Preventive Dental Checkups and Their Association With Access to Usual Source of Care Among Rural and Urban Adult Residents

Urban-rural differences in the prevalence of having a family dentist and their association with income inequality among Japanese individuals: a cross-sectional study

BACKGROUND

Few reported studies evaluate the status of those who have a family dentist (FD) by regional differences and the socioeconomic factors associated with this status. This study aimed to assess the prevalence of having an FD among Japanese individuals across three samples of municipality type: urban, intermediate, and rural areas, and determine the factors associated with having an FD.

METHODS

This was a cross-sectional study involving a web-based survey. In total, 2,429 participants (comprising men and women aged 20-69 years) were randomly selected from among the registrants of a web research company: 811 urban residents, 812 intermediate residents, and 806 rural residents. In each area, we categorized the participants into those who had an FD (FD group) and those who did not (non-FD group). A multivariate modified Poisson regression analysis was used to determine the factors associated with the FD group as compared to the non-FD group.

RESULTS

The proportion of the FD group was lowest in rural areas (42.3%), followed by intermediate (48.6%) and urban areas (49.7%). The regression analysis revealed a statistically significant tendency between associated factors in the two groups; that is, the higher the household income, the more likely that the family belonged to the FD group (prevalence ratio (95%CI), JPY 4-6 million: 1.43 (1.00-2.03), JPY ≥ 8 million: 1.72 (1.21-2.44)).

CONCLUSIONS

Rural areas have the lowest proportion of people with an FD among the three areas, and income inequality is associated with having an FD. Thus, when planning policies to encourage individuals to have an FD to manage their oral health, it is necessary to consider regional differences.

A cross-sectional study of the preventive health care activities of western Canadian rural-living patients unattached to primary care providers

Prevention services, such as screening tests and vaccination, are underutilized, especially by rural populations and patients without a usual primary care provider. Little is known about the compounding impacts on preventive care of being unattached and living in a rural area and there has been no comprehensive exploration of this highly vulnerable population’s prevention activities. The twofold purpose of this research was to examine rural unattached patients’ prevention activity self-efficacy and completion and to explore their experiences accessing healthcare, including COVID-19 impacts. Two thirds of patients had been unattached for over one year, and over 20 % had been unattached for over 5 years; males experienced longer unattachment compared to females. Completion rates of prevention activities were relatively low, ranging from 5.9 % (alcohol screening) to 59 % (vision test). Most participants did not complete their prevention care activities in line with the Lifetime Prevention Schedule timeline: 65 % of participants had less than half of their activities up-to-date and only 6.7 % of participants were up to date on 75 % or more of their prevention activities. Participants with higher prevention self-efficacy scores were more likely to be up-to-date on associated prevention activities but the longer patients had been unattached, the fewer their up-to-date prevention activities. Patients expressed negative impacts of COVID-19 including walk-in clinics shutting down limiting access to care. These results suggest serious gaps in rural unattached patients’ preventive care and highlight the need for support when they are without a usual primary care provider, which can be lengthy.

Urgent dental care use in the North East and Cumbria: predicting repeat attendance

Introduction Around one-third of the UK population are 'problem-orientated dental attenders', only seeking care when suffering with dental pain and often on a repeated basis to secondary care. Little is known about attendance in primary care. The aim here was to examine the period prevalence of repeat urgent care attenders and establish predictors of repeat attendance in primary care.

Methods Data on urgent and emergency dental care attendances in primary dental care in the North East and Cumbria were analysed from 2013-2019. Variables included: patient sex; ten-year age band; lower super output area; and Index of Multiple Deprivation. Period prevalence was calculated and data were considered year by year to identify trends in attendances. Analysis was with descriptive statistics and predictors of repeat attendance were identified using logistic regression modelling.

Results Over the six-year period, there were 601,432 attendances for urgent primary dental care, equating to a period prevalence of 2.76% for the geographic population studied. In total, 16.15% of attendances were repeat attendances (period prevalence 0.45%) and predictors included being a woman and residence in deprived and rural areas. All urgent care attendances decreased over the six-year period, with one-off attendances beginning to increase again in 2019, while repeat attendances stabilised.

