Wealth effect and dental care utilization in the United States

How an increase in income affects the use of dental care services among a low-income population: evidence from the Finnish basic income experiment

BACKGROUND

Previous research has shown that the use of dental care services has a significant socioeconomic gradient. Lower income groups tend to use dental care services less, and they often have poorer dental health than higher income groups. The purpose of this study is to evaluate how an increase in income affects the use of dental care services among a low-income population.

METHODS

The study examines the causal effect of increasing cash transfers on the use of dental care services by utilizing unique register-based data from a randomized field experiment conducted in Finland in 2017-2018. The Finnish basic income experiment introduced an exogenous increase in the income of persons who previously received basic unemployment benefits. Register-based data on the study population's use of public and private dental care services were collected both for the treatment group (N = 2,000) and the control group (N = 173,222) of the experiment over a five-year period 2015-2019: two years before, two years during, and one year after the experiment. The experiment's average treatment effect on the use of dental care services was estimated with OLS regressions.

RESULTS

The Finnish basic income experiment had no detectable effect on the overall use of dental care services. However, it decreased the probability of visiting public dental care (-2.7% points, -4.7%, p =.017) and increased the average amount of out-of-pocket spending on private care (12.1 euros, 29.8%, p =.032). The results suggest that, even in a country with a universal public dental care coverage, changes in cash transfers do affect the dental care patterns of low-income populations.

Comorbidity patterns in cardiovascular diseases: the role of life-stage and socioeconomic status

Cardiovascular diseases stand as a prominent global cause of mortality, their intricate origins often entwined with comorbidities and multimorbid conditions. Acknowledging the pivotal roles of age, sex, and social determinants of health in shaping the onset and progression of these diseases, our study delves into the nuanced interplay between life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Leveraging data from a cross-sectional survey encompassing Mexican adults, we unearth a robust association between these variables and the prevalence of comorbidities linked to cardiovascular conditions. To foster a comprehensive understanding of multimorbidity patterns across diverse life-stages, we scrutinize an extensive dataset comprising 47,377 cases diagnosed with cardiovascular ailments at Mexico's national reference hospital. Extracting sociodemographic details, primary diagnoses prompting hospitalization, and additional conditions identified through ICD-10 codes, we unveil subtle yet significant associations and discuss pertinent specific cases. Our results underscore a noteworthy trend: younger patients of lower socioeconomic status exhibit a heightened likelihood of cardiovascular comorbidities compared to their older counterparts with a higher socioeconomic status. By empowering clinicians to discern non-evident comorbidities, our study aims to refine therapeutic designs. These findings offer profound insights into the intricate interplay among life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Armed with data-supported approaches that account for these factors, clinical practices stand to be enhanced, and public health policies informed, ultimately advancing the prevention and management of cardiovascular disease in Mexico.

Payment Methods and Demographics Influence Patterns of Dental Service Utilization

OBJECTIVE

To describe the patterns of specific dental service utilization among the various sociodemographic groups in North Carolina served by the East Carolina University School of Dental Medicine (ECU SoDM).

DESIGN

This was a descriptive study utilizing self-reported patients' sociodemographic information, payment method history, and CDT codes of procedures performed. Deidentified clinical data recorded for 26 710 patients and 534 983 procedures from 2011 to 2020 were extracted from a centralized axiUm database. Data were analyzed using IBM SPSS Statistics, version 25.0. Cross-tabulations between dental service utilizations, patients' demographics, and payment method were performed using chi-square analysis.

SETTING

Nine dental clinic sites across the state of North Carolina.

PARTICIPANTS

In total, 26 710 adults 23 years to older than 65 years were included in the sample for this study.

MAIN OUTCOME MEASURES

In total, 534 983 procedure codes completed for the eligible patients were cross-tabulated with payment method.

RESULTS

Payment method was significantly related to individual characteristics including location of service, age, race, ethnicity, and untreated decay ( P < .001). Payment method is associated with the dental service type utilized by an individual ( P < .001). Patients who received Medicaid benefits were more likely to receive restorative procedures, removable prosthetics, or oral surgery. Despite NC Medicaid covering preventive procedures, patients who received Medicaid benefits showed lower utilization of preventive procedures than expected. Privately insured or self-paying individuals demonstrated a greater variety of service option utilization, as well as more frequent usage of more specialized procedure options such as endodontics, periodontics, fixed prosthodontics, and implants.

