%) | p-value^ |
|---|
| Oral hygiene |
| Less than once a day | 32 (16) | 17 (11, 21) | 0.02 | 4 (1, 7) | 0.02 | 7 (2, 11) | 0.02 | 1 (0, 7) | 0.2 | 18 (9) | 0.9 |
| Once a day | 92 (46) | 12 (8, 16) | 3 (1, 5) | 3 (1, 7) | 5 (2, 8) | 54 (27) |
| Twice/more a day | 76 (38) | 14 (9, 18) | 3 (2, 5) | 3 (1, 7) | 5 (2, 10) | 42 (21) |
| Toothbrush |
| Yes | 180 (90) | 13 (9, 17) | 0.02 | 3 (1, 5) | 0.006 | 3 (1, 7) | 0.003 | 5 (1, 8) | 0.05 | 104 (52) | 0.6 |
| No | 20 (10) | 18 (11, 22) | 5 (2, 7) | 8 (3, 12) | 0 (0, 5) | 10 (5) |
| Toothpaste |
| Yes | 174 (87) | 13 (9, 17) | 0.03 | 3 (1, 5) | 0.2 | 3 (1, 7) | 0.05 | 4 (1, 8) | 0.7 | 100 (50) | 0.8 |
| No | 26 (1 3) | 16 (11, 21) | 3 (1, 6) | 5 (2, 10) | 1 (0, 11) | 14 (7) |
| Dental floss |
| Yes | 48 (24) | 14 (11, 18) | 0.2 | 3 (1, 5) | 0.7 | 3 (0, 6) | 0.05 | 8 (4, 11) | <0.001 | 36 (18) | 0.004 |
| No | 152 (76) | 13 (9, 17) | 3 (1, 5) | 4 (1, 9) | 3 (0, 7) | 78 (39) |
| Mouth wash |
| Yes | 22 (11) | 13 (11, 16) | 0.6 | 3 (1, 5) | 0.9 | 2 (0, 4) | 0.08 | 6 (2, 10) | 0.3 | 16 (8) | 0.2 |
| No | 178 (89) | 13 (19, 18) | 3 (1, 5) | 3 (1, 8) | 4 (1, 8) | 98 (49) |
| Sugar consumption |
| Several times a day | 162 (81) | 13 (9, 18) | 0.9 | 3 (1, 5) | 0.2 | 3 (1, 7) | 0.2 | 5 (1, 9) | 0.02 | 93 (46.5) | 0.9 |
| Less | 38 (19) | 13 (9, 17) | 3 (1, 6) | 6 (2, 9) | 3 (0, 6) | 21 (10.5) |
*: Independent sample t-test; ^: Pearson’s chi-squared test.
A hundred and seventy-three (86.5%) of the participants, reported at least one oral healthcare need, and 114 (57%) of them had at least one dental visit during the previous year [Table/Fig-4]. Also, among those who reported at least one oral healthcare need during the previous year (n=173), 107 received dental services. In addition, the reason for the last dental visit in 72% of the patients was the dental treatment; while, 28% of them had preventive reasons or visited a dentist for the regular dental check-ups.
Oral healthcare utilisation among female cancer survivors in southern Iran, 2019 within the previous year.
| SES group (N) | OHC utilisation |
|---|
| Reported at least one oral healthcare need n (%, 95% CI) | Had at least one dental visit n (%, 95% CI) | Received dental services n (%, 95% CI) |
|---|
| Low (n=50) | 40 (80, 66-90) | 22 (44, 30-59) | 21 (42, 28-57) |
| Low-middle (n=50) | 42 (84, 71-93) | 33 (66, 51-79) | 30 (60, 45-74) |
| Middle-high (n=50) | 45 (90, 78-97) | 30 (60, 45-74) | 27 (54, 39-68) |
| High (n=50) | 46 (92, 81-98) | 29 (58, 43-72) | 29 (58, 43-72) |
| Total (N=200) | 173 (87, 81-91) | 114 (57, 50-64) | 107 (54, 46-61) |
OHC: Oral healthcare; SES: Socio-economic status
Among the participants categorised in low SES (n=50), 40 (80%, 95% CI: 66-90) reported at least one case of OHC need within the previous year, 22 (44%, 95% CI: 30-59) had at least one dental visit, and 21 (42%, 95% CI: 28-57) received the OHC services. While, in the high SES group, 46 reported at least one case of OHC need, 29 had at least one dental visit during the previous year, and all the 29 received OHC services. Details about all the four groups of SES are illustrated in [Table/Fig-4].
