Oral Health Care: A Missing Pillar of Total Health Care?



 

Nancy P Gordon, ScD1; David M Mosen, PhD, MPH2; Matthew P Banegas, PhD, MPH3

Perm J 2021;25:21.080

https://doi.org/10.7812/TPP/21.080

Introduction: Oral health is an important component of overall health, and preventive dental care is essential for maintaining good oral health. However, many patients face significant barriers to preventive dental care. We examined prevalence of and factors associated with no recent preventive dental care in an adult health plan population.

Methods: For this cross-sectional study, we used data for 19,672 Kaiser Permanente members aged 25-85 who participated in the 2014/2015 or 2017 Member Health Survey (MHS) and 20,329 Medicaid members who completed an intake questionnaire. We estimated percentages of adults with no preventive dental care (teeth cleaning and examination by a dental professional) in the prior 12 months, overall and among four racial groups, by age, sex, education, income, and dental care cost factors. We used logistic regression to model associations of sociodemographic and cost factors with no preventive dental care. We also examined lack of preventive dental care in subgroups at elevated risk for periodontal disease.

Results: Overall prevalence of no preventive dental care was 21%, with significant differences by race (non-Hispanic White, 19.6%; African-American/Black, 29.3%; Latinx, 24.9%, Asian American/Pacific Islander, 19.6%). Adults with lower educational attainment and household income and dental care cost barriers were more likely to lack preventive dental care. Racial and socioeconomic factors remained significant in the multivariable models. Lack of preventive dental care was fairly common among adults with diabetes, prediabetes, hypertension, smokers, frequent consumption of sugary beverages, and Medicaid coverage.

Conclusion: Oral health care should be better integrated with primary medical care to promote adult total health.

INTRODUCTION

Periodontal disease, especially in its more severe manifestations, may increase the risk of and exacerbate diabetes,1 hypertension,2 cardiovascular disease,3–6 and kidney disease,7,8 among other conditions. Poor oral health can also make it harder for individuals to talk, chew, swallow, smile, taste, and smell9 and has psychological effects on self-esteem, anxiety, and social interaction.10 In 2000, the US Surgeon General’s report on the status of oral health in the US declared that “oral health is integral to general health, … is a critical component of health, and must be included in the provision of health care.”9

Previous research on sociodemographic differences in dental care utilization patterns has focused on receipt of any type of dental care or on receipt of needed dental care in the past year. There is limited information about social determinants of receiving routine preventive dental care, including teeth cleaning and clinical examination of teeth, gums, bite, and oral cavity for signs of infection and oral cancers. To address this gap, we used data from the 2014/2015 and 2017 cycles of a general health survey conducted with adult members of a large Northern California health plan to assess differences in receipt of preventive dental care in the prior 12 months by key sociodemographic characteristics including age, sex, race/ethnicity, education, household income, dental insurance status, and whether cost was a barrier to getting dental care during that time. We also examined lack of recent preventive dental care in adults who had diabetes, hypertension, were current smokers, or consumed sugary beverages ³ 4 times per week, because these individuals are at higher risk for periodontal disease.

METHODS

Setting

Kaiser Permanente Northern California (KPNC) is an integrated healthcare delivery system that provides a wide range of primary and specialty care. It does not provide routine dental care services, but many health plan members have dental insurance through their employer or purchase dental coverage as a supplemental health plan benefit. The sociodemographically diverse health plan membership includes over 3.2 million adults. The KPNC adult membership has previously been shown to be very similar to the insured adult population of Northern California not covered by California’s Medicaid insurance program with regard to sociodemographic and health characteristics.11

Data Sources

The KPNC adult MHS is a self-administered survey conducted with an age-sex–stratified random sample of current health plan members aged 20 years and over who were enrolled during at least the fourth quarter of the preceding year. The MHS, which is conducted in English only, collects information about a wide range of sociodemographic and health-related characteristics. More information about the survey is found in an earlier publication12 and on the MHS website (www.memberhealthsurvey.kaiser.org). For information about KPNC Medicaid Managed Care members, we used electronic health record data entered from a staff-administered intake questionnaire that included a question related to dental care. Use of data from both data sources for this study was approved by the KPNC Institutional Review Board (IRB).