CONCLUSIONS

Payment method was found to be related to patients' demographics and type of dental service utilized. Adults older than 65 years demonstrated a higher proportion of self-payment for dental care, indicating a lack of payment options for this population. In the interest of providing care for underserved populations in North Carolina, policy makers should consider expanding dental coverage for adults older than 65 years.

Effects of universal oral healthcare coverage in an adult population: A long-term nationwide natural experiment

OBJECTIVES

A large and long-term natural experiment occurred in Finland from the late 1980s-2000, when adults' entitlement to subsidized oral healthcare was strongly dependent on the arbitrary classification based on their year of birth: people born in 1956 or later were entitled to subsidized care, while people born before 1956 were not. The aim of this study was to investigate the effect of this expanded universal oral healthcare coverage on service use and oral health outcomes.

METHODS

Data from annual nationally representative cross-sectional postal surveys among 15-64-year-olds between 1990 and 2014 were used. For this study, the following outcome variables were formed: experiencing toothache during the past month (yes/no), the number of missing teeth with three different thresholds (over 10, over 5 or at least 1 missing tooth), brushing more than once a day and the number of visits to the dentist. Regression discontinuity plots and bias-corrected local polynomial regression discontinuity estimators measuring the effect of the extended universal coverage on the outcomes at the year-of-birth cut-off of 1956 were generated separately from the data from 1990 to 2000 and from 2002 to 2014.

RESULTS

Between 1990 and 2000, the number of visits to the dentist (0.2 visits, 95% CI, confidence intervals: -0.03; 0.43) and the proportion of those who visited the dentist during the past 12 months (4.2%, 95% CI: 0.1%; 8.3%) increased at the year-of-birth cut-off of 1956. There were minor drops (1.5%-1.9%) in the number of missing teeth across all thresholds (over 10, over 5, or at least 1 missing teeth) at the cut-off. Analyses with the data from the surveys from 2002 to 2014 showed that there were no discontinuities in these outcomes at the cut-off of 1956. Regression discontinuity estimates related to toothache experience and toothbrushing frequency were inconclusive due to high variability in the underlying data and the likely small effect of the more universal coverage on these outcomes.

CONCLUSIONS

The current study provided evidence of the beneficial effects of universal oral healthcare coverage on the oral healthcare service use and teeth preservation from a large and long-term natural experiment occurred in Finland from the late 1980s to 2000.

Knowledge and Attitude Toward Esthetic Dentistry and Smile Perception

INTRODUCTION

A smile is important in human communication and is increasingly valued in modern society. The perception of smile attractiveness is subjective and depends on many factors.

AIM

This study aimed to evaluate and compare knowledge and attitude related to esthetic dentistry in dental students versus dental interns, general dentists, and dental specialists, examine the self-perception of their smile, and identify parameters that influence smile perception.

METHODS

This cross-sectional study was conducted at King Abdulaziz University Dental Hospital in Jeddah, Saudi Arabia. Participants included dental students, interns, general practitioners, and specialists. They completed an electronic questionnaire covering demographics, knowledge about esthetic dentistry, attitudes toward smile perception, and previous dental treatments. Data analysis involved descriptive statistics, bivariate analysis, and chi-square tests.

RESULTS

A total of 275 individuals participated in our study. The study found that dental students' exposure and awareness of esthetic dentistry topics increased with academic progression. Gender, age, and marital status influenced self-perception and smile evaluation. More females perceived gender as an influencing factor in smile evaluation, while more males believed in the existence of an ideal smile. A substantial portion of the sample had undergone dental treatments, with no significant income-related disparities observed.

CONCLUSION

This study highlights differences in knowledge and attitudes among dental students and professionals. Dental education appears to impact students' exposure to esthetic dentistry concepts. Moreover, gender, age, and marital status influence self-perception and evaluation of others' smiles.

Utilization of dental care among adult populations: a scoping review of applied models

BACKGROUND

The timely and appropriate utilization of dental health care is essential to the prevention and accurate treatment of oral diseases. Therefore, it is crucial that managers, health professionals and healthcare providers be fully aware of the predictors encouraging the utilization of dental services and reduce social inequalities. In this scoping review, we aimed to analyze the published articles and reports to find out the factors associated with dental services utilization and the comprehensiveness of the applied models among general adult populations.

