Adult Dental Health Survey IN BRIEF

• Highlights regular dental attendance in

2009: relationships between 2009 was 61%, illustrating a long-term

GENERAL
increase since 1968, associated with
improved oral health-related behaviours.

dental attendance patterns, • Reports that only 9% of adults have been

given advice on quitting smoking by any
member of the dental team.

oral health behaviour and the • Recounts that cost influenced choice of
dental treatment for 26% of adults.
• Stresses 12% of adults have extreme

current barriers to dental care

dental anxiety.

K. B. Hill,1 B. Chadwick,2 R. Freeman,3 I. O’Sullivan4 and J. J. Murray5

The importance of understanding barriers to dental attendance of adults in the UK was acknowledged in the first Adult
Dental Health Survey in 1968 and has been investigated in all subsequent ADH surveys. In 1968, approximately 40% of
dentate adults said they attended for a regular check-up; by 2009 this was 61%. Attendance patterns were associated with
greater frequency of toothbrushing, use of additional dental hygiene products, lower plaque and calculus levels. Just under
three-fifths of adults said they had tried to make an NHS dental appointment in the previous five years. The vast majority
(92%) successfully received and attended an appointment, while a further 1% received an appointment but did not attend.
The remaining 7% of adults were unable to make an appointment with an NHS dentist. The majority of adults were posi-
tive about their last visit to the dentist, with 80% of adults giving no negative feedback about their last dentist visit. Cost
and anxiety were important barriers to care. Twenty-six percent of adults said the type of treatment they had opted for
in the past had been affected by the cost and 19% said they had delayed dental treatment for the same reason. The 2009
survey data demonstrated a relationship between dental anxiety and dental attendance. Adults with extreme dental anxiety
were more likely to attend only when they had trouble with their teeth (22%) than for a regular check-up.

INTRODUCTION of adults in the UK was acknowledged considered to be one of the most important
This is the third in a series of papers fol- in the first Adult Dental Health Survey barriers to patients accessing dental care4,8
lowing the publication of the 2009 Adult (ADHS) back in 19682 and data on attend- and in the 2009 survey the Modified Dental
Dental Health Survey and covers the atti- ance have been collected in all subsequent Anxiety Scale (MDAS) 9 was included
tudes and barriers to dental care, includ- surveys in the series. A key finding in the together with questions concerning costs
ing dental attendance patterns and barriers first ADHS was that those attending the of dental treatment, perception of need and
to attendance. dentist for a regular dental examination lack of accessibility.
Regular attendance for a routine oral had large differences in oral health-related Since tailored oral health advice has
health examination has been encour- attitudes and behaviours as well as the been acknowledged as the primary con-
aged for the maintenance of oral health dental treatment received when compared sideration in the promotion of oral health
and has gained an increased importance to those adults who attended only when self-care, data on oral health-related
with the publication of the evidence-based experiencing pain or having trouble. preventive behaviours such as tooth-
guideline on dental recall.1 The importance Our understanding of the reasons for brushing advice and toothpaste use have
of understanding attendance patterns non-attendance or ‘barriers’ to attending been in the ADHS since its inception. In
together with barriers to dental attendance for regular dental care have changed in the ADHS 2009 additional risks to oral health,
intervening years3–5 with the contribution such as smoking and the advice received
1*
Senior Lecturer in Dental Public Health and Behav- from Cohen6 highlighting the role of dental from dental teams, were included for the
ioural Science, College of Medical and Dental Sciences,
School of Dentistry, St Chad’s Queensway, Birmingham,
anxiety, costs of dental treatment, lack of first time. Epidemiological studies have
B4 6NN; 2Professor Paediatric Dentistry, Paediatric access to dental services together with the linked participant dental anxiety status to
Dentistry Unit, School of Dentistry, Cardiff University,
Heath Park, Cardiff, CF14 4XY; 3Professor of Dental
individual’s perception of need as of cen- be positively associated with an increase
Public Health, Director of the Oral Health and Health tral importance. Therefore, the barriers that in decayed and missing teeth and nega-
Research Programme, Dental Health Services Research
Unit, University of Dundee, Dundee, DD2 4BF; 4Assistant
patients experience in relation to accessing tively associated with filled teeth,10,11 but
Divisional Director, Social Survey Division, ONS, Cardiff dental care may arise as a result of social associations with oral health-related pre-
Road, Newport, NP10 8XG; 5Emeritus Professor, School
of Dental Sciences, Newcastle University, NE2 4BW
structural conditions for example, socio- ventive behaviours such as tooth brush-
*Correspondence to: Dr Kirsty Hill economic factors,7 life experiences such as ing with a fluoride toothpaste are as yet
Email: [email protected]; Tel: 0121 466 5488
unemployment and/or psychosocial fac- not clearly understood. The aims of this
Refereed Paper tors such as dental anxiety.6 Questions on paper are, therefore, two-fold. Firstly, to
Accepted 4 October 2012
DOI: 10.1038/sj.bdj.2012.1176
psycho-social factors were first included explore the relationships between dental
© British Dental Journal 2013; 214: 25-32 in the 1988 ADHS. Dental anxiety is now attendance patterns, dental anxiety and

BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013 25

© 2013 Macmillan Publishers Limited. All rights reserved.
GENERAL

oral health-related preventive and risk

100%
behaviours; and secondly, to examine the
barriers to dental care.
80%
METHODS
The sample size for the survey was
60%
13,400  households, including: 1,150  in Never been to the dentist
Only with trouble
each English Strategic Health Authority Occasionally
and Wales, and 750 households in Northern 40%
Regularly

Ireland. A total of 11,380 individuals were

interviewed, and 6,469 dentate adults were
clinically examined. Scotland did not take 20%
part in this survey so we do not have data
for the UK. The data reported here are
0%
related mostly to the interview, although 16-24 25-34 35-44 45-54 55-64 66-74 75-84 85-over
data on plaque and calculus and most of the
Age
clinical data are reported in papers one and
two of the series.12,13 In most cases the data Fig. 1 Dental attendance patterns by age (England, Wales and Northern Ireland combined).
Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary report and thematic
for the three  countries are combined for series. Leeds: Health and Social Care Information Centre, 2010. With the permission of the
simplicity, but where they have been split Health and Social Care Information Centre. All rights reserved
by country it should be clearly indicated.
The interview explored a number of issues Table 1 Association of dental attendance patterns with other variables (England, Wales and
Northern Ireland combined)
including attendance, barriers, attitudes,
service questions, quality of life scales and Regular Occasional Trouble Never
Variable
attendance (%) attendance (%) only (%) attends (%)
dental anxiety. In the 2009 survey den-
tal anxiety was assessed by the Modified Frequency of cleaning

Dental Anxiety Scale (MDAS)9 a modified Twice or more a day 80 74 65 53

version of Corah’s Dental Anxiety Scale14 Once a day 19 23 30 37
and included a question assessing antici-
Less than once 1 2 4 6
patory dental anxiety associated with local
anaesthesia as well as four other scenarios Never 0 1 1 4

about which respondents had to report the Use of hygiene products

extent of their dental anxiety. A five point Only toothbrush and toothpaste 37 43 53 76
response format ranging from one (not
Other products 63 56 47 24
anxious) to five (extremely anxious) was
used to assess the level of dental anxiety. Uses mouthwash 31 32 31 19
The lowest possible score is five, indicating Uses electric toothbrush 31 25 16 7
low dental anxiety. The maximum possible Advice on brushing
score is 25, with scores of 19 and above
Received advice 82 78 70 -
indicating extreme dental anxiety, which
may be indicative of dental phobia. During Visible plaque
the dental examination the presence of 61 67 76 88
plaque and calculus were recorded. Visible calculus

RESULTS 64 65 79 86

Dental attendance patterns

in UK adults 1968‑2009 that they attend for an occasional check- attendance is associated with improved
up, 27% said that they attend only when reported oral health-related preventive
In 1968, approximately 40% of dentate having trouble and 2% said they never behaviours and lower visible plaque and
adults in England and Wales said they attend the dentist (Fig.  1). Importantly, calculus levels.
attended for a regular check-up. In 1978, attendance patterns were associated with
43% of dentate adults reported attend- other aspects of oral health-related pre- Oral health-related behaviours
ing for a regular check-up and by 1998 ventive behaviours, including frequency
of UK adults in 2009
this had increased to 59%. In 2009 almost of toothbrushing, use of additional den- The present and previous surveys have
two thirds (61%) of dentate adults said the tal hygiene products, plaque levels and reported that the majority of dentate
usual reason they attend the dentist is for presence of calculus and lower levels of adults claim to brush their teeth twice a
a regular check-up. A further 10% said anxiety (Table 1). As can be seen, regular day (Table 2).