According to the multivariable logistic regression model, the chance of occurrence of higher SES with OHC visits within the previous year was not significant (OR: 1.20, 95% CI: 0.9-1.6; p: 0.6) [Table/Fig-5]. Besides, FT and DMFT (PR: 1.55, 95% CI: 1.4-1.8, p<0.001; and PR: 1.11, 95% CI: 1.0-1.2, p=0.04 in respect) were significantly higher; while, DT (PR: 0.80 (0.7-1.0), p: 0.03) and MT (PR: 0.69 (0.6-0.8), p: <0.001) were significantly lower, in higher levels of SES [Table/Fig-5].
Factors associated with the dental health and oral healthcare utilisation among female cancer patients in southern Iran.
| Outcome/correlate | Unadjusted | Adjusted |
|---|
| OR | 95% CI | p-value* | OR | 95% CI | p-value |
|---|
| Higher SES | 1.15 | 0.9-1.5 | 0.9 | 1.20 | 0.9-1.6 | 0.6 |
| Metropolitan/other | 1.77 | 1.0-3.1 | 0.05 | 2.04 | 1.1-3.8 | 0.02 |
| Depression | 0.47 | 0.0-2.1 | 0.02 | 2.47 | 1.3-4.7 | 0.006 |
| Number of DT | PR | 95% CI | p-value^ | PR | 95% CI | p-value |
| Having dental visit (during the previous year) | 0.89 | 0.8-1.0 | 0.04 | 0.87 | 0.8-1.0 | 0.01 |
| Anxiety | 1.19 | 1.0-1.4 | 0.02 | 1.21 | 1.0-1.4 | 0.01 |
| Higher SES | 0.84 | 0.7-1.0 | 0.07 | 0.80 | 0.7-1.0 | 0.03 |
| Age category | 0.90 | 0.8-1.0 | 0.02 | 0.89 | 0.8-1.0 | 0.01 |
| History of smoking | 0.71 | 0.5-0.9 | 0.02 | 0.68 | 0.5-0.9 | 0.006 |
| Number of MT |
| Depression | 1.49 | 1.3-1.7 | <0.001 | 1.41 | 1.3-1.6 | <0.001 |
| Age category | 1.47 | 1.4-1.6 | <0.001 | 1.37 | 1.3-1.5 | <0.001 |
| Duration of initial diagnosis | 1.19 | 1.1-1.3 | <0.001 | 1.14 | 1.0-1.2 | <0.001 |
| Multimorbidity | 1.36 | 1.3-1.5 | <0.001 | 1.12 | 1.0-1.2 | 0.005 |
| Higher SES | 0.59 | 0.5-0.7 | <0.001 | 0.69 | 0.6-0.8 | <0.001 |
| Number of FT |
| Receiving dental services | 1.56 | 1.4-1.8 | <0.001 | 1.30 | 1.05-1.60 | 0.013 |
| Dental visit (within previous year) | 1.27 | 1.2-1.4 | <0.001 | 1.16 | 1.01-1.33 | 0.031 |
| Higher SES | 1.64 | 1.4-1.9 | <0.001 | 1.55 | 1.4-1.8 | <0.001 |
| Depression | 0.84 | 0.7-1.0 | 0.010 | 0.85 | 0.7-1.0 | 0.018 |
| History of smoking | 0.65 | 0.5-0.8 | <0.001 | 0.68 | 0.5-0.9 | 0.001 |
| DMFT |
| Job | 0.83 | 0.8-0.9 | 0.002 | 0.83 | 0.7-0.9 | 0.004 |
| History of Smoking | 0.81 | 0.7-0.9 | 0.002 | 0.81 | 0.7-0.9 | 0.003 |
| Higher SES | 1.00 | 0.9-1.1 | 0.9 | 1.11 | 1.0-1.2 | 0.04 |
| Toothpaste | 0.82 | 0.7-0.9 | <0.001 | 0.86 | 0.8-1.0 | 0.009 |
| Dental floss | 1.09 | 1.0-1.2 | 0.04 | 1.19 | 1.1-1.3 | <0.001 |
| Age category | 1.13 | 1.1-1.2 | <0.001 | 1.14 | 1.1-1.2 | <0.001 |
| Duration of initial diagnosis | 1.07 | 1.-1.1 | <0.001 | 1.04 | 1.0-1.2 | 0.01 |
| Depression | 1.20 | 1.1-1.3 | <0.001 | 1.23 | 1.1-1.4 | <0.001 |
*: Binary logistic regression; ^: Poisson regression; OR: Odds ratio; CI: Confidence interval; SES: Socio-economic status; DT: Decayed teeth; MT: Mobile teeth; FT: Filled teet
Discussion
Recent study aimed to investigate the status of OHC utilisation and the effects of SES on OHC utilisation and dental health status among female cancer survivors in southern Iran. A 61.8% of the participants who needed OHC services within the previous year received the services. SES was associated with oral health status, but it was not significant for OHC utilisation.