MATERIALS AND METHODS

This scoping study was based on the 5-steps of Arksey and O'Malley framework. Keywords were selected under two main concepts: determinants of dental care utilization and the concept of the applied models. Searches were conducted in some electronic databses including PubMed, Google Scholar and Scopus with variations, and a combination of the keywords under the two main afore-mentioned concepts. All the relevant articles reporting the utilization of dental care and its potential predictors among adult populations were chosen. No restrictions involving terms of study time, location or methodological aspects of oral health utilization were considered. Using tables and charts mapping, we tried to group the studies based on the year of their publication, geographic distribution, the range of included indices and the type of their measurement. Also, a directed content analysis method was used to investigate the comprehensiveness of the studies in regard to considering the determinant factors at different levels suggested by the Andesen model.

RESULTS

Fifty-two articles were included in the analysis. Thirty-six (69%) had been published between 2016 and 2020. The United States had conducted the most research in this scope. About 30% of studies had mentioned all three domains of demographics, social structure and beliefs, simultaneously. To evaluate the enabling factors, in 84.61% and 59.61% of studies, the income levels and insurance feature were assessed, respectively. 57.69% of the retrieved studies considered the perceived need features and 38.46% referred to the evaluated ones. The dental services utilization, in terms of the last visit during the "past 12 months", was assessed more commonly. Only 11.54% of studies did evaluate the contextual characteristics and about 71.15% of articles were relatively comprehensive.

CONCLUSION

Overall, it seems that in most of the studies, not all of the determinant factors at different levels of the Andersen model have been considered. In order to discover the conceptual linkages and feedback loops of the model, it is essential to conduct more comprehensive research in the future.

Impact of diabetes diagnosis on dental care utilization: evidence from Finland

BACKGROUND

Poor oral health is associated with many chronic diseases, including diabetes. As diabetes can worsen oral health and vice versa, care guidelines recommend that patients with diabetes maintain good oral health and have regular dental checkups. We analyzed the impact of receiving an initial type 2 diabetes diagnosis on dental care utilization.

METHODS

We used register data on residents aged over 25 in the city of Oulu, Finland, covering the years 2013-2018. We used the difference-in-differences method and individuals with no diabetes diagnosis as control group. As robustness checks, we used propensity score matching and constructed an alternative control group from patients that received the same diagnosis a few years apart.

RESULTS

Despite the guideline recommendations, we found that receiving a diabetes diagnosis did not increase the probability for dental care visits in a two-year follow-up. The findings remained similar for both high-income and low-income persons.

CONCLUSIONS

The finding is concerning in terms of diabetes management and oral health. Further research is needed on the reasons behind the lack of response to guidelines.

Socioeconomic differences in utilization of public and private dental care in Finland: Register-based evidence on a population aged 25 and over

Dental care utilization is known to have a strong socioeconomic gradient, with lower socioeconomic groups utilizing less of these services despite having poorer dental health. However, less is known about the utilization of dental services in the population concurrently in the public and private sectors in different socioeconomic groups. Additionally, evidence on how different sectors contribute to the overall socioeconomic gradient in dental care utilization is scarce. This study examines visits and absence of visits to public and private dentists in the years 2017-2018 by education, occupational class and income. Comprehensive register data was collected from the total population aged 25 and over in the city of Oulu, Finland (N = 118,397). The data were analyzed with descriptive methods and with multinomial logistic regressions for the probability of visits and with negative binomial regressions for the number of visits, adjusted for sociodemographic covariates. The results showed a clear socioeconomic gradient for the probability of visits according to income and education: the higher the income and the higher the education, the more likely was a visit to a dentist-especially a private dentist-during the two-year period. Similar results were obtained for the number of visits. Higher socioeconomic status was less associated with public dentist visits. While those with the lowest income visited public dentists more frequently than private dentists, their overall visits fell below that of others. Adjusted estimates by occupation did not show a clear socioeconomic gradient. The socioeconomic inequality in dentist visits in a country having a universally covered public dental care scheme puts a challenge for decision makers in designing an equal dental health care system. Experimenting with lower co-payments is a possible option.