Survey Samples

The MHS sample included pooled survey data from the 2014/2015 and 2017 MHS cycles for 19,672 adults aged 25 to 85 who had answered the question about the recency of receiving preventive dental care. Based on self-report, the sample included 10,346 non-Hispanic White (White), 1,953 African-American/Black (Black), 3,135 Latinx, 3,884 Asian American/Pacific Islander (Asian/PI), and 358 other race/ethnicity. For analyses conducted with the 2017 survey data alone, there were a total of 4,742 adults (1,636 White, 926 Black, 1,051 Latinx, 1,078 Asian/PI, and 51 other). None of these MHS respondents were covered by Medicaid (government-funded insurance for very low income individuals), but most of the older group were covered by Medicare, the US government-funded health insurance program available to US citizens aged 65 and over.

The KPNC Medicaid sample included 20,329 adults aged 25 to 65 who did not require an interpreter for medical care. Of these, 7,680 were White, 3,682 Black, 4,077 Latinx, 4,004 Asian/PI, 273 other, and 613 with unknown race.

Study Variables

The main outcome variable of interest in the MHS analyses was no preventive dental care in the prior 12 months. This information was ascertained by responses to the question “When did you last have your teeth cleaned and checked by a dentist or dental hygienist?” People who indicated either “more than 1 year ago” or “never had this done” were considered to have no recent preventive dental care. We examined this outcome by age group, sex (male or female), education (non-high school graduate, high school graduate, some college, and college graduate with a bachelor’s degree or higher), household income (< $25,000, $25,001-$50,000, $50,000-$80,000, and > $80,000), and in higher risk subgroups (adults with diabetes, prediabetes, hypertension, seniors with mouth problems, current smokers vs nonsmokers), variables that were all included in both survey cycles. We also examined this outcome using 3 variables that were only available in the 2017 survey: whether they had insurance that pays for routine dental check-ups and teeth cleaning (yes, no), whether in the past year they delayed or did not get dental care they thought they needed because of the cost (yes, no), and number of days per week (£ 1, 2-3, ³ 4) they consumed sugary beverages.

The KPNC Medicaid intake questionnaire asked whether the individual had seen a dentist within the past 12 months.

Statistical Analysis

The MHS data were analyzed using SAS version 9.4 (SAS Institute, Cary, North Carolina, 2013) procedures for data obtained from complex survey designs.13 All analyses used data weighted to reflect the age-sex composition of White, Black, Latinx, Asian/PI, and other race/ethnicity for adults ages 25 to 85 in the KPNC membership. To facilitate direct comparisons across racial/ethnic groups and within levels of education and income, we used the Proc Surveyreg procedure recommended by the Centers for Disease Control and Prevention to standardize prevalence estimates to the age-sex distribution of the 2016 US Census.14 All prevalence statistics reported in the tables and text for the full population and 4 racial/ethnic groups are age-sex standardized, with the exception of statistics reported by sex or age group, unless otherwise noted. A second step in the Proc Surveyreg models compared the age-standardized percentages for pairs of racial/ethnic groups (eg, White vs Black) to determine whether they were statistically significantly different at the p < 0.05 level. Proc Surveyreg models that controlled for sex (reference group: male) and age group (25-34, 35-49, 50-65, 66-75, 76-85) were used to test whether lack of preventive dental care significantly differed by levels of education, income, dental insurance status, and cost as a barrier to dental care in the full population and within each racial/ethnic group. In addition to these bivariate comparisons, we ran multivariable logistic regression models restricted to the 2017 data to examine the independent associations of the sociodemographic and dental cost factors with lack of preventive dental care in the past 12 months after adjusting for the other factors. The first multivariable model included age group, sex, race/ethnicity, education, and household income; the second model added coverage for preventive dental care; and the third model added whether cost had been a barrier to getting needed dental care. We did not adjust for multiple comparisons but report the results of all statistical tests.