26 BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013

© 2013 Macmillan Publishers Limited. All rights reserved.
 GENERAL

Presence of plaque and calculus

Table 2 Reported frequency of tooth cleaning by country 1988‑2009 in UK adults (2009)
England Wales Northern Ireland Two  thirds of dentate adults had visible
Reported frequency
of tooth cleaning plaque on at least one  tooth. The aver-
1988 1998 2009 1988 1998 2009 1988 1998 2009
age number of teeth with plaque was 6.0,
Twice a day or more often 67% 74% 75% 64% 74% 71% 69% 72% 75% almost one quarter of all standing teeth.
Sixty-four percent of dentate adults who
Once a day 27% 22% 23% 27% 21% 25% 22% 22% 22%
cleaned their teeth at least twice a day had
Less than once a day 5% 4% 2% 8% 4% 3% 7% 6% 3% visible plaque compared with 94% of those
who cleaned their teeth less than once a
Never 1% 0% 1% 1% 0% 15 1% 1% 0%
day or never. Men were more likely to have
Unweighted base 3,016 3,010 9,000 622 682 880 558 636 660 plaque than women (71% compared with
61%) and they also had a higher propor-
Weighted base (= 000s)     39,296     2,181     1,292
tion of affected teeth (27% versus 20%).
Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary report and thematic series. Leeds: Health and Social Care Dentate adults who said they attend the
Information Centre, 2010. With the permission of the Health and Social Care Information Centre. All rights reserved
dentist for a regular check-up were less
NB: Unweighted base is the actual of number of people interviewed; weighted base is an estimate against population values (per 100,000)
likely to have visible plaque (61%) than
those who reported only attending the
80 dentist in trouble (76%).
Calculus was present in at least one sex-
Regular check up
70 Occasional check up tant of the mouth in 68% of adults and on
Only with trouble average 1.8 sextants were affected. There
Never been to dentist was a strong association between the preva-
60
lence of calculus and usual reason for den-
tal attendance. While 64% of adults who
50
attended for a regular check-up had calculus,
Percentage

this rose to 79% of those adults who only

40
attended the dentist in trouble. Sixty-seven
percent of adults who reported brushing their
30
teeth twice a day or more had calculus com-
pared with 89% of those who said that they
20
brushed their teeth less than once a day or
never. Current smokers were also more likely
10
than those who used to smoke or had never
smoked to have calculus, 79% compared
0
Just toothbrush Mouthwash Electric toothbrush Dental floss with 65% and 66% respectively.
and toothpaste While twice-daily brushing is now a fact
of life for three quarters of the population,
Fig. 2 The use of dental hygiene products by reason for dental attendance, 2009 (England, Wales
and Northern Ireland combined). Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey the high levels of both plaque and calculus
2009 - Summary report and thematic series. Leeds: Health and Social Care Information Centre, 2010. in those who brush twice daily suggests
With the permission of the Health and Social Care Information Centre. All rights reserved there is still room for improving the effi-
cacy of brushing.
Dentate adults who said that they products for oral hygiene than other
brushed their teeth were asked whether, groups (Fig. 2). Smoking behaviour and smoking
in addition to a manual toothbrush and In the 1998 ADHS all dentate adults were
cessation advice for UK adults
in 2009
toothpaste, they used any other methods also asked about advice they might have
of maintaining oral hygiene. The use of received from a dentist or a member of the For the first time in the ADHS series, ques-
other products was reported by 58% of dental team on how to care for their oral tions on smoking behaviour were included
adults, with mouthwash (31%), electric health. Those who recalled advice on tooth and asked of all adults, including young
toothbrushes (26%), and dental floss brushing from the dental team rose from adults aged 16-18 years. These questions
(21%) the most frequently mentioned. 63% in 1998 to 78% in 2009. Interestingly, were included as there is clear evidence
More women than men (61% against 53%) 82% of regular attendees recalled receiving that smoking is associated with poor peri-
said they used something other than a oral health advice compared to 70% of those odontal health15 and smoking cessation
normal toothbrush. Additional methods attending with pain or with trouble only. The guidelines recommend that all health pro-
were most popular among adults aged majority of patients who need the advice most fessionals, including members of the dental
35-64  years. Regular dental attendees were least likely to recall having received team, should ask about smoking annually
were more likely to report using other information on oral health self-care (Table 1). and advise smokers to quit. The smoking

BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013 27

© 2013 Macmillan Publishers Limited. All rights reserved.
GENERAL

questions used were the Government har- population was associated with poorer households (62%) tried to make an NHS
monised questions on smoking that have adherence with toothbrushing regimes, low dental appointment.
been used in many other Government usage of additional interdental cleaning aids Adults who said they attended the dentist
sponsored health surveys. All respondents, and increased presence of plaque and cal- regularly were the most likely to say they
whether dentate or edentate, were asked culus. Moreover, compared with those that had tried to make an NHS dental appoint-
whether they currently smoked and if not, accessed care on a regular basis, the par- ment in the last three years (70% compared
whether they had ever smoked: 22% of ticipants who attended when in trouble had with 63% of occasional attendees and 38%
all adults said that they currently smoked poorer recall of being provided with dental of those who said they only went to the den-
and marginally more edentate adults said healthcare advice. Thus it is necessary to tist when they had trouble with their teeth).
they were smokers compared with dentate understand why a proportion of the UK adult It is noteworthy that 30% of adults who
adults, 24% compared with 22%. population in 2009 continue to attend only had been to the dentist in the year before
In order to assess whether dental health when in trouble in order to promote oral being interviewed for the survey had not
teams are regularly contributing to smoking health and reduce oral health inequalities. attempted to get an NHS appointment. This
cessation programmes, all dentate adults who suggests that many adults now receive den-
had visited a dentist in the two years before Access as a barrier to care in 2009: tal care from what they regard as a non-NHS
being interviewed were asked if any member
making an NHS appointment source and is in line with the current sur-
of the dental team had given them advice on All adults who participated in the sur- vey which reported that 27% had their last
giving up smoking at their most recent visit. vey were asked if they had tried to make course of treatment with a private dentist.
A small minority of adults (9%) reported hav- an NHS dental appointment in the last The experience of those adults who
ing been given advice on quitting smoking, three years. No attempt was made to define indicated that they had tried to make an
with 35% of adults stating they had never what constituted an NHS appointment and NHS dental appointment in the three years
smoked. While the remaining 57% said that the survey respondents were permitted to before being interviewed on the survey
they had not received any advice on smoking respond according to what they personally was assessed. The vast majority of these
cessation, it is likely that these individuals understood NHS dental care to be. There adults (92%) successfully received and
will have included many ex-smokers (and was no distinction made between primary attended an appointment while a further
therefore do not need any advice) and indi- and secondary care. The main reason why 1% of adults received an appointment but
viduals who the dental team already know respondents were not guided towards a defi- did not attend. The remaining 7% of adults
are not (and may never have been) smokers. nition of what constitutes an NHS dental were unable to make an appointment with
It is also important for adults who are appointment was that any such definition an NHS dentist. The inability to arrange
edentate to receive smoking cessation would be immensely complicated to define an NHS dental appointment varied by age
advice, given the association between in its entirety requiring issues such as dental with a general pattern of younger adults
smoking and oral cancer. All edentate charges and the provision of components being more likely to fail to get an appoint-
adults who had been to the dentist in the provided on a private basis to be clarified. ment; for example 10% of adults aged
two years before the interview were also Just under three fifths (58%) of adults 25-34  years were unable to get an NHS
asked if they had received any advice on said that they had tried to make an dental appointment compared with 4% of
stopping smoking from the dentist. As for NHS dental appointment in the previous 65-74-year-olds and 5% of 75-84-year-
dentate adults, a small proportion of adults three years; the remainder said they had olds. The inability to get an appointment
(7%) said that they had received smoking not. In terms of the socio-demographic with an NHS dentist did not vary by other
cessation advice, the vast majority (72%) characteristics of the population, differ- socio-demographic characteristics.
of adults with no teeth were not given any ences were observed between age-groups,
advice on smoking cessation, 22% said sex and adults from different household Costs as a barrier to
they had never smoked. socioeconomic classifications. Specifically,
dental treatment
Patient recall of smoking cessation advice a smaller proportion of older adults (aged Since the inception of the NHS in 1948,
seems low, suggesting either that the dental 85 and older) reported trying to make an the NHS dental service has undergone fre-
team is less confident discussing this aspect NHS dental appointment than adults in quent changes in administration. The 1998
of care or that advice is not recalled for all other age groups; 34% of adults aged survey referred to the changes in the previ-
whatever reason. To some extent dentists 85 and over said that they had tried to ous 10 years. When the data for the 1988
are probably being selective about giving make an NHS dental appointment in the and 1998 were compared, there had been
advice but it would be good to see all smok- last three  years compared with 64% of a three-fold increase in the proportion of
ers who engage with dental practitioners 45-54-years-olds and 57% of adults aged dentate adults reporting that their treat-
receiving and recalling advice. Interestingly, 16-24  years. Women were more likely ment was carried out privately: from 6%
64% of regular attendees have no recall of than men to have tried to make an NHS from 1988 to 19% in 1998. In 2009, paid for
being asked about diet, which one would dental appointment in the last three years, NHS dental care was the most commonly
think is an area dentists should be more 62% compared with 54%; and a smaller reported type of dental care received, with
comfortable with. proportion of adults from managerial and 45% of dentate adults receiving their last
In conclusion, attendance for dental treat- professional occupation households (56%) completed course of treatment in this way.
ment on an ad hoc basis in this UK adult than adults from intermediate occupation Private dental care was reported by 27% (a

