- Email: [email protected]
Oral Health Among Children With and Without Special Health Care Needs
Parental Perceptions of Dental/Oral Health Among Children With and Without Special Health Care Needs Mary Kay Kenney, PhD; Michael D. Kogan, PhD; James J. Crall, DDS, ScD Objectives.—The aims of this study were to determine the prevalence of parent-reported preventive dental care and better dental health in children with special health care needs (CSHCN) and to identify parent-reported dental problems, reasons for lack of preventive dental care, and factors associated with receiving preventive care and having better perceived dental health in CSHCN. A comparison group of children without special needs (CWOSN) was included. Methods.—We analyzed the 2003 National Survey of Children’s Health by using a sample of 17 001 CSHCN and a comparison group of CWOSN. Descriptive and between-group chi-square statistics were used to analyze child characteristics, parent-perceived dental problems, and reasons for lack of preventive dental care. Factors associated with receipt of preventive dental care and better reported dental health were examined using logistic regression. Results.—Approximately 80% of CSHCN and 72% of CWOSN received preventive dental care. CSHCN parents reported more
dental problems and fewer described their children as having good to excellent dental health compared to CWOSN, despite greater odds of having dental coverage and receiving preventive dental care. Disparities were evident in preventive dental care and dental health based on income, education, and insurance coverage. Conclusions.—Most parents of CSHCN and CWOSN report that their children receive preventive dental care and have good to excellent dental health; however, disparities in dental health and receipt of preventive dental care exist. Accessing care coordination by using the medical/dental home model, particularly for CSHCN, may alleviate the situation in which some of the most vulnerable children are experiencing the worst dental health.
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10.4% among CSHCN based on analysis of the National Survey of Children with Special Health Care Needs 2001. The odds of having unmet dental needs were greater for the economically disadvantaged and uninsured, but less for those with a regular doctor.3 In addition, differences in unmet need were evident, based on age, gender, race/ethnicity, and mother’s education. Analysis of 4 state surveys of CSHCN enrolled in the State Children’s Health Insurance Program (SCHIP) indicated that unmet dental care need varied from 7.9% to 30.9%, and the most frequent parent-reported reasons for unmet dental needs were lack of insurance and the cost of care.6 Estimates from the National Health Interview Survey on Disability 1994–1995 indicated that 8.1% of CSHCN had unmet dental needs, but that the odds were 4 times greater for the uninsured than the insured.7 The relationship between unmet dental need and dental/ oral health in CSHCN is unknown. Previous surveys of CSHCN have reported unmet dental needs or dental visits and the barriers to utilization. Issues that have not been addressed are oral health status and its relation to preventive dental care, which according to the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD), should be pursued aggressively by 6 to 12 months of age in children with disabilities.8,9 National estimates of oral health status and preventive dental care among CSHCN are currently not available. The National Survey of Children’s Health provides one opportunity to
KEY WORDS: children with special health care needs; dental insurance; National Survey of Children’s Health; parent-perceived dental health; preventive dental care Ambulatory Pediatrics 2008;8:312–20
hildren with special health care needs (CSHCN) are at greater risk for poorer oral health than children in the general population due to more frequent oral infections and periodontal disease, enamel irregularities, moderate-to-severe malocclusion, and craniofacial birth defects.1,2 Certain medications, special diets, and difficulty in maintaining daily hygiene further affect their oral health and increase their risk of dental caries. However, access to dental care to address their heightened need is often more compromised than access to medical care or prescription medicines.3,4 The US Surgeon General stated that ‘‘analysis of the determinants of oral health status, access to care, and the role of oral health’’ among people with disabilities are needed.5 Toward that end, unmet dental need has been estimated at From the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Rockville, Md (Dr Kenney and Dr Kogan); and School of Dentistry, University of California, Los Angeles, Maternal and Child Health Bureau National Oral Health Policy Center, Los Angeles, Calif (Dr Crall). The views in this article are those of the authors and not necessarily those of the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Address correspondence to Mary Kay Kenney, PhD, U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 5600 Fishers Lane, Rm 18-41, Rockville, Maryland 20857 (e-mail: [email protected]). Received for publication November 16, 2007; accepted April 17, 2008. AMBULATORY PEDIATRICS Copyright Ó 2008 by Academic Pediatric Association
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gain insight into the use of preventive dental care and oral/ dental health in CSHCN via parent report. An awareness of parent perceptions regarding their children’s oral health status, dental problems, and the use of preventive dental care is important for pediatric health care providers, who generally have the most consistent contact with CSHCN and their families. Parents are the principal decision makers regarding their child’s health. Their perceptions can have a major influence on preventive care and treatment choices, and are, therefore, important to a comprehensive understanding of the issues.10–12 The intent of this paper is to 1) determine the prevalence of parent-reported preventive dental care utilization and better reported dental health in CSHCN, 2) identify parent-reported dental problems and reasons for lack of preventive dental care, and 3) identify sociodemographic, insurance, and health service–related factors associated with preventive dental care and better parent-reported dental health. Comparison data from children without special needs (CWOSN) are included to aid interpretation of results. METHODS Data Source/Population The National Survey of Children’s Health was the data source for these analyses and has been described in detail elsewhere.13,14 The populations of interest were 1- to 17year-old CSHCN and CWOSN. Survey screening questions identify CSHCN, defined as children with a health condition lasting (or expected to last) at least 1 year and resulting in at least one of the following: using or needing more medical care, mental health services, or educational services than typically required by children of the same age; using or needing prescription medicines; having limitations in the ability to do things other children of the same age do; using or needing special therapy (ie, physical, occupational, or speech therapy) or assistive devices; and using or needing emotional, developmental, or behavioral treatment or counseling.13 Of the original 102 353 cases, the following exclusions were made: 1) cases with missing data for 1 or more variables of interest (except income) and 2) case children <1 year of age. After excluding 5843 cases with children aged <1 year, 733 cases with no responses for dental outcomes, and 9133 cases with missing data points for 1 or more of the remaining covariates (except income), the resulting sample size consisted of 86 644 cases. Human subjects review was not required. Variables Sociodemographics Included in the analysis were several sociodemographic independent variables having previously hypothesized associations with receipt of health/dental care: race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other), gender, age (1–5, 6–11, and 12–17 years), poverty (<100%, 100%–199%, 200%–399%, and $400% of federal poverty level), and parent education
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(less than high school, high school, and more than high school).3,6,7 Other independent factors with hypothesized associations included dental insurance coverage for any routine preventive dental care, including cleaning, x-rays, and examinations (yes/no), health insurance coverage (uninsured, public, private), and having a personal doctor (yes/no). Preventive Dental Care, Dental Health, and Dental Problems Preventive dental care prevalence was determined by answers to the following questions, all referenced to the previous 12 months: ‘‘Did [survey child] see a dentist for any routine preventive dental care, including checkups, screenings, and sealants? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists (yes/no).’’ Unmet need for preventive dental care was determined by the question ‘‘Did [survey child] receive all the routine preventive dental care [he/she] needed?’’ Fifteen response options (with multiple choices possible) were provided to explain why preventive care was not received (eg, costs too much, no insurance). Parent-perceived dental health was determined by ‘‘How would you describe the condition of [survey child’s] teeth: excellent, very good, good, fair, poor?’’ Parent-perceived dental problems in children described as having fair or poor dental health were established in response to ‘‘What specific problems does [survey child] have with [his/her] teeth?’’ Parents were provided 12 response options (eg, pain, cavities), with multiple choices possible. Analytic Approach All analyses were stratified on the basis of whether a child had special needs (CSHCN) or not (CWOSN). Bivariate chi-square statistics (c2; P < . 001) were used for between-group (ie, CSHCN vs CWOSN) comparisons of the following: sample percentages for each of the child/ family sociodemographic variables, the percentage of children receiving preventive dental care as a function of selected independent variables, and the proportions of the sum of parent-reported dental problems relative to the number of children with parent-reported fair/poor dental health. Pair-wise between-group comparisons (P < . 001) of weighted percentages were conducted following significant bivariate chi-square tests of variables in the analyses of sample sociodemographic characteristics and prevalence of preventive dental care. Parent-reported dental problems and reasons for not receiving all the needed preventive dental care were summarized using descriptive statistics. Logistic regression analyses were performed to determine the factors associated with 1) receipt of preventive dental care and 2) better parent-perceived dental health (ie, good/very good/excellent). Bivariate logistic models were constructed to identify characteristics significantly associated with the outcome variables, whereas multivariate models controlled for the effects of all other independent variables in the analysis. Both unadjusted (bivariate) and adjusted (multivariate) odds ratios and 95% confidence
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Table 1. Child and Respondent Demographic Characteristics Among CSHCN* and CWOSN† CSHCN
Total Reported dental health Excellent/very good Good Fair/poor Age, y 1–5 6–11 12–17 Income (FPL)§ <100% 100%–199% 200%–399% 400%þ Missing Race/ethnicity Hispanic Non-Hispanic Black Non-Hispanic Other Non-Hispanic White Gender Male Female Parent educationHigh school Dental insurance Yes No Personal doctor Yes No Health insurance Uninsured Public Private
No. Unweighted
No. Weighted
17 001
11 517 155
11 805 3521 1634
7 700 676 2 504 078 1 266 914
2977 5986 8038
CWOSN % (SE)
No. Unweighted
No. Weighted
% (SE)
P value‡
69 643
48 034 093
67.13 (0.65) 21.83 (0.57) 11.04 (0.46)
52 689 12 465 3943
34 687 471 9 568 958 3 478 209
72.67 (0.31) 20.05 (0.28) 7.29 (0.20)
<.001 <.001 <.001
2 249 828 4 394 292 4 873 035
19.53 (0.56) 38.15 (0.66) 42.31 (0.65)
21 176 22 016 26 451
14 757 868 16 347 320 16 928 905
30.72 (0.31) 34.03 (0.32) 35.24 (0.32)
<.001 <.001 <.001
1902 3067 5699 5311 1022
1 822 546 2 379 100 3 526 655 3 074 466 714 388
15.82 (0.56) 20.66 (0.58) 30.62 (0.59) 26.69 (0.54) 6.20 (0.33)
6203 12 222 24 344 21 425 5449
6 215 570 9 381 292 15 415 410 12 905 575 4 116 246
12.94 (0.26) 19.53 (0.27) 32.09 (0.30) 26.87 (0.28) 8.57 (0.20)
<.001
1024 1681 1335 12 961
772 590 1 859 947 846 492 8 038 126
6.71 (0.39) 16.15 (0.58) 7.35 (0.42) 69.79 (0.69)
5751 6988 5554 51 350
4 827 726 7 493 085 3 767 314 31 945 968
10.05 (0.22) 15.60 (0.27) 7.84 (0.23) 66.51 (0.34)
<.001
9782 7219
6 768 283 4 748 872
58.77 (0.66) 41.23 (0.66)
34 652 34 991
23 557 502 24 476 591
49.04 (0.33) 50.96 (0.33)
<.001 <.001
493 3248 13 260
560 264 2 821 515 8 135 377
4.86 (0.36) 24.50 (0.61) 70.64 (0.65)
2081 13 864 53 698
2 506 268 11 998 737 33 529 089
5.22 (0.19) 24.98 (0.30) 69.80 (0.32)
13 904 3097
9 478 321 2 038 834
82.30 (0.50) 17.70 (0.50)
53 659 15 984
37 510 915 10 523 178
78.09 (0.27) 21.91 (0.27)
<.001 <.001
15 642 1359
10 495 565 1 021 590
91.13 (0.40) 8.87 (0.40)
59 726 9917
40 357 638 7 676 455
84.02 (0.27) 15.98 (0.27)
<.001 <.001
768 4513 11 720
539 838 3 720 608 7 256 709
4.69 (0.29) 32.30 (0.68) 63.01 (0.68)
5258 12 615 51 770
3 921 786 10 813 018 33 299 290
8.16 (0.19) 22.51 (0.30) 69.32 (0.32)
<.001 <.001 <.001
<.001 <.001
*CSHCN indicates children with special health care needs. †CWOSN indicates children without special needs. ‡Results of significance testing for between-group pair-wise comparison of weighted percentages within each category of the independent variables. §FPL indicates federal poverty level.