Conclusion Interventions to encourage regular dental attendances should be targeted at patients from the most deprived and rural areas of the North East and Cumbria; however, a decrease in repeat attendance was noted in these areas.

Predictors of being a repeat attender for urgent and emergency dental care included being a woman and living in the most deprived and rural areas of the North East and Cumbria.

Over a six-year period (2013-2019), the number of one-off urgent and emergency dental care attenders to primary care in the North East and Cumbria decreased before beginning to increase.

Over the same period, the number of repeat urgent and emergency dental care attenders to primary care in the North East and Cumbria decreased before stabilising.

Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients’ reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Use of oral health care services in the United States: unequal, inequitable-a cross-sectional study

Background

Social determinants drive disparities in dental visiting. Disparities can be measured simply by comparing outcomes between groups (inequality) but can also consider concepts of social justice or fairness (inequity). This study aimed to assess differences in dental visiting in the United States in terms of both social inequality and inequity.

Methods

Data were obtained from a cross-sectional study—the National Health and Nutrition Examination Survey (NHANES) 2015–2016, and participants were US adults aged 30+ years. The outcome of interest, use of oral health care services, was measured in terms of dental visiting in the past 12 months. Disparity was operationalized through education and income. Other characteristics included age, gender, race/ethnicity, main language, country of birth, citizenship and oral health status. To characterize existing inequality in dental service use, we examined bivariate relationships using indices of inequality: the absolute and relative concentration index (ACI and RCI), the slope index of inequality (SII) and relative index of inequality (RII) and through concentration curves (CC). Indirect standardization with a non-linear model was used to measure inequity.

Results

A total of 4745 US adults were included. Bivariate analysis showed a gradient by both education and income in dental visiting, with a higher proportion (> 60%) of those with lower educational attainment /lower income having not visited a dentist. The concentration curves showed pro-higher education and income inequality. All measures of absolute and relative indices were negative, indicating that from lower to higher socioeconomic position (education and income), the prevalence of no dental visiting decreased: ACI and RCI estimates were approximately 8% and 20%, while SII and RII estimates were 50% and 30%. After need-standardization, the group with the highest educational level had nearly 2.5 times- and the highest income had near three times less probability of not having a dental visit in the past 12 months than those with the lowest education and income, respectively.

Conclusion

The findings indicate that use of oral health care is threatened by existing social inequalities and inequities, disproportionately burdening disadvantaged populations. Efforts to reduce both oral health inequalities and inequities must start with action in the social, economic and policy spheres.

Medicaid healthy behavior incentives and use of dental services

OBJECTIVE

To examine changes in access to dental care in states using Section 1115 waivers to implement healthy behavior incentive (HBI) programs in their Medicaid expansion under the ACA, compared to traditional expansion states and nonexpansion states.

DATA SOURCES

Behavioral Risk Factor Surveillance System from 2008 to 2018.

STUDY DESIGN

We used difference-in-differences analysis to compare changes in three Medicaid expansion states with HBI (Iowa, Indiana, Michigan) to traditional expansion (Minnesota, North Dakota, Ohio) and nonexpansion states (Nebraska, South Dakota, Wyoming) in the same mid-Western region of the country. The sample included 32 556 low-income adults.

DATA COLLECTION/EXTRACTION METHODS

NA.

PRINCIPAL FINDINGS

We found no significant changes in dental visits associated with HBI or traditional expansion relative to nonexpansion states. HBI expansion was associated with an increase of 2.2 percentage points in reporting a dental visit in the past year for adults in urban areas (P < 0.05) while the traditional expansion was associated with a reduction of 8.5 percentage points (P < 0.01) in utilization in rural areas relative to nonexpansion states. However, after adjustment for preexisting trends, the coefficients were no longer significant, suggesting that these differences are likely due to preexisting trends.

CONCLUSIONS

We did not find evidence of increased utilization of routine dental care associated with HBI programs.

