The dental care of U.S. children
Access, use and referrals by nondentist providers, 2003
May Chu, BS,
Luciana E. Sweis, DDS,
Albert H. Guay, DMD and
Richard J. Manski, DDS, MBA, PhD
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ABSTRACT
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Background. Improvements in oral health care services have not reached evenly across every segment of American society. The authors examine the role of nondentist practitioners in referring child patients for dental care by analyzing data from the 2003 Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.
Methods. The authors provide national estimates of the percentage of the civilian noninstitutionalized population of the United States aged 2 through 17 years who had a dental visit, who had a dental checkup and who received advice from a nondentist health care provider to have a dental checkup.
Results. Overall, 38 percent of all poor, near-poor or low-income children and 60 percent of all middle- or high-income children aged 2 through 17 years reported having had a dental checkup during 2003. The authors observed no significant differences between poor, near-poor and low-income children and higher-income children in terms of having been advised by a nondentist health care provider to have a dental checkup.
Conclusion. Although income may not predict the likelihood of patients’ receiving advice from a nondentist health care provider to have a dental checkup, children from families with higher levels of income were more likely to seek dental care than were children from families with lower levels of income.
Practice Implications. Efforts to increase access to dental care should aim to maximize the benefit of advice provided by nondentist health care practitioners to receive a dental checkup, so that children from families with limited income are as likely to receive a dental checkup as are children from families with higher levels of income.
Key Words: Dental care; utilization; access; checkup; Medical Expenditure Panel Survey; referralsAbbreviations: AHRQ: Agency for Healthcare Research and Quality. • FPG: Federal poverty guideline • MEPS: Medical Expenditure Panel Survey • MSA: Metropolitan Statistical Area • NHIS: National Health Interview Survey
Most Americans today benefit from the dramatic improvements in oral health care services gained during the past few years. However, these benefits have not reached evenly across every segment of American society. Significant differences in oral health continue to remain for some population groups, with variations occurring according to sex, age, geographical location, income, race/ethnicity, education level and insurance coverage status.
Caries continues to be the single most prevalent chronic disease among children in the United States, despite its being highly preventable through early and sustained home care and regular professional preventive services.1 The U.S. surgeon general’s 2000 report Oral Health in America2 highlighted the fact that "dental caries is the single most common chronic childhood disease—5 times more common than asthma and 7 times more common than hay fever." The report noted that one-fifth of America’s preschoolers and one-half of second graders had experienced caries. Among the highlights of the report’s data on children’s oral health was the emphasis on the striking disparities in dental disease according to income, with one of four children in America born into poverty and having twice as much dental caries as their more affluent peers.2 According to the U.S. surgeon general’s report, more than 108 million children and adults lacked dental insurance in 2000, which was more than 2.5 times the number who lacked medical insurance that year; these children also were 2.5 times less likely than insured children to receive dental care.2
An important factor to address is the importance of enhancing an understanding of the relationship between the oral cavity and the rest of the body. Dental health assessments often reveal warning signs of various systemic diseases. Unfortunately, the popular misconception that oral health is less important than, and separate from, general health may contribute to avoidance of or postponement of much-needed care and may affect existing conditions. Therefore, efforts to gain acceptance of the importance of oral health and its interdependence with general health should include a focus on medical practitioners and other nondental health care professionals as part of routine medical visits.
The American Academy of Pediatric Dentistry3 and the American Dental Association4 recommend that children have two dental visits per year beginning at the age of 1 year. In addition, the American Academy of Pediatrics5 recommends that children begin regular visits to a dental professional "six months after the first tooth erupts or by 12 months of age."
The literature on nondentists’ referral of young patients to dentists concentrates mostly on pediatricians, since they see a large number of young patients in well-child visits who may not have been seen by a dentist. If pediatricians’ awareness about oral health is increased, they may play an important role in establishing good oral health for their patients by referring them at an early age to a dentist for preventive treatment, therapeutic treatment or both.6 A survey done by University of Washington researchers revealed that pediatricians saw dental problems regularly. They reported some difficulty in achieving successful referrals. More that 90 percent said they felt they have an important role in identifying dental problems and providing preventive information to caregivers.6
Pediatric primary care providers in North Carolina who were surveyed indicated that they were very likely (78 percent) to refer children who had clinical caries or were at high risk of developing caries.7 The chances for an early referral increased as clinicians expressed confidence in their ability to adequately screen patients, they experienced little difficulty in arranging the referral and were in group practices.7 It appears that dental screenings can be incorporated easily into pediatric primary care practices,8 although in the North Carolina survey, practitioners not in group practices whose practices contained more than 60 percent infants and toddlers were less likely to refer their patients to dentists.7 Educational programs aimed at enhancing physicians’ knowledge of oral health and oral disease prevention can have a positive impact on physicians’ referring patients to dentists when patients are at an early age.9
Education also should be aimed at administrators and at nondental providers besides pediatricians. Such efforts could include an attempt to demonstrate the advantages of early referral to dentists, and the benefit of making a recommendation for referral on the basis of disease risk assessment and the esthetic and functional benefits to be gained by early intervention.10
This article examines the practice of nondentist health care providers in the role of providing advice to children and adolescents to obtain a dental checkup. Specifically, we study the patient practices of nondentist health providers as measured by their providing advice to child and adolescent patients to obtain a dental checkup and the relationship of this advice with actual dental visits, dental care checkups in the context of family income and other sociodemographic characteristics by analyzing data from the 2003 Medical Panel Expenditure Survey (MEPS)11 conducted by the Agency for Healthcare Research and Quality (AHRQ) (described in Cohen12).