intervals were computed. All estimates were statistically weighted to reflect population totals by using sample weights provided by the data collection agency. The statistical analysis was conducted using SUDAAN (Research Triangle Institute, Research Triangle Park, NC) to account for a complex sample design. RESULTS This sample represented children aged $1 year who would be expected to have erupted deciduous or permanent teeth and, according to the AAP and the AAPD guidelines, should have begun regular dental visits for routine preventive care.8,9 Of these children, 17 001 were CSHCN, comprising 19.6% of the total (Table 1). Table 1 indicates that the majority of parents described their children as having excellent or very good dental health; however, a higher proportion of CSHCN parents reported that their children had fair to poor dental health (P < . 001). Significantly higher proportions of CSHCN had a personal doctor, had dental
coverage for preventive care, and were publicly (vs privately) insured, whereas significantly fewer were uninsured (P < . 001). Dental Problems Significantly higher proportions of dental problems were reported by parents of CSHCN compared to parents of CWOSN (P < . 001). The highest frequency dental problems of children with fair/poor dental health were cavities, crooked or broken teeth, grinding, and pain, though the relative proportions of these problems varied as a function of age (Table 2). The highest frequency reported dental problems of 1- to 5-year-olds were cavities and broken teeth. Parents of 6- to 11-year-olds continued to report cavities as the most frequent problem, but crooked teeth were noted as a source of increasing concern. During adolescence, parent concerns about crooked teeth continued to grow in both groups. Overall, the more frequently reported problems were similar for CSHCN and CWOSN, though more
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Table 2. Prevalence Estimates of the Most Frequent Parent-Perceived Dental Problems of Children* CSHCN† Age 1–5 year-olds
6–11 year-olds
12–17 year-olds
CWOSN‡
Dental Problems
% (SE)
Dental Problems
% (SE)
Cavities Broken teeth§ Bad color Grindingk Pain Crooked teeth{ Cavities Crooked teeth{ Broken teeth§ Grindingk Pain Poor hygiene** Cavities Crooked teeth{ Broken teeth§ Pain Other Poor hygiene**
64.4 (5.84) 22.5 (6.70) 14.3 (5.95)†† 11.7 (4.83)†† 11.1 (6.05)†† 6.3 (1.91)†† 55.7 (3.02) 34.8 (2.87) 14.8 (2.40) 9.3 (1.88) 5.2 (1.35) 4.3 (1.17) 49.7 (3.20) 48.6 (3.21) 12.8 (2.40) 7.7 (1.38) 7.2 (1.73) 6.4 (1.44)
Cavities Broken teeth§ Crooked teeth{ Grindingk Bad color Other Cavities Crooked teeth{ Broken teeth§ Grindingk Pain Other Crooked teeth{ Cavities Broken teeth§ Pain Poor hygiene** Bad color
70.4 (2.32) 13.7 (1.65) 7.3 (1.20) 7.2 (1.23) 5.3 (1.26) 3.0 (0.59) 57.7 (1.83) 31.8 (1.77) 11.6 (1.30) 7.1 (0.88) 3.5 (0.97) 3.0 (0.71) 50.3 (2.19) 39.8 (2.12) 7.8 (1.16) 5.2 (1.00) 5.2 (1.22) 4.1 (0.99)
*Rank ordering of prevalence estimates by age. Children reported to have fair/poor dental health. Multiple responses were allowed. †CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §And/or teeth that need repair. kAnd/or soft teeth, teeth pulled, or teeth falling out. {And/or teeth that need braces. **And/or plaque, doesn’t brush regularly, needs cleaning. ††Some of the estimates in this report were based on small cell sizes (<30) because they reflect infrequent dental problems in the CSHCN population, such as tooth pain in the 1–5-year-old age group. These estimates are usually accompanied by large variances, indicating that the estimates may not be reliable. Using a ratio of the standard error over the percent estimate (ie, the coefficient of variation), a cutoff value of of 0.3 (or 30%) was adopted as an indicator of the estimate’s reliability. If the coefficient of variation is $0.3, then the percent estimate is considered unreliable. All unreliable estimates defined as such are marked. Not shown are the dental problems with the lowest frequencies and consistently unreliable estimates in all age groups: bad enamel, bad gums, nerve problems, and no problems.
widely reported among CSHCN parents. CSHCN with speech or behavior disorders, learning disabilities, physical impairment or developmental delay, and autism tended to be more frequently described as having fair/poor dental health (Figure). Routine Preventive Dental Care Most parents reported that their children received preventive care in the previous 12 months (Table 3); however, the proportion was higher for CSHCN (P < . 001). The unadjusted odds of receiving preventive care (for both CSHCN and CWOSN) were significantly lower for 1- to 5-year-olds and those that were less economically advantaged, were of non-White race/ethnicity, had less-educated parents, had no personal doctor or dental coverage, had poorer dental health, and were uninsured or publicly insured. After adjusting for covariates, the odds of receiving preventive dental care were no longer significantly different from the reference groups for the Hispanic and nonwhite CSHCN and Hispanic CWOSN, the CWOSN with fair/poor dental health, and the publicly insured CSHCN and CWOSN. Adjusting for covariates revealed marginally significant lower odds of receiving preventive care for male versus female CWOSN. Among the most common reasons reported for not receiving all the needed dental care were lack of insurance, dental care cost, health plan problem, appointment time issue, and unaccepted insurance (Table 4). Parents of both
CSHCN and CWOSN reported lack of insurance coverage as the primary reason and dental care cost as the second most common reason. Approximately 18% of CSHCN and 22% of CWOSN parents reported having no dental coverage to help pay for preventive dental care, including cleanings, x-rays, and examinations. For CSHCN who did not receive any preventive dental care within the previous 12 months, 46.2% had private health insurance, 42.5% had public insurance, and 11.3% were uninsured. Among CWOSN who did not receive any preventive dental care, 50.8% had private insurance, 32.0% had public insurance, and 17.3% were uninsured. More parents of CSHCN (4.4%) versus CWOSN (2.8%) who received preventive care reported not receiving all the preventive dental care that was needed (P <. 001). CSHCN with unmet need for preventive dental care had the following breakdown of general health insurance coverage: 36.6% with private insurance, 53.3% with public insurance, and 10.3% without any health insurance. For CWOSN, 43.9% were privately insured, 34.1% were publicly insured, and 22.0% had no health insurance. Thus, for CSHCN, relatively high percentages of children without preventive care or with unmet need for preventive care were publicly insured. Better Reported Dental Health We next examined the factors associated with better (ie, excellent/very good/good) reported dental health (Table 5).
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22.7
Speech 21.3
Behavior 19.7
LD DD or Physically Impaired
18.8
Autism
18.7
Hearing/Visually Impaired
18.6 18.1
Musculoskeletal Depression/ Anxiety
17.3 15.9
ADD 12.0
Asthma 8.1
*Diabetes 0.0
5.0
10.0
15.0
20.0
25.0
Figure. Percentage of children with special health care needs in reported fair/poor dental health across disorders. LD indicates learning disability; DD indicates developmental delay; ADD indicates attention deficit disorder. *Some of the estimates in this report were based on small cell sizes (<30). These estimates are usually accompanied by large variances, indicating that the estimates may not be reliable. Using a ratio of the standard error over the percent estimate (ie, the coefficient of variation), a cutoff value of 0.3 (or 30%) was adopted as an indicator of whether the estimate is reliable or not. If the coefficient of variation is $0.3, then the percent estimate is considered unreliable. All unreliable estimates defined as such are asterisked.
