Changes in Children's Oral Health Status and Receipt of Preventive Dental Visits

United States, 2003-2011/2012

Mahua Mandal, MPH, PhD; Burton L. Edelstein, DDS, MPH; Sai Ma, PhD; Cynthia S. Minkovitz, MD, MPP


Prev Chronic Dis. 2013;10 

In This Article


Data Source and Sample

We analyzed data from the 2003 National Survey of Children's Health (NSCH) and the 2011/2012 NSCH. These surveys were conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics and sponsored by the Maternal and Child Health Bureau, Health Resources and Services Administration. The NSCH is a telephone survey of parents or caregivers that measures health and health care use in a nationally representative sample of noninstitutionalized children aged 0 to 17 years in the United States.[15,16] The 2003 survey was administered in English and Spanish, and the 2011/2012 survey was administered in English, Spanish, Korean, Vietnamese, Mandarin, and Cantonese. We included children aged 1 through 17 years for whom complete data on oral health status or preventive dental visits were available. Our final sample sizes were 96,510 for 2003 (94.3% of total sample) and 90,555 for 2011/2012 (94.6% of total sample).[15,16]

Study Measures

To determine oral health status, both the 2003 and 2011/2012 surveys asked respondents to describe the condition of their children's teeth as excellent, very good, good, fair, or poor. Responses were dichotomized into excellent/very good and good/fair/poor.

The 2003 survey asked respondents if their children had visited a dentist in the past 12 months for any routine preventive care including check-ups, screenings, and sealants; the question was directed at respondents who reported their children had visited any type of dentist in the past year. The 2011/2012 survey asked respondents how many times their children had visited a dentist in the past 12 months for preventive dental care, including check-ups and dental cleanings; the question was asked among those reporting their children had visited a dentist for any kind of dental care in the past year. A dichotomous variable was created for each survey year indicating children who received at least 1 recent preventive dental visit and children who did not.

Previous research identifying child and family characteristics associated with children's oral health informed the selection of independent variables for this study.[9,13] Child characteristics included age (1–2 y,3–5 y,6–11 y,12–17 y); sex; race (non-Hispanic white, non-Hispanic black, Hispanic, other or multiracial); overall health status at time of survey (good/fair/poor, excellent/very good); health insurance (none, Medicaid or Children's Health Insurance Program, private or other); and number of times child had moved in his or her lifetime (none, 1–2, 3–4, 5 or more times). Family characteristics included primary language spoken at home (English, other); highest level of education in household (less than high school graduate, high school graduate, more than high school graduate); number of children aged less than 18 years living in the household (1, 2, 3, 4 or more); number of adults living in household (1, 2, 3 or more); and household poverty level (≤100% federal poverty level [FPL]; 101%–200% FPL; 201%–300% FPL; 301%–400% FPL; >400% FPL).

Missing Data

Missingness was examined for each variable. Household poverty level had about 8% missing data for each year; multiple imputation techniques were employed that used 5 imputed values provided by the NSCH.[15,16] Missing data for the remaining variables, which did not exceed 2.2%, were recoded as part of the reference group. Sensitivity analysis excluding missing data yielded similar results to analysis conducted with recoded missing data.

Statistical Analysis

All analyses used weighted data and accounted for the clustered design of the NSCH. First, bivariate and multivariable logistic regressions were used to examine the unadjusted and adjusted relations, respectively, between child and family characteristics and each dependent variable, oral health status, and preventive dental visits. Average marginal effects[17] were calculated to estimate the adjusted prevalence (adjusting for child and family characteristics) of oral health status and preventive dental visits in the United States and for each of the 50 states and the District of Columbia, in 2003 and 2011/2012. Significance of the change over time in estimated adjusted prevalence was determined by performing contrast testing[18] between 2011/2012 and 2003 outcomes. Subgroup analyses for the full samples were performed by children's insurance status and household poverty level. Finally, to examine state-level variation, multivariable logistic regression was used to compare the adjusted odds of each dependent variable across the 50 states and the District of Columbia. As the reference category, we used Nevada, the state with the lowest adjusted prevalence of children with excellent or very good oral health status in both survey years, and the lowest and second lowest adjusted prevalence of children having at least 1 recent preventive dental visit in 2003 and 2011/2012, respectively.