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 GENERAL

Table 3 Type of dental care received during last completed course of treatment by characteristics of dentate adults

Dentate adults* England, Wales and Northern Ireland: 2009

Characteristics Private Paid for NHS Free NHS NHS and Other† Not sure Total paid for or Unweighted Weighted
of dentate (%) dental care dental care private care (%) (%) free NHS dental base base (000s)
adults (%) (%) (%) care (%)

All 27 45 25 1 1 1 71 10,090 40,255

Age

16-24 17 28 53 0 1 1 81 960 6,085

25-34 21 47 29 1 1 2 77 1,320 6,192

35-44 26 48 22 1 1 1 71 1,950 7,854

45-54 28 51 18 1 1 1 70 1,970 7,178

55-64 33 50 14 1 1 1 64 1,810 6,173

65-74 33 49 16 1 0 0 65 1,280 3,936

75-84 38 42 17 1 0 2 59 680 2,378

85 or over 41 40 15 1 2 2 56 120 460

Sex

Male 27 47 23 1 1 1 70 4,490 19,552

Female 27 44 27 1 0 1 71 5,590 20,703

Country

England 27 46 24 1 1 1 70 8,590 36,924

Wales 29 37 33 0 0 1 70 870 2,131

Northern Ireland 16 52 29 1 1 2 81 630 1,200

English Strategic Health Authority

North East 18 50 29 1 1 1 80 860 1,824

North West 22 50 26 0 1 1 76 880 5,113

Yorkshire &
19 46 32 1 1 1 79 910 3,818
The Humber
East Midlands 24 47 27 1 0 0 74 980 3,057

