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Clemencia M. Vargas, DDS, PhD and Cynthia R. Ronzio, PhD

Clemencia M. Vargas is with the University of Maryland Dental School, Baltimore, and the National Center for Health Statistics, Hyattsville, Md. At the time of the study, Cynthia R. Ronzio was an Association of Schools of Public Health Fellow with the National Center for Health Statistics.

Correspondence: Requests for reprints should be sent to Clemencia M. Vargas, DDS, PhD, Department of Pediatric Dentistry, University of Maryland Dental School, 666 W Baltimore St, Room 3-E-11, Baltimore, MD 21201–1586 (e-mail: cmv001{at}dental.umaryland.edu).

	ABSTRACT

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Objectives. This study describes the relationship between dental needs and dental care utilization among children.

Methods. Data from the third National Health and Nutrition Examination Survey (1988-1994) were used to analyze dental care needs and dental care utilization.

Results. Younger children with perceived needs (needs perceived by the child or responsible adult) were more likely to be episodic users of dental care than children without perceived needs. Younger children with normative needs (defined by the presence of untreated caries diagnosed by a dentist) were less likely to be regular users. Older children with perceived or normative needs were more likely to be episodic users and less likely to have had a previous-year visit than children with no needs.

Conclusions. Despite their presence, dental needs do not drive dental care use among children, and children’s dental care utilization is inadequate.

	INTRODUCTION

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The main theme of the public health objectives described in Healthy People 2010 is the reduction of health disparities.¹ This goal responds to research that demonstrates persistent disparities in various health outcomes and health care access in terms of both race/ethnicity and socioeconomic status (SES). Disparities in oral health status and dental care access among children have particular health services and epidemiological significance: there is underutilization of oral health care services among children of all ages, and caries is the most prevalent non–self-limiting disease of childhood.²

It has already been demonstrated that a social gradient exists in children’s oral health status and dental care utilization. For example, children who are in a racial/ethnic minority or living in poverty are less likely to visit the dentist than their more advantaged counterparts.^1,3,4 It has also been shown that poor children have a higher prevalence of untreated dental caries than nonpoor children.⁵ Indeed, poor children and racial/ethnic minority children use preventive measures such as dental sealants comparatively less frequently.¹

Infrequent use of dental services and poverty status appear to independently affect children’s oral health status. A study of children registered with general dental practitioners in Britain’s National Health Service found that irregular dental visits and lower SES were independently associated with higher rates of decayed and missing teeth.⁶ Another study of British preschoolers found an inverse relationship between the presence of dental caries (treated and untreated) and contact with primary dental services, adjusted for low neighborhood SES.⁷ While we know that SES in part determines frequency of use of preventive services and oral health status in the United States (in terms of the presence of caries),² the relationship between oral health needs and use of dental services has yet to be quantified. This question addresses the equity of dental care services in meeting the oral health care needs of children. Quantifying this relationship will inform policies regarding the availability of and barriers to oral health services.

Oral health problems are not self-limiting; rather, they progress if left untreated. The relationship between needs and utilization in oral health is complicated by this progression. One conceptualization of this relationship is a spiral in which delayed care or the lack of care creates more severe health care needs, which, in turn, result in increased barriers to care. Delay in dental treatment creates barriers because the dental problems become more complicated and more expensive to treat.

With the understanding that untreated oral health needs create their own barriers to care, we hypothesize that there is a positive association between the presence of needs and inadequate utilization of oral health care, when adjustments are made for sociodemographic characteristics. While health care services cannot remove the effects of an adverse environment and are not the only solution to health inequalities,⁸ health services are important factors in protecting, promoting, and restoring health⁹ and thus can be an important step in reducing inequalities in health outcomes.

	METHODS

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Data Source
To analyze the relationship between perceived and normative dental needs and utilization of dental care (measured by a visit in the previous year and the pattern of dental visits), we used data from the third National Health and Nutrition Examination Survey (NHANES III). The NHANES III, conducted between 1988 and 1994 by the National Center for Health Statistics of the Centers for Disease Control and Prevention, is a national stratified multistage probability sample of the civilian noninstitutionalized population of the United States. The survey oversampled non-Hispanic Blacks, Mexican Americans, persons aged 2 months to 5 years, and persons aged 60 years and older to produce reliable estimates for these populations.

