Racial/Ethnic Disparity in Utilization of General Dental Care Services Among US Adults: Medical Expenditure Panel Survey 2012

Oral health inequities over time among older adults of different racial/ethnic backgrounds: a comparative decomposition analysis across Australia and the United States

BACKGROUND

Although the prevalence of poor oral health among older populations in Australia and the United States is higher, the contribution of ethnicity status is unknown. We aimed to estimate the contribution of social inequalities in oral health among older populations in Australia and the United States.

METHODS

Cross-sectional study design using data from Australia's National Survey of Adult Oral Health (NSAOH 2004-06 and 2017-18) and the United States' National Health and Nutrition Examination Survey (NHANES 2003-04 and 2011-16). Participants included in the analysis were aged 65 + years. Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographic (age, sex), socioeconomic position (educational attainment, household income) and dental behaviors (last dental visit) to changes in prevalence of edentulism and non-functional dentition, and mean number of missing teeth by ethnicity status over time in Australia and the United States.

RESULTS

The number of participants aged 65 + years who provided clinical and sociodemographic/dental behaviour data was 1043 and 1269 in NSAOH 2004-06 and 2017-18, and 1372 and 1328 in NHANES 2003-04 and 2011-16 respectively. The prevalence of edentulism was from 13 percent (NHANES 2011-16) to 28 percent (NSAOH 2004-06), while the prevalence of non-functional dentition was from 41 percent (NSAOH 2017-18 and NHANES 2011-16) to 61 percent (NHANES 2003-04). The mean number of missing teeth was from 11 (NSAOH 2017-18) to 18 (NHANES 2003-04). The prevalence of edentulism and non-functional dentition, and the mean number of missing teeth were higher among older Australians identifying as White and the opposite results were observed among older Americans identifying as Non-White. For older adults in Australia, risk factors with the greatest impact on oral health outcomes by ethnicity status were educational attainment and household income. For older adults in the United States, the most dominant risk factor for non-optimal oral health outcomes by ethnicity status was last dental visit.

CONCLUSIONS

There are important policy translation implications from our findings, as they indicate that social and structural systems in Australia and the United States operate differently in the context of oral health over time among culturally diverse older citizens. This information will help inform initiatives that both target effective oral health promotion for older, culturally-diverse populations and provide evidence for the distribution of resources in the public dental health setting for this age group and cultural demographic.

Health-based homophily in public housing developments

Public housing residents in the United States face disproportionately high risks for disease, presenting an urgent need for interventions. Evidence suggests interventions leveraging social networks can be successful when relationships are homophilous, as this leads to pooling of risk behaviors among interconnected alters. Yet, we know little about networks of public housing residents. To assess the feasibility of network-based interventions, we investigate the incidence of health-based homophily in public housing developments in Boston, Massachusetts. Employing multilevel models (HLM), we find that respondents report their own health characteristics to be similar to their network partners on oral health, weight, and consumption of sugar-sweetened beverages and foods. We discuss the implications of our findings for health-based interventions in low-income communities.

Predictors of Unmet Dental Health Needs in US Adults in 2018: A Cross-Sectional Analysis

OBJECTIVE

To identify predictors of unmet dental needs for adults 18 y of age or older in the United States.

METHOD

Using the Aday and Andersen framework and data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), we ran logistic regression to estimate predictors for adults of not having a dental visit within 5 y and having lost any teeth using a national sample of 155,060 survey respondents.

RESULTS

Results showed that predisposing factors (age, race/ethnicity, gender, and educational attainment) and enabling factors (income and health insurance status) are important predictors for losing teeth due to decay or gum disease. Men, the elderly, and less educated and low-income residents were less likely to have seen a dentist within the past 5 y and more likely to have lost their permanent teeth. Compared to non-Hispanic White adults, Hispanics adults were more likely to have had a dental visit within the past 5 y. Unmet dental needs varied across states. People living in states with extensive Medicaid dental care benefit coverage were less likely to lose their teeth and more likely to have had a dental visit within the past 5 y.

CONCLUSION

Efforts to improve oral health should address unmet dental needs of men and adults with low socioeconomic status. Studying the variation between state oral health care programs could further our understanding of how public policy can improve population oral health.

