Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2014; 59: 504–510 doi: 10.1111/adj.12216

Pattern and factors associated with utilization of dental services among older adults in rural Victoria RJ Mari~ no,* AR Khan,* R Tham,† C-W Khew,‡ C Stevenson‡ *Oral Health Cooperative Research Centre, Melbourne Dental School, The University of Melbourne, Victoria. †School of Rural Health, Monash University, Victoria. ‡Bendigo Health Care Group, Victoria.

ABSTRACT Background: In Australia, rural and regional areas have an increased proportion of older people who are ageing more rapidly than their metropolitan counterparts. This increase in the ageing population and its uneven geographic distribution is likely to pose an oral health challenge in the near future. Methods: A cross-sectional study conducted in a sample of 226 community-dwelling adults aged 55 years and older, living in the City of Greater Bendigo who completed a questionnaire and received an oral examination. Results: Overall, 51.2% of participants reported having been to the dentist in the previous 12 months. Reported barriers to dental care were: cost of services (32.7%), fear of dentists (25.8%), length of waiting lists (18.1%) and availability of oral health care services (11.1%). Living alone, gender, low income, lack of education, low self-perceived oral health needs, self-perceived barriers, edentulism, and presence of mobility problems were statistically significant variables associated with less use of dental services (p < 0.0001). Conclusions: Access to dental care is affected by financial and structural barriers as well as other predisposing and enabling factors among older adults. Thus, increase in user services will require efforts to reduce financial barriers and make dental care culturally and linguistically competent. Keywords: Dental services utilization, older adults, rural health. (Accepted for publication 26 February 2014.)

INTRODUCTION Australian data show that rural and regional areas have an increased proportion of older people living in their communities and these communities are ageing more rapidly than their metropolitan counterparts. This increase in the ageing population and its uneven geographic distribution is likely to pose an oral health challenge in the near future.1 When considering older populations, poor oral health impacts on functional, psychological and social well-being, and overall quality.2 Over the last few decades, the proportion of older Australians reporting their use of dental health services in the previous 12 months has increased substantially.2,3 Access to oral health services is critical, as it not only provides opportunities for early diagnosis and treatment of diseases and conditions, but is also beneficial for maintenance of good oral health, health promotion and educational awareness.4 However, it has been demonstrated that the use of dental health 504

services tends to decrease after retirement.5 A parallel decline in oral health status in older adult populations has also been identified.6,7 As a consequence, rural older adults are three times more likely to have no natural teeth compared to city-dwelling non-health card holders, and a significantly lower proportion of older adults living in rural areas have reported using dental services in the previous 12 months.8 This results in a continued widening of gaps in oral health and access to dental services, and in inequity in oral health outcomes among those living in rural and remote areas.9,10 Such an element of inequity of access to and utilization of dental services marginalizes this disadvantaged group and poses a serious threat to their health and oral health. Thus, achieving and maintaining good oral health in rural and remote communities is an important challenge to health providers and the wider society. A better understanding of factors related to use of oral health care services by older adults living in rural areas will need to be met with different health © 2014 Australian Dental Association

Dental services use among older adults strategies including primary, secondary and tertiary prevention. However, little research has focused on the oral health needs of older adults living in rural areas and there are few if any programmes designed to improve the oral health of these communities. This study aims to report on the patterns of use of oral health care services; factors associated with use of oral health care services, and self-reported barriers to using oral health services by older Victorians aged 55 years and above living in these rural areas, and to compare these findings with some indicators for the general Australian older population. This information is needed for service planning and delivery to ensure optimal dental care for all Australians. Assumptions derived from mainstream studies may not be applicable for rural populations. By providing specific information on those living in non-metropolitan communities, this information will generate a powerful advocacy tool for oral health care resources in this population group, and position oral health in the broader concept of personal and social well-being. MATERIALS AND METHODS The target population of this cross-sectional study were males and females, 55 years or older, functioning independently in the community, living in the City of Greater Bendigo, who were members of local social clubs. Estimates of the necessary sample size are based on the case of 10 independent variables accounting for 10% of the variance in the dependent variable; with a sample size of 210 this will yield a power of 0.84, that is an 84% chance of detecting an effect of that size at the level of significance of 0.01.11 The conceptual framework to be used in this study provides a framework of diverse variables that predict the utilization of medical, dental and hospital services.12–16 The model’s three domains; predisposing variables (demographic and attitude), enabling variables (e.g. income, availability of health insurance), and need have been found to be interrelated, and to predict personal health practices, use of professional health services, and satisfaction with one’s health. Procedure With the approval of the Human Ethics Research Committee of Melbourne University, club coordinators were asked for permission to address the club membership to recruit volunteers for this study. Once individual written consent was obtained, volunteers were asked to undergo a structured interview and a clinical examination. The interview covered a variety of topics including socio-demographic characteristics and use of oral health care services. The instrument also included © 2014 Australian Dental Association