Inequality and Inequity in the Use of Oral Health Services in Australian Adults

OBJECTIVE

Social determinants drive disparities in dental visiting. This study aimed to measure inequality and inequity in dental visiting among Australian adults.

METHODS

Data were obtained from the National Study of Adult Oral Health (2017 to 2018). Participants were Australian adults aged ≥30 y. The outcome of interest was dental visiting in the last 12 mo. Disparity indicators included education and income. Other sociodemographic characteristics included age, gender, Indigenous status, main language, place of birth, residential location, health card and dental insurance status, and individual's self-rated and impaired oral health. To characterize inequality in dental service use, we examined bivariate relationships using indices of inequality: the absolute and relative concentration indexes and the slope and relative indexes of inequality. Inequalities were depicted through concentration curves. Indirect standardization with a nonlinear model was used to measure inequity.

RESULTS

A total of 9,919 Australian adults were included. Bivariate analysis showed a gradient by education and income on dental visiting, with 48% of those with lowest educational attainment/income having not visited a dentist in the last 12 mo. The concentration curves showed pro-low education and pro-poor income inequalities. All measures of absolute and relative indices were negative, indicating that from the bottom to the top of the socioeconomic ladder (education and income), the prevalence of no dental visiting decreased: absolute and relative concentration index estimates were approximately 2.5% and 5.0%, while the slope and relative indexes of inequality estimates were 14% to 18% and 0.4%, respectively. After need standardization, the group with the highest education or income had almost 1.5-times less probability of not having a dental visit in the previous year than those with the lowest education or income.

CONCLUSION

The use of oral health services exhibited socioeconomic inequalities and inequities, disproportionately burdening disadvantaged Australian adults.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers when planning a dental labor force in relation to the capacity of supply dental services to 1) reduce the inequality and inequity in the use of oral health services and 2) meet identified oral health needs across the Australian population, which is important for preventive dental care.

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.

Longitudinal analysis of cost and dental utilization patterns for older adults in outpatient and long-term care settings in Minnesota

BACKGROUND

Dental utilization patterns and costs of providing comprehensive oral healthcare for older adults in different settings have not been examined.

METHODS

Retrospective longitudinal cohort data from Apple Tree Dental (ATD) were analyzed (N = 1,159 total; 503 outpatients, 656 long-term care residents) to describe oral health status at presentation, service utilization patterns, and care costs. Generalized estimating equation (GEE) repeated measures analysis identified significant contributors to service cost over the three-year study period.

RESULTS

Cohort mean age was 74 years (range = 55-104); the outpatient (OP) group was younger compared to the long-term care (LTC) group. Half (56%) had Medicaid, 22% had other insurance, and 22% self-paid. Most (72%) had functional dentitions (20+ teeth), 15% had impaired dentitions (9-19 teeth), 6% had severe tooth loss (1-8 teeth), and 7% were edentulous (OP = 2%, LTC = 11%). More in the OP group had functional dentition (83% vs. 63% LTC). The number of appointments declined from 5.0 in Year 1 (OP = 5.7, LTC = 4.4) to 3.3 in Year 3 (OP = 3.6, LTC = 3.0). The average cost to provide dental services was $1,375/year for three years (OP = $1,427, LTC = $1,336), and costs declined each year, from an average of $1,959 (OP = $2,068, LTC = $1,876) in Year 1 to $1,016 (OP = $989, LTC = $1,037) by Year 3. Those with functional dentition at presentation were significantly less costly than those with 1-19 teeth, while edentulous patients demonstrated the lowest cost and utilization. Year in treatment, insurance type, dentition type, and problem-focused first exam were significantly associated with year-over-year cost change in both OP and LTC patients.

CONCLUSION

Costs for providing comprehensive dental care in OP and LTC settings were similar, modest, and declined over time. Dentate patients with functional dentition and edentulous patients were less costly to treat. LTC patients had lower utilization than OP patients. Care patterns shifted over time to increased preventive care and decreased restorative care visits.

Providing dental insurance can positively impact oral health outcomes in Ontario

Background

Universal coverage for dental care is a topical policy debate across Canada, but the impact of dental insurance on improving oral health-related outcomes remains empirically unexplored in this population.

