OBJECTIVE: In this study we estimated factors associated with children being advised to see the dentist by a doctor or other health provider; tested for an association between the advisement on the likelihood that the child would visit the dentist; and estimated the effect of the advisement on dental costs.
METHODS: We identified a sample of 5268 children aged 2 to 11 years in the 2004 Medical Expenditures Panel Survey. A cross-sectional analysis with logistic regression models was conducted to estimate the likelihood of the child receiving a recommendation for a dental checkup, and to determine its effect on the likelihood of having a dental visit. Differences in cost for children who received a recommendation were assessed by using a linear regression model. All analyses were conducted separately on children aged 2 to 5 (n = 2031) and aged 6 to 11 (n = 3237) years.
RESULTS: Forty-seven percent of 2- to 5-year-olds and 37% of 6- to 11-year-olds had been advised to see the dentist. Children aged 2 to 5 who received a recommendation were more likely to have a dental visit (odds ratio: 2.89 [95% confidence interval: 2.16–3.87]), but no difference was observed among older children. Advice had no effect on dental costs in either age group.
CONCLUSIONS: Health providers' recommendation that pediatric patients visit the dentist was associated with an increase in dental visits among young children. Providers have the potential to play an important role in establishing a dental home for children at an early age. Future research should examine potential interventions to increase effective dental referrals by health providers.
WHAT'S KNOWN ON THIS SUBJECT:
Dental care is the greatest unmet health care need for children. Medical and dental professionals agree that physicians have an important role in increasing children's use of dental care. However, evidence for the effectiveness of a physician dental referral is poor.
WHAT THIS STUDY ADDS:
No previous study has examined the relationship between a health care provider's recommendation and dental use among a nationally representative sample of children. This study estimates the association between a child being advised to see the dentist and having a dental visit.
Dental caries is the most prevalent chronic disease of childhood, and dental care is the greatest unmet health care need among children.1,2 Approximately 80% of children experience dental caries by the age of 17.3 Medical and dental professionals agree that physicians have an important role in increasing children's use of dental care and promoting oral health.4,–,7 Before 2008, the American Academy of Pediatrics recommended that physicians advise all children to see the dentist by the age of 3 and for children at high risk to see the dentist by the age of 1.5 Early dental visits also have been promoted by other medical professional organizations.8 However, the effectiveness of a health provider's recommendation to see the dentist remains unknown.
A recent study revealed that approximately half of US children were advised to see a dentist by a health provider.9 A systematic review by the US Preventive Services Task Force revealed that evidence for the effectiveness of physician dental referral is poor, primarily because of the small number of studies and their poor quality.10 It is important to know whether a health provider's recommendation is effective in increasing the use of dental care because young children are more likely to visit a medical office than a dental office. There has been no previous study to our knowledge in which the relationship between a health care provider's recommendation and dental use was examined among a nationally representative sample of children.
In this study we addressed 3 aims. We estimated the factors associated with children being advised by a health provider to have a dental checkup and the association between being advised to see the dentist and having a dental visit. Children who were advised to see the dentist may have had greater dental needs than those who were not advised. To assess this possibility, we estimated differences in the amount of dental expenditures for children who were or were not advised to see the dentist among those who had a dental visit.
The Medical Expenditure Panel Survey (MEPS) is a nationally representative set of surveys that includes information on health care costs, use and insurance coverage developed by the Agency for Healthcare Research and Quality. In this study, we use information from the 2004 survey, which had a total sample size of 13018 households representing 32707 civilian, noninstitutionalized individuals. Our sample included children aged 2 to 11 years old and their dental use during 2004. We excluded adolescents because of their low rates of use of preventive medical services and small number of opportunities to receive a dental recommendation.11 We also excluded children in foster care because of differences in determinants of their use of dental and medical care.