KNOWLEDGE TRANSFER STATEMENT

Men, non-Hispanic Blacks, mixed and other race minorities, and low socioeconomic status adults are most at risk of unmet dental needs. States can address these needs by expanding Medicaid coverage for adults.

Use of oral health care services in the United States: unequal, inequitable-a cross-sectional study

Background

Social determinants drive disparities in dental visiting. Disparities can be measured simply by comparing outcomes between groups (inequality) but can also consider concepts of social justice or fairness (inequity). This study aimed to assess differences in dental visiting in the United States in terms of both social inequality and inequity.

Methods

Data were obtained from a cross-sectional study—the National Health and Nutrition Examination Survey (NHANES) 2015–2016, and participants were US adults aged 30+ years. The outcome of interest, use of oral health care services, was measured in terms of dental visiting in the past 12 months. Disparity was operationalized through education and income. Other characteristics included age, gender, race/ethnicity, main language, country of birth, citizenship and oral health status. To characterize existing inequality in dental service use, we examined bivariate relationships using indices of inequality: the absolute and relative concentration index (ACI and RCI), the slope index of inequality (SII) and relative index of inequality (RII) and through concentration curves (CC). Indirect standardization with a non-linear model was used to measure inequity.

Results

A total of 4745 US adults were included. Bivariate analysis showed a gradient by both education and income in dental visiting, with a higher proportion (> 60%) of those with lower educational attainment /lower income having not visited a dentist. The concentration curves showed pro-higher education and income inequality. All measures of absolute and relative indices were negative, indicating that from lower to higher socioeconomic position (education and income), the prevalence of no dental visiting decreased: ACI and RCI estimates were approximately 8% and 20%, while SII and RII estimates were 50% and 30%. After need-standardization, the group with the highest educational level had nearly 2.5 times- and the highest income had near three times less probability of not having a dental visit in the past 12 months than those with the lowest education and income, respectively.

Conclusion

The findings indicate that use of oral health care is threatened by existing social inequalities and inequities, disproportionately burdening disadvantaged populations. Efforts to reduce both oral health inequalities and inequities must start with action in the social, economic and policy spheres.

2020 trends in dental office visits during the COVID-19 pandemic

BACKGROUND

COVID-19 has created barriers to the delivery of health care services, including dental care. This study sought to quantify the change in dental visits in 2020 compared with 2019.

METHODS

This retrospective, observational study examined the percentage change in weekly visits to dental offices by state (inclusive of the District of Columbia), nationally, and by county-level COVID-19 incidence using geographic information from the mobile applications of 45 million smartphones during 2019 and 2020.

RESULTS

From March through August 2020, weekly visits to dental offices were 33% lower, on average, than in 2019. Weekly visits were 34% lower, on average, in counties with the highest COVID-19 rates. The greatest decline was observed during the week of April 12, 2020, when there were 66% fewer weekly visits to dental offices. The 5 states (inclusive of the District of Columbia) with the greatest declines in weekly visits from 2019 through 2020, ranging from declines of 38% through 53%, were California, Connecticut, District of Columbia, Massachusetts, and New Jersey.

CONCLUSIONS

Weekly visits to US dental offices declined drastically during the early phases of the COVID-19 pandemic. Although rates of weekly visits rebounded substantially by June 2020, rates remain about 20% lower than the prior year as of August 2020. These findings highlight the economic challenges faced by dentists owing to the pandemic.

PRACTICAL IMPLICATIONS

States exhibited widespread variation in rates of declining visits during the pandemic, suggesting that dental practices may need to consider different approaches to reopening and encouraging patients to return depending on location.

Medicaid healthy behavior incentives and use of dental services

OBJECTIVE

To examine changes in access to dental care in states using Section 1115 waivers to implement healthy behavior incentive (HBI) programs in their Medicaid expansion under the ACA, compared to traditional expansion states and nonexpansion states.

DATA SOURCES

Behavioral Risk Factor Surveillance System from 2008 to 2018.

STUDY DESIGN

We used difference-in-differences analysis to compare changes in three Medicaid expansion states with HBI (Iowa, Indiana, Michigan) to traditional expansion (Minnesota, North Dakota, Ohio) and nonexpansion states (Nebraska, South Dakota, Wyoming) in the same mid-Western region of the country. The sample included 32 556 low-income adults.