Multilevel Analysis of the Association of Dental-Hygienist-Related Factors on Regular Dental Check-Up Behavior

Few studies have examined the factors related to dental clinics during dental check-ups. We examined the association between dental-hygienist-related factors and patients’ regular dental check-ups. This nationwide cross-sectional study was based on a survey conducted in Japan in 2014. The analyzed population included 12,139 patients from 1181 dental clinics. We used three-level Poisson regression analysis, considering patient‒clinic‒prefecture, to examine the association of dental-hygienist-related factors with dental check-up behavior. Patients attending treatment and regular check-ups constituted 63.0% and 37.0%, respectively. The adjusted prevalence ratios (PRs) for patients undergoing regular dental check-ups at dental clinics with dedicated dental hygienists’ units, spending ≥20 min in patient education (compared to 0 min), and with three or more dental hygienists (compared to 0 hygienists) available were 1.17 (95% confidence interval [CI]: 1.06–1.30), 1.25 (95%CI: 1.07–1.46), and 2.05 (95%CI: 1.64–2.56), respectively. The median PR indicates that when a patient randomly moves to another dental clinic with more regular dental check-ups, this prevalence increased 1.69 times. These results suggest that dental check-up behavior is determined not only by individual factors but also dental-clinic-level factors. Improving the dental-hygienist-related factors is necessary to encourage people to visit dentists for regular check-ups.

Exploring the Impact of ACA on Rural-Urban Disparity in Oral Health Services Among US Noninstitutionalized Adults

PURPOSE

To explore the effect of the Affordable Care Act (ACA) on rural disparities in oral health services utilization based on disability status.

METHODS

Comparing the 2011-2013 with the 2014-2016 Medical Expenditure Panel Survey, the study estimated the impacts of ACA on the likelihood of having preventive checkup and utilization of dental treatments in adults older than 18.

FINDINGS

The sample consists of 216,184 noninstitutionalized adults with 14.5% living in rural areas. There was a slight improvement in the receipt of oral health services after ACA, but the improvement was not statistically significant. Disability remains a barrier to receiving preventive oral health checkups, and living in rural areas is a barrier for both utilization of preventive checkups and dental treatments.

CONCLUSIONS

Unmet needs for preventive checkups may result in unnecessary, costly dental treatments. More strategies are needed to reduce the disparities in oral health services.

Variation in dental services by rurality among privately insured adults in the United States

OBJECTIVES

Rurality is associated with reduced dental access and worse oral health outcomes. It is unknown whether there is variation in dental services received by rural adults who visit a dentist.

METHODS

This was a retrospective analysis of claims data from a large private insurer. All individuals who had at least one dental visit in 2018 were included. Patient demographics, whether or not a patient's ZIP code was rural as defined by the Federal Office of Rural Health Policy, as well as ZIP code demographics were collected. Differences in the frequency of dental services received were evaluated using χ² tests. Multilevel logistic regressions were used to evaluate the individual and ZIP code-level correlates of receiving a preventive dental procedure, a tooth extraction, or a denture-related dental procedure.

RESULTS

Rates of preventive, oral and maxillofacial surgery, and denture-related procedures were higher among rural adults. Accounting for individual age and gender, and ZIP code average income and dentist density, rural dwellers were more likely to receive a preventive procedure [odds ratio (OR) 1.15, P < 0.0001] or tooth extraction (OR 1.08, P < 0.0001), and less likely to have a denture-related procedure (OR 0.94, P = 0.015) compared to nonrural dwellers. Female gender was the strongest predictor of receiving a preventive procedure (OR 1.30, P < 0.0001).

CONCLUSIONS

Even among privately insured individuals with known access to dental care, rurality was associated with significant differences in the frequency of various dental procedures. Rural dental patients may have higher needs for oral surgical procedures, even when they have access to preventive care.

Utilisation of dental services by Brazilian adults in rural and urban areas: a multi-group structural equation analysis using the Andersen behavioural model

Background

The utilisation of health services is determined by complex interactions. In this context, rural populations face greater barriers in accessing dental services than do urban populations, and they generally have poorer oral health status. The evaluation of the determinants of health services utilisation is important to support planning and management of dental services. The aim of this study was to evaluate the predictors of dental services utilisation of Brazilian adults living in rural and urban areas.

