Barriers and facilitators in utilisation of dental health services across low- and middle-income countries: a scoping review

Study selection

Our initial search yielded a total of 15,140 citations (MEDLINE/PubMed = 5192; Scopus = 3193; Web of Science = 1581; Embase = 5100; Grey literature = 74). After removing duplicates (n = 8175), the title and abstract of the remaining (n = 6965) articles were screened using Rayyan software. Full-text review of 302 articles was performed, and 88 articles were excluded for reasons such as high-income country populations, provider-only perspectives, or lack of access determinants. Finally, 214 articles met the inclusion criteria and were incorporated into this scoping review (Supplementary Table S2). Figure 1 provides a summary of the selection process following PRISMA guidelines.

PRISMA 2020 flowchart for study selection process.

Study characteristics

Data from 214 studies conducted in 34 LMICs was included in this review. One of the study was a multi-country study which reported data from 1 UMI and 4 LMI countries, resulting in 218 country-level entries⁴. Based on these entries, 106 were from UMI countries, 104 from LMI countries, and only eight from LI countries. India accounted for the highest number of studies, followed by Brazil, Iran, and Nigeria (Table 1). Progressive increase in the number of studies from 2001 onwards was observed, with the peak annual output recorded in 2024 (n = 30) (Fig. 2). The cumulative sample comprised 701,090 participants, comprising 221,071 males and 229,236 females, with the remainder not mentioning gender-wise distribution. The age groups spread from infants to 103 years. Most studies focused on general adult populations, followed by children and older adults. Special population groups included pregnant women, children with special healthcare needs, individuals with disabilities, HIV-positive and transgender populations, with older adult and disability studies concentrated in UMI countries (Table 1).

Temporal distribution of studies.

Majority of study followed cross-sectional design (n = 177), the rest were case-control (n = 5), qualitative (n = 24), mixed-method (n = 7), and only one was longitudinal²⁰. Most studies were conducted in a community-based setting (n = 99), including 15 nationwide surveys, followed by public health or dental care centres (n = 69), schools or universities (n = 34), and a smaller number from private facilities (n = 3) and special care homes (n = 9). Data analyses commonly involved descriptive statistics (n = 111), regression (n = 75), and thematic or content analysis (n = 28). Few studies explicitly applied theoretical models to assess the barriers and facilitators, most commonly Anderson’s behavioural model (n = 53), followed by Penchansky & Thomas’ Five-As Access Model (n = 4), Jean-Frederic Levesque’s access model, Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) framework, and Bradshaw’s model of health needs^21,22,23 (Supplementary Table S2).

Pattern of dental services utilisation

Overall average prevalence of dental services utilisation, encompassing both regular and occasional dental care visits, was 30.35% while 47.09% participants had never utilised dental care in their lifetime. Utilisation rates varied slightly across income groups, with the highest rates reported in lower-middle-income countries (31.15%), followed by upper-middle-income (27.12%) and low-income countries (24.08%). The most common reason for seeking dental care, reported in 60 studies, was emergency-care situations, such as pain or swelling. This was followed by curative services (n = 57), including dental treatment procedures like extractions, restorations, periodontal or orthodontic interventions, and aesthetic care. Routine dental check-ups (n = 7) and preventive services (n = 5) were infrequently cited as reasons for utilisation. Public health centres emerged as the preferred point of care in most studies (n = 57), although a notable number reported a preference for private facilities (n = 27) (Supplementary Table S2).

TDF domain analysis

Across 11 TDF domains, “environmental context and resources” (n = 452, 41.5%; barriers: n = 301, 48.9%; facilitators: n = 151, 31.9%) was most prominent, followed by “beliefs about consequences” (n = 251, 23.1%; barriers: n = 118, 19.1%; facilitators: n = 133, 28.1%) and “knowledge” (n = 144,13.2%; barriers: n = 75, 52%; facilitators: n = 69, 47.9%). “emotion” (n = 55, 5%) comprised barriers only, while facilitators were more common in “social influences”, “reinforcement”, “behavioural regulation”, and “belief about capabilities”. Figures 3 and 4 illustrate the key barriers and facilitators observed across the domains, with the overall distribution and further stratification by income level and population group in Supplementary Figs. S1–S3.

Barriers to dental service access in LMICs aligned with the TDF domains. *ECAR Environmental context and resources.

Facilitators to dental service access in LMICs aligned with the TDF domains. *ECAR Environmental context and resources.

In UMI countries, barriers were dominated by “environmental context and resources”. Older adults faced physical limitations, low perceived need, and cultural norms, while pregnant women reported safety fears of dental procedures during pregnancy, and the absence of childcare support systems or creches. Persons with disabilities encountered inaccessible infrastructure and inadequate provider training, and those with inherited bleeding disorders expressed distrust in non-specialised providers. Facilitators were more prominent within the “environmental context and resources” domain, including urban residence and higher socioeconomic status (SES). School-based programs and access to paediatric specialists were facilitators for children, while for older adults, insurance schemes, proximity to health centres, and prosthetic needs such as dentures were enablers. For pregnant women, previous pregnancy experience and symptom-driven care-seeking encouraged service uptake. Children with special healthcare needs and persons with disabilities preferred integrated hospital care and communication-friendly professionals. Other groups, such as sex workers, often sought dental services for aesthetic reasons or infection control. Facilitators under the “knowledge” domain, such as education campaigns and media exposure, were more frequently observed in UMI countries, and the “skills” domain, referring to provider competencies, was also more prominent in these countries.

In LMI and LI countries, barriers were more widespread, dominated by structural issues such as high costs, low SES, lack of insurance, geographic inaccessibility, transport difficulties, and low perceived need. Social identity barriers such as male gender, minority status were also frequently documented. For children and adolescents, low household income, lack of transport, poor referral follow-up, and parental beliefs, combined with low education levels, restricted utilisation. Most studies on transgender individuals and people living with HIV emerged from LMI countries, and stigma and discrimination created significant barriers in this group, while inclusive facilities for the transgender community and symptom-based care seeking for HIV- positive people were important facilitators. Among rural populations, proximity to clinics and pain-driven care-seeking were key facilitators. The “Beliefs about consequences” domain was especially prominent in LMI countries, reflecting diverse oral health beliefs and behaviour. Poor awareness under the “knowledge domain” was common in LMI/LI countries, although some community-based education initiatives served as facilitators. Barriers related to “emotional” and “social influences” were also more evident, with cultural norms and family or peer influence shaping behaviour. Facilitators associated with the “reinforcement” and “beliefs about capabilities” domains emerged through community-based programs and increased confidence in accessing care. In LI countries, patterns closely resembled those of LMI countries, with no notable differences observed.