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METHODS
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The 2003 MEPS is the third in a series of nationally representative health surveys of the U.S. community-based population sponsored by AHRQ and the National Center for Health Statistics. The MEPS collects data on people’s health care expenditures, use and payment sources, along with information about their socioeconomic status, demographic characteristics and health insurance. The target for the 2003 MEPS was a sample of 16,440 households who had participated in the 2001 or 2002 National Health Interview Survey (NHIS). To collect health expenditure and use data for 2003, MEPS personnel interviewed each MEPS household in person three times across approximately 18 months. The combined NHIS response rate and full-year 2003 response rate of the MEPS sample through the third round was about 65 percent.11
The focus of this analysis is on overall entry into the dental care system, dental examinations and advice received by children and adolescents from nondentist health care providers to obtain a dental checkup. Specifically, we provide national estimates of the percentage of the U.S. civilian noninstitutionalized population aged 2 through 17 years who had a dental visit, who had a dental checkup or who received advice from a nondentist health care provider to have a dental checkup. We present data for each of several socioeconomic and demographic categories.
This study uses the terminology as described in the MEPS HC-079: 2003 Full Year Consolidated Data File, November 2005,13 and the dental visits public use data set of the 2003 MEPS HC-077B14 to distinguish between "dental checkup advice," "dental checkup" and "dental visit." The survey question regarding dental care checkup advice asked whether a doctor or other health care provider had ever given the respondent or his or her family member(s) advice about having regular dental checkups. "Having a dental checkup" was defined as the respondent’s or family member’s having received a dental checkup at least once a year. "Dental visits" was defined as care by or visits to any type of dental care provider, including general dentists, dental hygienists, dental technicians, oral surgeons, orthodontists, endodontists and periodontists. Although these two measures of use are similar, dental visits may include but are not limited to dental checkups.
Estimates obtained for this analysis are based on data from the child health supplement, preventive care and access to care sections of the Household Component of the Medical Expenditure Panel Survey13 and the MEPS dental visits event file for 2003.14 We computed all estimates and standard errors, taking into account the complex sampling design of MEPS with the use of the SUDAAN software package (Version 6.40, Research Triangle Institute, Research Triangle Park, N.C.). We discuss only differences that are statistically significant at the .05 level here.
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RESULTS
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There were 8,983 total participants in the 2003 MEPS aged 2 to 17 years, representing about 65,514,000 noninstitutionalized children in the United States. Of these, slightly less than one-fourth (2,230), representing about 15,936,000 children, were aged 2 through 5 years and slightly less than one-third (2,780), representing about 20,938,000 children, were aged 13 through 17 years. Approximately one-half (49 percent, n = 4,371) of all participants were female, 61 percent (n = 5,441) were Hispanic, black non-Hispanic or other/mixed-race non-Hispanic, and almost 58 percent (n = 5,172) were from poor, near-poor or low-income families.
Overall, 51 percent (n ~ 33,661,000) of all children aged 2 through 17 years had a dental checkup during 2003 (data not shown). We noted differences (P < .05) in the likelihood of a dental checkup according to the following characteristics and demographics:
- – income (those who were poor, near-poor or low-income were less likely than were those who were middle- or high-income);
- – age (those aged 2 through 5 years were less likely than were those aged 6 through 12 years and 13 through 17 years);
- – race/ethnicity (those who were Hispanic were less likely than were those who were black non-Hispanic or white non-Hispanic);
- – parents’ educational attainment level (those who had not graduated from high school were less likely compared with those who had at least a high school education);
- – health status (among the middle- or high-income families, those whose health status was fair or poor were less likely than were those whose health status was excellent, very good and good);
- – health insurance coverage (those who had only public health insurance or no insurance were less likely than were those who had only private insurance.