Methods

Data from 60,202 adults aged 18 years or older who took part in the Brazilian National Health Survey carried out in 2013 were analysed. Predisposing (age, sex, education, social networks), enabling financing (income, durable goods and household’s crowding), enabling organisation (health insurance, registration in primary health care [PHC]) and need variables (eating difficulties, self-perceived tooth loss and self-perceived oral health) were selected based upon the Andersen behavioural model. Multi-group structural equation modeling assessed the direct and indirect associations of independent variables with non-utilisation of dental services and the interval since the last dental visit for individuals living in rural and urban areas.

Results

Adults living in urban areas were more likely to use dental services than those living in rural areas. Lower enabling financing, lower perceived dental needs and lack of PHC registration were directly associated with lower utilisation of dental services (non-utilisation, β = − 0.36, β = − 0.16, β = − 0.03, respectively; and interval since last dental visit, β = 1.25, β = 0.82, β = − 0.12, respectively). The enabling financing (non-utilisation, β_rural = − 0.02 [95%CI: − 0.03 to − 0.02], β_urban = 0.00 [95%CI: − 0.01 to 0.00]) and PHC registration (non-utilisation, β_rural = − 0.03 [95%CI: − 0.04 to − 0.02], β_urban = − 0.01 [95%CI, − 0.01 to − 0.01]) non-standardised total effects were stronger in rural areas. Enabling organisation (β = 0.16) and social network (β = − 2.59) latent variables showed a direct effect on the interval since last dental visit in urban areas. Education and social networks influenced utilisation of dental services through different pathways. Males showed less use of dental services in both urban and rural areas (non-utilisation, β_rural = − 0.07, β_urban = − 0.04; interval since last dental visit, β_rural = − 0.07, β_urban = − 0.07) and older adults have used dental services longer than younger ones, mainly in rural areas (β_rural = 0.26, β_urban = 0.17).

Conclusion

Dental services utilisation was lower in rural areas in Brazil. The theoretical model was supported by empirical data and showed different relationships between the predictors in the two geographical contexts. In rural areas, financial aspects, education, primary care availability, sex and age were relevant factors for the utilisation of services.

Socioeconomic inequality in dental care utilization in Iran: a decomposition approach

PURPOSE

Socioeconomic inequalities in dental care utilization in Iran are rarely documented. This study aimed to provide insight into socioeconomic inequalities in dental care utilization and its main contributing factors among Iranian households.

DESIGN/METHODOLOGY/APPROACH

A total of 37,860 households from the 2017 Household Income and Expenditure Survey (HIES) were included in the study. Data on dental care utilization, age, gender and education attainment of the head of household, socioeconomic status of households, health insurance coverage, living areas and provinces were obtained for the survey. The concentration curve and the normalized concentration index (C_n) was used to illustrate and quantify socioeconomic inequalities in dental care utilization among Iranian households. The C_n was decomposed to identify the main determinants of the observed socioeconomic inequality in dental care utilization in Iran.

FINDINGS

The study indicated that the prevalence of dental care utilization among Iranian's households was 4.67% (95% confidence interval [CI]: 4.46 to 4.88%). The results suggested a higher concentration of dental care utilization among socioeconomically advantaged households (C_n = 0.2522; 95% CI: 0.2258 to 0.2791) in Iran. Pro-rich inequality in dental care utilization also found in rural (C_n = 0.2659; 95%CI: 0.2221 to 0.3098) and urban (C_n = 0.0.2504; 95% CI: 0.0.2159 to 0.2841) areas. The results revealed socioeconomic status of households, age and education status of head of households and residing provinces as the main contributing factors to the concentration of dental care utilization among the wealthy households.

ORIGINALITY/VALUE

This study revealed pro-rich inequalities in dental care utilization among households in Iran and its provinces. Thus, health policymakers should focus on designing effective evidence-based interventions to improve healthcare utilization among household with the older head of households, lower education status, and living in relatively poor provinces to reduce socioeconomic inequality in dental care utilization in Iran.

