The impact of COVID-19 on access to dental care: a report from the 2021 Adult Oral Health Survey

James Eaton

Main findings

  • Just over a third (35%) of adults in England who responded to the survey reported having a need for dental treatment or advice between March 2020 and March 2021, when access to dental services was limited because of the coronavirus (COVID-19) pandemic.

  • The most common reasons for needing treatment or advice were because of a broken or decayed tooth (36%) or toothache or mouth pain (31%). Around a quarter of participants reported that they did not have a problem but wanted a check-up (24%).

  • Two thirds of survey participants (68%) who needed advice contacted their usual dental practice. Less than 1 in 10 tried other approaches, for example contacting a new practice, searching the internet or social media or dialling 111. One in 6 (16%) of them did not seek any advice or treatment.

  • The most common outcome for those who had sought treatment or advice was that the problem was completely treated by a dental professional (48%). One in 10 (10%) did not receive any advice or treatment.

  • The most common reasons for not seeking help were that participants were worried about catching COVID-19 or were shielding (23% of those who did not seek help), or because they could not afford to pay for treatment or advice (13%).

Introduction

Background

On 25 March 2020 access to general dental services was paused across the UK and dental care hubs were established to deliver urgent care as part of the government’s response to the COVID-19 pandemic.[footnote 1] Personal protective equipment (PPE), infection prevention and control, and patient prioritisation guidance were issued to dental care providers[footnote 2] as services began to reopen in England from June 2020. This guidance further changed as the nation continued to navigate the pandemic and as wider restrictions were amended.

Although some access to dental services was maintained throughout subsequent lockdowns and changes in restrictions, there were longer-term impacts on access to dental services. These included the time needed to clear appointment backlogs, staff availability, physical distancing and PPE requirements[footnote 3], some of which still applied in February and March 2021, when the Adult Oral Health Survey (AOHS) was carried out.

About the survey

The 2021 AOHS was commissioned by Public Health England, now the Office for Health Improvement and Disparities. The survey was carried out by a consortium led by the National Centre for Social Research (NatCen), and includes the University of Birmingham, King’s College London, the School of Dental Sciences at Newcastle University, the Dental Public Health Group and Department of Epidemiology and Public Health at University College London (UCL), and the Office for National Statistics (ONS). The University of Leeds and School of Clinical Dentistry, University of Sheffield also provided guidance and support to the survey and its design.

The survey was designed as a continuation of the long-running Adult Dental Health Surveys, carried out in the United Kingdom since 1968. The last Adult Dental Health Survey report was in 2009 and was published by NHS Digital.

The 2021 survey differed from its predecessors in a number of ways:

  • it was carried out using web and paper self-completion questionnaires, rather than by face-to-face interviewing in respondents’ homes
  • it was not possible to carry out dental examinations of participants
  • the survey covered England only, rather than other nations of the UK
  • the name of the survey was changed to reflect its focus on the health of teeth and mouths

The survey was carried out in February and March 2021 with a representative sample of adults in England aged 16 and over. A sample of 19,286 addresses was selected using probability methods, and 2 adults per household were invited to take part in the survey.

A total of 6,343 responses were received from 4,429 households, 24% of the eligible addresses in the sample. Within participating households, 76% of eligible individuals took part. For further information on the survey response, see the accompanying technical report.

Data was collected using self-completion questionnaires, completed in web and paper form. The survey questionnaire covered self-assessed dental health, oral health behaviours, service use, barriers to care and impacts of oral and dental health. It included a set of questions designed to explore the impact of COVID-19 on oral health and access to care. This report presents the results of those questions, including analysis to explore variations in need for and access to treatment or advice among different groups in the population. Where differences are commented on in the text, these are significant at the 95% confidence level, unless otherwise stated. Disclosure control was applied and therefore no results are shown where the base was fewer than 50 responses.

The AOHS findings are based on participants’ responses at a particular point in time and it is not possible to make inferences about causal relationships. For example, those who reported their oral health as bad or very bad were most likely to report that they had suffered a broken or decayed tooth, or toothache or pain. It is not possible to say whether these problems were elements within a long-term experience of poor oral health or whether the assessment of poor oral health was specifically made in reference to those symptoms.

Full technical information about the 2021 AOHS is provided in the accompanying technical report.

This report only applies to England. For Scotland, see the Scottish Adult Oral Health Survey 2016 to 2018.

Need for dental treatment or advice

Survey participants were asked “Have you needed dental advice or treatment since the start of the first COVID-19 lockdown (in March 2020)?”. Those who reported that they had such a need were asked what type of problem they had and were offered a list of 6 types of problem, as well as the option that they did not have a problem but wanted a dental check-up.

Who needed treatment or advice

Just over a third (35%) of participants reported that they needed dental advice or treatment at some point between the start of the first lockdown in March 2020 and the time of interview (between February and March 2021).

Gender

Women were more likely than men to have needed treatment or advice: 37% of women, compared with 33% of men.

Age

The need for dental treatment or advice increased with age, from 22% of those aged 16 to 24 years to 45% of those aged 75 years and over.

Figure 1: need for dental treatment or advice by age

Base: all adults.