The NHANES III sample consisted of 39 994 persons between 2 months and 99 years of age. Data were collected from each participant via face-to-face home interviews; physical examinations, including a detailed oral examination; and laboratory analyses. Details of the plan, the complex sample design, and the informed consent protocol have been published previously.¹⁰

	POPULATION

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The NHANES III included 11 333 participants aged 2 to 18 years; of those, 10 332 received complete caries examinations. For this study we excluded participants with missing data for variables included in the analyses: dental visits in the previous year (n = 98), frequency of visits (n = 51), and education of responding adults (n = 875). Additionally, data from the questions used to identify perceived need were missing for 1020 children. These children were excluded from analyses of perceived need but not for those of normative need, because analyses for perceived and normative needs are conducted separately. The final sample included children aged 2 to 18 years (n = 9265). Excluded and included children did not differ in dental visits in the previous year or education of responsible adults; however, excluded children were older than children included in the study (P < .001).

Variables
The outcome variable is dental care utilization, represented by (1) a reported visit to the dentist during the previous year and (2) the pattern of dental visits, classified as regular use ("every year"), episodic use ("as needed"), or no use ("never"). Episodic visits and no visits to the dentist are considered signs of inadequate utilization and indicate that barriers to accessing dental care exist. Using dental care only "as needed" is not ideal because such visits are usually prompted by a dental condition that is causing an acute problem; for most dental needs, such episodic visits impede preventive activities.

The questions used to obtain information on dental visits were "How long ago was _____’s last visit to a dentist or dental hygienist?" and "How often do you visit the dentist?" The second question establishes a pattern of dental visits, which compensates for the lack of information on the reason for the visit and allows characterization of general dental care utilization by public health standards.

Dental care needs are classified as normative or perceived. Normative needs are those defined by a dental professional after an examination; for this study, normative needs are defined by the diagnosis of untreated caries in the dental examination. A detailed description of the dental examination has been published elsewhere.¹¹ Perceived needs are those defined by older children, responding adults, or both. Perceived need was determined with the question "What type of dental care does _____ need now?" A handheld card displaying treatment options was presented to the respondent. A positive response to "teeth filled or replaced," "teeth pulled," or "relief of pain" was coded as perceived dental need. Of the children with perceived dental needs, 79.9% needed teeth filled or replaced, 15.5% needed teeth pulled, and 2.1% needed pain relief.

Both classifications of dental need are used because each is related to dental care in a different manner; perceived needs can be a motivator to seek dental care, and normative needs identify the professionally defined need for dental care. Moreover, the correlation between perceived and normative needs is low (0.344 for all children).

Sociodemographic variables of interest included in these analyses, aside from age and sex, are self-reported race/ethnicity (recorded as non-Hispanic White, non-Hispanic Black, Mexican-American, and "other") and education, which is based on the educational attainment of the adult answering the survey on behalf of the child (categorized as less than high school, high school completion, and more than high school). Education is used in this analysis as a proxy for SES.

	DATA ANALYSIS

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Bivariate analyses were used to determine the distribution of dental care utilization in the previous year (yes/no), frequency of visits (regular, episodic, or never), and perceived and normative needs by sociodemographic variables. Logistic regression models were fitted to assess the likelihood of dental care utilization in the previous year and the frequency of visits for each type of dental need (normative or perceived), controlling for sociodemographic characteristics. Frequency of visits was recoded with dummy variables, so we compare persons in each specific category of frequency of dental care with everyone else. Differences between groups or between adjusted odds ratios were approximated with 95% confidence intervals (CIs) calculated with the formula Estimate ± 1.96 x SE.

Interaction terms of age and race/ethnicity and age and education were found significant at the .05 level, indicating that the effect of race/ethnicity and education on the visit outcome variable varied by age group. Therefore, separate models were fitted for 2 age groups, 2 to 5 years and 6 to 18 years. All analyses include the sampling weights provided with the data set to account for oversampling and nonresponse. Analyses were conducted in SUDAAN, a statistical package designed to calculate standard errors that account for effects associated with the survey’s complex sample design.¹²

	RESULTS

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A little more than a quarter of the children included in the study were 2 to 5 years old and the rest were 6 to 18 years old; 66% were non-Hispanic White, 15% were nonHispanic Black, and 9% were Mexican American. Classification by the responding adult’s educational attainment indicates that almost 25% of the children lived in households where the responding adult had less than a high school education and just over 40% lived with a responding adult who had more than a high school education.