Fifty-seven percent of the participants had at least one dental visit during the previous year. This finding is consistent with the results of studies conducted on adult population [6,19,20]. For instance, Bahramian H et al., showed that 56% of the participants visited a dentist at least once during the previous year [6]; and also, a systematic review reported that regular and preventive utilisation of dental services occurred in 54% of the individuals [19]. However, in another study on adult population in China, 21.4% of the participants between 35-44 years of utilised oral health services within the previous year [21]. This difference might be as a result of long working hours [22] or the age limitation (35-44-year-old) of the participants [20]. A brief expression of similar studies is shown in [Table/Fig-6] [6,19-29].
Comparison between findings of similar studies and the present study [6,19-29].
| Authors name Year and Reference no. | Place of study | Number of subjects | Variables compared | Conclusion |
|---|
| Bahramian H et al., 2019 [6] | Tehran, Iran | 20320 | Main outcomes: Dental service utilisation,Barriers of dental visit, Self-perceived oral health.Predisposing factors: Mental health, Age, Gender, Education, Wealth status | Only 56% of the participants visited a dentist at least once during the last year. Dental service utilisation was influenced by socio-economic factors and the mental health status of the adult population.
|
| Reda SM et al., 2018 [19] | Global | 7,395,697 | Main outcomes: Proportion of individuals regularly/preventively utilising dental services.Predisposing factors: Human Developmental Status (HDS), Age, General health, Oral health, Edentulous individuals, Supportive family structures, Health literacy | The global mean proportion of individuals regularly/preventively utilising dental services was 54%. Regular/preventive utilisation varied widely between and within countries. The observed differences within populations did not significantly change with time and were universally present.
|
| Alade OT et al. 2016 [25] | Ibadan, Nigeria | 342 | Cost per participant | More than 80% of the participants examined had an unmet oral health need. Outreach dental services provided similar dental treatment to services in a primary oral health clinic at a reduced cost.
|
| Gupta A et al. 2019 [20] | Boston, USA | 52,493,940 | Main outcomes: time since last dental visit, Unmet dental care need, Reasons for unmet dental care need.Predisposing factors: Age, Race, Education status, Income status, Marital status, Health insurance status, General health condition. | Of the women, 60.1% reported that it was one year or less since they last visited a dentist, and 1.2% reported never having visited a dentist. Age, race/ethnicity, education, poverty income ratio, general health status, and health insurance were significantly associated with “time since last dental visit”.