As with the preventive care model, an influential adjusted factor associated with better reported dental health for both CSHCN and CWOSN was age, but the odds of better dental health were higher only for the youngest children, particularly the 1- to 5-year-old CSHCN. Increasing income was also strongly associated with improved odds of better reported dental health for both groups. An unexpected finding was that, after adjustment, receiving preventive dental care was not associated with better reported dental health for CSHCN and was associated with poorer dental health for CWOSN. Differences were noted across the 2 adjusted models for factors related to having a personal doctor, dental coverage, health insurance coverage, and race/ethnicity. Although CSHCN and CWOSN with a personal doctor showed higher odds of receiving preventive care, the odds of better dental health for CSHCN were not improved by having a personal doctor. Having dental coverage doubled the odds of receiving preventive dental care, though its effect on having better reported dental health was considerably less. Private (vs public) insurance increased the odds for CSHCN of having better reported dental health, but not for receiving preventive dental care. For CWOSN, Hispanic ethnicity was associated with poorer reported dental health, but no difference in receipt of preventive dental care.
DISCUSSION The National Survey of Children’s Health provides new information about parent-perceived dental health and dental problems in CSHCN, the variation in parent-perceived dental health across a range of developmental conditions, and the factors associated with the use of preventive dental
care and better reported dental health. The current analysis indicated that approximately 1.3 million 1- to 17-year-old CSHCN (11.0%) already burdened with other developmental and health concerns were described by their parents as having fair to poor dental health. These figures may be somewhat at odds with recently published data indicating that the prevalence of untreated tooth decay in the general population during the 1999 to 2004 period was 20.5% for 2- to 5-year-olds, 24.5% for 6- to 11-year-olds, 16.9% for 12- to 15-year-olds, and 22.2% for 16- to 19-year-olds.15 Those proportions may be higher in CSHCN than the general population due to greater susceptibility to dental disorders and disease, suggesting possible parent underestimation of dental disease burden in the data presented here.1,2,16 Research findings regarding parent assessment of dental health are divided. It has been suggested that caregivers may base their judgments on fairly severe or extreme conditions and may be unaware of conditions in which the dentition is diseased, but not so obviously compromised.17 Yet, there is some evidence that parents’ judgments have a moderately high positive correlation with clinical evidence of tooth decay.10,12 Other findings indicate that caregivers’ assessments of their children’s dental health are positively associated with having carious teeth and a need for dental treatment.11 Thus, parents’ perceptions may be in the right direction, but may not always demonstrate a full appreciation of less observable, though active disease processes. Another finding presented here was that 20%, or 2.3 million CSHCN, were reported as not receiving routine preventive dental care within the previous 12 months. An additional 0.4 million children were underserved (ie, those who received preventive care, but not all the needed care).
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Table 3. Prevalence and Odds Ratios for Receiving Preventive Dental Care in the Past 12 Months CSHCN† % Total Reported dental health Fair/Poor Good Excellent/Very Good Age, y 1–5 6–11 12–17 Income (FPL)** <100% 100%–199% 200%–399% 400%þ Missing Race/ethnicity Hispanic Non-Hispanic Black Non-Hispanic Other Non-Hispanic White Gender Male Female Parent educationHigh School Personal doctor Yes No Dental insurance Yes No Health insurance Uninsured Public Private
Unadjusted OR§
CWOSN‡ Adjusted ORk
79.60
%
Unadjusted OR
Adjusted ORk
P value{ <.001
72.48
74.11 76.46 82.24
0.62 (0.49–0.77) 0.70 (0.60–0.82) reference
0.71 (0.55–0.91) 0.70 (0.58–0.85) reference
70.42 70.60 73.65
0.85 (0.75–0.97) 0.86 (0.79–0.93) reference
1.06 (0.90–1.26) 0.80 (0.73–0.88) reference
<.001 <.001 <.001
57.58 87.01 84.01
0.26 (0.22–0.31) 1.28 (1.07–1.52) reference
0.24 (0.20–0.29) 1.34 (1.12–1.61) reference
47.79 85.37 81.02
0.20 (0.19–0.22) 1.28 (1.16–1.41) reference
0.16 (0.15–0.18) 1.24 (1.12–1.36) reference
<.001 <.001 <.001
68.11 75.03 82.95 88.76 75.55
0.27 (0.21–0.34) 0.38 (0.31–0.47) 0.62 (0.50–0.75) reference 0.39 (0.29–0.54)
0.38 (0.28–0.51) 0.48 (0.37–0.62) 0.63 (0.52–0.77) reference 0.51 (0.37–0.71)
57.91 65.86 76.76 81.26 69.78
0.32 (0.29–0.35) 0.44 (0.41–0.49) 0.76 (0.70–0.82) reference 0.53 (0.47–0.60)
0.54 (0.46–0.63) 0.59 (0.53–0.66) 0.81 (0.75–0.89) reference 0.73 (0.63–0.84)
<.001 <.001 <.001 <.001 <.001
71.92 72.96 73.36 83.19
0.52 (0.39–0.69) 0.55 (0.45–0.66) 0.56 (0.42–0.74) reference
0.87 (0.63–1.19) 0.80 (0.64–1.01) 0.70 (0.48–1.01) reference
61.07 66.10 69.71 76.51
0.48 (0.43–0.54) 0.60 (0.55–0.65) 0.71 (0.62–0.81) reference
0.91 (0.80–1.04) 0.68 (0.61–0.76) 0.71 (0.60–0.84) reference
<.001 <.001 <.001 <.001
79.29 81.20
0.89 (0.77–1.02) reference
0.91 (0.78–1.06) reference
72.19 73.40
0.94 (0.89–1.00) reference
0.92 (0.86–0.98) reference
<.001 <.001
65.92 73.79 83.23
0.39 (0.28–0.54) 0.57 (0.49–0.66) reference
0.65 (0.44–0.96) 0.77 (0.64–0.93) reference
51.98 66.08 76.77
0.33 (0.28–0.38) 0.59 (0.55–0.63) reference
0.53 (0.44–0.65) 0.71 (0.65–0.78) reference
<.001 <.001 <.001
81.21 68.56
reference 0.50 (0.41–0.62)
reference 0.62 (0.49–0.80)
75.16 60.46
reference 0.51 (0.46–0.55)
reference 0.64 (0.58–0.71)
<.001 <.001
83.19 65.64
reference 0.39 (0.33–0.45)
reference 0.39 (0.33–0.47)
76.67 59.00
reference 0.44 (0.41–0.47)
reference 0.48 (0.44–0.53)
<.001 <.001
58.77 74.51 84.51
0.26 (0.20–0.34) 0.54 (0.46–0.62) reference
0.69 (0.50–0.94) 1.00 (0.81–1.25) reference
51.73 65.03 77.82
0.31 (0.27–0.34) 0.53 (0.49–0.57) reference
0.59 (0.52–0.68) 0.97 (0.87–1.08) reference
<.001 <.001 <.001
†CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §OR indicates odds ratio. kEach variable is adjusted for all other covariates listed in the table. {Results of significance testing for between-group pair-wise comparison of weighted percentages within each category of the independent variables. **FPL indicates federal poverty level.
CSHCN aged between 1 and 5 years were the least likely to obtain preventive dental care, though they would certainly have benefited from the early establishment of preventive strategies as recommended by the AAP and AAPD. Children who receive preventive dental care by age 1 are less likely to have subsequent restorative or emergency visits compared with children with their first preventive dental visits at age 2 or 3.18 Over a 5-year period, the cost for a child beginning preventive care by the first birthday is half the cost of beginning preventive care between the ages of 4 and 5. Without preventive services, dental care may be delayed until toothaches or abscesses necessitate treatment in an emergency room setting. Serious health complications from delayed treatment have also been reported.1,19,20 Consistent with other studies of medical and dental care access, disparities in receiving preventive care were asso-
ciated with insurance coverage and household income, as was parent-reported dental health.21,22 Among the most common reasons parents gave for not receiving all the needed preventive care were 1) lack of insurance coverage, 2) cost of obtaining dental services, 3) health plan problem, and 4) unaccepted insurance. The association suggests the importance of insurance coverage that specifically provides for routine preventive dental care. The vast majority of CSHCN who did not receive preventive dental care had some form of health insurance. For many this coverage did not include dental benefits for preventive care, as indicated by the difference in the percentage of parents with health care coverage (95.3%) and those with insurance that paid for routine preventive dental care (82.3%). In our sample, over 40% of the CSHCN who did not receive any routine preventive care and over 50% who
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Table 4. Prevalence Estimates of Reasons for Not Receiving Preventive Dental Care* CSHCN†
CWOSN‡
Reasons
% (SE)
Reasons
% (SE)
No insurance Costs too much Health plan problem Appointment time issue Insurance unaccepted Other Transportation problem Child refused Forgot appointment Unhappy with dentist Didn’t know where to go Treatment ongoing Inexperienced dentist
29.5 (2.74) 27.5 (2.26) 13.8 (2.51) 12.1 (1.41) 10.4 (2.10) 6.1 (1.14) 5.7 (1.28) 5.6 (1.24) 4.4 (0.95) 3.5 (1.25)§ 3.4 (0.91) 2.6 (0.64) 2.4 (0.90)§
No insurance Costs too much Appointment time issue Health plan problem Other Insurance unaccepted Didn’t know where to go Forgot appointment Child refused Treatment ongoing Transportation problem Inexperienced dentist Unhappy with dentist
31.3 (1.60) 29.9 (1.59) 17.7 (1.29) 9.9 (1.23) 8.9 (1.04) 6.1 (0.94) 5.0 (1.03) 4.4 (0.64) 3.1 (0.51) 3.1 (0.46) 2.9 (0.43) 2.3 (0.78)§ 1.8 (0.41)
*Rank ordering of prevalence estimates. Parent reported for past 12 months. Multiple responses were allowed. †CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §Some of the estimates in this report were based on small cell sizes (<30) because they reflect infrequently reported situations in the CSHCN or CWOSN populations (eg, having an inexperienced dentist). These estimates are usually accompanied by large variances, indicating that the estimates may not be reliable. Using a ratio of the standard error over the percent estimate (ie, the coefficient of variation), a cutoff value of 0.3 (or 30%) was adopted as an indicator of the estimate’s reliability. If the coefficient of variation is $0.3, then the percent estimate is considered unreliable. All unreliable estimates defined as such are marked. Not shown are the reasons with the lowest frequencies and consistently unreliable estimates: no referral was given to parent and no dental resources at survey child’s school.