Inequalities in Caries Experience Among Mongolian Children

Although inequalities in dental caries have been well-reported, there is only one Mongolian study on the association between socioeconomic status (SES) and caries experience, which was published ten years ago. This study aimed to determine the dental health status of Mongolian children living in urban and suburban areas of Ulaanbaatar city and examine its association with income and parental educational attainment. An oral examination was conducted by dentists and caries were measured as deft/DMFT indices. A questionnaire including demographic characteristics and socioeconomic status was completed by their parents or caregiver. Parental educational attainment and household income were used as the measures of SES. The relative index of inequality (RII) and slope index of inequality (SII) were employed to examine the association between SES on deft and DMFT after adjusting for covariates. Dental caries prevalence (those with deft/DMFT > 0) was 89.3% among the total number of participants. The mean deft/DMFT values for age groups 1-6, 7-12, and 13-18 were 5.83 (SD = 4.37, deft), 5.77 (SD = 3.31, deft/DMFT), and 3.59 (SD = 2.69, DMFT), respectively. Rather than residence area and parental educational attainment, significant caries experience inequality was observed in relation to income (RII 0.65 95%, CI 0.52 to 0.82, SII -2.30, 95% CI -4.16 to -0.45). A prevention strategy for lower socioeconomic groups and building integrated oral health surveillance to monitor epidemiological trends for further evaluation of its progress is necessary.

Development and testing of a patient-centered dental home assessment for low-income families

OBJECTIVES

The purpose of this study was to develop an instrument in English (ENG) and Spanish (SPA) for use in assessing perceptions of dental home characteristics among low-income adults.

METHODS

An expert panel selected 21 items from a pool of 81 items mapped to domains in the American Academy of Pediatrics' medical home. Pilot testing with mothers (n = 795) of children in Early Head Start (EHS) resulted in an expanded 36-item scale, which was field-tested in interviews with ENG- (NENG = 665) and SPA-speakers (NSPA = 116). An exploratory factor analysis of 23 usable items was carried out in an EHS reference group (NENG-EHS = 272). The selected model was evaluated by confirmatory factor analysis (CFA) in two other subgroups (NENG-NonEHS = 393; NSPA = 116). We tested measurement and structural invariances using a multiple-group approach. Known-groups validity was examined by testing factor mean differences between two groups defined by whether or not the mother used a single dental office.

RESULTS

A three-factor CFA model with 10 items was retained for its close fit for all three subgroups. Invariance tests found the two ENG subgroups to be homogenous and were combined. Several item and factor parameters in the SPA group differed from the combined ENG group. The proposed dental home measure demonstrated good known-group validity in that people who used the same dental office reported better dental care experiences.

CONCLUSIONS

An instrument to measure the dental home concept among low-income adults was developed with three domains (accessible-comprehensive, compassionate, and health literate care) that demonstrated good validity and reliability.

Dental care utilization: examining the associations between health services deficits and not having a dental visit in past 12 months

BACKGROUND

A growing literature supports the contention that closing the divide between dental and medical care can improve access to and coordination of patient care. Health service deficits (HSDs) entail: no routine medical exam, no personal healthcare provider (HCP), no health insurance, and/or delaying medical care because of cost all within the last 12 months. Examining the associations between HSDs and dental care utilization could inform strategies and interventions aimed at narrowing the gap between the medical and dental professions. This study explored whether HSDs are associated with not having a dental care visit within the last 12 months. In addition, the study sought to provide an updated analysis of the characteristics and factors associated with dental care utilization.

METHODS

Two thousand sixteen Behavioral Risk Factor Surveillance System survey data were analyzed using bivariate and multivariable techniques. The outcome variable for this study was: last dental visit was longer than 12 months ago.

RESULTS

US adults without healthcare insurance, without a personal HCP, who had delayed medical care because of cost, and who had their last routine medical visit longer than 12 months ago had greater odds of not having a dental visit within the last 12 months. Further, this study identified disparities in dental care utilization among males, rural residents, those earning less than $50,000 per year, Non-Hispanic Blacks and Non-Hispanic other races. Individuals with six or more and/or all of their permanent teeth removed and current smokers also had greater odds of not having had a dental care visit in the past 12 months.

CONCLUSIONS

Findings suggest that a stronger integration of medical and dental care might increase dental care utilization. In addition, persistent disparities in dental care utilization remain for several demographic groups. Targeted interventions offer the promise of helping achieve HP 2020 goals for improved oral health.