OBJECTIVE: To compare estimates of dental service use and delayed dental care across 4 national surveys of children’s health.
METHODS: Among children 2 to 17 years of age, prevalence estimates of the use of any dental services, preventive dental services, and delayed dental care in the past year were obtained from the 2003 and 2007 National Survey of Children’s Health, the 2003–2004 National Health and Nutrition Examination Survey (NHANES), the 2003 and 2007 National Health Interview Survey, and the 2003 and 2007 Medical Expenditure Panel Survey. Trends in parent-reported dental use, including delayed care, by sociodemographic characteristics were assessed by using logistic regression and odds ratios.
RESULTS: Data collection methodologies varied across the 4 surveys, and estimates of dental service use varied accordingly. Surveys differed in the survey items used, recall time frames, and protocols for eliciting visit history. As a result, estimates of any dental use ranged from 52% to 81%, whereas estimates of preventive dental use ranged from 67% to 78%. Rates of delayed dental care were low, ranging from 3% to 8%; however, surveys showed consistent sociodemographic disparities in use of dental services and delayed dental care.
CONCLUSIONS: Each survey has a unique approach to defining and eliciting parents’ reports of children’s dental service use, which could result in under- or overestimation of the number and nature of children’s dental services. Each survey’s methodology must be considered when accepting population-based estimates of dental service use to monitor progress in achieving national oral health goals.
- MEPS —
- Medical Expenditure Panel Survey
- NCHS —
- National Center for Health Statistics
- NHANES —
- National Health and Nutrition Examination Survey
- NHIS —
- National Health Interview Survey
- NSCH —
- National Survey of Children’s Health
What’s Known on This Subject:
Oral health researchers and policy makers primarily use 4 national surveys to examine use of dental services among US children. Estimates from the surveys may vary, posing a challenge to population-based monitoring.
What This Study Adds:
The authors of this study compared estimates of dental service use and delayed dental care obtained from 4 commonly used health surveys to appraise their utility for guiding pediatric oral health research and policy.
Good oral health is fundamental to a child’s health and well-being.1 Dental caries is the most common chronic condition in children,1 and parents often rate their children’s oral health as worse than their general, physical health.2 Primary and secondary prevention of pediatric dental disease is well established, and dental and medical provider communities have called on families to establish a relationship with a dentist for periodic preventive dental services, early intervention, and treatment beginning by the time the child is 1 year of age or the first tooth erupts, whichever comes first.1,3–5 Families face numerous challenges accessing and utilizing dental care, however, including the availability of dental providers who see young children or publicly insured children, lack of dental insurance, the cost of dental services, and the parents’ perception of the child’s need for dental care. In addition, these challenges are not distributed evenly across the pediatric population; children from low-income families, racial and ethnic minorities, and children with special health care needs bear a disproportionate burden of dental disease and limited access to dental care.1,5–10
Population-based monitoring of children’s oral health status and dental service use in the United States often is accomplished using 1 of 4 national health surveys: the National Survey of Children’s Health (NSCH), the National Health and Nutrition Examination Survey (NHANES), the National Health Interview Survey (NHIS), and the Medical Expenditure Panel Survey (MEPS). These surveys are used by oral health researchers and policy makers to define the scope of pediatric dental disease and dental service use; to describe and monitor socioeconomic and racial/ethnic disparities in receipt of dental care; to inform national oral health policy, addressing access to and financing of oral health services; and to track progress in meeting national oral health goals, such as those defined in Healthy People 2020.11 Population-based estimates of dental service use and need may vary by survey,12–15 however, posing a challenge for researchers and policy makers who must choose a data source to establish baseline estimates of children’s dental service use and disparities and to monitor changes over time. In this study, we compared estimates of dental service use and delayed dental care and trends in use and delay by key sociodemographic characteristics obtained from each of the 4 surveys, with the goal of appraising the utility of these data sources for guiding pediatric oral health research and setting policy.
Data Sources and Study Populations
We examined 4 surveys that are used to assess dental service use and delayed dental care among US children and youth (hereafter referred to as “children”). We selected 2 survey years, 2003 and 2007, to assess dental estimates over time. We restricted our analyses to children aged 2 to 17 years because 3 surveys restricted oral health survey items to children ≥1 or ≥2 years. Each survey is described as follows.