Methods

We used data on individuals 12 years of age and older from the Canadian Community Health Survey 2013–2014 to estimate the marginal effects (ME) of having dental insurance in Ontario, Canada’s most populated province (n = 42,553 representing 11,682,112 Ontarians). ME were derived from multi-variable logistic regression models for dental visiting behaviour and oral health status outcomes. We also investigated the ME of insurance across income, education and age subgroups.

Results

Having dental insurance increased the proportion of participants who visited the dentist in the past year (56.6 to 79.4%, ME: 22.8, 95% confidence interval (CI): 20.9–24.7) and who reported very good or excellent oral health (48.3 to 57.9%, ME: 9.6, 95%CI: 7.6–11.5). Compared to the highest income group, having dental insurance had a greater ME for the lowest income groups for dental visiting behaviour: dental visit in the past 12 months (ME highest: 17.9; 95% CI: 15.9–19.8 vs. ME lowest: 27.2; 95% CI: 25.0–29.3) and visiting a dentist only for emergencies (ME highest: -11.5; 95% CI: − 13.2 to − 9.9 vs. ME lowest: -27.2; 95% CI: − 29.5 to − 24.8).

Conclusions

Findings suggest that dental insurance is associated with improved dental visiting behaviours and oral health status outcomes. Policymakers could consider universal dental coverage as a means to support financially vulnerable populations and to reduce oral health disparities between the rich and the poor.

Income and wealth as correlates of socioeconomic disparity in dentist visits among adults aged 20 years and over in the United States, 2011-2014

BACKGROUND

Most studies in the United States (US) have used income and education as socioeconomic indicators but there is limited information on other indicators, such as wealth. We aimed to assess how two socioeconomic status measures, income and wealth, compare as correlates of socioeconomic disparity in dentist visits among adults in the US.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 were used to calculate self-reported dental visit prevalence for adults aged 20 years and over living in the US. Prevalence ratios using Poisson regressions were conducted separately with income and wealth as independent variables. The dependent variable was not having a dentist visit in the past 12 months. Covariates included sociodemographic factors and untreated dental caries. Parsimonious models, including only statistically significant (p < 0.05) covariates, were derived. The Akaike Information Criterion (AIC) measured the relative statistical quality of the income and wealth models. Analyses were additionally stratified by race/ethnicity in response to statistically significant interactions.

RESULTS

The prevalence of not having a dentist visit in the past 12 months among adults aged 20 years and over was 39%. Prevalence was highest in the poorest (58%) and lowest wealth (57%) groups. In the parsimonious models, adults in the poorest and lowest wealth groups were close to twice as likely to not have a dentist visit (RR 1.69; 95%CI: 1.51-1.90) and (RR 1.68; 95%CI: 1.52-1.85) respectively. In the income model the risk of not having a dentist visit were 16% higher in the age group 20-44 years compared with the 65+ year age group (RR 1.16; 95%CI: 1.04-1.30) but age was not statistically significant in the wealth model. The AIC scores were lower (better) for the income model. After stratifying by race/ethnicity, age remained a significant indicator for dentist visits for non-Hispanic whites, blacks, and Asians whereas age was not associated with dentist visits in the wealth model.

CONCLUSIONS

Income and wealth are both indicators of socioeconomic disparities in dentist visits in the US, but both do not have the same impact in some populations in the US.

Income-rich and wealth-poor? The impact of measures of socio-economic status in the analysis of the distribution of long-term care use among older people

This article aims to investigate the impact of using 2 measures of socio-economic status on the analysis of how informal care and home care use are distributed among older people living in the community. Using data from the Survey of Health, Ageing and Retirement in Europe for 14 European countries, we estimate differences in corrected concentration indices for use of informal care and home care, using equivalised household net income and equivalised net worth (as a proxy for wealth). We also calculate horizontal inequity indices using both measures of socio-economic status and accounting for differences in need. The findings show that using wealth as a ranking variable results, as a rule, in a less pro-poor inequality of use for both informal and home care. Once differences in need are controlled for (horizontal inequity), wealth still results in a less pro-poor distribution for informal care, in comparison with income, whereas the opposite is observed for home care. Possible explanations for these differences and research and policy implications are discussed.

Effect of length of dental resident clinical rotations on patient behavior

AIM

The purpose of this retrospective chart review study was to determine if the length of residents' comprehensive dental care rotations in a general practice residency affected late cancellations, broken appointments, completion of treatment, timeliness of recall visits, emergency visits, and the need for redo of restorations and prostheses.

