Dentist supply and children's oral health in the United States

Characteristics of Self-Rated Oral Health among Syrian Refugee Parents in Ontario

Background

Canada has been hosting Syrian refugees since early 2015. Almost half of the Syrian refugee population lives in Ontario, with dental health being at the top of the list of important immediate needs. The objective of the study was to evaluate self-rated oral health and its associated factors among Syrian refugee parents residing in Ontario.

Methods

This was a cross-sectional study where 540 Syrian refugee parents, residing in Ontario and with at least one child less than 18 years of age, were interviewed. Information about self-rated oral health was collected based on the question "In general, how would you rate the health of your teeth and mouth?" with answers ranging from 1 representing "excellent" and 5 representing "very poor." Multiple linear regression analysis was performed to assess the independent relationship between each of the sociodemographic-, migration-, health-, dental-related factors, and self-rated oral health.

Results

The overall prevalence of poor and very poor self-rated oral health was 43.5%. The results showed that the presence of dental health insurance, private sponsorship, improved physical and mental health, and regular visits to the dentist were factors related to improved oral health. Discussion. To achieve better oral health outcomes among refugee populations, including Syrian refugees, efforts should be focused on improving dental care and dental insurance for vulnerable populations.

Access to restorative oral health care for children living in Illinois with Medicaid vs private dental insurance: An audit study

BACKGROUND

Public dental insurance programs for children aim to provide access to care, but barriers remain that preclude care delivery. Understanding these barriers is an important health policy concern.

METHODS

A telephone audit sought to ascertain availability of oral health care for children in dental offices eligible to bill Medicaid. Female callers posing as mothers called eligible offices requesting appointments. In this cross-over design, offices were randomized to public or private insurance for initial calls and then to the other condition after a washout period.

RESULTS

Using mixed models, privately insured patients had 5.9 times (95% CI, 4.55 to 7.69) greater odds of obtaining an appointment than Medicaid patients. Compared with patients in Cook County, suburban patients had slightly better odds, whereas nonurban patients in larger and smaller rural counties had lower odds of success.

CONCLUSIONS

Medicaid compares poorly with private insurance for providing access to pediatric oral health care. Regardless of insurance conditions, access is poor in less urban environments compared with metropolitan communities.

PRACTICAL IMPLICATIONS

Even Medicaid-enrolled dental practices limit the care they extend to insured children. Providing Medicaid by itself cannot overcome large oral health care access disparities, which are greatest in rural communities.

Cost-effectiveness of Dental Workforce Expansion Through the National Health Service Corps and Its Association With Oral Health Outcomes Among US Children

Importance

Despite considerable efforts to improve oral health for all, large disparities remain among US children. A dental professional shortage is thought to be among the determinants associated with oral health disparities, particularly for those residing in underserved communities.

Objective

To evaluate the cost-effectiveness of expanding the dental workforce through the National Health Service Corps (NHSC) and associations with oral health outcomes among US children.

Design, Setting, and Participants

A cost-effectiveness analysis was conducted to estimate changes in total costs and quality-adjusted life years (QALYs) produced by increasing the NHSC funding for dental practitioners by 5% to 30% during a 10-year period. A microsimulation model of oral health outcomes using a decision analytic framework was constructed based on oral health and dental care utilization data of US children from 0 to 19 years old. Data from the nationally representative National Health and Nutrition Examination Survey (NHANES, 2011-2016) were linked to county-level dentist supply and oral health professional shortage areas (HPSAs) information. Changes in prevalence and cumulative incidence of dental caries were also estimated. Sensitivity analyses were conducted to assess the robustness of results to variation in model input parameters. Data analysis was conducted from August 1, 2021, to November 1, 2022.

Exposures

Expanding dental workforce through the NHSC program.

Main Outcomes and Measures

Changes in total QALYs, costs, and dental caries prevalence and cumulative incidence.

Results

This simulation model informed by NHANES data of 10 780 participants (mean [SD] age, 9.6 [0.1] years; 5326 [48.8%] female; 3337 [weighted percentage, 57.9%] non-Hispanic White individuals) found that when funding for the NHSC program increased by 10%, dental caries prevalence and total number of decayed teeth were estimated to decrease by 0.91 (95% CI, 0.82-1.00) percentage points and by 0.70 (95% CI, 0.62-0.79) million cases, respectively. When funding for the NHSC program increased between 5% and 30%, the estimated decreases in number of decayed teeth ranged from 0.35 (95% CI, 0.27-0.44) to 2.11 (95% CI, 2.03-2.20) million cases, total QALY gains ranged from 75.76 (95% CI, 59.44-92.08) to 450.50 (95% CI, 434.30-466.69) thousand QALYs, and total cost savings ranged from $105.53 (95% CI, $70.14-$140.83) to $508.23 (95% CI, $598.91-$669.22) million among children residing in dental HPSAs from a health care perspective. Benefits of the intervention accrued most substantially among Hispanic children and children in low-income households.