2003 and 2007 NSCH
Conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS), the NSCH is a telephone interview survey of parents or caregivers (hereafter referred to as “parents”) last conducted in 2003 and 2007. The survey measures health and health care use in a nationally representative sample of noninstitutionalized US children 0 to 17 years of age.16,17 Because this survey data were available only for 2003 and 2007, we chose to examine these same years for the remaining 3 surveys.
The NHANES is conducted annually by the NCHS and assesses the health and nutritional status of a nationally representative sample of the civilian, noninstitutionalized US population. Survey participants, including children, receive a physical examination, including an oral examination, and parents report on their children’s health and health care through in-person interviews.18 After 2003–2004, questions about children’s dental use were no longer asked, however.19
2003 and 2007 NHIS
Conducted annually by the NCHS, the NHIS includes in-person interviews of individuals about their health and the health of any children residing in the home.20,21 Individuals are sampled from a nationally representative population of noninstitutionalized, civilian households in the United States.
2003 and 2007 MEPS
Through the use of in-person interviews, survey staff for the MEPS collect data on the type and frequency of health care use and related medical expenditures among a nationally representative sample of noninstitutionalized US civilian families and individuals. MEPS is conducted annually by the Agency for Healthcare Research and Quality. MEPS survey collectors select a sample of individuals who are then surveyed 5 times over a 2½-year period. At each interview, parents are asked to report on their children’s health care, including dental care and use and expenditures since the last interview.22,23 Reports of medical and dental visits within the reference period are then aggregated into annual counts of medical and dental visits.
Dental Survey Items
Any Dental Use in the Past 12 Months
For this study, receipt of any dental care was defined as any visit to a dentist or dental specialist. Depending on the survey, parents were asked to report whether a child had a dental visit in the past 12 months, to identify the last time a child had a dental visit, or to relay the number of dental visits that occurred in a specified time period. For surveys in which parents were asked to identify the last time a child had a dental visit, we defined “use” as a visit within the past 12 months. Table 1 summarizes the survey items used to define children’s receipt of any dental use in the 4 surveys. The 2003 NSCH assessed any dental use, but the 2007 NSCH did not.
Preventive Dental Use in the Past 12 Months
Depending on the survey, receipt of preventive dental care was defined as a visit to a dentist for preventive dental care, including checkups, screenings, and sealants; a dental checkup; or a teeth cleaning (Table 1). Parents were asked to report on a child’s preventive dental use in the past 12 months or to identify the last time a child had a preventive dental visit. For surveys using the latter approach, we defined preventive use as a preventive visit within the past 12 months. The 2003 and 2007 NHIS did not assess preventive dental use.
Delayed Dental Care in the Past 12 Months
The 2003 and 2007 NSCH, 2003–2004 NHANES, and 2003 and 2007 MEPS included survey items assessing if a child delayed dental care or did not receive needed dental care (Table 1). For this analysis, the child was considered to have delayed dental care if care was delayed or not received in the past 12 months. The 2003 and 2007 NHIS survey item asked if the child’s lack of dental care was due to the family’s inability to afford care; the other surveys also ascertained reasons a child did not receive care, but this information was collected through a follow-up question, not as a primary question, as was done in the NHIS.
Trends in dental use and delayed dental care were examined by age, race/ethnicity, health insurance status, family income, and presence of a special health care need. Our choice of variables was guided by previous studies documenting disparities in dental use and delayed care associated with specific sociodemographic characteristics.10,12 The NSCH and MEPS were the only surveys to include children’s special health care need status, determined using a validated screening tool.16,17,22,23
Estimates of any dental service use, preventive dental service use, and delayed dental care in the past 12 months were calculated for each survey and survey year. When possible, 2003 and 2007 estimates from the same survey were compared by using a 2-sample test of proportions for independent samples. To compare estimates across surveys, each available estimate was compared with the MEPS estimate for the corresponding survey year by using the 2-sample test of proportion for independent samples. MEPS was chosen as the survey against which others were compared because MEPS is used to derive national oral health goals in Healthy People 2020.11 Trends in dental service use and delayed care, by sociodemographic characteristics, were assessed by using logistic regression and odds ratios.15 We examined how odds ratios differed by survey to draw conclusions about the consistency of sociodemographic trends in use and delay across surveys. Each survey had its own survey weights that we used to account for the complex survey design and to weight each survey’s study sample to reflect a nationally representative sample of US children. All analyses were conducted by using Stata 11.1 survey routines (Stata Corp, College Station, TX).