questions about attitudes to oral health and knowledge of causes and risk factors for dental caries, periodontal disease and oral cancer. Dental examinations were conducted by calibrated examiners at the clubs’ facilities. Clinical data were recorded following criteria and recommendations from well-established methods for oral health data collection.17,18 Data collection extended from February to October 2008. Measures In addition to age and gender, socio-demographic variables included living arrangement categorized as either ‘living alone’ or ‘living with spouse or others’; level of education grouped as: ‘no formal education/ primary complete’ and ‘secondary complete/tertiary education’. Participants were also asked whether they had a health care/pensioner card or not, medical history measured the presence (1) or absence (0) of mobility problems, and means of transportation to get to the dentist categorized as: ‘walking’, ‘by bus’ and ‘by car’. Additionally, main source of income and money situation were also assessed. Main source of income was categorized into three categories: ‘pension’; ‘employment based salary’; and ‘superannuation, investments and dividends’. Perceived money situation was categorized into ‘comfortable living’ and ‘money problems’. Psychosocial variables included assessing oral health beliefs by asking the participants the probability of the occurrence of 10 situations regarding oral health developed by Kiyak.19,20 In addition, participants were asked to indicate the importance of 10 health behaviours to maintain good oral health. An Importance of Oral Health Index was created by adding positive responses. The Oral Health Knowledge Index consisted of the sum of correct responses to 38 questions about knowledge of symptoms and causes of dental caries, periodontal disease and oral cancer. Oral health attitudes were measured by seven items concerned with: the inevitability of oral disease in older adults; the desirability of keeping natural teeth and the efficacy of preventive behaviours, such as selfexamination and dental visits. The knowledge and attitudes questions were adapted from Mari~ no’s structured interview schedule,21 which was also adapted from previous Australian studies.21–23 Self-efficacy was measured by eight questions asking about ability to prevent dental caries and to access oral health services.24,25 Participants were asked to indicate the type of dental treatment they thought they might need, including: tooth extraction; relief of dental pain; dental crown or fillings; dentures; soft tissue consultation; gum treatment and other treatments. A Dental Health Treatment Needs Index was created by adding 505

~o et al. RJ Marin positive responses. Participants were also asked about their perceived ‘urgency of dental treatment’ on a 10-point scale. During a dental examination, examiners recorded the number of teeth present, decayed tooth surfaces, and filled tooth surfaces. Participants were grouped as ‘dentate’ or ‘edentulous’. Use of oral health care services was investigated by asking participants to indicate the time interval since their last dental visit, with response option:5 ‘12 months or less’, ‘12 months to 2 years’, ‘2 to 5 years’, and ‘more than 5 years’. Dental attendance was dichotomized according to whether or not a participant had visited the dentist within the last 12 months. In addition, self-perceived barriers to oral health care was assessed by asking participants to report from a list of 11 commonly described categories: ‘cost’, ‘non availability of dentist’, ‘time waiting for appointments’, ‘rude behaviour from dentist’; ‘location of service’; ‘waiting time in the dental office’, ‘fear of dentist/treatment/procedures’, ‘physical disability’, ‘general health problem’ and ‘communication or language problems’, whether any of them prevented them from accessing dental care service. Responses were coded as ‘yes’ or ‘no’. A Barriers Index was created by adding positive responses. The statistical analysis provides basic descriptive information on selected socio-demographic, psychosocial, dental status and use of dental health service variables. To determine differences between groups on dependent variables, ANOVAs (continuous measures) and chi-square tests (categorical measures) were employed. To test if any combination of predisposing, enabling and need, and clinical variables, provided a multivariate explanation of the use of dental health care services, significant associations were then fitted in a logistic regression model. The final model was created using stepwise selection method. Data manipulation and analyses were conducted using SPSS PC (Version 20.0). RESULTS A total of 226 older adults from several local Bendigo clubs participated in the study and satisfied the inclusion criteria. The mean participants’ age was 70.7 (sd 7.1) years. Age ranged from 55 to 88 years, with the largest group of respondents aged between 65 to 74 years (49.1%). The majority of participants were females (62.0%) and had incomplete secondary education or less (56.3%), with 21.2% having completed secondary education. The majority (91.1%) were under health care/pensioner card. Sixty-three participants (27.7%) self-reported having mobility problems. Overall, 51.2% of participants reported having been to the dentist in the previous 12 months. Nineteen participants (8.4%) reported that their last visit 506