Unweighted data for the KPNC Medicaid sample were analyzed using SAS Proc Freq to produce overall and racial/ethnic-specific (White, Black, Latinx, and Asian/PI) percentages of men and women who had not seen a dentist for any reason in the prior 12 months. Sex-specific multivariable logistic regression models that included indicator variables for racial/ethnic groups (White adults as the reference group) and controlled for age (25-34, 35-49, 50-65) were used to assess whether racial/ethnic group differences were statistically significant at the p < 0.05 level.

All differences mentioned in the text are statistically significant at p < 0.05 and all confidence intervals (CIs) are 95% CIs.

RESULTS

Compared to the White and Asian/PI groups, the Black and Latinx adults were younger, less educated (higher percentages with a high school education or less and lower percentages of college graduates) and had lower household income (Table 1). While 81% of adults reported having dental insurance that pays for preventive dental visits, older adults were less likely to have coverage than younger adults. Approximately 17% of adults said that they had delayed or did not get dental care due to cost in the prior 12 months, with no difference by age group. Overall, Black, Latinx, and Asian/PI adults were more likely than White adults to have insurance that covered preventive dental care, although the difference, while statistically significant, was not large. Among those aged 66-85, Black adults were significantly more likely than White, Latinx, and Asian/PI adults to report having insurance that covered preventive dental care.

Overall and among White and Asian/PI adults, those in the 25-34 and 76-85 age groups were more likely to lack preventive dental care (Table 2). Among Latinx adults, those in the two younger and two older groups were more likely than those aged 50-65 to have no preventive dental care, while among Black adults, there was very little variation across age groups. In all but the youngest group, Black women and men were more likely than similarly aged White and Asian/PI women and men to lack preventive dental care. A consistent pattern of sex differences was not seen across the narrower age groups.

Approximately 21% of adults had no preventive dental care, with Black and Latinx adults more likely than White and Asian/PI adults to lack preventive dental care (Table 3). Overall and among all but Black adults, men were more likely than women to lack preventive dental care.

Overall and within each of the racial/ethnic groups, college graduates were significantly less likely to lack preventive dental care than those with lower educational attainment. Overall and across all racial/ethnic groups, no preventive dental care was also inversely associated with household income. Of those adults with a household income of $25,000-$35,000, 34% had no preventive dental care in the prior 12 months. Overall and across all racial/ethnic groups, more than twice as many adults who lacked preventive dental insurance had no preventive dental care, with a similar ratio found for adults who indicated that they had versus had not delayed or foregone dental care due to cost.

Demographic factors that were significant in the bivariate analyses remained significant in the multivariable model (Table 4, Model 1). Adding dental insurance to the model (Model 2) affected the associations somewhat, particularly the association for household incomes < $50,000, but these changes were modest. Model 2 shows that controlling for all demographic variables and dental insurance status, men were significantly more likely than women, and adults aged 25-34 and 35-49 were significantly more likely adults aged ³ 50 to lack preventive dental care. White, Latinx, and Asian/PI adults were significantly less likely than Black adults to lack preventive dental care. Lower income adults were less likely to have insurance covering preventive dental care (< $25,000 vs > $80,000, 64.7% vs 93.0%, supplemental material). Adding cost as a barrier to dental care (Model 3) had only a modest effect on the associations and model fit.