Conclusions and Relevance

This cost-effectiveness analysis using a decision analytic model suggests that expanding the dental workforce through the NHSC program would be associated with cost savings and a reduced risk of dental caries among children living in HPSAs.

Effects of Adult Medicaid Dental Benefits Elimination on Child Dental Care Use

OBJECTIVE

The objective of this study was to examine the effect of adult dental benefit cuts on child dental use in Washington state Medicaid and determine if cuts affect child demographic subgroups differentially.

RESEARCH DESIGN

The study used an interrupted time-series methodology to measure differences in child dental use after adult dental benefit elimination and reinstatement. Monthly data came from Washington state Medicaid enrollee and dental claim files from January 2008 to December 2015.

SUBJECTS

Medicaid-enrolled children with at least one Medicaid-enrolled adult in the same household were the intervention group, and Medicaid-enrolled children without a Medicaid-enrolled adult in the same household were the control group.

MEASURES

The outcome was the monthly proportion of Medicaid-enrolled children with a dental examination per 10,000 Medicaid-enrolled children.

RESULTS

After adult dental benefits elimination, dental examinations among children with Medicaid-enrolled adults in the same household gradually decreased, corresponding to 65 fewer dental examinations per 10,000 children per year (5.4 fewer dental examinations per 10,000 children per month; 95% confidence interval: -7.7, -3.1; P =0.006). Adult dental benefits had no effect on dental examination for children without a Medicaid-enrolled adult in the same household. Dental examinations for children with a Medicaid-enrolled adult in the same household continued to gradually decrease after adult benefits reinstatement. Children younger than age 6 were the most adversely impacted by changes to adult Medicaid dental benefits.

CONCLUSION

Policymakers should consider the spillover effects and ethical considerations of eliminating adult Medicaid dental benefits on children's access to dental care.

Community-Academic Partnership to Improve the Oral Health of Underserved Schoolchildren in Rural North Carolina

BACKGROUND

Dental caries is the most common chronic illness for children. Caries can reduce the quality of life, cause missed classroom hours, and decrease cognition. Strategies to improve children's oral health must be evidence-based, developed, and implemented in consultation with communities.

METHODS

A community-academic partnership was formed between East Carolina University School of Dental Medicine and the Bertie County Public School District to develop and implement a school-based oral health prevention program using the PRECEDE-PROCEED Model.

RESULTS

The PRECEDE component involved social, epidemiological, environmental, educational, ecological, administrative, and policy factors that informed the development of the oral health program. The PROCEED component consisted of implementation and evaluation.

CONCLUSIONS

School-based oral health programs can increase access to care for vulnerable children and improve learning. The application of the PRECEDE-PROCEED model proved to be a valuable method for developing, implementing, and evaluating a school-based oral health program.

Socioeconomic Factors Associated With the Risk and Prevalence of Dental Caries and Dental Treatment Trends in Children: A Cross-Sectional Analysis of National Survey of Children's Health (NSCH) Data, 2016-2019

Introduction In the United States of America, early childhood caries (ECC) is the most common chronic childhood disease of early onset, with dental caries being the most prevalent chronic disease among children aged 6-19 years. Children without an established medical home, from low-income households, and who are uninsured have historically shown to be prone to dental caries and attribute to higher health care costs. Early recognition of these risk factors by a pediatrician helps prevent the development of medical and psychosocial complications in the child. Methods The cross-sectional data of the prevalence of dental caries and dental treatment trends in children and three socioeconomic risk factors, namely establishment of a medical home, household income, and child's health insurance, were accessed from the National Survey of Children's Health (NSCH) for the years 2016-2019. The association of the risk factors with the prevalence of dental caries and with the prevalence of dental treatment were analyzed using two-sample proportion tests and chi-square (χ2) tests for dichotomous categorical variables and non-dichotomous categorical variables, respectively. Standardized residuals were calculated and analyzed as well. Furthermore, the odds ratios were calculated and utilized to quantify the influence of each category on the highly associated category with having teeth decay and not receiving dental treatment under each socioeconomic risk factor. Results The results of this study revealed that the three socioeconomic factors considered have statistically significant associations with tooth decay and dental treatment. The prevalence and associative risk of tooth decay and untreated caries were the highest in the children without a medical home. Additionally, the odds of having tooth decay was >50% higher for the children from the lowest household income category (0-99% federal poverty level [FPL]) compared to those from the high household income categories (200-399% FPL and >400% FPL). Public insurance coverage was associated with the highest prevalence of dental caries and not receiving fluoride treatment. Furthermore, the likelihood of not availing dental treatment is nearly two times or more higher for the uninsured children than children having public insurance, or private insurance, or a combination of both. Conclusion Our study findings reveal that children belonging to certain socioeconomic risk categories are at a higher risk of developing dental caries and not receiving dental treatment. As a consequence, the study implies that increased support and expansion of public health insurance will benefit oral health care for the children. Pediatricians play an integral part in developing a medical home for the child by providing preventative dental care and establishing continued care through dental referrals.