to the dentist had been more than 12 months and less than two years ago. An additional 25.3% had not been to the dentist within the last two years, but less than five years and 15.1% had not been for more than five years. Amongst those who visited the dentist in the last 12 months, the most common reasons for their last visit to a dentist were dental check-up (41.7%), followed by dental crown/filling (20.9%), prosthesis repair (14.8%) and tooth extraction (12.2%). Univariate associations between use of dental health services in the last 12 months by participants, and socio-demographic, predisposing, enabling and clinical variables are shown in Table 1. Levels of significance were reached between dental visits and age, gender, level of education, living arrangement, monetary situation and source of income. When participants were asked about perceived barriers to care, the three most frequent barriers to care cited by participants were cost of services (32.7%), fear of the dentists (25.8%) and the length of waiting lists (18.1%). Another commonly mentioned barrier was availability of oral health care services (11.1%). No other category was reported by more than 10% of the sample. Sixty-four participants (27.4%) reported two barriers to dental health services; 12.8% and 7.3% reported two and three barriers, respectively; and the remainder, 15.1%, reported between four and six barriers. One hundred and seven participants (45.7%) reported no barriers to care. The univariate analysis indicated that each added barrier decreased the likelihood of having had a dental visit (OR = 0.77; 95% CI: 0.62–0.95). Also, those who did visit the dentist were more likely to have higher scores for oral health attitudes than those who did not visit a dentist (5.2 vs. 4.8, respectively; p < 0.05). Participants who did visit the dentist in the last 12 months had higher scores for oral health selfefficacy than those who did not (5.5 vs. 5.8, respectively; p < 0.001). Each added self-efficacy point had more than twice the likelihood of having had a dental visit (OR = 2.30; 95% CI: 1.36–3.87). About a quarter (23.5%) reported no need for dental treatment; about a third (38.0%) reported needing one dental treatment; a quarter (25.2%) reported needing two dental treatments, with the remaining 13.2% reported needing between three and seven different dental treatments. The most frequent treatments nominated by participants were fillings (20.1%) and dentures (30.0%). Additionally, 64.7% of participants indicated the need for a dental check-up. Participants who visited the dentist had a lower selfperceived oral health needs score than those who did not (1.2 vs. 1.6, respectively; p < 0.01). Oral health knowledge, self-perceived oral and general health, self-perceived urgency of treatment and holding a © 2014 Australian Dental Association

Dental services use among older adults Table 1. Univariate associations between socio-demographic variables and use of dental health service in the previous 12 months Predisposing, enabling, and need factors

Mean age (years) Gender Male Female Level of education No formal education Some secondary Secondary complete and tertiary Living arrangement Living alone Living with spouse and children Money situation Not make ends meet Comfortable Source of income Government pension Wage, salaries Superannuation, interest or dividends Health card Yes No Self-assessed need for check-up Yes No Oral health knowledge Oral health treatment need Attitudes to health care Self-efficacy Barriers to treatment Urgency of treatment Edentulous Yes No Missing teeth§ Decayed tooth surface§

n

Used dental service in last 12 months

Odds ratio (95% CI‡)

(%) Yes

No 72.0 (7.3)

0.95 (0.92–0.99)

86 140

69.6 (6.8)† ** 39.5 57.9

60.5 41.1

1.00 2.10 (1.24–3.70)

125 47 50

42.2 53.2 74.0

57.8 46.8 26.0

0.26 (0.13–0.54) 0.40 (0.17–0.94) 1.00

56 169

58.9 47.9 *** 59.0 34.2 ** 45.4 47.8 75.8 ** 49.0 70.0 **

41.1 65.8

0.53 (0.30–0.95) 1.00

41.0 52.1

0.37 (0.21–0.66) 1.00

54.6 52.2 24.2

0.27 (0.12–0.63) 0.29 (0.09–0.92) 1.00

51.0 30.0

2.43 (0.89–6.50) 1.00

(4.6)† (1.1)† (1.6)† (0.9)† (1.5)† (2.5)†

41.1 61.0 24.1 1.2 5.2 5.8 0.9 5.0 35.1 75.6

2.20 1.00 1.00 0.32 1.20 2.42 0.77 0.97 0.18 1.00

(9.5)† (0.6)†

20.7 (9.6) 0.2 (0.5)