West Midlands 24 48 27 0 0 1 75 760 3,758

East of England 26 49 23 1 1 1 72 930 4,103

London 31 39 26 3 0 0 65 630 5,105

South East Coast 36 40 20 1 1 1 61 830 3,232

South Central 40 42 14 2 1 1 56 890 2,981

South West 32 45 21 1 1 1 66 930 3,935

Socio-economic classification of household‡

Managerial and
professional 35 48 13 1 1 1 62 3,760 15,143
occupations
Intermediate
27 46 25 1 0 1 71 1,850 7,227
occupations
Routine and
manual 19 42 37 1 1 1 79 3,160 12,707
operations
Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary report and thematic series. Leeds: Health and Social Care Information Centre, 2010. With the permission of the Health and Social Care
Information Centre. All rights reserved
*Excludes those who reported never attending the dentist or who had had their last course of treatment abroad.
†Includes respondents who said they were treated in a dental hospital.
‡Excludes people in households where the household reference person was not interviewed. Respondents whose household reference person was a full-time student, in the Armed Forces, had an inadequately described
occupation, had never worked or were long-term unemployed are not shown as separate categories but are included in the total.

BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013 29

© 2013 Macmillan Publishers Limited. All rights reserved.
GENERAL

further increase from 1998) and free NHS

care by 25% of all dentate adults during Table 4 Modified dental anxiety scale (England, Wales and Northern Ireland combined)
their last completed course of treatment; All adults* England, Wales, Northern Ireland: 2009
very few respondents (1%) reported receiv- Anxiety Not anxious Slightly/fairly Very/extremely
ing mixed NHS and private care. It is clear anxious anxious
from these results that for the majority of Going for treatment tomorrow % 53 34 3
dentate adults (71%) the NHS is the primary
In the waiting room % 50 35 15
provider of dental health services (Table 3).
Also, just over a quarter of adults (26%) If tooth drilled % 28 42 30
said that the type of dental treatment they For scale and polish % 62 30 8
opted to have in the past had been affected
For injection % 30 41 28
by the cost of this treatment and almost
one fifth (19%) said that they had delayed Mean
Total MDAS score 5-9 10-18 19+
score
dental treatment for the same reason.
These were not completely overlapping % 51 36 12 10.8
groups as indicated by the finding that Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary report and thematic series. Leeds: Health and Social Care
Information Centre, 2010. With the permission of the Health and Social Care Information Centre. All rights reserved
15% of adults indicated that both the type
*
Adults who have never been to a dentist were not asked the MDAS questions
of treatment and timing of this treatment
had been influenced by the cost in the past.
Although men and women were equally 40

likely to say that the type of dental treat- Men

35
ment they had in the past was influenced Women
by cost, a greater proportion of women 30
than men, 20% compared with 17%, said
that they had delayed their dental treat- 25
ment because of costs. Finally, people from
Percentage

all occupational classes reported that they 20

had delayed treatment because of cost, but

15
the differences were quite small; as might
be expected in the context of lower income, 10
a greater proportion of adults from routine
and manual occupation households said 5

that they had delayed dental treatment

0
because of the cost (20%) compared with Anxiety going for Anxiety in the Anxiety if Anxiety for scale Anxiety for injection
adults from managerial and professional treatment tomorrow waiting room tooth drilled and polish

occupation households (17%).

MDAS Categories

Dental anxiety as a barrier Fig. 3 Percentage reporting very/extremely anxious by sex (England, Wales and Northern
to dental treatment Ireland combined). Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary
report and thematic series. Leeds: Health and Social Care Information Centre, 2010. With the
Respondents were previously asked permission of the Health and Social Care Information Centre. All rights reserved
two  questions relating to dental anxiety
in the 1988 and 1998 national surveys. (51%) who had ever been to a dentist had an The 2009 survey data demonstrated a
While the prevalence of dental anxiety fell MDAS score of between 5 and 9, indicating relationship between dental anxiety status
between 1988 (60%) and 1998 (32%) the low/no dental anxiety (Table 4). and dental attendance. Adults with MDAS
incidence of extreme dental fear remained The two items on the MDAS that elic- scores indicative of extreme dental anxiety
constant in the order of 10% of the adult ited anxiety most often were both asso- were more likely to attend only when they
population and was associated with access- ciated with receiving dental treatment; have trouble with their teeth (22%) than
ing dental treatment only when in pain. 30% of adults said that they would feel for a regular check-up (8%).
This suggested that a continuum of dental very or extremely anxious having a tooth
anxiety existed ranging from those who feel drilled and 28% reported similar levels of Oral health status of
relaxed during dental treatment, to those anxiety about having a local anaesthetic
anxious patients
who are dentally anxious but cope, through injection. A smaller proportion of adults There was a difference between people cat-
to those who are dentally phobic and avoid were very or extremely anxious about sit- egorised on the basis of their experience of
care. Dental anxiety therefore acts as a psy- ting in the dentist’s waiting room (15%), restorative dental treatment. For example,
chological barrier to seeking dental care about having to go to the dentist tomor- 6% of adults with 12 or more restored oth-
and its association with oral health is of row (13%) and having a scale and polish erwise sound teeth had total MDAS scores
central importance. Just over half of adults (8%) (Fig. 3). of 19 or more compared with 14% of adults