The figure
shows the percentage of the population that had had a dental checkup during 2003 according to income and insurance coverage. Data show that children of families with higher income (200 percent or more of the federal poverty guideline [FPG]) were more likely (P < .05) to have received a dental checkup than were lower-income children (less than 200 percent of the FPG) for each insurance status category. The difference was particularly striking for the uninsured, with middle- and high-income children more than twice as likely as lower-income children to have received a dental checkup in 2003.
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Figure. Dental checkups by health insurance status and income, 2003, from the 2003 Medical Expenditure Panel Survey. Private Health Insurance Only: Participants who had private health insurance and no dental insurance. Public Health Insurance Only: Participants who had public health insurance, no private health insurance and no dental insurance. Private Dental Insurance: Participants who had private dental coverage (individuals may have private or public health insurance). No Insurance: Participants who had no private health insurance, public health insurance or dental insurance. Source: Agency for Healthcare Research and Quality.13,14
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Table 1 (page 1328) and Table 2 (page 1329) provide data according to poverty status on the percentage of the population that had had a visit or a dental checkup or who received advice from a non-dentist health care provider to have a dental checkup during 2003. Table 1 provides data for children from families who were in the limited-income or poor, near-poor or low-income categories (less than 200 percent of the FPG). Overall, 38 percent (n ~ 9,516,000) of all poor, near-poor or low-income children aged 2 through 17 years had a dental checkup during 2003. Interestingly, income-stratified data show differences in several categories not observed with aggregated data. For instance, poor, near-poor or low-income black non-Hispanic children did not differ significantly (P > .05) from similar white non-Hispanic children in terms of having had a dental checkup. On the other hand, poor, near-poor or low-income black non-Hispanic and white non-Hispanic children were more likely (P < .05) than were similar Hispanic children to have had a dental checkup. We detected no significant differences between poor, near-poor or low-income children who had dental insurance (P >.05) and similar children who had only health insurance in terms of having had a dental checkup. Also, poor, near-poor or low-income children who had a good, fair or poor health status did not differ significantly (P > .05) from similar children who had an excellent or very good health status in having had a dental checkup.
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TABLE 1 Dental services obtained by poor, near-poor or low-income* U.S. children aged 2 through 17 years, by selected population characteristics, 2003.
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TABLE 2 Dental services obtained by middle- or high-income* U.S. children aged 2 through 17 years, by selected population characteristics, 2003.
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Table 1
also shows that the rates of dental care use closely match the rates of reported checkups, overall and for each category reported. On the other hand, Table 1 shows that dental checkup rates for poor, near-poor and low-income children are lower overall (P < .05) than the rates of similar children who were advised by a nondentist health provider to have a dental checkup. These lower rates are consistent across several categories, including sex, age (2 through 5 years and 6 through 12 years), race/ethnicity (Hispanic and black non-Hispanic), education, health status and insurance coverage (public health insurance only and no insurance). We detected no significant differences between the categories of age 13 through 17 years, white non-Hispanic race/ethnicity and only private health and dental insurance.
Table 2 provides data for children from middle- or high-income families (
200 percent of the FPG). Overall, 60 percent (n ~ 24,225,000) of all middle- or high-income children aged 2 through 17 years had had a dental checkup during 2003. Middle- or high-income black non-Hispanic children did not differ significantly (P > .05) from similar Hispanic children in terms of having had a dental checkup. However, middle- or high-income black non-Hispanic children and Hispanic children were less likely (P > .05) than similar white non-Hispanic children to have had a dental checkup. Middle- or high-income children whose parents had higher levels of education were more likely (P < .05) to have had a dental checkup than were similar children whose parents had less education. Middle- or high-income children with poor, fair or good health status were less likely (P < .05) to have had a dental checkup than were similar children with a very good or excellent health status. Middle- or high-income children with private dental insurance were much more likely (P < .05) than were similar children with private or public health insurance only or with no insurance to have had a dental checkup.
As with Table 1, Table 2 also shows that rates of dental care use closely match rates of reported checkups overall and for each category reported. Unlike Table 1, Table 2 shows that dental checkup rates overall for higher-income children are greater (P < .05) than rates for similar children advised by a nondentist health provider to have a dental checkup. These higher rates are consistent across several categories, including sex, age (6 through 12 years and 12 through 17 years), race/ethnicity (white non-Hispanic), education (some college), health status (excellent and very good) and insurance coverage (private dental insurance). We detected no significant differences between the categories of race/ethnicity (Hispanic and black non-Hispanic), education (some or no schooling and high school degree), health status (good or fair or poor) and insurance coverage (private health insurance only, public health insurance only and no insurance).
