The present study adopted Andersen model [10] and evaluated factors associated with children having visited the dentist at least once in their life. It was found that most children have never visited a dentist. Children with severe dental caries and presence of dental pain visited dentist in a higher frequency than children without severe caries or history of dental pain. Also, the fact that a child had visited a dentist at least once was associated with oral hygiene practices and dental fear.
The low prevalence of dental visits observed in this study is similar to a previous study in a South Brazilian city, where only 26% of children had visited a dentist at the age of 3 [23]. The low frequency of dental visit by children aged 4–5 years in this group is even more worrying compared to younger children in Pelotas, a study performed ten years earlier, found that a similar prevalence of children had never had a dental visit, showing that no substantial change has been observed in dental services use in one decade [7]. This low demand for dental care becomes worrying, as it reveals the lack of a policy to encourage and support early dental care measures, both by the population and by the public sector [24]. Noteworthy, Brazil has the largest public health system in the world, which provides preventive and curative care to the entire population, including children, and the system includes strategies for the care of pregnant woman (Smiling Brazil, launched in 2004). The lack of health literacy in relation to the importance of dental visits during the first years may be a reason for such a low prevalence of dental service use by children [25].
In the present study, the demand for services had no significant association with demographic and socioeconomic variables, such as sex, children's age, maternal education. However, these findings differ from other authors who found significant associations [23, 24]. Family income, which is an enabling factor also associated with services use, was also not associated in this sample. This could be explained by similarities in the characteristics of sample included, as all children belonged to public schools.
The utilization of dental services by children is often driven by the presence of oral problems. The fact that children have visited the dentist at least once in the life in this sample was strongly associated with need factors, suggesting that parents perceive oral health problems and take their children to the dentist, in most of the cases to treat and not to prevent oral diseases [26]. In this sample, having severe dental caries influenced parents’ taking their children to the dentist. When CAST codes were considered, the higher the maximum score presented by the child, the higher the frequency of dental service use. It is recognized that until decay interferes with the child’s life, parents may be unaware that a dental problem even exists. Parental perception of their child´s OHRQoL was also associated with utilization of dental services, this is in agreement with previous studies that showed that caregivers’ unfavorable perception of their children’s oral health motivated them to seek dental care for them [7, 27]. The findings confirm the fact that a greater need for oral health (perceived or normative) is an important predictor of use of oral health services in preschoolers [7]. The use of dental services by children and adolescents is often motivated by the presence of pain. In previous study [7], having experienced pain influenced parents to take their children to the dentist, while having teeth affected by caries did not. However, only 30.9% of children who had pain were taken to the dentist. The fact that an adult performs oral hygiene was also associated with visiting the dentist. This could be explained because parents can detect oral health problems during teeth brushing, and take the child to the dentist, or because parents are following instructions provided by dentist that, ideally, an adult should brush the child's teeth within this age group.
Only one of the studies included in a systematic review explicitly examined the role of psychosocial factors in dental services used [9]. Vingilis et al [28] showed that psychological distress was not significantly associated with at least one dental appointment in the last two years. Children with dental fear visited a dentist with lower frequency than children without dental fear. It is widely recognized that fear of dental treatment leads to irregular or delayed dental visits. People with fear avoid going to the dentist, which consequently leads to the need for more invasive dental procedures, which generate greater discomfort or pain to the patient, thus generating an even greater fear of having the next appointment, establishing the so-called “fear cycle” [29]. Noteworthy, children in this sample who visited a dentist may have acquired positive perceptions of the dental environment, which contributed to reduce dental fear. Thus, it should be considered that answers to the question about the child having fear of the dentist will have very different meanings for those who did visit the dentist (i.e., an actualized experience) and for those who did not visit the dentist (i.e., an anticipatory response or perception).
As strength of the present study, representative sample of preschool children was included and variables associated with dental service use were selected based on the Andersen model. The main limitation is the cross-sectional design which limited the extent to which causal inferences could be made. Only children enrolled in public schools were included because the city had no registered private school by the time of data collection. Also, we have explored the outcome of use regardless of the reason, and the predictors could be different for those who go to the dentist for preventive reasons and those who go for problems, pain or emergencies. However, only a few children visited dentist for preventive reasons, what limited the data analysis. The outcome adopted has been considered an important question related todental services use [30].
Dental visits are an important component of health care use. It is worrisome that few children had ever visited a dentist. Visits to the dentist by preschool children is of fundamental importance for the practice of primary prevention measures in oral health [3]. Preventive dental consultations in young children seem to decrease subsequent visits related to dental problems and can make care more effective and less costly when compared to emergency or hospital care [31]. So, every effort should be made to ensure that the first dental appointment occurs in the first year of life, so that those responsible receive adequate guidance for the installation of good oral hygiene habits and the establishment of regular consultations. Postponing dental visits can have deleterious effect on oral health [32] and well-being [33, 34]. Therefore, knowledge about the factors associated with use of dental care services is important. This knowledge can be beneficial in terms of clinical relevance to expand knowledge from the use of services and visits to the dentist at least once in a lifetime in a given population. Based on the identified need, it is necessary to develop ways to inform and raise awareness among caregivers about the importance of dental care for preschoolers for maintaining oral health and quality of life of children.