30 BRITISH DENTAL JOURNAL VOLUME 214 NO. 1 JAN 12 2013

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 GENERAL

concerns related to not having been given

Issue reported
enough time to discuss with the dentist
Was NOT treated with
respect and dignity and not being involved in decisions about
DID NOT get answers to questions dental care or treatment (11%).
that could be understood
DID NOT have confidence The survey collected self-reported den-
and trust in dentist
tal health and there were clear differences
Dentist DID NOT explain reasons for dental care or
treatm ent in a way that could be understood between adults with good or bad indicators
Dentist DID NOT listen carefully to what
had to say about oral health of oral health in terms of the dimensions
Was NOT given enough time to used to assess the relationship between
discuss oral health with dentist
Was NOT involved as much as wanted in
the patient and dentist. For example, a
decisions about dental care or treatment
greater proportion of adults with bad or
very bad self-reported dental health than
At least one issue reported adults with good or very good self-reported
0 5 10 15 20 25 dental health, said that the dentist did not
Percentage
listen to them; felt that they were not given
enough time to discuss their oral health; not
Fig. 4 Relationship with dentist at last visit (England, Wales and Northern Ireland combined). involved in decisions about their oral health
Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary report and thematic
series. Leeds: Health and Social Care Information Centre, 2010. With the permission of the and had less confidence in the dentist.
Health and Social Care Information Centre. All rights reserved
Rating the dental practice
All adults who said that they had been
Table 5 Rating of the dental practice (England, Wales and Northern Ireland combined)
to the dentist in the previous two  years
All adults* England, Wales and Northern Ireland: 2009 were asked to rate the dental practice they
last attended on a number of domains
Percentage rating good/very good
including waiting times, explanation of
Length of time waiting for a routine appointment† 85 NHS charges, access, quality of care and
Length of time waiting for an urgent appointment† 87 reputation of the dentist. Eighty-five per-
cent of adults rated the practice they had
Availability of evening/weekend appointments †
53
attended most recently as good or very
Transport facilities and access 77 good for length of time waiting for routine
Convenience of dental practice location 80 appointments. Similarly, the vast majority
of adults (87%) indicated that their dental
Standard and quality of care 90
practice was good or very good in terms
Explanation of NHS changes ‡
56 of the length of time waiting for an urgent
Reputation of dentists 79 appointment, however, just over half (53%)
said that their practice was good or very
Reproduced from O’Sullivan I, (ed). Adult Dental Health Survey 2009 - Summary report and thematic series. Leeds: Health and Social Care
Information Centre, 2010. With the permission of the Health and Social Care Information Centre. All rights reserved good at providing evening and/or week-
*All adults who have attended the dentist in the last two years
end appointments. Adults were less posi-
†Excludes those who said it was not applicable
‡Only applies to NHS patients
tive about how well their dental practice
explained NHS dental charges to them,
56% saying that their practice was good
with fewer than 12 restored otherwise sound felt the dentist communicated with them at or very good at doing this. The standard
teeth. It may be that the experience of hav- their last visit. The purpose of these ques- of quality and care at the dental practice
ing had many teeth restored is an indica- tions was to determine the success of the was also perceived by the vast majority of
tion of willingness to undergo restorative interactions between patients and dentists adults as being either good or very good
treatment and consequently, of lower dental and to investigate whether people felt (90%), however, a slightly smaller propor-
anxiety, or that the experience of restorative involved in decisions about their oral health. tion of adults indicated that the reputation
treatment itself acts to reduce the likelihood Encouragingly, the majority of adults of the dentists at their practice was good
of experiencing dental anxiety. were positive about their last visit to the or very good (79%). Nevertheless 93% of
dentist with 80% of adults giving no nega- adults said that they would go back to this
Relationship with the dentist tive feedback about their last visit to the practice in the future (Table 5).
The ability of clinicians, including den- dentist (Fig. 4). However, 20% of consulta-
tists, to communicate effectively with their tions were considered to be less than sat- CONCLUSION
patients is an essential skill. All adults isfactory in one way or another and it is The data presented here show that the
who had visited the dentist (whether they important to determine what exactly about demand for dental care has grown sub-
attended an NHS or private dentist) were the dentist/patient interaction was prob- stantially over the last few decades, with
asked a series of questions about how they lematic The two most commonly reported a steadily increasing proportion of the