Oral health and caries/gingivitis-associated factors of adolescents aged 12-15 in Shandong province, China: a cross-sectional Oral Health Survey

Background

We aimed to analyse the oral health status of adolescents in Shandong province, including dental caries and gingivitis, and their associated factors.

Methods

Adolescents aged 12–15-years in Shandong province were recruited. Caries and gingival status were assessed following the World Health Organisation diagnostic criteria. Information including the sociodemographic, oral hygiene knowledge, attitudes and practices were collected through the questionnaire. Chi-square test and multivariate logistic regression analysis were used to investigate the oral diseases associated factors.

Results

In total, 3868 students (50.2% males) were enrolled. Of these, 39.9% of the participants experienced caries, and 81.7% and 31.3% had calculus and bleeding gingival, respectively. Multivariate logistic regression analysis revealed that there was an association between dental caries and toothaches, dental visits and sleeping troubles caused by oral problems (P < 0.024). A low-frequency of brushing, high sugar consumption and no flossing were more associated with calculus formation and gingival bleeding (P < 0.008).

Conclusion

Compared to caries, worse gingival condition was more prevalent among adolescents in Shandong province. Brushing behaviour is associated with gingivitis, while dental visits and toothaches are associated with caries. Hence, prevention-oriented dental visits and oral hygiene training are strongly recommended to improve oral health status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01640-x.

A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees

IMPORTANCE

Dental surgery under general anesthesia (DGA) is an ineffective, costly treatment for caries. Interventions to reduce the need for DGA are challenging because children's parents may not seek care until surgery is required. Community water fluoridation (CWF) effectively prevents early childhood caries, but its effectiveness in reducing severe early childhood caries is unknown.

OBJECTIVE

To determine whether access to CWF is associated with the prevalence of DGA.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional analysis of Medicaid claims data from 2011 to 2012. Deidentified data were derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida for children aged 9 years and younger enrolled in either a fee-for-service or managed care plan through their state's Medicaid program. Linear regression models tested for associations between CWF and covariates. Multivariable linear regression models tested for associations between CWF and outcomes. Regression models included clustered SEs at the county level. Data analysis was performed from December 2018 to March 2020.

EXPOSURES

Access to CWF was determined by estimating the proportion of a county's total population that had access to a fluoridated public water system.

MAIN OUTCOMES AND MEASURES

The main outcome was county-level DGA prevalence. Other outcomes were caries-related visit prevalence and patient quality indicators (asthma and diabetes). Covariates included county-level demographic, socioeconomic, and dental practitioner variables.

RESULTS

A total of 436 counties within 5 states per year (872 county-year observations), were included in the analysis. Adjusted analysis revealed that a 10% increase in the proportion of county's population access to CWF was associated with lower caries-related visit prevalence (-0.45 percentage points; 95% CI, -0.59 to -0.31 percentage points; P < .001). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (-0.39 percentage points; 95% CI, -0.67 to -0.12 percentage points; P = .006) but not in adjusted analysis (-0.23 percentage points; 95% CI, -0.49 to 0.02 percentage points; P = .07). Increasing the proportion of county's access to CWF by 10% was not associated with the prevalence of asthma-related exacerbations (-0.02 percentage points; 95% CI, -0.10 to 0.05 percentage points; P = .53) or diabetes-related exacerbations (-0.0003 percentage points; 95% CI, -0.0014 to 0.0009 percentage points; P = .66).

CONCLUSIONS AND RELEVANCE

This study extends our understanding of CWF's benefits for children's oral health. Specifically, these findings suggest that increasing a population's access to CWF's is associated with decreased caries-related visits and may also be associated with use of dental surgical services within high-risk populations.

