According to the World Health Organization (WHO), oral health refers to the condition of the mouth, teeth, and orofacial structures, which enables individuals to carry out fundamental activities such as eating, breathing, and speaking. It also encompasses psychosocial aspects, including self-assurance, overall well-being, and the capability to interact socially and perform professional duties free from pain, discomfort, and embarrassment. Oral health undergoes transformations throughout one’s lifespan and is an inseparable component of general health (1). Oral diseases impact approximately 45% or 3.5 billion individuals worldwide, underscoring the fact that almost half of the global population is affected (2). Over the past three decades, the global number of cases has surged by 1 billion, which serves as a clear indication that numerous individuals lack access to sufficient oral healthcare services. Inequalities in oral health are defined as preventable disparities in oral health status that are deemed unfair and unacceptable (3). When addressing socioeconomic disparities in the utilization of dental healthcare, research has revealed that individuals from socioeconomically vulnerable backgrounds possess a greater need for dental services. Paradoxically, they tend to underutilize these services, thereby further exacerbating existing inequalities (4). The accessibility of oral health services exhibits substantial variation, both within countries and across different nations (5). Disparities in dental attendance also persist among various demographic groups (6). High household income, second and middle household wealth status and access to free public health care are significant predictors in the utilization of dental services (7). The odds of non-utilization of dental services were lower for adults living in cities. Sex, skin color, dental treatment needs, poor socioeconomic characteristics, perceived dental treatment needs, and decayed teeth were also associated with non-utilization of dental services (8, 9).

Also, the distribution of oral health services frequently proves inadequate or inaccessible to marginalized or at-risk segments of society. The distribution of dental healthcare providers predominantly favors urban regions, rendering them inaccessible to a significant portion of the population residing in villages and rural areas. Consequently, individuals often incur substantial time and travel expenses when seeking professional oral healthcare services. Therefore, these disparities in oral health status and utilization of dental care services are not inevitable or coincidental. Inequalities arise due to a complex interplay of interconnected factors, many of which are largely beyond the direct influence of individuals. Consequently, investigating these factors becomes invaluable in developing health policy strategies aimed at reducing disparities and inequality in oral health. Within this framework, the aim of this paper is to assess the association of demografic and socioeconomic determinants with utilization of dental services among Serbian adults.

A total of 12,439 people aged 20 years and older were surveyed. The mean age of respondents was 52.8 ± 17.7 years, and women were significantly older than men (t = −6.765, p < 0.001). Most of the respondents were married or living in cohabitation (63.2%) and were from Šumadija and Western Serbia region (32%). 56.4% of respondents had a high school diploma, and women were significantly more likely to have a primary school diploma or lower education compared to men (p < 0.001). The highest percentage of respondents belonged to the poor category (40.4%). Almost two-thirds of respondents (61.4%) were unemployed or inactive. Men were significantly more likely to be employed (42.9%) than women (32.2%) (p < 0.001). The sociodemographic characteristics of respondents by gender and overall are shown in Table 1.

More than two thirds of adults aged reported that they have a chosen dentist (elected doctor) (68.2%). A slightly higher percentage of adults had their chosen dentist in private practice, in relation to the public sector (41.7% versus 26.5%). In terms of the results, it was observed that there is a significant difference in dental healthcare utilization based on gender, with women visiting the dentist more frequently (p < 0.001). The number of adults who visit their chosen dentist (elected doctor) reduces with age (р < 0.001). The greatest number of visits to the dentist in the past year was recorded in the age group of 20–34 years (29.1%), while the lowest number of visits was recorded in the oldest age group of 75+ years (4.2%). Analysis carried out by marital status, indicates that there is a statistically significant difference in the visits to the dentist depending on the marital status of the patients (р < 0.001). The highest percentage of respondents who regularly visit their dentist is in the category of married/common-law (62.0%). Significant differences in visits to a dentist exist in the relation to the regions. So, during the last 12 months, the largest percentage of adults from Shumadia and Western Serbia visited a dentist (34.4%), and the lowest percentage was among the adults from Southern and Eastern Serbia (20.7%). There is a statistically significant difference in the distribution of adults who visit their chosen dentist depending on the level of education (р < 0.001). In the adults with no education or with primary education, 12.1% of visited a dentist in the last 12 months, and this is smaller number of visits compared to adults with the secondary(60.1%) and high level of education (27.8%). At the same time, the majority of adults who have never visited a dentist is in the group of adults with the lowest level of education (61.7%), which is 12 times more than the ones that have the highest level of education (5.1%). The population of adults, which according to the index of wellbeing belong to the category of the poorest, visit their dentist in a smaller percentage (32.1%) compared to adults who belong to the richest category of the population (48.9%) (р < 0.001). Accordingly, the highest percentage of those who have never visited a dentist is among the poorest adults (56.5%), which is 2 times more than among the adults belonging to the richest population group (26.2%). According to the employment status, there is a statistically significant difference in visits to the dentist (р < 0.001). Employed adults usually visit a dentist regularly (50.8%) compared to inactive adults who more often never visit a dentist (59.8%) (Table 2).

A univariate analysis revealed several predictors of non-use of dental health services, including male gender, older age, lower educational attainment, lower socioeconomic status, unemployment, and individuals who were widowed or divorced. Specifically, men were approximately 1.8 times more likely than women to not utilize dental healthcare services (OR = 1.81). The likelihood of not utilizing dental healthcare protection rises with increasing age, reaching its peak within the 65–74 age range (OR = 0.441), after which it declines. Individuals who have experienced marital dissolution due to divorce or the death of a spouse exhibit a higher probability of not utilizing health protection (OR = 1.868). As the level of education and wealth diminishes, the probability of abstaining from health protection increases by 5.8 times among respondents with an elementary school education (OR = 5.852) and 1.7 times among the most economically disadvantaged respondents (OR = 1.745). Regarding inactivity, respondents who are not employed have a 2.6-fold higher likelihood of not utilizing oral health care compared to employed respondents (OR = 2.610). The multivariate model demonstrates that the most significant demographic and socioeconomic factors influencing dental healthcare utilization are male gender, being widowed, having a lower level of education, and experiencing financial difficulties (Table 3).