DATA COLLECTION/EXTRACTION METHODS

NA.

PRINCIPAL FINDINGS

We found no significant changes in dental visits associated with HBI or traditional expansion relative to nonexpansion states. HBI expansion was associated with an increase of 2.2 percentage points in reporting a dental visit in the past year for adults in urban areas (P < 0.05) while the traditional expansion was associated with a reduction of 8.5 percentage points (P < 0.01) in utilization in rural areas relative to nonexpansion states. However, after adjustment for preexisting trends, the coefficients were no longer significant, suggesting that these differences are likely due to preexisting trends.

CONCLUSIONS

We did not find evidence of increased utilization of routine dental care associated with HBI programs.

Disparities in Dental Service Use among Adult Populations in the United States

OBJECTIVES

This article aims to examine the disparities in dental service utilization among 3 age groups: younger adults (20-49 y), middle-aged adults (50-64 y), and older adults (65+ y), among Whites, Hispanics, Blacks, Asians, American Indians or Alaska Natives (AIAN), and Native Hawaiian or other Pacific Islanders (NHOPI).

METHODS

Weighted logistic regression models were conducted to analyze 9 waves of cross-sectional survey data (2002-2018) from the Behavioral Risk Factor Surveillance System. We estimated age group- and race/ethnic-specific prevalences of dental service utilization adjusting sociodemographics and self-rated health for each wave and compared with crude analysis. Next, we performed linear regression analysis of the trend of adjusted prevalences over time and the average level by race/ethnicity and age groups.

RESULTS

Racial/ethnic disparities increased with age, even though the adjusted prevalences of dental service utilization were less apparent than the crude analysis. The all-wave average prevalence was 71%. Black older adults had the lowest level of dental service utilization (65%) as compared with the 2 highest groups: White older adults (79%) and Asian older adults (76%). The general younger adult populations had low prevalences, with the lowest among Asian younger adults (65%). AIAN and NHOPI individuals from all age groups tended to have average or below average prevalences. In addition, a decreasing trend of dental service utilization was observed among White individuals of all age groups (0.2%-0.3% lower per year, P < 0.01) and AIAN younger adults (0.5% lower per year, P < 0.01).

CONCLUSION

Health policy, federal funding, and community-based programs should address the needs of dental service utilization for racial/ethnic minorities including Blacks, AIANs, and NHOPIs.

KNOWLEDGE TRANSFER STATEMENT

Our study offers insights into our understanding of disparities in dental service utilization among minority racial/ethnic groups. As health policy, federal funding, and community-based programs seek to improve oral health, there is a need to address access to and utilization of dental service for Blacks, American Indians or Alaska Natives, and Native Hawaiian or other Pacific Islanders.

Prevalence and Patterns of Dental Care Utilization among US-Born and Non-US Born Hispanics in the Hispanic Community Health Study/Study of Latinos

OBJECTIVES

Access to routine dental services is important to maintaining good oral health. The aims of this study were to describe the dental care utilization patterns of a diverse group of Hispanic/Latino men and women and assess differences in dental care utilization by perceived need for dental care and proxy measures of acculturation.

METHODS

Data from 13,792 participants of the Hispanic Community Health Study were analyzed with SAS 9.4. Time since last dental visit was dichotomized into <1 and ≥1 y. Acculturation measures included the language and social subscales of the Short Acculturation Scale for Hispanics, the Multiethnic Study of Atherosclerosis nativity subscore, and immigrant generation. Survey logistic regression adjusted for demographic (age and sex) and health-related variables, estimated associations among perceived need for dental care, acculturation measures, and dental care utilization.

RESULTS

About a quarter (23%) of the participants were born in the 50 US states, excluding territories, while 77% were non-US born. Overall, 74% perceived a need for dental care. Upon covariate adjustment, perceiving a need for dental care was associated with reduced odds of reporting a past-year dental visit (odds ratio, 0.32; 95% CI, 0.28 to 0.37), while there appeared to be no meaningful association between proxy measures of acculturation and past-year dental visit. Having health insurance was significantly associated with a past-year dental visit (odds ratio, 2.23; 95% CI, 1.99 to 2.49) for all groups combined and among the different Hispanic/Latino background groups.