The Impact of the Affordable Care Act's Dependent Coverage Mandate on Use of Dental Treatments and Preventive Services

BACKGROUND

Oral health problems are the leading chronic conditions among children and younger adults. Lack of dental coverage is thought to be an important barrier to care but little empirical evidence exists on the causal effect of private dental coverage on use of dental services. We explore the relationship between dental coverage and dental services utilization with an analysis of a natural experiment of increasing private dental coverage stemming from the Affordable Care Act's (ACA)-dependent coverage mandate.

OBJECTIVES

To evaluate whether increased private dental insurance due to the spillover effect of the ACA-dependent coverage health insurance mandate affected utilization of dental services among a group of affected young adults.

DATA

2006-2013 Medical Expenditure Panel Surveys.

STUDY DESIGN

We used a difference-in-difference regression approach comparing changes in dental care utilization for 25-year olds affected by the policy to unaffected 27-year olds. We evaluate effects on dental treatments and preventive services RESULTS:: Compared to 27-year olds, 25-year olds were 8 percentage points more likely to have private dental coverage in the 3 years following the mandate. We do not find compelling evidence that young adults increased their use of preventive dental services in response to gaining insurance. We do find a nearly 5 percentage point increase in the likelihood of dental treatments among 25-year olds following the mandate, an effect that appears concentrated among women.

CONCLUSIONS

Increases in private dental coverage due to the ACA's-dependent coverage mandate do not appear to be driving significant changes in overall preventive dental services utilization but there is evidence of an increase in restorative care.

Increased public reimbursement for prophylactic visits with dentists associated with increased receipt of preventive dental services in children

OBJECTIVE

To determine whether higher reimbursement for children's preventive dentistry correlates with greater utilization of preventive dental care.

METHODS

A cross-sectional analysis of National Survey of Children's Health 2011/2012 was conducted, combined with state Medicaid reimbursement rates for preventive dentistry. Analyses included prevalence, unadjusted odds ratios, and multivariable logistic regression for receipt of preventive dental services.

RESULTS

Of all surveyed American children 1-17 years, almost 20 percent had not received preventive dental care in prior year; this percentage is even higher in those with public insurance. Each $10 increase in state reimbursement was associated with a 17 percent decrease in odds of children not receiving preventive services.

CONCLUSIONS

Higher state reimbursement for preventive services may increase children's receipt of preventive dental care.

The Effects of Distance to Dentists and Dentist Supply on Children's Use of Dental Care

OBJECTIVE

To examine the effects of distance to dentists and dentist supply on dental services use among children with Medicaid coverage in Iowa.

DATA SOURCE

Iowa Medicaid claims for enrolled children between 2000 and 2009.

STUDY DESIGN

The study sample included 41,554 children (providing 158,942 child-year observations) who were born in Iowa between 2000 and 2006 and enrolled from birth in the Iowa Medicaid program. Children were followed through 2009. We used logistic regression to simultaneously examine the effects of distance (miles to nearest dentist) and county-level dentist supply on a broad range of dental services controlling for key confounders. Additional models only used within-child variation over time to remove unobservable time-invariant confounders.

PRINCIPAL FINDINGS

Distance was related to lower utilization of comprehensive dental exams (2 percent lower odds per 1 mile increase in distance), an effect that also held in models using within-child variation only. Dentist supply was positively related to comprehensive exams and other preventive services and negatively related to major dental treatments; however, these associations became smaller and insignificant when examining within-child changes except for other preventive services.

CONCLUSIONS

Longer distance to dentists is a barrier for use of comprehensive dental exams, conditional on dentist supply.

Annual Report on Children's Health Care: Dental and Orthodontic Utilization and Expenditures for Children, 2010-2012

OBJECTIVE

To examine general dental and orthodontic utilization and expenditures by health insurance status, public health insurance eligibility, and sociodemographic characteristics among children aged 0 to 17 years using data from 2010-2012.

METHODS

Nationally representative data from the Medical Expenditure Panel Survey (2010-2012) provided data on insurance status, public health insurance eligibility, and visits to dental providers for both general dental care and orthodontic care.

RESULTS

Overall, 41.9% of US children reported an annual dental office-based visit for general (nonorthodontic) dental care. Fewer Hispanic (34.7%) and non-Latino black children (34.8%) received dental care compared to non-Hispanic whites (47.3%) and Asians (40.3%). Children living in families with the lowest income were also the least likely to have a visit (32.9%) compared to children in the highest-income families (54.7%). Among children eligible for public coverage, Medicaid-eligible children had the lowest percentage of preventive dental visits (29.2%). Socioeconomic and racial/ethnic disparities in use and expenditures for orthodontic care are much greater than those for general and preventive dental care. Average expenditures for orthodontic care were $1,823, of which 56% ($1,023) was paid out of pocket by families.