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DISCUSSION
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The MEPS data provide nationally representative estimates and include data elements that describe dental visits, dental checkups and advice to receive a dental checkup for a variety of demographic and socioeconomic categories. Although these data and analyses are useful, they have limitations. For instance, data are self-reported and may be less accurate than would be data collected by means of observation or dental record abstraction. On the other hand, these data are useful and provide important observations on dental care in the context of disaggregated income. Generally, the rate at which nondentist health care providers recommended that patients seek a dental examination uniformly hovered just below 50 percent in both income groups. Results suggest that the message has gotten out to some nondentist health providers that children should visit the dentist even at a very young age, as evidenced by the rate of referral for dental examinations for children aged 2 through 5 years. About one-half of low-income children either are unable to respond to these recommendations when given or have parents who choose not to respond. The reasons for not following up on referrals were not probed in the MEPS interviews.
We detected no significant differences between overall health status and an initial dental care encounter in the low-income group as compared with the higher-income group. Perhaps these data suggest that having insufficient economic resources may mask the effect of health status among poorer children. Overall, good general health among poorer children may be insufficient to overcome other difficulties related to access to dental care. It also is interesting that the use of dental care between rural and urban populations did not differ significantly when we controlled for income category. Income level, rather than geographical location, seems to be a more important determinant for entry into the dental care system. We also were not surprised to find that the rate at which children seek dental care is related to the educational level achieved by their caregivers. This may suggest that the awareness of good health and what is required to maintain it increases as the level of education increases.
Access to dental care is a complex matter, and we did not examine in this study all of the important factors that have a bearing on it. For example, we did not consider the availability of dentists to provide care financed by public assistance programs. Nonetheless, we examined several important factors in this study, including income, parents’ educational level, racial/ethnic background and insurance coverage status. It should be apparent that all of these factors are important in determining children’s use of dental care. Assistance programs aimed at facilitating entry into the dental care system should consider how these socioeconomic and health-related characteristics might affect their operation. For example, simply reducing financial barriers may not solve an apparent access problem. These data illustrate that factors other than income may affect a person’s propensity to use dental care. An adequate base level of income or subsidization of actual income by insurance, for example, may be beneficial in helping make dental care available. However, adequate resources alone may not guarantee an adequate level of dental care. Awareness of the need for good oral health among those with lower incomes, perhaps through education, may also be required.
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CONCLUSION
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Overall, 51 percent of all children aged 2 through 17 years had a dental checkup during 2003. Income-stratified data show that while poor, near-poor and low-income children were as likely as higher-income children to be advised by a nondentist health care provider to have a dental checkup, they were less likely to report having had a dental checkup during 2003 than were higher-income children. These data illustrate that although children with differing levels of income did not differ significantly in having received advice from a nondentist health care provider to have a dental checkup, children with higher levels of income were more likely than were children with less income to actually seek a checkup. Our data suggest that additional effort is warranted to ensure that all children get needed or recommended dental care.
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FOOTNOTES
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Ms. Chu is a survey statistician, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, Md. 20850, e-mail "may.chu{at}ahrq.hhs.gov". Address reprint requests to Ms. Chu.
Dr. Sweis was the 2005–2006 Hillenbrand Fellow, American Dental Association, Chicago, when this article was written. She now is a clinical assistant professor, Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago College of Dentistry.
Dr. Guay is the chief policy advisor, American Dental Association, Chicago.
Dr. Manski is the senior scholar, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Md., and a professor and the director, Division of Health Services Research, Dental School, University of Maryland, Baltimore.
The investigation described in this article was supported by intramural funds from the Agency for Healthcare Research and Quality, Rockville, Md.
The views expressed in this article are those of the authors, and no official endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services is intended or should be inferred.
The authors thank Joel Cohen, Steven Cohen and Doris Lefkowitz for their comments on an earlier draft, and Teresita Monasterio of Social and Scientific Systems, Bethesda, Md., for her skillful computer programming support.
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REFERENCES
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- Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey HC-077B: 2003 dental visits, August 2005. Available at: "http://www.meps.ahrq.gov/mepsweb/data_stats/download_data/pufs/h77b/h77bdoc.pdf#xml=http://207.188.212.220/cgi-bin/texis/webinator/search/pdfhi.txt?query=dental+visits&pr=MEPSFULLSITE&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&sufs=0&order=r&cq=&id=46dd08bc1bd". Accessed Sept. 4, 2007.
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ABSTRACT
METHODS