A total of 5547 children were eligible for this study. Of these children, ∼5% were missing data and were excluded from the analysis. The final sample size was 5268 children, and all analyses were conducted separately on 2- to 5-year-olds (n = 2031) and 6- to 11-year-olds (n = 3237) because of differences in their medical and dental use and oral health risks. Parents were sent materials to record information about the child's use of health services. They were then interviewed via telephone using computer-assisted personal interviewing. Previously published reports have provided detailed information about MEPS methodology and data-collection procedures.12
We created 3 dependent variables for the 3 study aims: (1) whether the child was advised to see the dentist within the previous year; (2) whether the child had a dental visit in 2004; and (3) total dental expenditures.
Receipt of advice about a dental visit was assessed by asking the parents whether a doctor or other health care provider had ever advised a dental checkup. A health provider was defined for the respondent as a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else the child would see for health care, and the question was asked within a series of questions on preventive health care that the child received during visits to the doctor or other health provider. If the parents reported receiving a recommendation, they were asked whether it was within the previous year, within the previous 2 years, or >2 years ago. We created 3 binary variables to indicate whether the child had been advised to go to the dentist within the previous year, the previous 2 or more years, or never. We categorized recommendations within the previous year separately, because a more recent recommendation is important for timely follow-up care at the dentist.
A binary variable that indicated whether the child had a dental visit in 2004 was the dependent variable to assess the association between a recommendation and dental use. Dental visits included care of any type provided by general dentists, dental hygienists, and all dental specialists.
Total dental expenditures were defined in MEPS as the sum of direct payments for all dental care provided, including out-of-pocket payments and payments by private insurance, public insurance, and other sources. Dental-expenditure data were collected by asking parents about care that the child received at each dental visit and the associated expenditures, including the source of payment and amount, and they were asked to provide documentation such as a bill or receipt, if available.
For the second and third aims, the main independent variable was whether the child had been advised to see a dentist as defined above. By using the Andersen13 behavioral model for health care service use as a guide (Fig 1), we controlled for potential child and family characteristics that could affect dental and medical use. On the basis of previous research in dental and health services use, we hypothesized that the child's dental use would be influenced by child-predisposing characteristics (age, race, ethnicity, special health care need, health status, and residing in a metropolitan statistical area [MSA] and US geographic region of residence)2,14,–,16 and child- and family-enabling characteristics (family income as a percentage of poverty, parent's education, whether the child had a regular source of medical care, whether the parent was a regular user of dental care, and medical and dental insurance coverage).2,17,–,20
We identified parents who reported using dental care at least once per year as a “regular user” of dental care. Having a regular source of medical care was determined in the MEPS by asking if there was a particular doctor's office, clinic, health center, or other place that the parent takes the child if he or she is sick or needs advice about his or her health. We created 4 binary variables to capture the child's medical and dental health insurance status: private health insurance with dental coverage; private health insurance without dental coverage; public insurance (included Medicaid, Child Health Insurance Program, or other public insurance); and neither medical nor dental insurance. We created a binary variable to indicate children with special health care needs (CSHCN), determined in the MEPS by using the 5-item, validated CSHCN screening questionnaire based on the Maternal and Child Health Bureau definition of CSHCN.21,22 In our sample of CSHCN, we did not include children who were identified as CSHCN only because they took a regular medication because of reasons described in a previous article.16
Bivariate and logistic regression was used to estimate the relationship between a child being advised to see the dentist within the previous year and associated factors. We used a separate logistic regression model to estimate the likelihood of having a dental visit in 2004. We tested for differences in the amount of total dental expenditures by using multivariate regression analyses among children who had a dental visit. The analyses were completed in Stata 10 (Stata Corp, College Station, TX), and estimates were corrected for the complex survey design by using Stata survey procedures. All tests used a significance level of .05.
In this national sample, 47% of 2- to 5-year-olds and 37% of 6- to 11-year-olds had been advised to have a dental checkup by a health provider within the previous year, and 39% of 2- to 5-year-olds and 60% of 6- to 11-year-olds had at least 1 dental visit in 2004. Several differences were found between children who had been advised to see the dentist within the previous year and other children in the bivariate analysis (Table 1).