Error bars show the 95% confidence interval around the estimates.

Source: Table 1 in the data tables.

Self-assessed oral health

More than half (56%) of adults who reported that their oral health was bad or very bad felt that they needed treatment or advice, compared with 42% of those with fair oral health and 30% of those who reported that their oral health was good or very good.

Figure 2: need for dental treatment or advice by self-assessed oral health

Base: all adults.

Error bars show the 95% confidence interval around the estimates.

Source: Table 2 in the data tables.

Usual pattern of dental attendance

Adults who usually visited the dentist for a regular check-up (39%) were more likely to say they had needed treatment or advice than those who visited only when they were having trouble (31%), for the occasional check-up (26%) or those who had never been to the dentist (17%). Perceptions of the need for treatment or advice may have been influenced by participants’ normal pattern of dental attendance.

Variations by household income and neighbourhood deprivation showed no clear pattern.

Figure 3: need for dental treatment or advice by usual pattern of dental attendance

Base: all adults.

Error bars show the 95% confidence interval around the estimates.

Source: Table 2 in the data tables.

What treatment or advice was needed

The following analysis is based on participants who felt they needed treatment or advice. They could give one or more reasons for this need.

The most common reason was because of a broken or decayed tooth (36% of those who needed help), followed by toothache or pain in the mouth (31%). Around a quarter of participants reported that they did not have a problem but wanted a check-up (24%).

Figure 4: what treatment or advice was needed

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 3 in the data tables.

There were some differences across groups in the reasons people gave for needing treatment or advice. Other differences were not statistically significant.

Gender

Men were more likely than women to have reported a decayed or broken tooth as their reason for needing treatment or advice (40% of men, compared with 33% of women).

Age

Needing treatment or advice because of toothache or pain in the mouth was more common among adults aged between 25 and 34 (42%), and declined thereafter with age, being lowest among those aged 65 and over (22% of those aged 65 to 74, 21% of those aged 75 and over).

Household income

Equivalised household income takes into account the number of adults and dependent children in the household, as well as overall household income. Households are divided into quintiles (fifths) based on this measure.

The proportion of adults who needed help due to toothache or pain increased from 27% among those in the fifth of households with the highest incomes to 40% among those in the lowest income quintile.

Adults in the 2 highest income quintiles were more likely to report that they did not have a problem but wanted a check-up (30% in each quintile) than those in the lower income quintiles. This proportion was lowest (17%) among those in the lowest income quintile.

Neighbourhood deprivation

Neighbourhood deprivation is measured using the English Index of Multiple Deprivation (IMD). IMD is based on 37 indicators, across 7 domains of deprivation. IMD is a measure of the overall deprivation experienced by people living in a neighbourhood, although not everyone who lives in a deprived neighbourhood will be deprived themselves. To enable comparisons, areas are classified into quintiles (fifths).

The proportions reporting broken or decayed teeth was lower in the least deprived fifth of neighbourhoods (30%) than in other areas (between 36% and 40%). There was a similar and more pronounced pattern for those reporting toothache or other oral pain, from 24% and 25% of those in the 2 least deprived neighbourhoods to 41% of those in the most deprived fifth of neighbourhoods.

Conversely, the proportion who reported that they wanted a check-up increased from 15% of those living in in the most deprived IMD quintile to 30% of those living in the least deprived quintile.

Figure 5: reason for needing dental treatment or advice by neighbourhood deprivation

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 3 in the data tables.

Self-assessed oral health

The survey captured participants’ views at a particular moment, and it is not possible to conclude whether their assessment of their dental health at the time of the survey preceded or was caused by the problems with their teeth or mouth during the previous year.

Those who assessed their oral health as bad or very bad were more likely than those with better oral health to have reported problems. More than half (57%) of those with bad or very bad oral health reported a broken or decayed tooth, compared with 42% of those with fair oral health and 28% of those with good or very good oral health. Toothache or pain was reported by half of those with bad or very bad oral health (47%), compared with 40% of those with fair oral health and 23% of those with good or very good oral health.

A third (32%) of those with good or very good oral health had no problem but wanted a check-up, compared with 16% of those who judged their oral health to be fair and 6% of those with bad or very bad oral health to.

Figure 6: reason for needing dental treatment or advice by self-assessed oral health

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 4 in the data tables.

Usual pattern of dental attendance

Those who usually only visited a dentist when they had trouble were more likely to report needing treatment or advice because of broken or decayed teeth (45%), compared with those who went for regular or occasional check-ups (34% and 33% respectively). Needing treatment or advice because of toothache or other pain followed a similar pattern (reported by 53% of those who only went with trouble, 38% of those who went for occasional check-ups and 25% of those who usually went for regular check-ups).

Conversely, 29% of adults who usually went to the dentist for regular check-ups reported that they had wanted a check-up, compared with 18% of those who went for occasional check-ups and 6% of those who usually only visited a dentist when they had trouble.

Figure 7: reason for needing dental treatment or advice by usual pattern of dental attendance

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 4 in the data tables.