METHODS

Patients who presented for comprehensive care from 2010 to 2013, during which residents had 3- to 4-month dental clinic rotations, comprised Group 1, and patients who presented for comprehensive care from 2013 to 2016, during which residents had 11-month dental clinic rotations, comprised Group 2. Subjects were excluded if they only presented for emergency care, they had only one visit, or their care was delivered in both time periods. There were 105 patients in Group 1 and 55 patients in Group 2.

RESULTS

The statistically significant results were that Group 1 patients had more late cancellations and broken appointments and failed to reach recall status more often than Group 2 patients, and that Group 1 patients had fewer emergency visits.

CONCLUSION

Within the limitations of this retrospective study, the results suggest that short block rotations have an adverse effect on resident experience and outcomes of patient care in a hospital outpatient setting.

Barriers to oral health across selected European countries and the USA

In this review we consider oral-health access among older adults within and between the USA and various European countries with regard to possible primary financial and modifiable secondary non-financial factors. For older adults, the likelihood 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 (European) 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.

Towards an understanding of the structural determinants of oral health inequalities: A comparative analysis between Canada and the United States

Objective

To compare the magnitude of, and contributors to, income-related inequalities in oral health outcomes within and between Canada and the United States over time.

Methods

The concentration index was used to estimate income-related inequalities in three oral health outcomes from the Nutrition Canada National Survey 1970–1972, Canadian Health Measures Survey 2007–2009, Health and Nutrition Examination Survey I 1971–1974, and National Health and Nutrition Examination Survey 2007–2008. Concentration indices were decomposed to determine the contribution of demographic and socioeconomic factors to oral health inequalities.

Results

Our estimates show that over time in both countries, inequalities in decayed teeth and edentulism were concentrated among the poor and inequalities in filled teeth were concentrated among the rich. Over time, inequalities in decayed teeth increased and decreased for measures of filled teeth and edentulism in both countries. Inequalities were higher in the United States compared to Canada for filled and decayed teeth outcomes. Socioeconomic characteristics (education, income) contributed greater to inequalities than demographic characteristics (age, sex). As well, income contributed more to inequalities in recent surveys in both Canada and the United States.

Conclusions

Inequalities in oral health have persisted over the past 35 years in Canada and the United States, and are associated with age, sex, education, and income and have varied over time.

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Highlights changes and contributors to oral health inequalities in Canada and the U.S. since 1970.

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Provides a comparative framework for analysing income-related oral health inequalities.

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Hypotheses-generating findings on contributors to income-related oral health inequalities.

Wealth-related versus income-related inequalities in dental care use under universal public coverage: a panel data analysis of the Japanese Study of Aging and Retirement

BACKGROUND

There is a substantial body of evidence of income-related inequalities in dental care use, attributed to the fact that dental care is often not covered by public health insurance. Wealth-related inequalities have also been shown to be greater than income-related inequalities. Japan is one of the exceptions, as the the universal pubic health insurance system has covered dental care. The aim of this study was therefore to compare wealth- and income-related inequalities in dental care use among middle-aged and older adults in Japan to infer the mechanisms of wealth-related inequalities in dental care use.

METHODS

Data were derived from the Japanese Study of Aging and Retirement, a survey of community-dwelling middle-aged and older adults living in five municipalities in eastern Japan. Of the participants in the second wave conducted in 2009, we analyzed 2581 residents. Dental care use was measured according to whether the participant had been seen by a dentist or a dental hygienist in the past year. The main explanatory variables were income and wealth (financial assets, real assets and total wealth). The need for dental care was measured using age, the use of dentures and chewing ability. The concentration indices for the distribution of actual and need-standardized dental care use were calculated.

RESULTS

Among the respondents, 47.9% had received dental care in the past year. The concentration index of actual dental care use (CI) showed a pro-rich inequality for both income and wealth. The CIs for all three wealth measures were larger than that for income. A broadly comparable pattern was seen after need-standardization (income: 0.020, financial assets: 0.035, real assets: 0.047, total wealth: 0.050).

CONCLUSIONS

The results showed that wealth-related inequalities in dental care use were greater than income-related inequalities in Japan, where most dental care is covered by the public health insurance system. This suggests that wealth-related inequalities in dental care use cannot be explained by economic budget constraints alone. Further studies should investigate the mechanisms of wealth-related inequalities in dental care use.