Likelihood of Being Advised to See the Dentist in the Previous Year
Among both age groups, children whose parents were regular users of dental care were more likely to have been advised to see the dentist in the previous year (2- to 5-year-olds: odds ratio [OR]: 1.60 [95% confidence interval (CI): 1.21–2.11]) (6- to 11-year-olds: OR: 1.37 [95% CI: 1.05–1.79]) (Table 2). Likewise, children who had a regular source of medical care were more likely to be advised to see a dentist among both 2- to 5-year-olds (OR: 2.07 [95% CI: 1.16–3.07]) and 6- to 11-year-olds (OR: 1.78 [95% CI: 1.15–2.76]). Children living in an MSA in both age groups were more likely to be advised to see the dentist than other children, and children aged 2 to 5 from low-income families were less likely to receive a recommendation.
Likelihood of Having a Dental Visit
Children in both age groups who had been advised to have a dental checkup within the previous year were more likely to see a dentist than other children in the bivariate analyses (Table 1). However, in the multivariate analysis, only children in the 2- to 5-year-old age group who received a recommendation were more likely to have a dental visit than were children who did not (OR: 2.89 [95% CI: 2.16–3.87]) (Table 2). Children who were advised to see the dentist within 2 or more years were no more likely to see a dentist than were children who had never been advised among both age groups. Children in both age groups whose parents were a regular user of dental care had a greater likelihood of having a dental visit than were other children (2- to 5-year-olds: OR: 1.65 [95% CI: 1.23–2.22]) (6- to 11-year-olds: OR: 2.76 [95% CI: 2.14–3.56]).
Amount of Dental Expenditures
Among children aged 2 to 5 who had a dental visit, those who were advised to see the dentist within the previous year had an average of $187 in total dental expenditures compared with $204 for children who had not been advised to do so. Children aged 6 to 11 who had been advised to visit a dentist had $504 in total dental expenditures per person compared with $397 per person for other children. No statistically significant differences in the amount of total dental expenditures for children who had and had not been advised to see the dentist were found among either age group (regression results not shown).
Approximately 47% of children aged 2 to 5 years were advised to see the dentist in the previous year, and those who received a recommendation were almost 3 times more likely to have a dental visit than were children who did not receive a recommendation. Children aged 6 to 11 years who were advised to see a dentist in the previous year were no more likely to see a dentist than were those who were not advised. Young children were more likely to see a medical provider than were older children; however, young children were less likely to see a dentist. Moreover, older children were more likely to have a regular dentist, thereby reducing the need for a recommendation from the health provider. Therefore, younger children could be expected to have more opportunity to receive a recommendation to see the dentist, and the recommendation has the potential to be more effective because they may be less likely to visit the dentist in the absence of a recommendation. These findings suggest that health care providers can play an important role in ensuring that preschool-aged children establish a dental home at an early age and obtain dental care.
The strongest predictor of whether a child was advised to see the dentist was whether the child had a regular source of medical care. In addition, children who had parents who were regular users of dental care were also more likely to be advised to see the dentist. Parents who are regular users of dental care may generate a recommendation by asking if the child should see the dentist. Children living in an MSA were also more likely to be advised to see the dentist than were other children. The supply of dentists is likely greater in an MSA; thus health providers may be more likely to make a recommendation because they are more likely to have established relationships with dentists or they believe that parents will be able to locate a dentist for the child on their own. Children of low-income and middle-income parents were less likely to be advised to see the dentist than were children of high-income parents. Children in lower-income families may be less likely to have seen a health provider and, therefore, would have less opportunity to receive a dental recommendation. Health providers may also be assuming that children of lower-income parents would not be able to follow through with the recommendation to see a dentist and, thus, are not advising a dental checkup. Given the disparities in access to dental care among low-income children, health providers should be encouraged to advise dental visits to children of lower-income parents.