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© 2013 Macmillan Publishers Limited. All rights reserved.
GENERAL

population regarding themselves as regu- This study was commissioned by the NHS 5. Hill K B, White D A, Morris A J, Hall A C, Goodwin
Information Centre for Health and Social Care N, Burke F J. National evaluation of personal dental
lar attendees. With a growth in demand, and was conducted on behalf of the Department services: a qualitative investigation into patients’
access to NHS dental care has been a great of Health in England, the Welsh Assembly Health perceptions of dental services. Br Dent J 2003;
Department and the Department of Health, Social 195: 654–658.
concern in the United Kingdom since the Services and Public Safety in Northern Ireland. 6. Cohen L K. Converting unmet need for care to
The Survey was managed by the Office
mid‑1990s and the findings presented in for National Statistics with a major contribution
effective demand. Int Dent J 1987; 37: 114–116.
7. Berkman L F, Glass T, Brissette I, Seeman T E. From
this report show that for the vast major- from The National Centre for Social Research.
social integration to health: Durkheim in the new
We would like to thank all of the specialists and
ity of patients NHS dentistry is reason- colleagues who contributed from both organisa- millennium. Soc Sci Med 2000; 51: 843–857.
tions and also Dr Nigel Nuttall who has made 8. Vassend O. Anxiety, pain and discomfort associated
ably accessible, although this finding is with dental treatment. Behav Res Ther 1993;
such a huge contribution to the questionnaire
not universal. This growth in the use of element of the national survey series over the 31: 659–666.
last 15 years. Our thanks also go to the field 9. Humphris G M, Morrison T, Lindsay S J. The
services has been associated with improve- teams of dentists and recorders who undertook Modified Dental Anxiety Scale: validation and
ments in cleaning and in the last decade the examinations and interviews around the United Kingdom norms. Community Dent Health
country, whose enthusiasm and work ethic often 1995; 12: 143–150.
there appears to have been a distinct extended beyond the call of duty. Not least we are 10. Schuller A A, Willumsen T, Holst D. Are there dif-
shift towards a greater preventive ethos, grateful to the 11,380 individuals who gave their ferences in oral health and oral health behaviour
time as survey participants.
including in some cases the introduction of Adult Dental Health Survey 2009 – The Health between individuals with high and low dental fear?
and Social Care Information Centre, Leeds. Community Dent Oral Epidemiol 2003; 31: 116–121.
smoking cessation. Dentists fared well in Copyright ©2011, Re-used with the permission of 11. Armfield J M, Slade G D, Spencer A J. Dental fear
patient ratings, which should be a source the Health and Social Care Information Centre. All and adult oral health in Australia. Community Dent
rights reserved. Oral Epidemiol 2009; 37: 220–230.
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dental health in England and Wales in 1968. G V A, Murray J J, Steele J G. Adult Dental Health
Perhaps the most difficult and resistant London: HMSO, 1970. Survey 2009: common oral health conditions and
barrier is around extreme dental anxiety 3. Finch H, Keegan, J, Ward K, Sanyal Sen B. Barriers their impact on the population. Br Dent J 2012;
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ance together with potentially higher need, primary dental care in three inner city boroughs. of tooth loss after cigarette smoking cessation. Prev
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