Lack of Preventive Dental Care in High Health Risk Groups

Among all adults, 28.6% of those with diabetes, 24.3% of those with hypertension, and 16.9% of those with prediabetes lacked recent preventive dental care. Among adults with these conditions, Black adults were significantly more likely to lack preventive dental care than White, Latinx, and Asian/PI adults. Among the approximately 8% of adults aged 65-85 who reported having trouble with their teeth or gums, 43.9% lacked preventive dental care. Black seniors were twice as likely as White seniors (12.1% vs 5.7%) to report mouth problems, and among those with mouth problems, were twice as likely as White seniors (odds ratio = 2.16; confidence interval: 1.19-3.92) to lack preventive dental care. Lack of preventive dental care was fairly common among current smokers (36.1%) and adults who consumed sugary beverages ³ 4 times a week (27.2%).

Lack of Dental Care in KPNC Medicaid Sample Ages 25-64

Approximately 44% (42.4% of women vs 46.2% of men, p < 0.05) of Medicaid-covered adults reported that they had not seen a dentist in the past 12 months. By race/ethnicity, 41.5% of White, 43.8% of Black, 43.6% of Latinx, and 41.3% of Asian/PI women and 43.8% of White, 52.1% of Black, 47.6% of Latinx, and 45.5% of Asian/PI men aged 25-65 had not seen a dentist. After adjusting for age, Black and Latinx adults were more likely than White adults to report no dental visit in the prior year (Black men: adjusted odds ratio = 1.40, confidence interval: 1.22-1.61; Latino men: adjusted odds ratio = 1.18, confidence interval: 1.03-1.35; both Black and Latina women: adjusted odds ratio = 1.11, confidence interval: 1.01-1.22).

DISCUSSION

The primary aim of this study was to estimate the percentages of adults and subgroups of higher risk adults in a health plan population who lacked recent preventive dental care, ie, no teeth cleaning and dental examination in the prior 12 months. We also wanted to identify sociodemographic and dental care cost factors associated with lack of preventive dental care in this insured population. We found that approximately one-fifth of adult health plan members not covered by Medicaid lacked recent preventive dental care. Adults with a lower level of educational attainment, lower household income, and no dental insurance covering preventive care were less likely to have received preventive dental care. Asian/PI adults did not significantly differ from White adults, while higher percentages of Latinx adults in the youngest and older age groups lacked preventive dental care. In all but the youngest age group, Black adults were more likely than White adults to lack preventive dental care, even though they were more likely than White adults to report having dental insurance covering preventive care. This racial disparity remained after multivariable adjustment and was seen among high-risk adults and seniors who were experiencing oral health problems. However, among Medicaid patients, the Black-White disparity was seen among men only. These findings mirror those found in other recent surveys.15

Dental care is not a covered benefit in most managed care health insurance plans, and it is not a required benefit for adults covered through the Affordable Care Act. In contrast, as of 2018, all KPNC adult members covered through California’s Medicaid program would, at time of enrollment, have been eligible for preventive and other dental care services as part of their Medicaid coverage. However, this dental benefit coverage for adults through Medicaid is not common across the US.

Currently, traditional Medicare plans do not cover preventive and diagnostic dental care services. In our survey, approximately 40% of KPNC members aged 66-85 lacked dental insurance covering preventive care, which is close to the 47% of seniors found to lack dental insurance in a recent national survey.15 Results from that national survey also showed that among those with dental coverage through a Medicare Advantage plan, 72% chose their plan because of its dental benefit.

Having preventive dental insurance does not remove the cost barrier of premiums, co-pays, co-insurance and deductibles.16 In this study, even after accounting for income and dental insurance, adults who reported that cost was a barrier to needed dental care were 3 times more likely to lack recent preventive dental care than those who did not. These findings coincide with results from the oral health module of the 2018 Consumer Survey of Health Care Access, which reported that 22% of adult respondents who indicated a need for dental care reported cost as the major barrier.17

However, there are factors in addition to affordability that affect use of dental care. While a 2015 national survey found that among adults who had not been to a dentist in the previous 12 months, affordability (59%) was the most frequently indicated reason for not seeing a dentist more frequently, 22% cited fear of the dentist, 15% that they had trouble finding a dentist, and 10% that they felt no need for dental care because their mouth was healthy.18