144 76 163 23 33 206 20 141 77

148 78

58.9 39.0 24.1 1.6 4.8 5.5 1.3 5.1 ** 64.9 24.4 11.8 0.2

(3.6) (1.2) (1.5) (2.0) (1.0) (2.0)

(1.24–3.88) (0.93–1.07) (0.16–0.64) (1.00–1.42) (1.40–4.19) (0.62–0.95) (0.92–1.02) (0.10–0.33)

0.77 (0.62–0.95) 0.76 (0.47–1.22)

†Mean and standard deviation; ‡CI = confidence interval; §Dentate participants only. *p < 0.05; **p < 0.01; ***p < 0.001. Figures may not add due to missing values

pensioner/health care card were not associated with use of oral health care services. Regarding clinical conditions, findings indicated the mean number of decayed, missing and filled tooth surfaces was 87.7 (sd 35.3) surfaces, ranging from 5 to 128. The mean number of coronal decayed and filled surfaces was 15.6 (sd 18.4). Eighty-nine (38.1%) participants had 21 teeth or more. Eighty-two (34.2%) participants were fully edentulous. As expected, dentate participants had visited the dentist recently and had a significantly higher mean number of filled surfaces than participants who had not been to the dentist recently (15.5 vs. 28.4; p < 0.001). Edentulous participants were less likely to have been to the dentist in the previous 12 months than those with natural teeth (OR = 0.18; 95% CI: 0.10–0.32). To better explore the probability of using oral health care services in the last 12 months, a logistic © 2014 Australian Dental Association

regression analysis was performed using 13 predictors including five predisposing variables (age, gender, education, living arrangement and source of income), five enabling and needs variables (oral health knowledge, attitude to oral health, perceived needs, importance of oral health care and self-perceived barriers to dental care) and three clinical variables (number of natural teeth, decayed tooth surfaces and self-reported mobility problems). The final model included eight statistically significant variables significantly associated with using oral health care services [v2 (9) = 80.29; p < 0.0001]. Participants who lived alone were less likely to have visited the dentist (OR = 0.26; 95% CI: 0.10–0.65). Female participants were more than twice as likely to have visited the dentist than males (OR = 2.98; 95% CI: 1.38–6.46). Self-perceived barriers to oral health care was associated with visiting a dentist in the last 12 months, each perceived need decreased 507

~o et al. RJ Marin the odds of using oral health services (OR = 0.59; 95% CI: 0.43–0.82). Those who reported mobility problems were less likely to have visited the dentist compared to those without these problems (OR = 0.41; 95% CI: 0.18–0.93). In the same manner, those who self-perceived less oral health needs were less likely to have visited the dentist than those who selfperceived more oral health needs (OR = 0.37; 95% CI: 0.15–0.90). Participants with less than complete secondary education were less likely to have visited the dentist than those with higher levels of education (OR = 0.44; 95% CI: 0.22–0.90). Additionally, those who were on a salary or income from business or property were less likely to have visited the dentist than those whose source of income were investments and superannuation (OR = 0.14; 95% CI: 0.03–0.61). Edentulous participants were less likely to have visited the dentist than those with natural teeth (OR = 0.10; 95% CI: 0.04–0.22) (Table 2). The variance for oral health care services utilization, using the full model, was 45.5% (Nagelkerke r2 = 0.455). DISCUSSION Consistent with other reports, and even though the sample was largely dentate, about half (51.2%) had visited a dentist in the last 12 months.1,2,26 This proportion is somewhat lower than that reported for

Table 2. Regression coefficient, odds ratios and 95% confidence interval for odds ratios for the factors predicting use of oral health care services among older adults b coefficient Living arrangement Living alone –1.36 Living with spouse and others Gender (female = 1) 1.08 Number of self-perceived –0.53 barriers to oral health care Mobility problems (Yes = 1) –0.90 Self-assessed number of oral –0.99 health treatment needs Level of education Less than secondary complete –0.82 Secondary complete and higher levels Source of income –1.96 Wage or salary/income from business or property Superannuation, investments and dividends Dentate status Edentulous –2.33 Dentate Constant 4.626