did not receive all the needed care were publicly insured. Furthermore, the majority of uninsured CSHCN who did not receive any or all the needed preventive dental care were at income levels below 200% of the federal poverty level, suggesting that many were probably eligible for public insurance of one type or another. Although the rate of untreated dental caries is particularly high in US children at the lowest poverty level, only a fraction of the children covered by Medicaid receive preventive dental visits, despite these visits being a program provision.15,23 Dental sealants, shown to be effective in reducing cavities, are underused in the Medicaid population, although they provide savings for the program.24 Finally, a large proportion of uninsured children are eligible, but unenrolled, in public insurance programs.25 Several potential ways to improve the use of preventive dental services in the Medicaid/SCHIP programs have been suggested: parent education, integration of oral health with the general health/behavioral assessment by the health care provider, expansion of the settings where the publicly insured child can be reached (eg, community-based public dental clinics, school-based programs), administrative simplification, oversight of contract standards for managed care network adequacy and incentives, and outreach.22,26–28 It must be noted that although age and income were significant determinants of preventive care and better dental health, other factors such as dental coverage for preventive services had a much stronger effect on receiving preventive care than on having better reported dental health. Given that not having dental coverage was strongly related to not having preventive care, a strong association with poorer reported dental health might also be expected due to the inaccessibility of preventive
services. However, parents reported other dental concerns besides dental caries (eg, crooked teeth) that would require dental/orthodontic procedures beyond preventive care. An understanding of parents’ perceptions regarding the need for more extensive dental services is lacking at present. The above considerations suggest the potential benefit of linkages between the dental home and a system of comprehensive, coordinated care in the medical home to reduce disparities in dental health and preventive dental care, particularly among CSHCN.3,8,29–31 As has been shown here and stated elsewhere, having insurance or even having free access to preventive care does not guarantee utilization of dental or medical health services, particularly for low income groups.23,32 However, receiving comprehensive, coordinated care through a medical home has been shown to increase outpatient and decrease inpatient/emergency room utilization, improve health care equity and health outcomes, increase use of preventive care and satisfaction with health care, and lower costs.33–36 Though having a personal doctor did not increase the odds of having better dental health for CSHCN in this study, the survey did not assess the extent to which CSHCN with a personal doctor received care coordination within their regular source of care. New legislation has been proposed to provide medical homes to Medicaid and SCHIP recipients, and some demonstration models, including those with Medicaid and SCHIP populations, have shown significant increases in meeting the medical needs of children.37–41 One published account of gains in meeting dental needs through coordinated care in a Medicaid managed care program is available.42 Considerable work remains to define the health care team composition (including dental professionals)
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Table 5. Unadjusted and Adjusted Odds Ratios for Excellent/Very Good/Good Reported Dental Health CSHCN†
Age, y 1–5 6–11 12–17 Income (FPL){ <100% 100%–199% 200%–399% 400%þ Race/ethnicity Hispanic Non-Hispanic Black Non-Hispanic Other Non-Hispanic White Sex Male Female EducationHigh School Personal doctor Yes No Dental insurance Dental coverage No dental coverage Health insurance Uninsured Public Private Personal doctor Yes No Preventive care Yes No
CWOSN‡
Unadjusted OR§
Adjusted ORk
Unadjusted OR
Adjusted ORk
1.41 (1.03–1.93) 0.71 (0.58–0.86) reference
1.76 (1.27–2.43) 0.75 (0.61–0.92) reference
1.28 (1.10–1.50) 0.67 (0.59–0.77) reference
1.38 (1.14–1.67) 0.68 (0.59–0.78) reference
0.21 (0.15–0.28) 0.34 (0.26–0.45) 0.52 (0.39–0.69) reference
0.43 (0.28–0.67) 0.55 (0.39–0.79) 0.61 (0.45–0.83) reference
0.16 (0.13–0.19) 0.28 (0.23–0.34) 0.59 (0.49–0.71) reference
0.32 (0.25–0.41) 0.42 (0.34–0.52) 0.67 (0.56–0.81) reference
0.51 (0.36–0.74) 0.53 (0.41–0.68) 0.70 (0.49–1.00) reference
0.80 (0.58–1.11) 0.87 (0.65–1.16) 0.73 (0.49–1.07) reference
0.23 (0.20–0.27) 0.48 (0.41–0.56) 0.62 (0.49–0.79) reference
0.46 (0.38–0.54) 0.77 (0.65–0.92) 0.65 (0.50–0.85) reference
0.84 (0.69–1.01) reference
0.86 (0.71–1.05) reference
1.04 (0.92–1.16) reference
0.99 (0.87–1.11) reference
0.23 (0.16–0.34) 0.45 (0.37–0.55) reference
0.51 (0.33–0.79) 0.72 (0.57–0.91) reference
0.18 (0.14–0.21) 0.41 (0.36–0.47) reference
0.51 (0.40–0.65) 0.69 (0.60–0.80) reference
reference 0.56 (0.43–0.71)
reference 0.97 (0.72–1.32)
reference 0.45 (0.39–0.51)
reference 0.75 (0.64–0.89)
reference 0.70 (0.55–0.90)
reference 0.74 (0.56–0.98)
reference 0.63 (0.55–0.72)
reference 0.83 (0.71–0.98)
0.31 (0.21–0.47) 0.35 (0.29–0.42) reference
0.60 (0.39–0.94) 0.60 (0.45–0.80) reference
0.28 (0.24–0.33) 0.35 (0.31–0.40) reference
0.71 (0.56–0.89) 0.86 (0.72–1.03) reference
reference 0.67 (0.50–0.88)
reference 1.03 (0.76–1.41)
reference 0.44 (0.39–0.51)
reference 0.74 (0.63–0.87)
reference 0.68 (0.55–0.84)
reference 0.85 (0.65–1.10)
reference 0.88 (0.78–1.00)
reference 1.23 (1.05–1.45)
†CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §OR indicates odds ratio. kEach variable is adjusted for all other covariates listed in the table. {FPL indicates federal poverty level.
and technology requirements, develop the optimal medical home curricula and performance measures, and evaluate the effectiveness and cost of coordinated services as well as their financing and methods of provider compensation.43,44 Some of the study limitations have been alluded to earlier in this paper. For example, estimates of preventive dental visits were obtained through parent report, possibly resulting in bias introduced by poor recall or socially desirable responses. However, for the reasons mentioned, it is felt that though some bias may be inherent in the methods, the perspective of the parent’s assessment is important for a comprehensive view of the issue of dental care for CSHCN. Furthermore, significant factors associated with preventive care in CSHSN and reported dental health are sufficiently consistent with other literature on oral health in children to give credence to their influence as they are presented here.
Further data and questionnaire limitations are detailed elsewhere.13,14
CONCLUSION The results of the National Survey of Children’s Health 2003 suggest that although the large majority of CSHCN and CWOSN parents report that their children receive preventive dental care, a substantial portion report that their children experience fair to poor dental health, particularly among CSHCN. Despite improvements in access to preventive care, gaps in dental health for CSHCN are most evident based on income level, parent education, and having health/dental insurance coverage. Having dental coverage for preventive services improves the odds of obtaining preventive care but may only be part of a larger picture of dental health, particularly as perceived by parents of CSHCN, possibly due to the need for more extensive types of dental
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services. Increased understanding of different care coordination models within a medical home and their relation to improving dental outcomes should aid in addressing oral health disparities. REFERENCES 1. Foster H, Fitzgerald J. Dental diseases in children with chronic illness. Arch Dis Child. 2005;90:703–708. 2. Weddell J, Sanders B, Jones J. Dental problems of children with disabilities. In: McDonald RE, Avery DR, Dean JA, eds. Dentistry for the Child and Adolescent. St. Louis, Mo: Mosby; 2004:524. 3. Lewis C, Robertson A, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics. 2005;116:e426–e431. 4. Newacheck P, McManus M, Fox H, et al. Access to health care for children with special health care needs. Pediatrics. 2000;105: 760–766. 5. U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. May 2000. Available at: http:// www.surgeongeneral.gov/library/oralhealth/. Accessed March 14, 2008. 6. Szilagyi P, Shenkman E, Brach C, et al. Children with special health care needs enrolled in the state children’s health insurance program (SCHIP): patient characteristics and health care needs. Pediatrics. 2003;112:e508–e520. 7. Newacheck P, Hung Y, Wright K. Racial and ethnic disparities in access to care for children with special health care needs. Ambul Pediatr. 2002;2:247–254. 8. American Academy of Pediatrics. Policy statement. Oral health risk assessment timing and establishment of a dental home. Pediatrics. 2003;111:1113. 9. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/ counseling, and oral treatment for infants, children, and adolescents. Available at: http://www.aapd.org/media/Policies_Guidelines/G_ Periodicity.pdf. Accessed March 14, 2008. 10. Jokovic A, Locker D, Stephens M, et al. Measuring parental perceptions of child oral health-related quality of life. J Public Health Dent. 2003;63:67–72. 11. Talekar BS, Rozier RG, Slade GD, Ennett ST. Parental perceptions of their preschool-aged children’s oral health. J Am Dent Assoc. 2005; 136:364–372. 12. Pahel BT, Rozier RG, Slade GD. Parental perceptions of children’s oral health: the Early Childhood Oral Health Impact Scale (ECOHIS). Health Qual Life Outcomes. 2007;5:6. 13. Blumberg S, Olson L, Frankel M, et al. Design and operation of the National Survey of Children’s Health, 2003. National Center for Health Statistics. Vital Health Stat. 2005;1(43). 14. van Dyck P, Kogan MD, Heppel D, et al. The National Survey of Children’s Health: a new data resource. Matern Child Health J. 2004;8: 183–188. 15. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988–1994 and 1999–2004. Vital Health Stat. 2007;11(248):1–92. 16. Hennequin M, Faulks D, Veyrune JL, Bourdiol P. Significance of oral health in persons with Down syndrome: a literature review. Dev Med Child Neurol. 1999;41:275–283. 17. Hennequin M, Faulks D, Roux D. Accuracy of estimation of dental treatment need in special care patients. J Dent. 2000;28:131–136. 18. Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics. 2004; 114:e418–e423. 19. Pettinato ES, Webb MD, Seale NS. A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventive care. Pediatr Dent. 2000;22: 463–468. 20. Navazesh M, Mulligan R, Sorbel S. Toxic shock and Down Syndrome in a dental patient: a case report and review of the literature. Spec Care Dentist. 1994;14:246–251.