Sample sizes ranged from 2866 children 2 to 17 years of age in the 2003 NHANES to 87 581children 2 to 17 years of age in the 2003 NSCH. Table 2 presents the sample sizes corresponding to each measure within each survey and survey year.
Estimates of Dental Service Use and Delayed Dental Care
In 2003, estimates of any dental use in the past year among children ranged from a low of 52% in MEPS to a high of 81% in NSCH (Table 2). Estimates derived from NHANES, NHIS, and NSCH were significantly greater than the 2003 MEPS estimate (P < .05). From 2003 to 2007, there were no meaningful gains in the proportion of children reported to have received any dental care. NHANES had the lowest estimate of preventive dental use in 2003, 67%, whereas MEPS had the highest, 78%, a statistically significant difference between the surveys (P < .05). Data from the NSCH for 2003 and 2007 showed that the proportion of children with a preventive dental visit increased from 76% in 2003 to 83% in 2007. MEPS data also documented a slight increase from 78% in 2003 to 81% in 2007.
Based on surveys conducted in 2003, parent reports of delayed dental care for children were as follows: 8% in NHANES, 7% in NSCH, 6% in NHIS, and 4% in MEPS (Table 2). From 2003 to 2007, estimates of delayed care reported in NSCH and MEPS significantly decreased (P < .05), with 3% of children in the 2007 NSCH and 2007 MEPS experiencing delayed care. In 2007, the NHIS showed a slight, nonsignificant increase in delayed care (Table 2).
Dental Use and Delayed Dental Care by Sociodemographic Characteristics
In 2003 and 2007, children older than 5 years had higher odds of receiving any dental visit and higher odds of having a preventive dental visit compared with children younger than 5 years, yet they also had greater delayed dental care. Children who were nonwhite, Hispanic, publicly insured or uninsured, and with lower family income had lower odds of any dental use (Table 3), lower odds of preventive dental use (Table 4), and higher odds of delayed dental care (Table 5) with the exception that race/ethnicity was either not associated with delayed dental care or black children had lower odds of delayed dental care compared to whites across surveys in 2007. Furthermore, a gradient effect was noted in insurance and income. Uninsured and low-income families had even lower odds of any dental use or of preventive dental service use and higher odds of delayed care than children who were publicly insured or who were from middle-income families. Children with special health care needs had higher odds of any dental use, preventive dental use, and delayed care.
The survey items and data collection procedures employed to determine children’s use of dental services vary across the 4 surveys, and we found that the resulting prevalence estimates of dental service use varied accordingly. Estimates of any dental use varied the most because MEPS estimates were particularly low. Estimates of preventive dental use and delayed dental care also differed among surveys, although with less variation. When estimates within a survey could be compared between 2003 and 2007, any dental use and preventive dental use increased or remained unchanged. Estimates of delayed dental care were fairly low across all surveys, and the proportion of children with delayed dental care either decreased from 2003 to 2007 or remained statistically unchanged. Across surveys, disparate use of dental services and delay by key sociodemographic characteristics were similar, and socioeconomic gradients were consistent.
Each survey’s unique data collection methodology likely contributes to the variation in the estimates of dental use. NHIS, NSCH, and MEPS use 1 survey item to assess a child’s general dental use or preventive dental use, with no additional follow-up questions about the visit. NHANES also uses only 1 question and includes a follow-up question about the reason for the visit. MEPS also adopts an unique, alternative approach to enumerating dental visits that differs from the other surveys. The MEPS interviewer uses prompts and probes to improve the parent’s recall of a child’s dental visit experience in the several months before the interview and then elicits additional information, including the nature of the visit, the type of dental provider, the treatments and services performed, and associated dental expenditures.
MEPS estimates illustrate how these various approaches affect results. In MEPS, the proportion of children with any dental use in the past year is lower (52% [in 2003] and 53% [in 2007]) than the estimate of the proportion of children reported to have received a preventive dental visit in the past year (78% [in 2003] and 81% [in 2007]). The former is derived from detailed questioning of parents about each dental visit, whereas the latter is based on a single item about dental checkups and involved no further questioning. Public health, medical, and dental practitioners provide consistent messages to families that children’s good oral health can be maintained through personal oral health hygiene practices and dental checkups at least once per year.1,3,24 As a result, social desirability bias may influence parents to report that their children receive dental care yearly, leading to overreporting of children’s dental visits; however, when additional information is requested about a visit, parents may be more cautious about reporting visits. MEPS’ use of probes and detailed follow-up about the visit may guard against this bias and protect against threats to the validity and accuracy of parent-report. Based on our analysis, we cannot know if MEPS’ approach results in an undercount of visits, particularly if parents do not report visits for which they know they may be unable to answer detailed questions, or provides a more cautious representation of visit experience.
