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


Oral health status and preventive dental visits improved nationally between 2003 and 2011/2012, with greater improvement observed for preventive visits. Significant improvements were seen among children in almost all categories of health insurance and household income, although oral health status of children without health insurance did not improve over time. In both years, outcomes were better among children with health insurance than among those without and among children living in households with incomes above the FPL than in those below. These findings suggest continued disparities in children's oral health.

Oral health status improved in half of states, and preventive dental visits improved in nearly 90% of states. No state significantly worsened in either outcome over time. Children in Nevada had the worst oral health status in 2003 and in 2011/2012. Florida had the lowest percentage, and Nevada the second lowest percentage, of children receiving at least 1 recent preventive dental visit in 2011/2012. Changes in preventive dental visits had more state-level variation than changes in oral health status. Given that estimated state prevalences were adjusted for child and family characteristics, the observed variation may be due to larger variability among programs and policies that support dental visits (eg, workforce, insurance) than among those that support health status (eg, fluoridation, school-based sealant programs). For example, a report on state pediatric dental policies found that in 2009 Medicaid paid medical staff for early preventive dental health care in 35 states, whereas only 10 states had sealant programs in place for at least 50% of schools with children at high risk of cavities.[19]

Our study had several study limitations. First, estimates of children's dental outcomes may vary depending on the survey used. For example, compared with parents surveyed in the 2003 Medical Expenditure Panel Survey (MEPS), fewer parents surveyed for the 2003 NSCH reported children aged 2 to 17 years used preventive dental care in the past 12 months (75.6% NSCH vs 78.3% MEPS). In 2007, however, this reversed, with a higher proportion of NSCH-surveyed parents reporting their children received preventive dental care (82.6% NSCH vs 80.9% MEPS). The surveys' differing data collection methods likely contributed to differences in estimates of preventive dental care.[11] NSCH asks parents about their child's dental use in the past 12 months, whereas MEPS asks parents about the timing of the last dental visit over the course of several months or years. Additionally, MEPS interviewers use prompts to improve parents' recall of a child's dental visit (20,21). Although methodological discrepancies across surveys may result in overestimation or underestimation, biased estimates of changes in oral health outcomes are unlikely when using the same methods across multiple years.

A second limitation is potential response bias. Because of social desirability, parents may overestimate children's preventive dental visits. Conversely, although parents' recall and self-report of selected dental treatments (eg, root canal) have been found to be valid,[22] they may underestimate their children's routine dental visits.[23] Given that NSCH is a representative survey, it is unlikely the direction or magnitude of response bias would change significantly across survey years. Relatedly, little research has been conducted on the validity of parents' reports of the condition of their children's teeth. In 1 study, compared with clinicians' determination of restorative treatment needs, caregivers overestimated children's positive oral health status.[24] Although caregivers in our study may have overestimated children's positive oral health status, they were asked the same question in both 2003 and 2011/2012. Furthermore, the question ascertaining preventive dental visits was slightly different in the 2 survey years. The 2003 survey asked parents to respond yes or no to whether their child had had a preventive dental visit in the past 12 months, but the 2011/2012 survey asked parents how many times in the past 12 months their child had seen a dentist for preventive care. Because the manner in which this difference may have affected changes in responses cannot be determined, we must use caution in interpreting the result. Additionally, we were not able to distinguish among various types of preventive visits or services provided (eg, dental cleaning, fluoride application, sealant). A child with 1 preventive visit may not have received all necessary preventive care.

Finally, our study includes health insurance as a covariate but does not include a measure of dental insurance. Although preventive dental care services are a covered benefit for children receiving Medicaid, our study lacks information about dental insurance for children who are covered by private health insurance. Both oral health outcomes we examined improved over time among children with private health insurance, which may indicate these children were either covered by dental insurance or that their parents paid out of pocket for dental services.

Despite these limitations, this study has numerous strengths. First, NSCH provides both national and state-level estimates, permitting analysis of geographic variation in children's oral health outcomes. Second, children's oral health outcomes are adjusted for an array of child and family characteristics, allowing for examination of differences beyond states' sociodemographic variability. Finally, analyzing data from NSCH 2003 and NSCH 2011/2012 allows for sufficient passage of time between surveys to adequately assess changes. More than 75% of the increase in unadjusted prevalence of children's oral health status and 100% of the increase in unadjusted prevalence of preventive visits took place between 2003 and 2007.[25]

National and state-level improvements in children's oral health status and use of preventive services suggests there has been progress toward the oral health objectives of Healthy People 2020, which include reducing the proportion of children and adolescents who have dental caries and untreated dental decay and increasing the proportion of low-income children and adolescents who received any preventive dental service during the past year. Further improvements may be realized by working with primary care clinicians to ensure dental homes are established starting at an early age. Additionally, public health agencies should conduct outreach to Hispanic communities and target low-income families through the Special Supplemental Nutrition Program for Women, Infants, and Children. Geographic variability in improvements in oral health status and receipt of services suggests an ongoing need to examine programs and policies implemented at the state level, with an eye toward adapting efforts in states with the largest gains to states with the worst oral health outcomes. Understanding these differences is critical to addressing the most common chronic disease of childhood and achieving the oral health objectives of Healthy People 2020.