AMBULATORY PEDIATRICS 21. Houtrow AJ, Kim SE, Chen AY, Newacheck PW. Preventive health care for children with and without special health care needs. Pediatrics. 2007;119:e821–e828. 22. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA. 2000;284:2625–2631. 23. Maserejian NN, Trachtenberg F, Link C, Tavares M. Underutilization of dental care when it is freely available: a prospective study of the New England Children’s Amalgam Trial. J Public Health Dent. Available at: http://www.blackwell-synergy.com/doi/pdf/10.1111/ j.1752-7325.2007.00074.x. Accessed March 2, 2008. 24. Weintraub JA, Stearns SC, Rozier RG, Huang CC. Treatment outcomes and costs of dental sealants among children enrolled in Medicaid. Am J Public Health. 2001;91:1877–1881. 25. Hudson JL, Selden TM. Children’s eligibility and coverage: recent trends and a look ahead. Health Aff (Millwood). 2007;26:w618–w629. 26. Watson M, Manski RJ, Macek MD. The impact of income on children’s and adolescents’ preventive dental visits. J Am Dent Assoc. 2001;132:1580–1587. 27. Scherrer CR, Griffin PM, Swann JL. Public health sealant delivery programs: optimal delivery and the cost of practice acts. Med Decis Making. 2007;27:762–771. 28. Griffin SO, Jones KA, Lockwood S, et al. Impact of increasing Medicaid dental reimbursement and implementing school sealant programs on sealant prevalence. J Public Health Manag Pract. 2007;13:202–206. 29. Crall JJ. Children’s oral health services: organization and financing considerations. Ambul Pediatr. 2002;2(2 suppl):148–153. 30. Ziring PR, Brazdziunas D, Cooley WC, et al. American Academy of Pediatrics. Committee on Children With Disabilities. Care coordination: integrating health and related systems of care for children with special health care needs. Pediatrics. 1999;104:978–981. 31. American Academy of Pediatrics. Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184–186. 32. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics. 2004;113(5 suppl):1493–1498. 33. Bindman AB, Grumbach K, Osmond D, et al. Primary care and receipt of preventive services. J Gen Intern Med. 1996;11:269–276. 34. Liptak GS, Burns CM, Davidson PW, McAnarney ER. Effects of providing comprehensive ambulatory services to children with chronic conditions. Arch Pediatr Adolesc Med. 1998;152:1003–1008. 35. Bartman BA, Moy E, D’Angelo LJ. Access to ambulatory care for adolescents: the role of a usual source of care. J Health Care Poor Underserved. 1997;8:214–226. 36. Momany ET, Flach SD, Nelson FD, Damiano PC. A cost analysis of the Iowa Medicaid primary care case management program. Health Serv Res. 2006;41:1357–1371. 37. Medical Homes Act of 2007. U.S. Senate Bill 2376. 2007. Available at: http://thomas.loc.gov/cgi-bin/query/c?c110:./temp/ c110zzszRw. Accessed on March 14, 2008. 38. Willson CF. Community care of North Carolina: saving state money and improving patient care. N C Med J. 2005;66:229–233. 39. Palfrey JS, Sofis LA, Davidson EJ, et al. The Pediatric Alliance for Coordinated Care: evaluation of a medical home model. Pediatrics. 2004;113(5 suppl):1507–1516. 40. McMenamy JM, Perrin EC. Filling the GAPS: description and evaluation of a primary care intervention for children with chronic health conditions. Ambul Pediatr. 2004;4:249–256. 41. Jessop DJ, Stein RE. Providing comprehensive health care to children with chronic illness. Pediatrics. 1994;93:602–607. 42. Mitchell JM, Gaskin DJ. Do children receiving supplemental security income who are enrolled in Medicaid fare better under a fee-for-service or comprehensive capitation model? Pediatrics. 2004;114:196–204. 43. Stille CJ, Jerant A, Bell D, et al. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005;142:700–708. 44. Perrin JM, Romm D, Bloom SR, et al. A family-centered, community-based system of services for children and youth with special health care needs. Arch Pediatr Adolesc Med. 2007;161:933–936.
dental problems and fewer described their children as having good to excellent dental health compared to CWOSN, despite greater odds of having dental coverage and receiving preventive dental care. Disparities were evident in preventive dental care and dental health based on income, education, and insurance coverage. Conclusions.—Most parents of CSHCN and CWOSN report that their children receive preventive dental care and have good to excellent dental health; however, disparities in dental health and receipt of preventive dental care exist. Accessing care coordination by using the medical/dental home model, particularly for CSHCN, may alleviate the situation in which some of the most vulnerable children are experiencing the worst dental health.
C
10.4% among CSHCN based on analysis of the National Survey of Children with Special Health Care Needs 2001. The odds of having unmet dental needs were greater for the economically disadvantaged and uninsured, but less for those with a regular doctor.3 In addition, differences in unmet need were evident, based on age, gender, race/ethnicity, and mother’s education. Analysis of 4 state surveys of CSHCN enrolled in the State Children’s Health Insurance Program (SCHIP) indicated that unmet dental care need varied from 7.9% to 30.9%, and the most frequent parent-reported reasons for unmet dental needs were lack of insurance and the cost of care.6 Estimates from the National Health Interview Survey on Disability 1994–1995 indicated that 8.1% of CSHCN had unmet dental needs, but that the odds were 4 times greater for the uninsured than the insured.7 The relationship between unmet dental need and dental/ oral health in CSHCN is unknown. Previous surveys of CSHCN have reported unmet dental needs or dental visits and the barriers to utilization. Issues that have not been addressed are oral health status and its relation to preventive dental care, which according to the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD), should be pursued aggressively by 6 to 12 months of age in children with disabilities.8,9 National estimates of oral health status and preventive dental care among CSHCN are currently not available. The National Survey of Children’s Health provides one opportunity to
KEY WORDS: children with special health care needs; dental insurance; National Survey of Children’s Health; parent-perceived dental health; preventive dental care Ambulatory Pediatrics 2008;8:312–20
hildren with special health care needs (CSHCN) are at greater risk for poorer oral health than children in the general population due to more frequent oral infections and periodontal disease, enamel irregularities, moderate-to-severe malocclusion, and craniofacial birth defects.1,2 Certain medications, special diets, and difficulty in maintaining daily hygiene further affect their oral health and increase their risk of dental caries. However, access to dental care to address their heightened need is often more compromised than access to medical care or prescription medicines.3,4 The US Surgeon General stated that ‘‘analysis of the determinants of oral health status, access to care, and the role of oral health’’ among people with disabilities are needed.5 Toward that end, unmet dental need has been estimated at From the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Rockville, Md (Dr Kenney and Dr Kogan); and School of Dentistry, University of California, Los Angeles, Maternal and Child Health Bureau National Oral Health Policy Center, Los Angeles, Calif (Dr Crall). The views in this article are those of the authors and not necessarily those of the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Address correspondence to Mary Kay Kenney, PhD, U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 5600 Fishers Lane, Rm 18-41, Rockville, Maryland 20857 (e-mail: [email protected]). Received for publication November 16, 2007; accepted April 17, 2008. AMBULATORY PEDIATRICS Copyright Ó 2008 by Academic Pediatric Association
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gain insight into the use of preventive dental care and oral/ dental health in CSHCN via parent report. An awareness of parent perceptions regarding their children’s oral health status, dental problems, and the use of preventive dental care is important for pediatric health care providers, who generally have the most consistent contact with CSHCN and their families. Parents are the principal decision makers regarding their child’s health. Their perceptions can have a major influence on preventive care and treatment choices, and are, therefore, important to a comprehensive understanding of the issues.10–12 The intent of this paper is to 1) determine the prevalence of parent-reported preventive dental care utilization and better reported dental health in CSHCN, 2) identify parent-reported dental problems and reasons for lack of preventive dental care, and 3) identify sociodemographic, insurance, and health service–related factors associated with preventive dental care and better parent-reported dental health. Comparison data from children without special needs (CWOSN) are included to aid interpretation of results. METHODS Data Source/Population The National Survey of Children’s Health was the data source for these analyses and has been described in detail elsewhere.13,14 The populations of interest were 1- to 17year-old CSHCN and CWOSN. Survey screening questions identify CSHCN, defined as children with a health condition lasting (or expected to last) at least 1 year and resulting in at least one of the following: using or needing more medical care, mental health services, or educational services than typically required by children of the same age; using or needing prescription medicines; having limitations in the ability to do things other children of the same age do; using or needing special therapy (ie, physical, occupational, or speech therapy) or assistive devices; and using or needing emotional, developmental, or behavioral treatment or counseling.13 Of the original 102 353 cases, the following exclusions were made: 1) cases with missing data for 1 or more variables of interest (except income) and 2) case children <1 year of age. After excluding 5843 cases with children aged <1 year, 733 cases with no responses for dental outcomes, and 9133 cases with missing data points for 1 or more of the remaining covariates (except income), the resulting sample size consisted of 86 644 cases. Human subjects review was not required. Variables Sociodemographics Included in the analysis were several sociodemographic independent variables having previously hypothesized associations with receipt of health/dental care: race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other), gender, age (1–5, 6–11, and 12–17 years), poverty (<100%, 100%–199%, 200%–399%, and $400% of federal poverty level), and parent education