The 4 surveys also differed in the recall period used to determine if and when dental services occurred. In some surveys, parents were asked about their child’s dental use in the past 12 months; in others, parents were asked to relay the timing of the last dental visit over the course of several months or years. With the use of retrospective questions, errors of omission (an individual does not recall an event that occurred), errors of commission (recalling an event that did not occur), and telescoping (recalling an event as happening earlier or later than it actually did) are known threats to accuracy.25,26 In addition, underreporting of health service use increases as the recall time period increases, particularly for visits that are not rare or particularly memorable.26 This could arguably be the case for most children’s dental visits. Although it has been suggested that a recall time frame of ≥12 months may be too long and lead to underreporting of health services in most cases,26 children’s dental use may be different. As previously mentioned, social desirability bias may lead parents to overreport children’s dental use in a 12-month time frame to meet the expectation of at least 1 dental visit per year. Insofar as probes and prompts help to sharpen parents’ recall of services received, MEPS’ lower estimates may be a reflection of actual service use.
There is a difference of opinion about the accuracy and best use of MEPS data.15,27 The current study is the first to address these concerns regarding dental visits by children by using data from 4 different national surveys for 1 or 2 comparable years. In comparing the methodologies of the 4 surveys, the in-depth approach of MEPS includes the greatest number of protections against overestimating the number and nature of dental services. We conclude, as did Macek et al, that if accurate estimates are necessary, MEPS should be used.15 Furthermore, Healthy People 2020 uses MEPS data to establish national pediatric oral health goals,11 reinforcing the utility of MEPS estimates for monitoring national progress in children’s use of dental care.
Specific research or policy questions also will guide the selection of a data source, however. For example, if the question necessitates clinical oral health data, the in-person examination data from NHANES should be used. If costs associated with dental care are of interest, MEPS is the only 1 of the 4 surveys with detailed expenditure data. Questions concerning state-level geographic variation or other social, behavioral, or emotional factors that may influence receipt of dental care are best addressed using the NSCH, which provides contextual factors that the other surveys lack. To examine trends in disparities or explore factors that may mitigate disparities, each of the 4 surveys could be considered; however, caution is warranted in using NHANES when examining racial/ethnic disparities. With its small child sample size relative to the other surveys, racial/ethnic differences in dental use or need may be limited to white, black, and Hispanic subgroups.
As each survey has strengths, each has limitations. No survey validated a parent’s report of children’s dental service use. Although self-reported dental use among adults has been shown to be valid,28 parent recall of children’s dental use could be less accurate. Our analysis could only infer, and we can only speculate which survey estimates may reflect overreporting and why. Recognizing the challenges of validity often associated with survey-based oral health surveillance, the Affordable Care Act of 2010 includes a provision requiring the Agency for Healthcare Research and Quality to verify dental utilization and expenditures in MEPS.29 This requirement provides a means of further improving the validity of MEPS for dental service use surveillance.
Estimates of dental use and delayed dental care vary across 4 commonly used national surveys of children’s health. Each survey has a unique approach to defining and eliciting parents’ reports of children’s dental service use and delay, which must be considered when accepting population-based estimates of dental service use or when monitoring progress toward national oral health goals.
- Accepted June 22, 2012.
- Address correspondence to Melissa A. Romaire, PhD, MPH, RTI International, 3040 E. Cornwallis Rd, PO Box 12194, Research Triangle Park, NC 27709. E-mail:
Dr Romaire made substantial contributions to the conception, design, analysis, and interpretation of data, conducted the initial analyses, drafted the initial article, revised it for intellectual content, and approved the final article as submitted; Dr Bell made substantial contributions to the conception, design, analysis, and interpretation of data, revised the article for intellectual content, and approved the final article as submitted; and Dr Huebner made substantial contributions to the conception, design, analysis, and interpretation of data, revised the article for intellectual content, and approved the final article as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This study was funded by grant R40 MC17168 (principal investigator: Dr Bell) through the US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program.
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- Copyright © 2012 by the American Academy of Pediatrics