Many studies show that inequalities in oral health are higher than those in general health, and that the mouth and teeth diseases are more common among the poor (11). Oral health is an important component of the general health of people and inequalities in oral health are most often associated with certain behaviors related to the health, such as smoking, alcohol consumption, unhealthy diet, inadequate hygiene, while they are partly determined by access to healthy food, dental medications and dental services. Many authors believe that the level of usage of dental services in these inequalities have an important role (12), which has been shown in various studies that suggest a connection between socioeconomic factors and the use of dental health care of people around the world. Socioeconomic status was singled out as an important determinant of access to dental health services (13). Less use of dental care is more common in lower socioeconomic status socio-economic groups, primarily because of financial difficulties (14). Also, low socioeconomic status is often associated with a fear of a dental treatment, due to the lack of information. Unemployment is recognized as the one of the important factors that correlate with no usage of the dental care system (13).

The study of socio-demographic factors associated with barriers to accessibility, availability and acceptability of health care usage, identifies female gender as a significant predictor of disparities in the usage of health care that arise from the dual role of women and their responsibilities at the workplace and at home (15). The higher education level contributes to a clearer perception of the problems of oral health. The data show that people with higher levels of education and higher incomes are more likely to use preventive dental health services and have less dental diseases than osobe with low education and low income (16), which is also shown by the results our research. Among the population of rural areas there is a greater presence of caries, missing teeth and filled teeth compared to urban areas. The higher prevalence of oral diseases in adult who come from rural areas is the result of differences in the usage of dental services, oral hygiene habits, different socioeconomic status, health insurance and the abilities of the usage rate of dental services (17). The low level of education, rural environments, improper fear of the dentist and a dental treatment, low income levels and lack of the knowledge on proper techniques and equipment for maintaining oral hygiene are associated with a reduced degree of awareness on the importance of oral health, inadequate maintenance of oral hygiene, infrequent visits to the dentist and reduced use of dental services in the population (18).

Additionally, previous research has consistently indicated the presence of an inequality that favors the affluent when it comes to accessing oral healthcare. The economically disadvantaged population tends to rely more on public healthcare institutions, whereas those with higher socioeconomic status are inclined to seek services from private facilities. Income-related determinants significantly contribute to the greater utilization of public sector services among the poor, while the wealthier individuals are more likely to utilize private sector services. Consequently, poor oral health often serves as a visible manifestation of social disparities (19).Discrepancies in the provision of oral health care indicate inequitable access, resulting in certain groups being at a disadvantage regarding their oral health. Consequently, addressing these disparities entails ensuring that socially disadvantaged groups have equal opportunities to attain and maintain oral health. The pursuit of fairness in oral health care entails endeavors to eliminate inequalities in the provision of oral health services. This includes equal access to available care based on individual needs, equitable utilization of services based on needs, and the provision of equal quality of care for all individuals. Despite the long-standing recognition of the imperative to address disparities in oral health (20), there remains insufficient public attention given to the crucial role of access to high-quality oral health care for low-income individuals, the uninsured, ethnic minorities, immigrants, and rural populations (21, 22). It is necessary to delve more extensively into disparities across all aspects of oral health care, including resource allocation for oral health protection, utilization of oral health services, quality of oral health care services, oral health care workforce, and financing of oral health care, particularly in terms of the financial burden placed on individuals and households (23–27).

Interventions that target various levels of influence are pivotal and can yield superior efficacy compared to those exclusively focused on a single level (28). Enhancing access to oral health care can be achieved through the promotion of supportive networks within families, friends, and the broader social circle, as well as fostering effective collaboration among healthcare providers. Additionally, raising awareness about the significance of oral health and healthcare is essential for shaping public health policies within the community (14).

A comprehensive approach to promoting oral health is crucial, encompassing all stages of life and emphasizing the adoption of appropriate oral health behaviors. This approach should consider both population-level and individual-level interventions that align with the social and cultural determinants of oral health (29).

The integration of universal strategies aimed at the entire population with targeted interventions tailored to high-risk groups is expected to substantially enhance ongoing endeavors to achieve equity in oral health care. Such programs hold significant promise for advancing equitable access and improving oral health outcomes. Interventions aimed at diminishing disparities in oral health care should go beyond the current efforts and focus on strengthening the linkages between healthcare systems and the communities they serve, particularly at the policy and community level. It is crucial to enhance collaboration, communication, and engagement between healthcare providers, policymakers, and the local community to effectively address and bridge gaps in oral health access and outcomes (30).

The results suggest that individual sociodemographic factors influence utilization of dental services by Serbian adults. Adults men, from lower education, divorced, inactive, from low socioeconomic background reported not utilization oral health care. This study confirmed the existence of socioeconomic disparities in the utilization of dental services among adults in Serbia. The implementation of educational programs and preventive measures, would contribute to raising awareness about the importance of oral health and increased use of dental services. Actions toward health inequalities need to address socioeconomic factors.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Institute of Public Health of Serbia “Dr. Milan Jovanović Batut”. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

SC, KJ, and ISV design and writing manuscript. OM, SR, JR, and VS conducted the statistical analyses, commented on the manuscript and contributed to the background, and discussion section. JDj, DS, and ZS contributed to investigation. GDj, ODj, MDj, and VM critical revision and approval of the final draft. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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