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(less than high school, high school, and more than high school).3,6,7 Other independent factors with hypothesized associations included dental insurance coverage for any routine preventive dental care, including cleaning, x-rays, and examinations (yes/no), health insurance coverage (uninsured, public, private), and having a personal doctor (yes/no). Preventive Dental Care, Dental Health, and Dental Problems Preventive dental care prevalence was determined by answers to the following questions, all referenced to the previous 12 months: ‘‘Did [survey child] see a dentist for any routine preventive dental care, including checkups, screenings, and sealants? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists (yes/no).’’ Unmet need for preventive dental care was determined by the question ‘‘Did [survey child] receive all the routine preventive dental care [he/she] needed?’’ Fifteen response options (with multiple choices possible) were provided to explain why preventive care was not received (eg, costs too much, no insurance). Parent-perceived dental health was determined by ‘‘How would you describe the condition of [survey child’s] teeth: excellent, very good, good, fair, poor?’’ Parent-perceived dental problems in children described as having fair or poor dental health were established in response to ‘‘What specific problems does [survey child] have with [his/her] teeth?’’ Parents were provided 12 response options (eg, pain, cavities), with multiple choices possible. Analytic Approach All analyses were stratified on the basis of whether a child had special needs (CSHCN) or not (CWOSN). Bivariate chi-square statistics (c2; P < . 001) were used for between-group (ie, CSHCN vs CWOSN) comparisons of the following: sample percentages for each of the child/ family sociodemographic variables, the percentage of children receiving preventive dental care as a function of selected independent variables, and the proportions of the sum of parent-reported dental problems relative to the number of children with parent-reported fair/poor dental health. Pair-wise between-group comparisons (P < . 001) of weighted percentages were conducted following significant bivariate chi-square tests of variables in the analyses of sample sociodemographic characteristics and prevalence of preventive dental care. Parent-reported dental problems and reasons for not receiving all the needed preventive dental care were summarized using descriptive statistics. Logistic regression analyses were performed to determine the factors associated with 1) receipt of preventive dental care and 2) better parent-perceived dental health (ie, good/very good/excellent). Bivariate logistic models were constructed to identify characteristics significantly associated with the outcome variables, whereas multivariate models controlled for the effects of all other independent variables in the analysis. Both unadjusted (bivariate) and adjusted (multivariate) odds ratios and 95% confidence
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Table 1. Child and Respondent Demographic Characteristics Among CSHCN* and CWOSN† CSHCN
Total Reported dental health Excellent/very good Good Fair/poor Age, y 1–5 6–11 12–17 Income (FPL)§ <100% 100%–199% 200%–399% 400%þ Missing Race/ethnicity Hispanic Non-Hispanic Black Non-Hispanic Other Non-Hispanic White Gender Male Female Parent education
No. Unweighted
No. Weighted
17 001
11 517 155
11 805 3521 1634
7 700 676 2 504 078 1 266 914
2977 5986 8038
CWOSN % (SE)
No. Unweighted
No. Weighted
% (SE)
P value‡
69 643
48 034 093
67.13 (0.65) 21.83 (0.57) 11.04 (0.46)
52 689 12 465 3943
34 687 471 9 568 958 3 478 209
72.67 (0.31) 20.05 (0.28) 7.29 (0.20)
<.001 <.001 <.001
2 249 828 4 394 292 4 873 035
19.53 (0.56) 38.15 (0.66) 42.31 (0.65)
21 176 22 016 26 451
14 757 868 16 347 320 16 928 905
30.72 (0.31) 34.03 (0.32) 35.24 (0.32)
<.001 <.001 <.001
1902 3067 5699 5311 1022
1 822 546 2 379 100 3 526 655 3 074 466 714 388
15.82 (0.56) 20.66 (0.58) 30.62 (0.59) 26.69 (0.54) 6.20 (0.33)
6203 12 222 24 344 21 425 5449
6 215 570 9 381 292 15 415 410 12 905 575 4 116 246
12.94 (0.26) 19.53 (0.27) 32.09 (0.30) 26.87 (0.28) 8.57 (0.20)
<.001
1024 1681 1335 12 961
772 590 1 859 947 846 492 8 038 126
6.71 (0.39) 16.15 (0.58) 7.35 (0.42) 69.79 (0.69)
5751 6988 5554 51 350
4 827 726 7 493 085 3 767 314 31 945 968
10.05 (0.22) 15.60 (0.27) 7.84 (0.23) 66.51 (0.34)
<.001
9782 7219
6 768 283 4 748 872
58.77 (0.66) 41.23 (0.66)
34 652 34 991
23 557 502 24 476 591
49.04 (0.33) 50.96 (0.33)
<.001 <.001
493 3248 13 260
560 264 2 821 515 8 135 377
4.86 (0.36) 24.50 (0.61) 70.64 (0.65)
2081 13 864 53 698
2 506 268 11 998 737 33 529 089
5.22 (0.19) 24.98 (0.30) 69.80 (0.32)
13 904 3097
9 478 321 2 038 834
82.30 (0.50) 17.70 (0.50)
53 659 15 984
37 510 915 10 523 178
78.09 (0.27) 21.91 (0.27)
<.001 <.001
15 642 1359
10 495 565 1 021 590
91.13 (0.40) 8.87 (0.40)
59 726 9917
40 357 638 7 676 455
84.02 (0.27) 15.98 (0.27)
<.001 <.001
768 4513 11 720
539 838 3 720 608 7 256 709
4.69 (0.29) 32.30 (0.68) 63.01 (0.68)
5258 12 615 51 770
3 921 786 10 813 018 33 299 290
8.16 (0.19) 22.51 (0.30) 69.32 (0.32)
<.001 <.001 <.001
<.001 <.001
*CSHCN indicates children with special health care needs. †CWOSN indicates children without special needs. ‡Results of significance testing for between-group pair-wise comparison of weighted percentages within each category of the independent variables. §FPL indicates federal poverty level.
intervals were computed. All estimates were statistically weighted to reflect population totals by using sample weights provided by the data collection agency. The statistical analysis was conducted using SUDAAN (Research Triangle Institute, Research Triangle Park, NC) to account for a complex sample design. RESULTS This sample represented children aged $1 year who would be expected to have erupted deciduous or permanent teeth and, according to the AAP and the AAPD guidelines, should have begun regular dental visits for routine preventive care.8,9 Of these children, 17 001 were CSHCN, comprising 19.6% of the total (Table 1). Table 1 indicates that the majority of parents described their children as having excellent or very good dental health; however, a higher proportion of CSHCN parents reported that their children had fair to poor dental health (P < . 001). Significantly higher proportions of CSHCN had a personal doctor, had dental
coverage for preventive care, and were publicly (vs privately) insured, whereas significantly fewer were uninsured (P < . 001). Dental Problems Significantly higher proportions of dental problems were reported by parents of CSHCN compared to parents of CWOSN (P < . 001). The highest frequency dental problems of children with fair/poor dental health were cavities, crooked or broken teeth, grinding, and pain, though the relative proportions of these problems varied as a function of age (Table 2). The highest frequency reported dental problems of 1- to 5-year-olds were cavities and broken teeth. Parents of 6- to 11-year-olds continued to report cavities as the most frequent problem, but crooked teeth were noted as a source of increasing concern. During adolescence, parent concerns about crooked teeth continued to grow in both groups. Overall, the more frequently reported problems were similar for CSHCN and CWOSN, though more
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Table 2. Prevalence Estimates of the Most Frequent Parent-Perceived Dental Problems of Children* CSHCN† Age 1–5 year-olds
6–11 year-olds
12–17 year-olds
CWOSN‡
Dental Problems
% (SE)
Dental Problems
% (SE)
Cavities Broken teeth§ Bad color Grindingk Pain Crooked teeth{ Cavities Crooked teeth{ Broken teeth§ Grindingk Pain Poor hygiene** Cavities Crooked teeth{ Broken teeth§ Pain Other Poor hygiene**
64.4 (5.84) 22.5 (6.70) 14.3 (5.95)†† 11.7 (4.83)†† 11.1 (6.05)†† 6.3 (1.91)†† 55.7 (3.02) 34.8 (2.87) 14.8 (2.40) 9.3 (1.88) 5.2 (1.35) 4.3 (1.17) 49.7 (3.20) 48.6 (3.21) 12.8 (2.40) 7.7 (1.38) 7.2 (1.73) 6.4 (1.44)
Cavities Broken teeth§ Crooked teeth{ Grindingk Bad color Other Cavities Crooked teeth{ Broken teeth§ Grindingk Pain Other Crooked teeth{ Cavities Broken teeth§ Pain Poor hygiene** Bad color
70.4 (2.32) 13.7 (1.65) 7.3 (1.20) 7.2 (1.23) 5.3 (1.26) 3.0 (0.59) 57.7 (1.83) 31.8 (1.77) 11.6 (1.30) 7.1 (0.88) 3.5 (0.97) 3.0 (0.71) 50.3 (2.19) 39.8 (2.12) 7.8 (1.16) 5.2 (1.00) 5.2 (1.22) 4.1 (0.99)
*Rank ordering of prevalence estimates by age. Children reported to have fair/poor dental health. Multiple responses were allowed. †CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §And/or teeth that need repair. kAnd/or soft teeth, teeth pulled, or teeth falling out. {And/or teeth that need braces. **And/or plaque, doesn’t brush regularly, needs cleaning. ††Some of the estimates in this report were based on small cell sizes (<30) because they reflect infrequent dental problems in the CSHCN population, such as tooth pain in the 1–5-year-old age group. These estimates are usually accompanied by large variances, indicating that the estimates may not be reliable. Using a ratio of the standard error over the percent estimate (ie, the coefficient of variation), a cutoff value of of 0.3 (or 30%) was adopted as an indicator of the estimate’s reliability. If the coefficient of variation is $0.3, then the percent estimate is considered unreliable. All unreliable estimates defined as such are marked. Not shown are the dental problems with the lowest frequencies and consistently unreliable estimates in all age groups: bad enamel, bad gums, nerve problems, and no problems.