|
| Kim N et al., 2017 [26] | South Korea | 17,141 | Main outcomes: experience of unmet dental care needsPredisposing factors: Demographic factors, Socio-economic factors, Need factors, Oral health-related factors | Perceived unmet dental needs were among 43.9% of the participants, with the most common reason being financial difficulties. The disparities in unmet dental care needs were strongly associated with income level, normative treatment needs, and self-perceived oral health status.
|
| Kim Y et al., 2019 [22] | South Korea | 4203 | Main outcome: Unmet dental needs.Predisposing factors: Working hours, Demographic variables, Region of residence, Socio-economic variables, Occupation type, Household income, Health-related variables, Health insurance, Self-reported oral health status, Dental care indicators | Unmet dental needs were experienced among 39.5% of the individuals. Among adults who have experienced dental pain, unmet dental needs had higher odds of occurring in males who worked longer, and this relationship appears to be influenced by consumption of alcohol, region of residence, tooth-brushing frequency, and access to and perception of dental care.
|
| Malecki K et al., 2015 [27] | Wisconsin, USA | 1453 | Main outcomes: Oral health status and unmet oral healthcare needs.Predisposing factors: Socio-demographic predictors, Preventive oral health behaviours, Psychosocial correlates, Community-level correlates | More than 15% of participants had untreated cavities, and 20% did not receive needed oral healthcare. Individuals who self-reported unmet need for dental care were four times as likely to have untreated cavities as were those who did not report such a need.
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| Pradeep Y et al., 2016 [28] | India | 3102 | Main outcomes: Perceived need for dental care, actual dental service utilisation, reason for not seeking for dental care, normative need of an individual participant.Predisposing factors: Age, Gender, Social class, Residence. | Of the participants, 40% perceived a need for dental care. Among the people who perceived need for care, only 21.4% utilised dental care and 78.6% of them had unmet dental needs. The two main reasons for not seeking dental care was lack of money, i.e., unaffordable dental treatment (48%) and having the perception that they do not have any dental problem (19.4%).
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| Wiener RC et al., 2018 [29] | USA | 4,845 | Main outcome: presence of unmet dental care needs.Predisposing variables: Age, Gender, Race, Personal health conditions, BMI, Alcohol use, Dental visits. | Among participants, 47% had unmet dental care need. A significant association between low food security and unmet dental care need was identified among adults in the United States.
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| Eslamipour F et al., 2018 [23] | Isfahan, Iran | 1360 | Main outcomes: Access to oral healthcare services, satisfaction with the services.Predisposing variables: Demographic variables,Oral health status, Oral healthcare behaviours,Barriers to accessing dental health-care services | Among the referrals to dentists, 69% were for treatment reasons. Most participants were satisfied with access to dental healthcare, but they were dissatisfied with the costs and inadequate insurance coverage. About half of the participants were satisfied with the services provided to them, and the highest level of satisfaction was reported for easy access to health-care centres.
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| Rezaie S et al., 2018 [24] | Krmanshah, Iran | 1067 | Main outcome: Whether a household’s head had visited a dentist for dental treatment in the past 12 months.Predisposing variables: Socio-demographic characteristics and Economic status. | Among household heads, 60.3% were reported to have visited a dentist for dental treatments. Dental health-care utilisation among households in the study area was influenced by being socio-economically disadvantaged, self-rated poor oral health and not regularly brushing own teeth.
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| Xu M et al., 2020 [21] | China | 7206 | Main outcome: Oral health service utilisation in the 12 months prior to data collection.Predisposing factors: Gender, Education, Health beliefs. | Among adults aged 35-44, 21.4% and among older adults (65-74-year-old), 20.7% utilised oral health services in the past 12 months. Nearly, 80% of adults and more than 90% of older visited a dentist for treatment.