Community factors predicting dental care utilization among older adults

BACKGROUND

Few investigators have studied the influence of community factors on dental care utilization among older adults. The authors' objective in this study was to investigate the effect of community factors on dental care utilization after adjustment for individual factors.

METHODS

Using data from a cross-sectional survey of Ohio residents, the authors assessed dental care utilization in a sample of 2,166 adults 65 years or older. They linked individual-level dental care utilization, predisposing factors (age, sex, race or ethnicity, marital status, education), enabling factors (poverty, dental insurance) and need-related factors (physical and mental health problems) with county-level data (socioeconomic environment and health resource environment) from the 2010 Area Health Resource Files (from the U.S. Department of Health and Human Services) and the American Community Survey (from the 2006-2010 U.S. census). By using multilevel logistic regression models, the authors evaluated the association between dental care utilization and community factors after adjustment for individual factors.

RESULTS

The results indicated that individual factors such as being female, married and nonpoor and having a higher educational level and private dental insurance were associated with higher odds of having utilized dental care. Furthermore, older adults living in a county with a higher dentist-to-population ratio were more likely to use dental services even after the authors adjusted the results for the individual-level factors (odds ratio = 1.10; P = .03).

CONCLUSIONS

County-level dentist-to-population ratio has independent effects on older adults' dental care utilization even after adjustment for individual-level characteristics. Practical Implications. A comprehensive policy plan is required to intervene at both the individual and community levels to improve dental care utilization among older adults. By understanding the factors influencing dental care utilization among older adults, U.S. dentists will be better positioned to meet the dental needs of this population.

A Research Note on Transitions in Out-of-Pocket Spending on Dental Services

OBJECTIVE

We analyze correlates of the direction and magnitude of changes in out-of-pocket (OOP) payments for dental care by older Americans over a recent 4-year period.

METHODS

We analyzed data from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of the direction and linear regression models of the amounts of OOP changes over survey periods.

RESULTS

Financial-based factors were more strongly associated with the direction and magnitude of changing self-payments for dental care than were health factors.

DISCUSSION

Findings suggested that dental coverage, income, and wealth and changes in these financial factors were more strongly correlated with the persistence of and changes in OOP payments for dental care over time than were health status and changes in health status. The sensitivity to dental coverage changes should be considered as insurance and retirement policy reforms are deliberated.

Response error in reporting dental coverage by older Americans in the health and retirement study

The aim of this research was to analyze the inconsistency in responses to survey questions within the Health and Retirement Study (HRS) regarding insurance coverage of dental services. Self-reports of dental coverage in the dental services section were compared with those in the insurance section of the 2002 HRS to identify inconsistent responses. Logistic regression identified characteristics of persons reporting discrepancies and assessed the effect of measurement error on dental coverage coefficient estimates in dental utilization models. In 18% of cases, data reported in the insurance section contradicted data reported in the dental use section of the HRS by those who said insurance at least partially covered (or would have covered) their (hypothetical) dental use. Additional findings included distinct characteristics of persons with potential reporting errors and a downward bias to the regression coefficient for coverage in a dental use model without controls for inconsistent self-reports of coverage. This study offers evidence for the need to validate self-reports of dental insurance coverage among a survey population of older Americans to obtain more accurate estimates of coverage and its impact on dental utilization.

A population-based study of edentulism in the US: does depression and rural residency matter after controlling for potential confounders?

Background

Oral health is an integral component of general health and well-being. While edentulism has been examined in relation to socioeconomic status, rural residency, chronic disease and mental health, no study that we know of has examined edentulism and these factors together. The objective of this study was to determine whether depression and rural residency were significantly associated with partial and full edentulism in US adults after controlling for potential confounders.

Methods

2006 Behavioral Risk Factor Surveillance Survey (BRFSS) data were analyzed to identify factors associated with increased odds of partial or full edentulism. This year of BRFSS data was chosen for analysis because in this year the standardized and validated Personal Health Questionnaire-8 (PHQ-8) was used to measure current depression. This measure was part of the optional questions BRFSS asks, and in 2006 33 states and/or territories included them in their annual surveillance data collection. Bivariate and logistic regression analyses were performed on weighted BRFSS data.