widely reported among CSHCN parents. CSHCN with speech or behavior disorders, learning disabilities, physical impairment or developmental delay, and autism tended to be more frequently described as having fair/poor dental health (Figure). Routine Preventive Dental Care Most parents reported that their children received preventive care in the previous 12 months (Table 3); however, the proportion was higher for CSHCN (P < . 001). The unadjusted odds of receiving preventive care (for both CSHCN and CWOSN) were significantly lower for 1- to 5-year-olds and those that were less economically advantaged, were of non-White race/ethnicity, had less-educated parents, had no personal doctor or dental coverage, had poorer dental health, and were uninsured or publicly insured. After adjusting for covariates, the odds of receiving preventive dental care were no longer significantly different from the reference groups for the Hispanic and nonwhite CSHCN and Hispanic CWOSN, the CWOSN with fair/poor dental health, and the publicly insured CSHCN and CWOSN. Adjusting for covariates revealed marginally significant lower odds of receiving preventive care for male versus female CWOSN. Among the most common reasons reported for not receiving all the needed dental care were lack of insurance, dental care cost, health plan problem, appointment time issue, and unaccepted insurance (Table 4). Parents of both
CSHCN and CWOSN reported lack of insurance coverage as the primary reason and dental care cost as the second most common reason. Approximately 18% of CSHCN and 22% of CWOSN parents reported having no dental coverage to help pay for preventive dental care, including cleanings, x-rays, and examinations. For CSHCN who did not receive any preventive dental care within the previous 12 months, 46.2% had private health insurance, 42.5% had public insurance, and 11.3% were uninsured. Among CWOSN who did not receive any preventive dental care, 50.8% had private insurance, 32.0% had public insurance, and 17.3% were uninsured. More parents of CSHCN (4.4%) versus CWOSN (2.8%) who received preventive care reported not receiving all the preventive dental care that was needed (P <. 001). CSHCN with unmet need for preventive dental care had the following breakdown of general health insurance coverage: 36.6% with private insurance, 53.3% with public insurance, and 10.3% without any health insurance. For CWOSN, 43.9% were privately insured, 34.1% were publicly insured, and 22.0% had no health insurance. Thus, for CSHCN, relatively high percentages of children without preventive care or with unmet need for preventive care were publicly insured. Better Reported Dental Health We next examined the factors associated with better (ie, excellent/very good/good) reported dental health (Table 5).
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22.7
Speech 21.3
Behavior 19.7
LD DD or Physically Impaired
18.8
Autism
18.7
Hearing/Visually Impaired
18.6 18.1
Musculoskeletal Depression/ Anxiety
17.3 15.9
ADD 12.0
Asthma 8.1
*Diabetes 0.0
5.0
10.0
15.0
20.0
25.0
Figure. Percentage of children with special health care needs in reported fair/poor dental health across disorders. LD indicates learning disability; DD indicates developmental delay; ADD indicates attention deficit disorder. *Some of the estimates in this report were based on small cell sizes (<30). These estimates are usually accompanied by large variances, indicating that the estimates may not be reliable. Using a ratio of the standard error over the percent estimate (ie, the coefficient of variation), a cutoff value of 0.3 (or 30%) was adopted as an indicator of whether the estimate is reliable or not. If the coefficient of variation is $0.3, then the percent estimate is considered unreliable. All unreliable estimates defined as such are asterisked.
As with the preventive care model, an influential adjusted factor associated with better reported dental health for both CSHCN and CWOSN was age, but the odds of better dental health were higher only for the youngest children, particularly the 1- to 5-year-old CSHCN. Increasing income was also strongly associated with improved odds of better reported dental health for both groups. An unexpected finding was that, after adjustment, receiving preventive dental care was not associated with better reported dental health for CSHCN and was associated with poorer dental health for CWOSN. Differences were noted across the 2 adjusted models for factors related to having a personal doctor, dental coverage, health insurance coverage, and race/ethnicity. Although CSHCN and CWOSN with a personal doctor showed higher odds of receiving preventive care, the odds of better dental health for CSHCN were not improved by having a personal doctor. Having dental coverage doubled the odds of receiving preventive dental care, though its effect on having better reported dental health was considerably less. Private (vs public) insurance increased the odds for CSHCN of having better reported dental health, but not for receiving preventive dental care. For CWOSN, Hispanic ethnicity was associated with poorer reported dental health, but no difference in receipt of preventive dental care.
DISCUSSION The National Survey of Children’s Health provides new information about parent-perceived dental health and dental problems in CSHCN, the variation in parent-perceived dental health across a range of developmental conditions, and the factors associated with the use of preventive dental
care and better reported dental health. The current analysis indicated that approximately 1.3 million 1- to 17-year-old CSHCN (11.0%) already burdened with other developmental and health concerns were described by their parents as having fair to poor dental health. These figures may be somewhat at odds with recently published data indicating that the prevalence of untreated tooth decay in the general population during the 1999 to 2004 period was 20.5% for 2- to 5-year-olds, 24.5% for 6- to 11-year-olds, 16.9% for 12- to 15-year-olds, and 22.2% for 16- to 19-year-olds.15 Those proportions may be higher in CSHCN than the general population due to greater susceptibility to dental disorders and disease, suggesting possible parent underestimation of dental disease burden in the data presented here.1,2,16 Research findings regarding parent assessment of dental health are divided. It has been suggested that caregivers may base their judgments on fairly severe or extreme conditions and may be unaware of conditions in which the dentition is diseased, but not so obviously compromised.17 Yet, there is some evidence that parents’ judgments have a moderately high positive correlation with clinical evidence of tooth decay.10,12 Other findings indicate that caregivers’ assessments of their children’s dental health are positively associated with having carious teeth and a need for dental treatment.11 Thus, parents’ perceptions may be in the right direction, but may not always demonstrate a full appreciation of less observable, though active disease processes. Another finding presented here was that 20%, or 2.3 million CSHCN, were reported as not receiving routine preventive dental care within the previous 12 months. An additional 0.4 million children were underserved (ie, those who received preventive care, but not all the needed care).
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Table 3. Prevalence and Odds Ratios for Receiving Preventive Dental Care in the Past 12 Months CSHCN† % Total Reported dental health Fair/Poor Good Excellent/Very Good Age, y 1–5 6–11 12–17 Income (FPL)** <100% 100%–199% 200%–399% 400%þ Missing Race/ethnicity Hispanic Non-Hispanic Black Non-Hispanic Other Non-Hispanic White Gender Male Female Parent education
Unadjusted OR§
CWOSN‡ Adjusted ORk
79.60
%
Unadjusted OR
Adjusted ORk
P value{ <.001
72.48
74.11 76.46 82.24
0.62 (0.49–0.77) 0.70 (0.60–0.82) reference
0.71 (0.55–0.91) 0.70 (0.58–0.85) reference
70.42 70.60 73.65
0.85 (0.75–0.97) 0.86 (0.79–0.93) reference
1.06 (0.90–1.26) 0.80 (0.73–0.88) reference
<.001 <.001 <.001
57.58 87.01 84.01
0.26 (0.22–0.31) 1.28 (1.07–1.52) reference
0.24 (0.20–0.29) 1.34 (1.12–1.61) reference
47.79 85.37 81.02
0.20 (0.19–0.22) 1.28 (1.16–1.41) reference
0.16 (0.15–0.18) 1.24 (1.12–1.36) reference
<.001 <.001 <.001
68.11 75.03 82.95 88.76 75.55
0.27 (0.21–0.34) 0.38 (0.31–0.47) 0.62 (0.50–0.75) reference 0.39 (0.29–0.54)
0.38 (0.28–0.51) 0.48 (0.37–0.62) 0.63 (0.52–0.77) reference 0.51 (0.37–0.71)
57.91 65.86 76.76 81.26 69.78
0.32 (0.29–0.35) 0.44 (0.41–0.49) 0.76 (0.70–0.82) reference 0.53 (0.47–0.60)
0.54 (0.46–0.63) 0.59 (0.53–0.66) 0.81 (0.75–0.89) reference 0.73 (0.63–0.84)
<.001 <.001 <.001 <.001 <.001
71.92 72.96 73.36 83.19
0.52 (0.39–0.69) 0.55 (0.45–0.66) 0.56 (0.42–0.74) reference
0.87 (0.63–1.19) 0.80 (0.64–1.01) 0.70 (0.48–1.01) reference
61.07 66.10 69.71 76.51
0.48 (0.43–0.54) 0.60 (0.55–0.65) 0.71 (0.62–0.81) reference
0.91 (0.80–1.04) 0.68 (0.61–0.76) 0.71 (0.60–0.84) reference
<.001 <.001 <.001 <.001
79.29 81.20
0.89 (0.77–1.02) reference
0.91 (0.78–1.06) reference
72.19 73.40
0.94 (0.89–1.00) reference
0.92 (0.86–0.98) reference
<.001 <.001
65.92 73.79 83.23
0.39 (0.28–0.54) 0.57 (0.49–0.66) reference
0.65 (0.44–0.96) 0.77 (0.64–0.93) reference
51.98 66.08 76.77
0.33 (0.28–0.38) 0.59 (0.55–0.63) reference
0.53 (0.44–0.65) 0.71 (0.65–0.78) reference
<.001 <.001 <.001
81.21 68.56
reference 0.50 (0.41–0.62)
reference 0.62 (0.49–0.80)
75.16 60.46
reference 0.51 (0.46–0.55)
reference 0.64 (0.58–0.71)
<.001 <.001
83.19 65.64
reference 0.39 (0.33–0.45)
reference 0.39 (0.33–0.47)
76.67 59.00
reference 0.44 (0.41–0.47)
reference 0.48 (0.44–0.53)
<.001 <.001
58.77 74.51 84.51
0.26 (0.20–0.34) 0.54 (0.46–0.62) reference
0.69 (0.50–0.94) 1.00 (0.81–1.25) reference
51.73 65.03 77.82
0.31 (0.27–0.34) 0.53 (0.49–0.57) reference
0.59 (0.52–0.68) 0.97 (0.87–1.08) reference
<.001 <.001 <.001
†CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §OR indicates odds ratio. kEach variable is adjusted for all other covariates listed in the table. {Results of significance testing for between-group pair-wise comparison of weighted percentages within each category of the independent variables. **FPL indicates federal poverty level.