Odds ratio

95% confidence interval

0.26 2.98 0.59

0.10–0.65 1.00 1.38–6.46 0.43–0.82

0.41 0.37

0.18–0.93 0.15–0.90

0.44

0.22–0.90 1.00

0.14

0.03–0.61 1.00

0.10

0.04–0.23 1.00

The variance in dental visits accounted for using the full model was 45.2% (g2 = 0.452). 508

adults aged 55 years and above living in urban or rural settings by the Victorian component of the national oral health survey.1,2 Furthermore, 15% of the participants reported not going to the dentist for more than five years. This finding is even more striking given that more than 90% of this older rural group was eligible for public, low fee oral health care service. Furthermore, the data were collected when the Medicare Chronic Disease Dental scheme was in operation.27 This supports indications that the capacity to provide dental services for Australian rural populations is not being met.22 Participants nominated several barriers to access dental services commonly reported by many studies (e.g. money situation, cost, length of waiting list and availability of oral health care services),23,24 as having a significant impact on their access to dental care services in rural settings. Structural barriers such as length of waiting lists and waiting time in the surgery before treatment were the most mentioned barriers. Evidence based literature has identified several socio-demographic, psychosocial and clinical factors associated with use of dental services among older adults globally.23–25 Consistent with other reports, visits to the dentist also varied according to socioeconomic status. Source of income and level of education were associated with use of services. By living arrangement, those living alone were less likely to use oral health services than those who live with their spouses and/or children.26 Thus, the access to oral health information might have been less than ideal. Lack of information has been highlighted as a barrier to accessing health services.27 Nevertheless, present findings gave no evidence to support other commonly assumed predictors of oral health care services usage, e.g. age and distance to health services were not among the most commonly mentioned barriers. Importance to oral health, perceived treatment need and number of remaining teeth have also been described as good predictors to utilization of dental services.25,28 The present study found that utilization of dental services is strongly influenced by perceived need of oral health treatment and edentulism. Edentulous participants were significantly less likely to visit a dentist in the last 12 months compared to those with natural teeth. This provides a strong argument for increasing the awareness that, at any age, it should not be considered a sign that one does not need to visit dentist.29 However, further investigation is required to explore the relationship between retaining natural teeth and use of dental services. Self-assessed need of oral health care, an important attitudinal predictor for seeking oral health care,25 was found to be associated with use of oral health services in the © 2014 Australian Dental Association

Dental services use among older adults present study. However, oral health attitudes were not significantly related to use of oral health care services. Findings from the present study identified a large level of need and inequities in the use of oral health care services by older adults. This highlights the need to improve access to oral health care services as a high priority in the promotion of good health in older adults. More importantly, findings also suggest many older adults believed that attempts to intervene by reducing the cost of care might not, by itself, be enough to increase oral health service use among this population. Therefore, there is also a need to promote their understanding regarding the importance of the relationship of oral health to good general health and well-being. This requires special attention as it has been reported that not all those who made dental visits receive systematic oral health education.25 On the other hand, it seems important to increase the understanding of attitudinal factors related to lack of a perceived need for oral health care. Mari~ no and his collaborators32 highlighted the need to understand the context of older adults’ life experience as a key element in addressing this issue. In making these observations, the limitations of this study need to be recognized. This was a random sample of volunteers, who felt reasonably well and capable of independently managing most of their daily activities and able to participate in social clubs. Therefore, a self-selection bias might be present. Also, while this information is useful, it only provides initial information at a state level, the findings are not intended to be representative of the entire Australian older population. Missing from this study was the opportunity to generate qualitative data on the older adults’ oral health experience. This data would provide a broader understanding of older adults’ perception and ideas. Nonetheless, while our data may have limitations, there is a scarcity of information regarding oral health of rural older adults in Victoria. Even less is known about their oral health perceptions, experience and contextual issues. It is not to be inferred from this study that a final definitive model has been developed to determine the predictors and barriers to use of dental services, rather this study has raised some potentially important factors to be explored in future research. Oral health services may not have been used for many reasons. Increasing the use of services will require further efforts beyond the reduction of financial barriers. Access to oral health services among older adults is affected by many deeply entrenched socio-demographic, financial, psychosocial and structural barriers, as well as other predisposing and enabling factors. © 2014 Australian Dental Association