Table 1 shows the distribution of children reporting a dental visit in the previous year and their pattern of dental visits. Among the 2- to 5-year-olds, 37.1% (SE = 1.43) reported having regular dental visits, yet more than half of the children (53.8%, SE = 1.36) had never been to the dentist. A dental visit in the previous year was reported by 43.3% (SE = 1.43) of the children in this age group. Among the 6- to 18-year-olds, the percentage reporting dental visits in the previous year was higher (77.0%, SE = 1.27) and the percentage who had never been to the dentist was considerably lower (8.0%, SE = 0.79) than among the 2- to 5-year-olds. In both age groups, SES factors were positively associated with having had a visit in the previous year.

The distribution of perceived and normative needs for each age group and for all children is presented in Table 2. Perceived needs were reported for substantially fewer children in the younger age category (9.4%, SE = 0.79) than in the 6- to 18-year-old group (21.1%, SE = 1.29). There was not a significant difference in normative needs between the 2 age groups. Children from families with low educational attainment were almost 3 times as likely to have dental needs as their counterparts from families with high educational attainment. Among racial/ethnic groups, Mexican American children had the highest prevalence of perceived and normative needs; the percentage of Mexican American children with dental needs was almost twice as high as the percentage of nonHispanic White children with dental needs. Non-Hispanic Black children fell in between these 2 groups.

	DISCUSSION

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We found that children with either perceived or normative dental needs were more likely than their counterparts with no dental needs to have had inadequate dental care. We consider episodic use ("as needed") or no use ("never") to be inadequate dental care. Young children without perceived needs were more likely to have never visited a dentist than those with perceived needs.

Our results showing that children from low-SES backgrounds and those belonging to a racial/ethnic minority were less likely than others to have had a dental visit in the previous year corroborate previous research.^3,13 Furthermore, we found that socially disadvantaged children were more likely than more advantaged children to be episodic users of dental care and that advantaged children were more likely to be regular users. A pattern of episodic, rather than regular, utilization of dental services is interpreted as inadequate dental care; episodic dental care utilization hinders preventive efforts as well as early diagnosis and treatment.

Age played a strong role in underutilization of dental care among the children in this sample. In spite of recommendations to start dental visits at age 1 year,^14,15 children aged 2 to 5 years were almost 6 times as likely as older children to have never visited the dentist. The younger children were also half as likely as children in the older group to be regular users of dental care. This strong effect of age suggests additional factors determining dental care patterns. For example, there is an increasing lack of dental providers who accept young, precooperative children, particularly those covered by Medicaid,¹⁶ as patients. Another factor could be that some parents mistakenly believe that younger children do not need to visit the dentist because the young children’s teeth are not permanent.

Measures of the effect of sociodemographic characteristics on dental care utilization (Table 4) supply more information on the relationship between need and use of care. Education, as an economic indicator, and race/ethnicity contribute independently to dental care utilization. Clearly, then, the low utilization of dental care among nonHispanic Black and Mexican American children is associated with their social position as a racial/ethnic group, in addition to economic circumstances. It has been shown that because of racial/ethnic dynamics in the United States, there is a deficit of health care providers in minority areas as well as disproportionately fewer minority health care providers.² Moreover, low-SES and racial/ethnic minority families experience competing needs, such as other health issues, inflexible work hours, and distance to providers, which drain already limited resources available for dental care.

Considering that dental caries is a not self-limiting disease and requires professional treatment, the oral health needs of affected children can be expected to increase in volume and severity if appropriate preventive and curative measures are not implemented. Barriers to dental care increase as oral health problems go untreated, owing to increased cost, increased time required for treatment, fear, and the number (and distribution) of providers willing to treat complicated cases.

The inability to pay for care, of course, exacerbates this problem. Yet dental care has been classified as discretionary care; care is initiated by the patient after he or she realizes that there is a need for care.¹⁷ Our results, which show that children with dental needs were less likely to use dental care regularly than children with no dental needs, do not support the hypothesis that dental care is sought once a need is established. A study of adult dental pain demonstrated that adults of low SES who reported experiencing dental pain on 2 occasions were less likely than their counterparts of high SES to report visiting a dentist while they had the pain.¹⁸ Taken together, these 2 studies indicate that the characteristics of discretionary care do not apply similarly to individuals from different socioeconomic groups. Poor persons actually do not have the option of initiating care because of economic limitations and a paucity of providers who will treat them, in addition to competing needs for their already limited resources.¹⁶ Therefore, we can conclude that under the current dental care system in the United States, dental care is discretionary for the well-off but more of a luxury for the poor.

There is a corollary between our results showing a relationship between underutilization and oral health needs and those presented by Hart.¹⁹ Hart, a physician practicing in Wales, made the empirical observation that areas with high health care needs seemed to have the poorest supply of physicians and other health care resources; he termed this relationship the "Inverse Care Law," whereby those who need the most health care get the least.¹⁹ Linking the geographic distribution of resources with geographic measures of need and access would be an informative area of future research.