There are several steps that health systems and clinicians can take to move closer to the goal of oral health-medical health integration. First, physicians and their supporting staff could start asking about recency of last dental cleaning and examination as a vital sign at virtual and in-person visits. Second, physicians can talk with their patients about the importance of maintaining good oral health practices and getting preventive dental care at least every 12 months to maintain good health. Oral health and preventive dental care can be built into discussions about avoiding consumption of sugar-sweetened beverages and high sugar foods, not only because such consumption can lead to obesity and type II diabetes, but also because of the damage that can be done to teeth. Third, physicians and health systems can more broadly publicize the availability of supplemental dental care plans to patients. Fourth, physicians and health systems can move toward better coordination of medical and oral health care by educating patients to inform their dental care provider about health conditions and medications they take that may make them at higher risk for periodontal disease, tooth decay, and other oral health problems. Fifth, health systems can provide a service that educates members about how to find a dentist and can maintain a directory of community-based dental services available on a sliding fee basis. Results from the 2019 Kaiser Permanente National Social Risk Survey showed that approximately 22% of adult health plan members wanted help from the health plan with accessing dental services, and higher percentages of Blacks, Hispanics, and Asian/PIs than Whites indicated this need (Kaiser Permanente Washington Health Research Institute, personal communication).

Finally, on a policy level, comprehensive dental care, including preventive and restorative care, should be included as an essential health benefit for adults covered by Medicaid, ACA, or Medicare, as would be the case through the Medicare Dental Benefit Act of 2021 (S-97; HR 502) and the Elijah E. Cummings Lower Drug Costs Now Act (HR 3). These bills would amend the Social Security Act to expand Medicare benefits to cover preventive and restorative dental and oral health services, which would both improve access to affordable dental care for seniors and reinforce the concept of routine and restorative dental care as an important component of total health care.

A major strength of our study was the large, diverse sample of insured adults that enabled us to examine the relationships between sociodemographic factors and adults’ lack of recent preventive dental care, overall and within and across racial/ethnic groups. There are some limitations to consider. First, we used self-reported survey data about recency of preventive dental care and household income, which is subject to survey response bias that could not be completely adjusted for by use of survey weighting factors. Second, we restricted multivariable models to the 2017 survey data because the earlier survey (2014/2015) did not include a question about insurance covering preventive dental care. Another limitation was the lack of socioeconomic data for the Medicaid sample, which prevented us from examining factors associated with lack of dental care in the prior 12 months. Finally, the study results cannot be generalized to uninsured adults, adults in other parts of the US, and non–English-speaking adults.

CONCLUSION

This study highlights significant disparities in the receipt of preventive dental care services across key demographic and socioeconomic groups. Eliminating oral health disparities represents an important component to achieving health equity.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Funding Statement

Nancy P Gordon, ScD, received support for her work on this study from the KPNC Community Benefit Program. David M Mosen, PhD, MPH, and Matthew P Banegas, PhD, MPH, received support from NIDCR (R21DE029026, MPI: Mosen/Banegas).

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1 Kaiser Permanente Division of Research, Oakland, CA

2 Kaiser Permanente Center for Health Research, Portland, OR

3 Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA

Corresponding Author

Nancy P Gordon, ScD (Nancy.Gordon@kp.org)

Author Contributions

Nancy P Gordon, ScD, conceived the study design, collected the data, and analyzed the data. Nancy P Gordon, ScD, David M Mosen, PhD, MPH, and Matthew P Banegas, PhD, MPH interpreted the data. Nancy P Gordon, ScD, wrote the first draft of the manuscript and David M Mosen, PhD, MPH, and Matthew P Banegas, PhD, MPH, contributed to subsequent drafts. All authors approved the final version of this manuscript.