ACKNOWLEDGEMENTS This research was supported by funding from Dental Health Services Victoria (DHSV) Research and Innovation Grants. We would like to acknowledge the participants and the participating clubs. In particular, we would like to thank Ms Tania Bonetto, Mr Bajram Bajrami and Dr Elmira Habibi for assisting with the collection of the data. REFERENCES 1. Slade GD, Spencer AJ, Roberts-Thomson KF, eds. Australia’s dental generations: the National Survey of Adult Oral Health 2004–06. AIHW cat. no. DEN 165. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 34), 2007. 2. Australian Institute of Health and Welfare Dental Statistics and Research Unit. Geographic variation in oral health and use of dental services in the Australian population 2004–06. Research Report No. 41. AIHW cat. no. DEN 188. Canberra: AIHW, 2009. 3. Barnard PD. National Oral Health Survey Australia 1987– 1988. Canberra: Australian Government Publishing Service, 1993. 4. Dolan TA, Peek CW, Stuck AE, Beck JC. Functional health and dental service use among older adults. J Gerontol A Biol Sci Med Sci 1998;53:M413–M418. 5. Australian Institute of Health and Welfare Dental Statistics and Research Unit. Oral health and access to dental care. Canberra: AIHW Dental Statistics and Research Unit, 2001. 6. National Institute of Dental and Craniofacial Research, National Institute of Health, HHS. Oral health of United States adults. NIDCR, NIH, US Department of Health and Human Services, 1987. 7. Gift HC, Newman JF. How older adults use oral health care services: results of a national health interview survey. J Am Dent Assoc 1993;124:89–93. 8. Brennan DS, Spencer AJ, Szuster FS. Rates of dental service provision between capital city and non-capital locations in Australian private general practice. Aust J Rural Health 1998;6:12–17. 9. Kruger E, Tennant M. Oral health workforce in rural and remote Western Australia: practice perceptions. Aust J Rural Health 2005;13:321–326. 10. Mari~ no R, Calache H, Whelan M. Dental status and sociodemographic profile of adult users of public oral health care services in Victoria. Journal of Theory and Practice of Dental Public Health 2013;1:16–23. 11. Lemeshow S. Adequacy of sample size in health studies. West Sussex, England: John Wiley & Sons Ltd, 1990. 12. Andersen RM. Behavioral model of families’ use of health services. Research Series No. 25. Chicago: Center for Health Administration Studies, The University of Chicago, 1968. 13. Andersen R, Harada N, Chiu V, Makinodan T. Application of the behavioral model to health studies of Asian and Pacific Islander Americans. Asian Am Pac Isl J Health 1995;3:128–141. 14. Andersen R, Newman J. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc 1973;51:95–125. 15. Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations. Health Serv Res 2000;34:1273–1302. 16. Aday L, Awe W. Health sources utilization models. In: Gochman B, eds. Handbook of Health Research. Vol. Determinants of health behavior (personal and social). New York: Plenum, 1997:153–172. 509

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28. Paley GA, Slack-Smith LM, O’Grady MJ. Aged care staff perspectives on oral care for residents: Western Australia. Gerodontology 2004;21:146–154. 29. White J. Oral health problems of elderly women in Australia: an holistic approach. Research Thesis. 1996. URL: ‘http://ses. library.usyd.edu.au//bitstream/2123/4630/1/0442.pdf‘. Accessed December 2013. 30. Kiyak HA, Reichmuth M. Barriers to and enablers of older adult’s use of dental services. J Dent Educ 2005;69:975–986. 31. Mari~ no R, Wright C, Schofield M, Calache H, Minichiello V. Factors associated with self-reported use of dental health services among older Greek and Italian immigrants. Spec Care Dentist 2005;25:29–36. 32. Mari~ no R, Wright FAC, Minichiello V, Schofield M. Oral health beliefs and practices among Greek and Italian older Australian: a focus group approach. Australas J Ageing 2002;21:193–198. 33. Gilbert GH, Duncan RP, Crandall LA, Heft MW. Older Floridian’s attitudes toward and use of dental care. J Aging Health 1994;6:89–110. 34. Slade GD, Spencer AJ, Roberts-Thomson K. Tooth loss and chewing capacity among older adults in Adelaide. Aust N Z J Public Health 1996;20:76–82. 35. Mari~ no R, Wright FAC, Minichiello V, Schofield M. Oral health through the life experiences of older Greek and Italian adults. Aust J Prim Health 2002;8:20–29.

Address for correspondence: Associate Professor Rodrigo J Mari~ no Oral Health Cooperative Research Centre Melbourne Dental School The University of Melbourne Melbourne VIC 3010 Email: [email protected]

© 2014 Australian Dental Association

Pattern and factors associated with utilization of dental services among older adults in rural Victoria.

In Australia, rural and regional areas have an increased proportion of older people who are ageing more rapidly than their metropolitan counterparts. ...
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