An important limitation of our study is the lack of data on dental insurance coverage. Dental insurance is a very important determinant of dental care; unfortunately NHANES III does not provide information on dental insurance for the whole survey population. However, most poor children covered by Medicaid do not get dental care.¹⁶

Our recommendations address the availability and affordability of care. Reducing disparities in the distribution of social resources should have long-term effects on distribution of health risks.⁸ Dental diseases are preventable; hence prevention should be the first line of action. When dental diseases are already present, early treatment acts as a preventive measure. To provide preventive care and early treatment, there is a need for a greater number of dental providers who will treat young children and children from low-SES families. In concert with the recommendations in the surgeon general’s report,² we also suggest reducing barriers at the provider level. This could be done by guaranteeing adequate payment through Medicaid and State Children’s Health Insurance Program payments; training more pediatric dentists, particularly those from racial/ethnic minority groups; and providing incentives for dental care providers to practice in underserved areas.

	Acknowledgments

 
Portions of this article were presented at the First National Oral Health Conference, Chicago, Ill, May 2000, and at The Face of a Child: The Surgeon General’s Conference on Children and Oral Health, Washington, DC, June 2000.

The authors thank Drs Jennifer Madans and Thomas Hogdson for their valuable comments on an earlier version of the article.

	Footnotes

 
C. M. Vargas and C. R. Ronzio designed the study, interpreted the data, and wrote the article. C. M. Vargas did the statistical analyses.

Peer Reviewed

Accepted for publication November 13, 2001.

	References

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1. Healthy People 2010. Conference edition. Washington, DC: US Dept of Health and Human Services; January 2000.

2. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental and Craniofacial Research; 2000.

3. Aday LA, Forthofer RN. A profile of black and Hispanic subgroups’ access to dental care: findings from the National Health Interview Survey. J Public Health Dent. 1992; 52:210–215.[Medline]

4. Bloom B, Gift HC, Jack SS. Dental services and oral health; United States, 1989. Vital Health Stat 10. 1992;No. 183: 1–95.

5. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988–1994. J Am Dent Assoc. 1998;129:1229–1241.[Abstract/Free Full Text]

6. Tickle M, Williams M, Jenner T, Blinkhorn A. The effects of socioeconomic status and dental attendance on dental caries’ experience, and treatment patterns in 5-year-old children. Br Dent J. 1999;186:135–137.[Medline]

7. Tickle M, Moulding G, Milsom K, Blinkhorn A. Dental caries, contact with dental services and deprivation in young children: their relationship at a small area level. Br Dent J. 2000;189:376–379.[Medline]

8. McKeown T. The Role of Medicine—Dream, Mirage, or Nemesis. Oxford, England: Basil Blackwell; 1979.

9. Webb E. Children and the inverse care law. BMJ. 1998;316:1588–1591.[Free Full Text]

10. Plan and operation of the Third National Health and Nutrition Examination Survey, 1988–94. Vital Health Stat 1. 1994;No. 32.

11. Kaste LM, Selwitz RH, Oldakowski RA, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1–17 years of age: United States, 1988–1991. J Dent Res. 1996;75(special issue):631–641.

12. Shah BV, Barnwell BG, Bieler GS. SUDAAN User’s Manual: Software for Analysis of Correlated Data. Release 6.40. Research Triangle Park, NC: Research Triangle Institute; 1995.

13. Edelstein BL, Manski RJ, Moeller JF. Pediatric dental visits in 1996: an analysis of the federal Medical Expenditure Panel Survey. Pediatr Dent. 2000;22:17–20.[Medline]

14. American Academy of Pediatric Dentistry. Infant oral health care. Pediatr Dent. 1997:19:70–72.

15. Edelstein BL. Evidence-based dental care for children and the age 1 dental visit. Pediatr Ann. 1998;27:569–574.[Medline]

16. Children’s Dental Services Under Medicaid. Access and Utilization. Washington, DC: US Dept of Health and Human Services, Office of the Inspector General; 1996.

17. Wolinsky FD. Racial differences in illness behavior. J Community Health. 1982;8:87–101.[Medline]

18. Vargas CM, Macek MD, Marcus SE. Sociodemographic correlates of tooth pain among adults: United States, 1989. Pain. 2000;85:87–92.[Medline]

19. Hart JT. The inverse care law. Lancet. 1971;1:405–412.[Medline]

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