Results

Logistic regression analysis using either full or partial edentulism as the dependent variable yielded that rural residency or living in a rural locale, low and/or middle socioeconomic status (SES), depression as measured by the PHQ-8, and African American race/ethnicity were all independent risk factors when controlling for these and a number of additional covariates.

Conclusions

This study adds to the epidemiological literature by assessing partial and full edentulism in the US utilizing data from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Examining data collected through a large national surveillance system such as BRFSS allows for an analysis that incorporates an array of covariates not available from clinically-based data alone. This study demonstrated that current depression and rural residency are important factors related to partial and full edentulism after controlling for potential confounders.

Oral Health Knowledge and Dental Visits in Community Living Older Adults in Rural Appalachia-West Virginia: A Cross-Sectional Analysis

INTRODUCTION

The purpose of this study was to investigate the relationship between oral health knowledge and dental visits of older adults in an Appalachian county.

METHODS

A cross-sectional study design was used. Surveys were returned from 205 older adults (50 years and above) from an Appalachian county. Questions were asked about oral health, last dental visit and sociodemographics.

RESULTS

The variable of interest, oral health knowledge, was associated with dental visit. Having low oral health knowledge increased odds of having delayed a dental visit beyond a year (unadjusted odds ratio: 2.99; 95% Confidence interval: 1.70, 5.28). Even after considering the number of existing teeth, and controlling for age, sex, education and smoking, the association remained positive and independently significant (adjusted odds ratio: 2.25; 95% Confidence interval: 1.05, 4.82). Education was the only sociodemographic variable associated with last dental visit.

CONCLUSION

The surveyed older adults have a need for increasing dental visits within the previous year. Increasing dental knowledge was associated with odds of increased dental visits. Improving dental knowledge may be a strategy to improve the number of older adults having a dental visit within the year.

A multi-country comparison of reasons for dental non-attendance

The purpose of this study was to describe differences across countries with respect to the reasons for dental non-attendance by Europeans currently 50 yr of age and older. The analyses were based on retrospective life-history data from the Survey of Health, Ageing, and Retirement in Europe and included information on various reasons why respondents from 13 European countries had never had regular dental visits in their lifetime. A series of logistic regression models was estimated to identify reasons for dental non-attendance across different welfare-state regimes. The highest proportion of respondents without any regular dental attendance throughout their lifetime was found for the Southern welfare-state regime, followed by the Eastern, the Bismarckian, and the Scandinavian welfare-state regimes. Factors such as patients' perception that regular dental treatment is 'not necessary' or 'not usual' appear to be the predominant reason for non-attendance in all welfare-state regimes. The health system-level factor 'no place to receive this type of care close to home' and the perception of regular dental treatment as 'not necessary' were more often referred to within the Southern, Eastern, and Bismarckian welfare-state regimes than in Scandinavia. This could be relevant information for health-care decision makers in order to prioritize interventions towards increasing rates of regular dental attendance.

Gender-stratified models to examine the relationship between financial hardship and self-reported oral health for older US men and women

OBJECTIVES

We evaluated the relationship between financial hardship and self-reported oral health for older men and women.

METHODS

We focused on adults in the 2008 Health and Retirement Study (n = 1,359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.

RESULTS

In the non-gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).

CONCLUSIONS

Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults' oral health should account for gender-based heterogeneity in financial hardship experiences.

Dental usage under changing economic conditions

OBJECTIVE

The purpose of this article is to examine the relationship between changes in household finances (wealth and income) and changes in dental utilization at the onset of the recent recession in a population of older Americans.

METHODS

Data from the Health and Retirement Study (HRS) were analyzed for U.S. individuals aged 51 years and older during the 2006 and 2008 waves of the HRS. We estimated logistic models of (a) starting and (b) stopping dental use between 2006 and 2008 survey periods as a function of changes in household wealth and income, controlling for other potentially confounding covariates.

RESULTS

We found that only when household wealth falls by 50 percent or more were older adults less likely to seek dental care. Changes in household income and other changes in household wealth were not associated with changes in dental utilization among this population.

CONCLUSIONS

Older Americans' dental care utilization appeared to be fairly resilient to changes in household finances; only when wealth fell by 50 percent or more did individuals decrease dental use. This finding might extend to other health-care services that are preventive, routine, and relatively inexpensive.