Sources of treatment or advice

Those who had needed dental treatment or advice between March 2020 and March 2021 were asked what action they took. Two thirds (68%) of those who needed treatment or advice between March 2020 and March 2021 contacted their usual dental practice. This is the proportion of all adults who answered this question and does not take into account whether all adults had a dental practice that they usually attended.

Smaller proportions of participants did other things: 10% contacted a new dental practice, 8% searched for dental advice on the internet or social media and 6% contacted 111 for help and advice. (Calling 999 was offered as an option; no participants reported this.)

One in 6 (16%) did not seek any advice or treatment.

Figure 8: actions taken when dental treatment or advice was needed

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 5 in the data tables.

There were some differences across some groups in the proportions who contacted their usual dentist. The proportions who did nothing also varied across some groups.

Age

Older adults who needed treatment or advice were more likely to contact their usual dental practice: this proportion was higher among those aged over 55 (between 77% and 79%), compared with 55% to 62% of adults aged under 45.

A quarter (24%) of those aged 35 to 44 who needed treatment or advice did not seek any help, compared with between 13% and 17% of those in younger or older age groups.

Figure 9: contacted usual dental practice for dental treatment or advice by age

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 5 in the data tables.

Neighbourhood deprivation

The proportion of participants who contacted their usual dental practice when they needed treatment increased from 57% in the most deprived fifth of areas to 78% in the least deprived fifth of areas.

Figure 10: contacted usual dental practice for dental treatment or advice by neighbourhood deprivation

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 5 in the data tables.

Self-assessed oral health

The survey captured participants’ views at a particular moment, and it is not possible to conclude whether their assessment of their dental health at the time of the survey was influenced by how the problems with their teeth or mouth were dealt with.

Among those who had needed treatment and advice and who assessed their oral health as good or very good, 74% had contacted their usual dental practice, compared with 47% of those who rated their oral health as bad or very bad. (This comparison does not take into account whether these survey participants had a dentist at the time.)

Figure 11: contacted usual dental practice for dental treatment or advice by self-assessed oral health

Base: adults who needed treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 6 in the data tables.

The proportion who had not done anything about their need for treatment or advice increased from 13% of those with good or very good oral health to 24% of those with bad or very bad oral health.

Usual pattern of dental attendance

Adults who reported going for regular check-ups were most likely to have contacted their usual practice when they needed treatment or advice. 78% did so, compared with 54% of those who went for occasional check-ups and 46% of those who only went to the dentist when they had trouble.

Outcomes of seeking treatment or advice

Those who had sought treatment or advice from any source were asked what happened. The most common outcome was that the problem was completely treated by a dental professional (48%). Smaller proportions of participants received temporary treatment from a dental professional (15%), advice on how to manage the problem on their own (15%) or a prescription for antibiotics (11%). One in 10 (10%) received no professional treatment or advice.

Figure 12: outcomes when looked for dental treatment or advice

Base: adults who sought treatment or advice.

Error bars show the 95% confidence interval around the estimates.

Source: Table 7 in the data tables.

These proportions were similar for those who contacted their usual dental practice. Half (51%) reported having been completely treated by a dental professional, 15% received temporary treatment, 15% were given advice on how to manage the problem on their own, 11% received a prescription for antibiotics and 7% received no professional treatment or advice.

Among those who needed treatment for a broken or decayed tooth, 51% reported that they had been completely treated by a dental professional, 24% received temporary treatment, 16% were given advice on how to manage the problem on their own, 8% received a prescription for antibiotics and 13% received no professional treatment or advice.

Among those who reported toothache or other pain, 43% reported having had complete professional treatment, 19% received temporary treatment, 23% were given advice on how to manage the problem on their own, 25% received a prescription for antibiotics and 11% received no professional treatment or advice.

The characteristics of those who needed treatment or advice varied according to the problem they had and the actions they took. These will have influenced the outcomes of treatment, and consequently no comparisons of outcomes have been made across groups.

Reasons for not seeking treatment or advice

Among the 35% of survey participants who reported that they had needed advice or treatment, around 1 in 6 (16%) reported that they had not sought it. These participants were asked why they had not looked for help. Half of them either chose a reason other than those listed in the questionnaire (30%), didn’t know (3%) or preferred not to say (17%).

Among the options in the questionnaire, the most common reason for not seeking help was that participants were worried about catching COVID-19 or were shielding (23% of those who did not seek help). Other reasons were that they could not afford to pay for treatment or advice (13%), the problem got better without help (9%), the participant did not know how to access treatment or advice (9%), they could not find a dentist who would treat them (7%), they could not travel to the dentist (5%) or they had COVID-19 (3%).

There was very little difference between different kinds of adults in the proportions who did not seek treatment or advice because they were worried about contracting COVID-19 or were shielding. Those who described their oral health as good or very good were least likely to have avoided seeking help because of this (17%, compared with 31% of those with fair oral health and 28% of those with bad or very bad oral health).

The proportions of participants who did not seek help because they could not afford to pay for it varied with neighbourhood deprivation (from 3% in the least deprived quintile to 26% in the most derived quintile), household income (from 5% of those in the highest income quintile to 34% of those in the lowest income quintile) and with self-assessed dental health (from 4% of those with good or very good oral health to 34% of those with bad or very bad oral health).

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