IRB Review

There was no IRB review for this specific project. Use of the MHS data for these analyses falls under the scope of KPNC IRB approval for IRBnet #1263352 (“Study of demographic, health-related, and health care-related characteristics of an adult health plan membership and how these may be changing over time”). Use of the KPNC Medicaid member data for this study falls under the scope of KPNC IRB approval for IRBnet #1676097 (“Building an evidence case for capturing educational attainment in the electronic health record as a social determinant of health”).

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Table 1. Characteristics of study sample

  All White Black Latinx Asian/PI
  N % N % N % N % N %
All 19,672 (100%) 10,346 (100%) 1,953 (100%) 3,133 (100%) 3,884 (100%)
Age                    
25-34 2,350 (17.7%) 946 (14.1%)a,b 192 (16.2%)a,b 558 (26.1%)b,c,d 606 (22.3%)a,c,d
35-49 4,454 (28.9%) 1,811 (24.5%) 512 (29.2%) 869 (35.0%) 1,178 (36.7%)
50-65 5,590 (31.6%) 3,208 (34.8%)a,b 648 (35.6%)a,b 928 (26.4%)c,d 1,093 (28.0%)c,d
66-75 3,826 (14.2%) 2,442 (18.3%) 336 (13.1%) 405 (8.5%) 578 (9.3%)
76-85 3,052 (6.2%) 1,939 (8.3%)a,b,c 265 (5.9%)b,d 373 (4.0%)c,d 429 (3.7%)c,d
Sex                    
Male 9,135 (46.6%) 4,927 (47.2%)a,c 867 (43.0%)b,d 1,395 (46.1%) 1,781 (46.3%)
Female 10,537 (53.4%) 5,419 (52.8%) 1,086 (57.0%) 1,736 (53.9%) 2,103 (53.7%)
Education                    
£ High school graduate 4,425 (19.0%) 2,032 (16.6%)a,b,c 502 (24.9%)a,b,d 1,143 (35.8%)b,c,d 515 (12.6%)a,c,d
< High school graduate 6,58 (2.4%) 219 (1.4%) 55 (2.1%) 260 (7.6%) 114 (2.7%)
High school graduate 3,598 (16.6%) 1,813 (15.2%) 447 (22.8%) 883 (28.2%) 401 (9.9%)
Some college 6,233 (30.6%) 3,320 (30.6%) 771 (39.5%) 1,074 (35.0%) 953 (24.4%)
College graduate 9,025 (50.4%) 4,250 (52.8%)a,b,c 661 (35.6%)b,d 885 (29.2%)b,d 2,382 (63.0%)a,c,d
Household income                    
< $25,000 1,919 (8.8%) 895 (7.7%)a,c 293 (15.7%)a,b,d 350 (11.1%)b,c,d 338 (8.4%)a,c
$25,000-$50,000 3,633 (17.6%) 1,792 (15.5%) 445 (23.6%) 708 (23.4%) 614 (16.1%)
>$50,000-$80,000 4,243 (22.3%) 2,196 (21.5%) 434 (23.8%) 789 (27.2%) 753 (20.4%)
> $80,000 8,683 (50.4%) 4,788 (55.3%)a,c 664 (36.9%)b,d 1,097 (38.3%)b,d 1,985 (55.1%)a,c
Has insurance that covers preventive dental care                    
Yes 3,711 (80.9%) 1,192 (78.8%)a,b,c 782 (85.9%)a,d 834 (82.3%)c,d 861 (83.0%)d
No 1,031 (19.1%) 444 (21.2%) 144 (14.1%) 217 (17.7%) 217 (17.0%)
Ages 25-65                    
Yes 2,794 (86.4%) 836 (84.3%)c 592 (88.6%)d 665 (88.2%)d 669 (89.0%)d
No 430 (13.6%) 170 (15.7%) 79 (11.4%) 94 (11.8%) 85 (11.0%)
Ages 66-85                    
Yes 917 (58.9%) 356 (57.2%)c 190 (75.5%)a,b,d 169 (58.9%)c 192 (59.1%)c
No 601 (41.1%) 274 (42.8%) 65 (24.5%) 123 (41.1%) 132 (40.9%)
Delayed or did not get dental care due to cost                    
Yes 798 (16.8%) 246 (16.8%)a,b,c 202 (22.1%)b,d 215 (21.1%)b,d 124 (12.1%)c,d
No 371 (83.2%) 1,305 (83.2%) 683 (77.9%) 781 (78.9%) 905 (87.9%)

