CONCISE REVIEW Barriers to oral health across selected European countries and the USA Richard Manski and John Moeller Dental Public Health, University of Maryland School of Dentistry, Baltimore, MD, USA. In this review we consider oral-health access among older adults within and between the USA and various European coun- tries with regard to possible primary financial and modifiable secondary non-financial factors. For older adults, the likeli- hood of using dental services has been associated, in the health literature, with a multiplicity of factors. These factors are traditionally classified into predisposing, enabling and need categories, and can be further classified into modifiable and non-modifiable subcategories. This raises the question of which single factor or group of factors has the most influence in keeping older adults from seeking care, and how these influences might differ between the USA and various other (Euro- pean) countries. As it turns out, there is variation in the magnitude of effects across certain measurable potential barriers, but generally it takes a combination of characteristics associated with non-use to have a substantial impact. Key words: Dental insurance coverage, elderly populations, inequalities, USA, Europe INTRODUCTION In this paper we provide a concise review of the litera- ture on barriers to oral health for older adults across selected European countries and the USA. In the health economics literature, the likelihood of older adults using dental services has been associated with a multiplicity of factors. We include possible primary financial and modifiable secondary non-financial fac- tors that may impede access to dental care for an older population. These factors are traditionally clas- sified into predisposing, enabling and need categories, and can be further classified into modifiable and non- modifiable subcategories 1,2 . For example, age and sex are considered as non-modifiable predisposing factors, whereas dental anxiety is a potentially modifiable pre- disposing correlate of dental use. We begin our review by first examining modifiable financial barriers to oral health care. FINANCIAL FACTORS ‘Dental tourism could save you big money’ was the headline of a story in the travel section of a national news network just a few years back 3 . Noting that somewhat less than half of Americans had dental insurance and a report by Senator Sanders on the ‘Dental Crisis in America’, this story estimated that about 400,000 Americans travelled beyond the US border to receive less expensive dental care 3 . Dental tourism is not unique to the USA; according to Inter- national Medical Travel Journal, cost savings is the primary driver for UK citizens to seek dental care abroad, noting that a filling ranged in cost from €8 in Hungary to €156 in England 4 . There is no doubt that cost is a significant factor in patients’ decision to seek dental care 5–8 . Dating back to 1986, Bomberg and Ernst 5 reported that paying for dental care can be dif- ficult, and among the reasons given for not going to the dentist were out-of-pocket costs. Other studies showed that patients often feel that dental care is too expensive and therefore choose to delay seeking care, suggesting that cost does influence the decision to seek dental care in the long term as well as in the short term 6–8 . It is therefore not surprising that both wealth and income have a strong and independent positive effect on dental-care use among the elderly 9 . Simi- larly, it is not surprising that having dental insurance coverage, which lowers the out-of-pocket cost of care, also increases the likelihood of dental-care use 10,11 . © 2017 FDI World Dental Federation 133 International Dental Journal 2017; 67: 133–138 doi: 10.1111/idj.12283