At the time this study was conducted, the American Academy of Pediatrics recommended that physicians and other health providers advise all children to see the dentist by the age of 3 and children at high risk to see the dentist by the age of 1.5 Because of the increasing prevalence of early childhood caries among preschool-aged children and the effectiveness of interventions such as fluoride varnish to prevent caries in young children, professional guidelines now recommend that all children be referred to the dentist by 1 year of age when there is an adequate supply of dentists.23,–,25 The findings in this study suggest that studies are warranted to identify strategies to increase the rate at which health providers recommend a dental checkup.
Interventions such as guidelines and checklists are effective in improving referral rates from primary care to secondary care.26 However, physicians face a number of barriers when referring young children to the dentist.6 Physicians can have limited knowledge of oral health–related issues,6 which may inhibit a physician's willingness or ability to appropriately advise that a child visit the dentist. Moreover, health providers face additional barriers in referring subgroups of patients such as those with Medicaid or are uninsured, particularly when the supply of dentists is limited.6 If the medical provider is unable to identify a dentist to whom to refer the child, they may be unwilling to advise the parent to take the child in for a dental checkup.
Multifaceted interventions that cultivate partnerships between medical and dental providers and provide educational training to medical providers on oral health and on the importance and timing of recommending a dental checkup may increase recommendation rates for dental visits. Collaborations could facilitate identification of dentists who provide dental care for young children, which would be helpful in both making targeted recommendations and developing a list of providers to share with parents. Future studies are warranted that examine the relationship between medical provider recommendations and dental use while controlling for the supply of dental providers, as well as intervention studies to educate health providers and establish collaborations between medical and dental providers.
Among both child age groups, having a parent who was a regular user of dental care significantly increased the likelihood that the child would visit the dentist. Other recent studies have also found a link between parent and child dental health and use.19,27,–,31 However, 1 study found that only 38% of low-income parents had a regular source of dental care.19 These findings emphasize the need to target parents in efforts to improve access to dental care for children, particularly for low-income children. If parents can be educated on their own need for regular dental care and access to dental care can be expanded to parents, then the children of those parents would be more likely to visit the dentist as well.
There are several limitations to this study. This study might have suffered from selection bias, because children who were advised to see the dentist by a health provider may have been more likely to be users of the health care system. We minimized this potential bias by controlling for the child having a regular source of medical care and having a parent who was a regular user of dental care.
We did not have a measure of the child's disease status. Studies have revealed that physicians can identify a child's dental disease status accurately and are more likely to refer children with disease than those without or with elevated risk but no disease.4,32 However, children who were advised within the previous year did not differ from other children in the amount of total dental expenditures.
The study was based on self-reported measures and, thus, is subject to reporting bias. Estimates for dental visits and expenditures were not verified with providers like the medical data were. In addition, the study is cross-sectional, so we cannot establish a causal relationship. Nonetheless, the study is the first, to our knowledge, to have examined the correlation between a recommendation to see a dentist by a health provider and dental use in a nationally representative sample.
Children aged 2 to 5 years who received a recommendation to see a dentist were significantly more likely to have had a dental visit; however, there was no association between a recommendation and dental use among children aged 6 to 11 years old. Health providers have the potential to play an important role in establishing a dental home among young children and improving oral health by recommending that they visit the dentist. Moreover, children of parents who were regular users of dental care were more likely to visit the dentist. Dental use among children, therefore, might be improved by increasing access to care for parents. Future research should examine potential interventions to increase dental recommendations by primary health care providers and determine their dental outcomes.
- Accepted May 11, 2010.
- Address correspondence to Heather A. Beil, MPH, Department of Health Policy and Management, UNC Chapel Hill Gillings School of Global Public Health, CB 7411, Chapel Hill, NC 27599. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- MEPS =
- Medical Expenditure Panel Survey •
- MSA =
- metropolitan statistical area •
- CSHCN =
- children with special health care needs •
- OR =
- odds ratio •
- CI =
- confidence interval
- 2.↵US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General—Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000
- 3.↵US Department of Health and Human Services. Guide to Children's Dental Care in Medicaid. Baltimore, MD: Centers for Medicare and Medicaid Services; 2004
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- Copyright © 2010 by the American Academy of Pediatrics