CSHCN aged between 1 and 5 years were the least likely to obtain preventive dental care, though they would certainly have benefited from the early establishment of preventive strategies as recommended by the AAP and AAPD. Children who receive preventive dental care by age 1 are less likely to have subsequent restorative or emergency visits compared with children with their first preventive dental visits at age 2 or 3.18 Over a 5-year period, the cost for a child beginning preventive care by the first birthday is half the cost of beginning preventive care between the ages of 4 and 5. Without preventive services, dental care may be delayed until toothaches or abscesses necessitate treatment in an emergency room setting. Serious health complications from delayed treatment have also been reported.1,19,20 Consistent with other studies of medical and dental care access, disparities in receiving preventive care were asso-
ciated with insurance coverage and household income, as was parent-reported dental health.21,22 Among the most common reasons parents gave for not receiving all the needed preventive care were 1) lack of insurance coverage, 2) cost of obtaining dental services, 3) health plan problem, and 4) unaccepted insurance. The association suggests the importance of insurance coverage that specifically provides for routine preventive dental care. The vast majority of CSHCN who did not receive preventive dental care had some form of health insurance. For many this coverage did not include dental benefits for preventive care, as indicated by the difference in the percentage of parents with health care coverage (95.3%) and those with insurance that paid for routine preventive dental care (82.3%). In our sample, over 40% of the CSHCN who did not receive any routine preventive care and over 50% who
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Table 4. Prevalence Estimates of Reasons for Not Receiving Preventive Dental Care* CSHCN†
CWOSN‡
Reasons
% (SE)
Reasons
% (SE)
No insurance Costs too much Health plan problem Appointment time issue Insurance unaccepted Other Transportation problem Child refused Forgot appointment Unhappy with dentist Didn’t know where to go Treatment ongoing Inexperienced dentist
29.5 (2.74) 27.5 (2.26) 13.8 (2.51) 12.1 (1.41) 10.4 (2.10) 6.1 (1.14) 5.7 (1.28) 5.6 (1.24) 4.4 (0.95) 3.5 (1.25)§ 3.4 (0.91) 2.6 (0.64) 2.4 (0.90)§
No insurance Costs too much Appointment time issue Health plan problem Other Insurance unaccepted Didn’t know where to go Forgot appointment Child refused Treatment ongoing Transportation problem Inexperienced dentist Unhappy with dentist
31.3 (1.60) 29.9 (1.59) 17.7 (1.29) 9.9 (1.23) 8.9 (1.04) 6.1 (0.94) 5.0 (1.03) 4.4 (0.64) 3.1 (0.51) 3.1 (0.46) 2.9 (0.43) 2.3 (0.78)§ 1.8 (0.41)
*Rank ordering of prevalence estimates. Parent reported for past 12 months. Multiple responses were allowed. †CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §Some of the estimates in this report were based on small cell sizes (<30) because they reflect infrequently reported situations in the CSHCN or CWOSN populations (eg, having an inexperienced dentist). These estimates are usually accompanied by large variances, indicating that the estimates may not be reliable. Using a ratio of the standard error over the percent estimate (ie, the coefficient of variation), a cutoff value of 0.3 (or 30%) was adopted as an indicator of the estimate’s reliability. If the coefficient of variation is $0.3, then the percent estimate is considered unreliable. All unreliable estimates defined as such are marked. Not shown are the reasons with the lowest frequencies and consistently unreliable estimates: no referral was given to parent and no dental resources at survey child’s school.
did not receive all the needed care were publicly insured. Furthermore, the majority of uninsured CSHCN who did not receive any or all the needed preventive dental care were at income levels below 200% of the federal poverty level, suggesting that many were probably eligible for public insurance of one type or another. Although the rate of untreated dental caries is particularly high in US children at the lowest poverty level, only a fraction of the children covered by Medicaid receive preventive dental visits, despite these visits being a program provision.15,23 Dental sealants, shown to be effective in reducing cavities, are underused in the Medicaid population, although they provide savings for the program.24 Finally, a large proportion of uninsured children are eligible, but unenrolled, in public insurance programs.25 Several potential ways to improve the use of preventive dental services in the Medicaid/SCHIP programs have been suggested: parent education, integration of oral health with the general health/behavioral assessment by the health care provider, expansion of the settings where the publicly insured child can be reached (eg, community-based public dental clinics, school-based programs), administrative simplification, oversight of contract standards for managed care network adequacy and incentives, and outreach.22,26–28 It must be noted that although age and income were significant determinants of preventive care and better dental health, other factors such as dental coverage for preventive services had a much stronger effect on receiving preventive care than on having better reported dental health. Given that not having dental coverage was strongly related to not having preventive care, a strong association with poorer reported dental health might also be expected due to the inaccessibility of preventive
services. However, parents reported other dental concerns besides dental caries (eg, crooked teeth) that would require dental/orthodontic procedures beyond preventive care. An understanding of parents’ perceptions regarding the need for more extensive dental services is lacking at present. The above considerations suggest the potential benefit of linkages between the dental home and a system of comprehensive, coordinated care in the medical home to reduce disparities in dental health and preventive dental care, particularly among CSHCN.3,8,29–31 As has been shown here and stated elsewhere, having insurance or even having free access to preventive care does not guarantee utilization of dental or medical health services, particularly for low income groups.23,32 However, receiving comprehensive, coordinated care through a medical home has been shown to increase outpatient and decrease inpatient/emergency room utilization, improve health care equity and health outcomes, increase use of preventive care and satisfaction with health care, and lower costs.33–36 Though having a personal doctor did not increase the odds of having better dental health for CSHCN in this study, the survey did not assess the extent to which CSHCN with a personal doctor received care coordination within their regular source of care. New legislation has been proposed to provide medical homes to Medicaid and SCHIP recipients, and some demonstration models, including those with Medicaid and SCHIP populations, have shown significant increases in meeting the medical needs of children.37–41 One published account of gains in meeting dental needs through coordinated care in a Medicaid managed care program is available.42 Considerable work remains to define the health care team composition (including dental professionals)
AMBULATORY PEDIATRICS
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Table 5. Unadjusted and Adjusted Odds Ratios for Excellent/Very Good/Good Reported Dental Health CSHCN†
Age, y 1–5 6–11 12–17 Income (FPL){ <100% 100%–199% 200%–399% 400%þ Race/ethnicity Hispanic Non-Hispanic Black Non-Hispanic Other Non-Hispanic White Sex Male Female Education
CWOSN‡
Unadjusted OR§
Adjusted ORk
Unadjusted OR
Adjusted ORk
1.41 (1.03–1.93) 0.71 (0.58–0.86) reference
1.76 (1.27–2.43) 0.75 (0.61–0.92) reference
1.28 (1.10–1.50) 0.67 (0.59–0.77) reference
1.38 (1.14–1.67) 0.68 (0.59–0.78) reference
0.21 (0.15–0.28) 0.34 (0.26–0.45) 0.52 (0.39–0.69) reference
0.43 (0.28–0.67) 0.55 (0.39–0.79) 0.61 (0.45–0.83) reference
0.16 (0.13–0.19) 0.28 (0.23–0.34) 0.59 (0.49–0.71) reference
0.32 (0.25–0.41) 0.42 (0.34–0.52) 0.67 (0.56–0.81) reference
0.51 (0.36–0.74) 0.53 (0.41–0.68) 0.70 (0.49–1.00) reference
0.80 (0.58–1.11) 0.87 (0.65–1.16) 0.73 (0.49–1.07) reference
0.23 (0.20–0.27) 0.48 (0.41–0.56) 0.62 (0.49–0.79) reference
0.46 (0.38–0.54) 0.77 (0.65–0.92) 0.65 (0.50–0.85) reference
0.84 (0.69–1.01) reference
0.86 (0.71–1.05) reference
1.04 (0.92–1.16) reference
0.99 (0.87–1.11) reference
0.23 (0.16–0.34) 0.45 (0.37–0.55) reference
0.51 (0.33–0.79) 0.72 (0.57–0.91) reference
0.18 (0.14–0.21) 0.41 (0.36–0.47) reference
0.51 (0.40–0.65) 0.69 (0.60–0.80) reference
reference 0.56 (0.43–0.71)
reference 0.97 (0.72–1.32)
reference 0.45 (0.39–0.51)
reference 0.75 (0.64–0.89)
reference 0.70 (0.55–0.90)
reference 0.74 (0.56–0.98)
reference 0.63 (0.55–0.72)
reference 0.83 (0.71–0.98)
0.31 (0.21–0.47) 0.35 (0.29–0.42) reference
0.60 (0.39–0.94) 0.60 (0.45–0.80) reference
0.28 (0.24–0.33) 0.35 (0.31–0.40) reference
0.71 (0.56–0.89) 0.86 (0.72–1.03) reference
reference 0.67 (0.50–0.88)
reference 1.03 (0.76–1.41)
reference 0.44 (0.39–0.51)
reference 0.74 (0.63–0.87)
reference 0.68 (0.55–0.84)
reference 0.85 (0.65–1.10)
reference 0.88 (0.78–1.00)
reference 1.23 (1.05–1.45)
†CSHCN indicates children with special health care needs. ‡CWOSN indicates children without special needs. §OR indicates odds ratio. kEach variable is adjusted for all other covariates listed in the table. {FPL indicates federal poverty level.
and technology requirements, develop the optimal medical home curricula and performance measures, and evaluate the effectiveness and cost of coordinated services as well as their financing and methods of provider compensation.43,44 Some of the study limitations have been alluded to earlier in this paper. For example, estimates of preventive dental visits were obtained through parent report, possibly resulting in bias introduced by poor recall or socially desirable responses. However, for the reasons mentioned, it is felt that though some bias may be inherent in the methods, the perspective of the parent’s assessment is important for a comprehensive view of the issue of dental care for CSHCN. Furthermore, significant factors associated with preventive care in CSHSN and reported dental health are sufficiently consistent with other literature on oral health in children to give credence to their influence as they are presented here.
Further data and questionnaire limitations are detailed elsewhere.13,14
CONCLUSION The results of the National Survey of Children’s Health 2003 suggest that although the large majority of CSHCN and CWOSN parents report that their children receive preventive dental care, a substantial portion report that their children experience fair to poor dental health, particularly among CSHCN. Despite improvements in access to preventive care, gaps in dental health for CSHCN are most evident based on income level, parent education, and having health/dental insurance coverage. Having dental coverage for preventive services improves the odds of obtaining preventive care but may only be part of a larger picture of dental health, particularly as perceived by parents of CSHCN, possibly due to the need for more extensive types of dental
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