CONCLUSIONS

Acculturation affects general health and contributes to general health disparities; however, its role in dental care utilization remains questionable. Given that acculturation is a process that occurs over several years, longitudinal studies that evaluate oral health trajectories along the acculturation continuum are needed.

KNOWLEDGE TRANSFER STATEMENT

The results of this study are valuable for dental public health program planning and implementation for minority groups, as it describes the varying patterns of dental care utilization among US-born and non-US born Hispanics/Latinos and identifies factors that may partly explain dental care utilization patterns, such as acculturation.

Characteristics of US Adults Delaying Dental Care Due to the COVID-19 Pandemic

Background:

Coronavirus disease 2019 (COVID-19) has disrupted the delivery of health care services, including dental care. The objective of this study was to quantify and describe US adults who delayed dental care due to the COVID-19 pandemic.

Methods:

We analyzed cross-sectional responses collected from a nationally representative and long-running panel survey of US adults conducted in late May and early June 2020 (response rate = 70%). The survey included questions about dental care delayed due to the COVID-19 pandemic, purpose of the delayed dental visits, timing of future dental visits, and demographic information. Pearson’s chi-square tests were used to determine if rates of delayed dental care varied by subgroup. A multivariable regression model, adjusted for age, race, Hispanic ethnicity, census division, and rurality, was estimated to predict the odds of reporting delayed dental care.

Results:

Nearly half of respondents (46.7%) reported delaying going to the dentist or receiving dental care due to the COVID-19 pandemic. Among adults who reported delaying dental care due to the pandemic, 74.7% reported delaying a checkup, 12.4% reported delaying care to address something that was bothering them, and 10.5% reported delaying care to get planned treatment. About 44.4% of adults reported that they planned to visit the dentist within the next 3 mo. In the multivariable regression model, only living in an urban (vs. rural) area was associated with significantly higher odds of delayed dental care due to the pandemic (odds ratio: 1.5; 95% confidence interval: 1.1, 2.1).

Conclusions:

Nearly half of US adults reported delaying dental care due to the COVID-19 pandemic during the spring of 2020. Our results offer insight into the experiences of patients seeking dental care this spring and the economic challenges faced by dental providers due to the pandemic.

Knowledge Transfer Statement:

This article describes US adults who delayed dental care due to the COVID-19 pandemic. Results can be used by clinicians and policymakers to understand delayed care during the pandemic.

Trends in use of dental care provider types and services in the United States in 2000-2016: Rural-urban comparisons

BACKGROUND

The authors conducted a study to assess recent trends in dental care provider mix (type of dental professionals visited) and service mix (types of dental procedures) use in the United States and to assess rural-urban disparities.

METHODS

Data were from the 2000 through 2016 Medical Expenditure Panel Survey. The sample was limited to respondents who reported at least 1 dental visit to a dental professional in the survey year (N = 138,734 adults ≥ 18 years). The authors estimated rates of visiting 3 dental professionals and undergoing 5 dental procedures and assessed the time trends by rural-urban residence and variation within rural areas. Multiple logistic regression was used to assess the association between rural and urban residence and service and provider mix.

RESULTS

A decreasing trend was observed in visiting a general dentist, and an increasing trend was observed in visiting a dental hygienist for both urban and rural residents (trend P values < .001). An increasing trend in having preventive procedures and a decreasing trend in having restorative and oral surgery procedures were observed only for urban residents (trend P values < .001). The combined data for 2000 through 2016 showed that rural residents were less likely to receive diagnostic services (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.72 to 0.93) and preventive services (AOR, 0.87; 95% CI, 0.78 to 0.96), and more likely to receive restorative (AOR, 1.11; 95% CI, 1.02 to 1.21) and oral surgery services (AOR, 1.23; 95% CI, 1.11 to 1.37).

CONCLUSIONS

Although preventive dental services increased while surgical procedures decreased from 2000 through 2016 in the United States, significant oral health care disparities were found between rural and urban residents.

PRACTICAL IMPLICATIONS

These results of this study may help inform future initiatives to improve oral health in underserved communities. By understanding the types of providers visited and dental services received, US dentists will be better positioned to meet their patients' oral health needs.

