Most oral health problems are multifactorial, such as biological, socioeconomic, cultural, and environmental factors.[8] According to the National Oral Health Survey Data, an unequal prevalence between tooth decay and filling based on the WHO age group is observed in Malawi (a low-income country).[9] The RTI and PTI have not reached the target, indicating that individuals who had tooth cavity did not compensate for filling that cavity. Similar to the results of study in China, a low number of tooth fillings indicated a high rate of untreated caries.[10] Low treatment needs of tooth filling are affected by individual characteristics and other factors that influence a person’s ability to fill the tooth decay as much as prevent further damage.[11]
Relationship between sociodemographic factors and dental utilization toward tooth decay and filling
In Tanzania, a person’s attitude in deciding to fill their teeth was influenced by several factors, such as sociodemographic factors, and employment status related to personal income.[11] Women have a high number of decays and low number of fillings.[9, 12] According to John, three main factors in development of tooth decay in women, that is, estrogen hormone accumulation, lower saliva flow rate, and eating more foods containing sugar during pregnancy, are correlated with rates of caries and trigger the demineralization process.[13]
Based on location of residence in this study, individuals in rural areas had a higher number of tooth decay and lower number of tooth filling than those in urban areas. This contradicts the result of the study of Tafere et al., where patients living in urban areas had 1.6 times more dental caries than patients in rural areas. This is influenced by the habits of people living in urban areas who tend to consume more sweet foods.[9, 12] Factors such as fluoride content in other studies showed that there was a significant relationship between rural water and dental health condition.[14] Limited access to healthcare facilities in rural areas led to a high untreated caries rate than in urban areas.[15] The results of this study are related to GIS mapping. Figure 1 shows that Eastern Indonesia had a low proportion of tooth filling. This condition is related to the development of infrastructure and resources, such as the low distribution of healthcare facilities and dentists in Eastern Indonesia (Fig. 2).
Based on the household knowledge index regarding ease of access to healthcare services, > 30% of respondents in rural areas reported that is extremely difficult to reach and access hospitals, healthcare centers, and dental clinics than in urban areas.[16] Tooth filling demand in urban areas is higher than in rural areas, due to factors such as distance and availability of primary healthcare services to obtain dental treatment.[17]
The low prevalence of filling cavities is influenced by personal knowledge.[9] Educational level of the Indonesian population is dominated by secondary educational. It involves a person’s ability to read. Reading is a person’s basic literacy ability in expanding access to information that could increase knowledge and skill, and also improve their quality of life.[18] A study that showed low oral health literacy has a high risk of oral health such as dental caries.[19] A good level of knowledge helps a person to seek appropriate preventive treatment such as tooth filling.[12, 20]
According to the National Labor Force Survey Indonesia, the percentage of formal workers from 2019 (44,12%) to 2021 (40,55%) decreased occurred.[21] In 2019, the proportion of formal workers is lower that of informal workers.[22] The number of people in Indonesia who worked in August 2021 is 131,05 million people with an unemployment rate reaching 6,49%. A study also analyzed unemployment and employment groups toward oral health status and showed that the unemployment group had a risk of poor oral health and a higher number of cavities. The unemployed group has unstable financial conditions ability to pay dental treatment fee.[23]. High GDP per capita is statistically significant providing a protective effect in free caries.[24] Similar to other studies, an increasing number of unemployed individuals can reduce preventive efforts toward the utilization of dental visits.[23, 25]
Inadequate utilization of healthcare services causes an increased burden of dental caries.[12] Community factors cause low dental utilization in Indonesia such as not being able to pay for treatment, availability access to reach healthcare facilities, economic status, low educational level, and insurance ownership.[26] The study in Romania and China showed children and 40,6% of adolescents will visit dentists when complaints or emergencies arise and infrequent dental visit increase the prevalence of caries and a decrease the number of tooth fillings.[27]
Relationship between the number and ratio of healthcare facilities and dentists and tooth decay and filling
Indonesia is a widely spread archipelago and has uneven development. According to the Human Development Index, disparities occur in all dimensions of human development between urban and rural residential locations.[26]
Two factors of optimal utilization of dental health services should be considered; availability and accessibility of healthcare workers and facilities.[9, 11, 28] Availability of dentists in providing services is a supporting factor to improve health status. Of 69% of dentists worldwide, only 27% provide services.[29] Studies in Laos and Western Australia showed the low purchasing power of people as a determinant economic factor and the reason why disparities of dentists refused to practice in an isolated area.[30, 31] In many developing countries, unequal distribution of dentists and location of healthcare facilities result in untreated dental caries.[11, 32] Studies in Africa showed inadequate workplace infrastructure as a factor that causes limited availability of dentist in their area.[33] Similarly, a study in Malaysia reported that unequal distribution of healthcare services causes difficult access to dental healthcare services.[34]
Oral health promotion will not be effective if approached only individually and in a segmented way. Approaches can be broad and holistic from upstream, midstream, and downstream levels to address the health inequality of the population.[35–37] Downstream intervention is defined as an approach that concentrates on individual clinical actions, health behaviors, and biological risk factors. Interventions at this level are often applied, but the results failed to significantly reduce gaps and did not show sustainable improvements to address oral health problems. For example, education intervention lead to short-term changes in behavior and health literacy to produce long-term improvement, especially in socioeconomic inequality groups.[35]
Upstream level intervention is a shift of an individual-oriented approach to the wider realm by linking all aspects. This level of intervention aimed to control underlying causal determinant factors such as socioeconomic, policies, and environmental conditions. The goals of the upstream level are to achieve wider and sustainable health equity related to education level, occupation, living conditions, and access to drinking water, which are factors outside the scope of the healthcare system. Upstream interventions are generally conducted by governments or policymakers who operated holistically from top to bottom across an entire population.[35, 36, 38] The implementation process requires intersectoral collaboration to support each other. Examples of upstream interventions can be conducted at both local and national levels in promoting oral health related to dental caries.[35] The strategy in assigning dentists in rural areas is to launch a program to place young dentist graduates in isolated areas.[39] Obstacles that occur in this program are temporary assignments, so other strategies are needed such as establishing appropriate incentive policies and providing opportunities to continue further studies and return to their job site.[40, 41] This effort had a positive impact on rural communities in obtaining services.[39, 42, 43]
The local level at the school environment started to involve schools and teachers to become part of the health promotion network. Training of teachers can be part of spreading information to children and putting in the school curriculum on how to maintain and improve dental and oral health status.[35, 44] Moreover, healthy low sugar foods can be provided in schools. Other community action policies in various segments such as elderly health in nursing homes and elderly care centers, maternal and child, and caregivers providing balance nutrition food and maintaining oral hygiene can be applied. Subsidized sales of toothpaste and toothbrush through the local community in an effort to change oral health behaviors.[35, 38] Promotion of dental health as an intervention at the national level such as supporting regulation content and timing of children’s food and drink advertisement, making more strike about policies labeling food and beverage content, increasing food and beverage taxes to reduce sugar consumption, abolishing taxes of fluoridated toothpaste, and encouraging availability of sugar-free pediatric drugs and fluoridation of drinking water. The government can participate in making strategic policies in granting permits to the establishment of healthcare facilities, especially in rural areas, and minimizing permits for new private hospitals in urban areas. The establishment of a private and public dental teaching hospital is an obligation to provide healthcare to people with various socioeconomic backgrounds. This strategy seeks to overcome the problem of inequality in providing oral health services due to the higher population of dentists in urban areas than in rural areas.[45]
WHO’s recommendation regarding a combination of downstream, midstream, and upstream approaches can effectively promote oral health to achieve equity and equality of outcomes across the population.[35–37]