CONCLUSIONS

Our findings provide a baseline assessment for examining trends in the future, especially as coverage patterns for children may change as the Affordable Care Act is implemented and the future of the State Child Health Insurance Program remains uncertain beyond 2017.

Geography matters: state-level variation in children's oral health care access and oral health status

OBJECTIVES

To ascertain differences across states in children's oral health care access and oral health status and the factors that contribute to those differences.

STUDY DESIGN

Observational study using cross-sectional surveys.

METHODS

Using the 2007 National Survey of Children's Health, we examined state variation in parents' report of children's oral health care access (absence of a preventive dental visit) and oral health status. We assessed the unadjusted prevalences of these outcomes, then adjusted with child-, family-, and neighbourhood-level variables using logistic regression; these results are presented directly and graphically. Using multilevel analysis, we then calculated the degree to which child-, family-, and community-level variables explained state variation. Finally, we quantified the influence of state-level variables on state variation.

RESULTS

Unadjusted rates of no preventive dental care ranged 9.0-26.8% (mean 17.5%), with little impact of adjusting (10.3-26.7%). Almost 9% of the population had fair/poor oral health; unadjusted range 4.1-14.5%. Adjusting analyses affected fair/poor oral health more than access (5.7-10.7%). Child, family and community factors explained ∼¼ of the state variation in no preventive visit and ∼½ of fair/poor oral health. State-level factors further contributed to explaining up to a third of residual state variation.

CONCLUSION

Geography matters: where a child lives has a large impact on his or her access to oral health care and oral health status, even after adjusting for child, family, community, and state variables. As state-level variation persists, other factors and richer data are needed to clarify the variation and drive changes for more egalitarian and overall improved oral health.

Associations of Provider-to-Population Ratios and Population Health by County-Level Rurality

PURPOSE

To explore the relationship between provider-to-population ratios, rurality and population health in the United States using counties as the unit of analysis.

METHOD

Population ratios for registered nurses (RNs), primary care physicians, and dentists were included in multivariable regression analyses. Population health indices assessed were premature death rate, self-rated health, teen birth rate, and mammography screening rate.

FINDINGS

County levels of health and health care providers per capita declined as rurality increased. In adjusted regression models, the highest RN-to-population ratio was associated with significantly better health measures in most urban/rural categories, with the magnitude of these associations generally increasing as rurality increased. In the smallest rural counties, the highest RN-to-population quartile was associated with 1,655 fewer years of potential life lost (YPLL), 2% lower rates of poor or fair health, 11/1,000 fewer teen births, and 6% more mammography screening relative to the lowest quartile. For primary care physicians, more significant associations were found in medium and small rural counties where the highest quartile was associated with 1,482 fewer YPLL, 3% lower rates of poor or fair health, 7/1,000 fewer teen births, and 4% more mammography screening. The highest quartile of dentist-to-population ratio was generally associated with lower rates of premature death and poor or fair health in urban, large-, and medium-sized rural counties, but not in small rural counties.

CONCLUSIONS

The consistency of the results by provider type suggests that the supply of health care professionals, particularly in rural areas, positively impacts the health of the population.

Effectiveness of an Alternative Dental Workforce Model on the Oral Health of Low-Income Children in a School-Based Setting

OBJECTIVES

We evaluated the effect of an alternative dental workforce program-Kansas's Extended Care Permit (ECP) program--as a function of changes in oral health.

METHODS

We examined data from the 2008 to 2012 electronic medical records of children (n = 295) in a Midwestern US suburb who participated in a school-based oral health program in which preventive oral health care was delivered by ECP dental hygienists. We examined changes in oral health status as a function of sealants, caries, restorations, and treatment urgency with descriptive statistics, multivariate analysis of variance, Kruskal-Wallis test, and Pearson correlations.

RESULTS

The number of encounters with the ECP dental hygienist had a statistically significant effect on changes in decay (P = .014), restorations (P = .002), and treatment urgency (P = .038). Based on Pearson correlations, as encounters increased, there was a significant decrease in decay (-0.12), increase in restorations (0.21), and decrease in treatment urgency (-0.15).

CONCLUSIONS

Increasing numbers of encounters with alternative providers (ECP dental hygienists), such as with school-based oral health programs, can improve the oral health status of low-income children who would not otherwise have received oral health services.