Percentages for age groups and sex are based on weighted survey data. Percentages for all other factors are based on weighted survey data standardized to the age-sex distribution of the US population in 2016 using 10 groups (male, female × 5 age groups above). All Ns are raw numbers of respondents in each cell and may be less than the racial/ethnic group total N due to missing data.

a Significantly different (p < 0.05) from Latinx.

b Significantly different (p < 0.05) from Asian/Pacific Islanders.

c Significantly different (p < 0.05) from African-American/Blacks (p < 0.05).

d Significantly different (p < 0.05) from Whites.

White = non-Hispanic White; Black = African-American/Black; Asian/PI = Asian American or Pacific Islander.

Table 2. Estimated percentages of adults aged 25-85 who did not have their teeth cleaned and examined by a dental care professional in the past 12 months, by age group, sex, and race/ethnicity

  All White Black Latinx Asian/PI
  % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
All          
25-34 26.9 (25.1-28.8) 25.2 (22.4-28.0)a 31.9 (25.3-38.5) 30.5 (26.6-34.3)b 25.9 (22.3-29.4)
35-49 19.3 (18.1-20.5) 18.3 (16.5-20.1)a,c 28.2 (24.2-32.2)a,b,d 22.5 (19.7-25.3)c,d 16.0 (13.9-18.1)a,c
50-65 17.3 (16.3-18.3) 16.1 (14.8-17.4)a,c 26.4 (22.9-29.8)a,b,d 19.5 (16.9-22.0)c,d 14.8 (12.7-17.0)a,c
66-75 20.2 (18.9-21.5) 18.7 (17.1-20.3)a,c 30.9 (25.7-36.0)b,d 24.4 (20.0-28.8)b,d 18.3 (15.1-21.6)a,c
76-85 26.4 (24.6-28.3) 23.9 (21.6-26.1)a,c 36.3 (30.0-42.6)b 33.5 (28.4-38.6)b 29.1 (24.3-33.9)
Men          
25-34 30.5 (27.5-33.5) 29.6 (25.1-34.2) 25.4 (15.2-35.5) 34.9 (28.5-41.3) 29.9 (24.0-35.8)
35-49 21.1 (19.3-23.0) 19.8 (17.0-22.6)c 33.6 (27.1-40.0)a,b,d 24.6 (20.2-28.9)c,d 17.2 (14.0-20.5)a,c
50-65 18.9 (17.5-20.4) 17.6 (15.7-19.5)a,c 27.1 (21.8-32.4)b,d 22.3 (18.3-26.3)b 17.2 (13.9-20.4)c
66-75 20.7 (18.8-22.6) 19.3 (17.0-21.7)c 30.3 (22.5-38.0)b,d 22.9 (16.8-29.0) 19.1 (14.3-23.8)c
76-85 27.2 (24.7-29.6) 23.9 (21.0-26.9)a,c 37.1 (28.6-45.6)b 39.6 (31.7-47.5)b,d 27.7 (21.3-34.1)a
Women          
25-34 24.0 (21.7-26.2) 21.2 (17.8-24.6)c,e 36.4 (27.8-44.9)b,d 26.9 (22.2-31.6)e 22.7 (18.4-26.9)c
35-49 17.7 (16.2-16.9) 16.8 (14.5-19.1)c 24.2 (19.3-29.1)b,d,e 20.7 (17.1-24.2)d 15.0 (12.3-17.7)a,c
50-65 15.8 (14.5-17.1) 14.7 (13.0-16.5)a,e 25.8 (21.2-30.4)a,b,d 17.0 (13.7-20.3)c,e 12.8 (10.0-15.5)c,e
66-75 19.8 (17.9-21.6) 18.1 (14.9-20.3)a,c 31.3 (24.4-38.2)b,d 25.7 (19.3-32.1)b,d 17.7 (13.2-22.2)a,c
76-85 25.9 (23.3-28.5) 23.8 (20.6-27.0)c 35.7 (26.9-44.6)b 28.9 (22.3-35.5)e 30.2 (23.2-37.2)