Health Care Disparities in Race-Ethnic Minority Communities and Populations: Does the Availability of Health Care Providers Play a Role?

OBJECTIVES

To examine disparities in use and access to different health care providers by community and individual race-ethnicity and to test provider supply as a potential mediator.

DATA SOURCES

National secondary data from 2014 Medical Expenditure Panel Survey, 5-year estimates (2010-2014) from American Community Survey, and 2014 InfoUSA.

STUDY DESIGN

Multiple logistic regression models examined the association of community and individual race-ethnicity with reported health care visits and access. Mediation analyses tested the role of provider supply.

DATA EXTRACTION METHODS

Individual-level survey data were linked to race-ethnic composition and health business counts of the respondent's primary care service area (PCSA).

PRINCIPAL FINDINGS

Minority PCSAs are significantly and independently associated with lower odds of having a visit to a physician assistant/nurse practitioner, dentist, or other health professionals and having a usual care provider (all p < 0.05). Few significant associations were observed for integrated PCSAs or for health provider supply. A modest mediation effect for provider supply was observed for travel time to usual care provider and visit to other health professionals.

CONCLUSIONS

Use of a range of health services is lower in minority communities and individuals. However, provider supply was not an important explanatory factor of these disparities.

Racial/Ethnic Disparities in Dental Service Utilization for Foreign-Born and U.S.-Born Middle-Aged and Older Adults

This study examines racial/ethnic disparities of dental service utilization for foreign-born and U.S.-born dentate residents aged 50 years and older. Generalized linear mixed-effects models (GLMM) were used to perform longitudinal analyses of five-wave data of dental service utilization from the Health and Retirement Study (HRS). We used stratified analyses for the foreign-born and U.S.-born and assessed the nonlinear trend in rates of dental service utilization for different racial/ethnic groups. Findings indicate that Whites had higher rates of service utilization than Blacks and Hispanics regardless of birthplace. For all groups, the rates of service utilization decreased around age 80, and the rates of decline for Whites were slower than others. The U.S.-born showed the trend of higher rates of service utilization than the foreign-born for all racial/ethnic groups. These findings suggest the importance of developing culturally competent programs to meet the dental needs of the increasingly diverse populations in the United States.

Factors associated with future dental care utilization among low-income smokers overdue for dental visits

BACKGROUND

Smokers are at increased risk of oral disease. While routine dental care can help prevent and treat oral health problems, smokers have far lower rates of dental care utilization compared with non-smokers. We sought to better understand which factors may facilitate or hinder dental care utilization among low-income smokers participating in a randomized intervention trial in order to inform future intervention planning.

METHODS

This is a secondary analysis of data collected between 2015 and 2017 as part of the OralHealth4Life trial. Participants were eligible callers to the Louisiana, Nebraska, and Oregon state tobacco quitlines who had no dental appointment in the prior or upcoming six months. We examined the association between participants' baseline characteristics and their receiving professional dental care between baseline and the 6-month follow-up survey.

RESULTS

Participants were racially diverse (42% non-White) and two-thirds had an annual household income under $20,000. Most (86.7%) had not had a dental cleaning in more than one year. Commonly cited barriers to dental care included cost (83.7%) and no dental insurance (78.1%). Those with dental insurance were more likely to see a dentist at follow-up (RR 1.66). Similarly, those reporting a dental insurance barrier to care were less likely to see a dentist at follow-up (RR 0.69); however, there was no significant utilization difference between those reporting a cost barrier vs. those who did not. After controlling for these financial factors, the following baseline characteristics were significantly associated with a higher likelihood of dental care utilization at 6 months: higher motivation (RR 2.16) and self-efficacy (RR 1.80) to visit the dentist, having a disability (RR 1.63), having a higher education level (RR 1.52), and having perceived gum disease (RR 1.49). Factors significantly associated with a lower likelihood of dental care utilization included being married (RR 0.68) and not having a last dental cleaning within the past year (RR 0.47).

CONCLUSIONS

Our findings provide important insight into factors that may facilitate or deter use of professional dental care among low-income smokers. This information could inform the development of future interventions to promote dental care utilization.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02347124 ; registered 27 January 2015.