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| Assar S et al., [Present study] | Shiraz, Iran | 200 | Main outcome: Dental visits within the previous year.Predisposing variables: Demographic variables, Socio-economic status, Oral healthcare, Health status, Type of received cancer treatments | Among participants, 86% reported at least one dental need within the previous year; which 62% of them received dental services. Treatment reasons for dental visits were 2.5 times higher than preventive reasons or regular dental check-ups
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A total of about 38% of those who needed a dentist during the previous year did not receive dental services. The literature review showed a variety of results (10.8-80%) for unfulfilled dental needs among normal adults [20,22,25-29]. The differences could have arisen from the availability and accessibility of dental services, treatment expenses, insurance coverage, individuals’ income, long working hours, oral health unawareness, and psychological disorders [20,22,25-29].
In the current study, treatment reasons for the last dental visit were about 2.5 times more prevalent than preventive reasons or regular dental check-ups. In accordance with this result, a number of studies showed a larger proportion for treatment reasons than preventive reasons for dental visits [23,24]. As an example, Eslamipour F et al., reported that 69% of the referrals to the dentists were for treatment reasons [23]; and also, a total of 60.3% of household heads who participated in the study of Rezaei S et al., were reported to have visited a dentist for dental treatments in the previous year [24]. It is essential to consider that concentration on preventive OHC plans and services rather than treatments could decrease OHC expenses which especially is crucial for cancer survivors and should be regarded in future policies.
The results of the present study showed that SES was not associated with the prevalence of having a dental visit during the previous year among female cancer survivors. However, in studies conducted on adult population, costs of dental treatments, individuals’ income, dental insurance, the level of education, health literacy, and the number of family members were the factors affecting the utilisation of OHC services [5,6,19,24,30-32]. For instance, a study on 37,860 households from the 2017 Households Income and Expenditure Survey (HIES) in Iran showed that the utilisation of OHC was more common among households with higher SES [9]. Accordant with this, Bahadori M et al., reported that high costs of dental care caused limitations for patients referring to dental clinics in Tehran (Iran capital) [5]. Comparing to the result of the present study, one should consider that cancer treatment expenses are still globally high [4,33,34], and dental treatments are expensive and limit the patients’ opportunities to have access to OHC services [5]; and also, oral health unawareness and/or ignorance among all levels of SES in cancer survivors [35,36] might all explain the difference between the current result and the studies conducted on the normal adult population.
Based on the present study, FT and DMFT were significantly higher; while, DT and MT were significantly lower, in higher levels of SES. Literally, results of MT and FT showed the different destiny of carious teeth among different levels of SES. DMFT did not indicate preventive or treatment needs of individuals as it gave equal weight to untreated dental caries as well as missing or well-restored teeth [37]. In addition, the negative effect of SES on DT in this study was consistent with the past researches [38,39]. This is the first study that planned to investigate the OHC utilisation among female cancer survivors in southern Iran. The results of the present study provided crucial information about the utilisation of OHC services which contributes to increasing awareness about the oral health of cancer survivors. Also, present finings prepared useful evidence for future policy makings regarding this group.
Limitation(s)
The small sample size and cross-sectional design were among the limitations of the current study. Moreover, the examination of other oral health-related indices, such as periodontal indices, was not possible due to the lack of cooperation on the part of the participants.
Conclusion(s)
The socio-economic status was found to be associated with oral health; and was not a determinant for the rate of utilised OHC services. Treatment in comparison with prevention/regular dental check-ups was the most prevalent reason for the last dental visit. Further studies are required to investigate the patterns and correlates of OHC status and utilisation among cancer survivors in developing countries.
Independent sample t-test; ^: Pearson’s chi-squared test; bold p-values are significant; DMFT: Decayed missing filled teeth*: Independent sample t-test; ^: Pearson’s chi-squared test; bold p-values are significant; DMFT: Decayed missing filled teeth*: Independent sample t-test; ^: Pearson’s chi-squared test.OHC: Oral healthcare; SES: Socio-economic status*: Binary logistic regression; ^: Poisson regression; OR: Odds ratio; CI: Confidence interval; SES: Socio-economic status; DT: Decayed teeth; MT: Mobile teeth; FT: Filled teet