Estimates are based on weighted data from the pooled 2014/15 and 2017 Member Health Surveys that have not been age-standardized to the U.S. population.

a Significantly different (p < 0.05) from Latinx.

b Significantly different (p < 0.05) from Whites.

c Significantly different (p < 0.05) from African-American/Blacks.

d Significantly different (p < 0.05) from Asian American/Pacific Islanders.

e Significantly different (p < 0.05) from men in same age and race/ethnic group.

White = non-Hispanic White; Black = African-American/Black; Asian/PI = Asian American or Pacific Islander; CI = confidence interval.

Table 3. Age-sex standardized estimates of percentages of adults aged 25-85 who did not have their teeth cleaned and examined by a dental care professional in the past 12 months, by social determinants

  All White Black Latinx Asian/PI
  % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
All 21.0 (20.4-21.7) 19.6 (18.7-20.5)a,b 29.3 (27.1-31.6)b,c,d 24.9 (23.2-26.5)a,c,d 19.6 (18.2-21.0)a,b
Sex          
Men 23.5 (22.4-24.6) 22.2 (20.6-23.8)a,b 29.3 (25.5-33.1)c,d 27.6 (25.0-30.2)a,c,d 21.7 (19.5-23.9)a,b
Women 19.7 (18.9-20.6)e 18.1 (16.8-19.3)a,b,e 29.7 (26.5-32.9)b,c,d 22.6 (20.5-24.6)a,c,d,e 17.8 (16.1-19.6)a,b,e
Education          
≤ High school graduate 30.6 (28.9-32.3) 29.6 (26.6-32.7) 36.8 (31.8-41.8) 30.0 (27.1-32.9) 30.6 (26.0-35.1)
High school graduate 29.6 (27.8-31.4) 29.0 (26.0-32.7)a 36.2 (31.1-41.4) 28.3 (25.1-31.4) 28.3 (23.5-33.1)
Some college 25.0 (23.7-26.3)e 23.7 (21.8-25.6)a,e 3593 (32.0-39.9)c 25.1 (22.4-27.8)a 21.5 (18.6-24.4)a,e
College graduate 14.5 (13.7-15.3) e 13.6 (12.5-14.7) a,e 17.5 (14.5-20.6) c,e 15.5 (13.1-18.0) e 15.4 (13.9-16.9) e
Household income          
< $25,000 43.6 (40.0-46.4) 39.6 (35.1-44.1)a 55.9 (49.5-62.3)c 42.4 (36.0-48.7)a 42.7 (35.9-49.5)a
$25,000-$50,000 32.2 (30.3-34.1)e 31.4 (28.3-34.5)a,e 39.8 (34.7-44.9)c,e 34.4 (30.6-38.3)e 28.4 (24.4-32.5)a,e
$50,001-$80,000 21.5 (20.0-22.9)e 20.7 (18.5-22.9)e 24.3 (19.9-28.8)e 22.4 (19.4-25.4)e 20.0 (17.1-23.0)e
> $80,000 13.4 (12.6-14.2) e 13.2 (12.1-14.3) e 16.8 (13.4-20.2) e 14.0 (11.8-16.2) e 12.4 (10.9-13.9) e
Has insurance that covers preventive dental care          
No 38.9 (34.4-43.5) 36.1 (29.3-43.0)a 63.9 (54.4-73.3)b,c,d 45.9 (37.3-54.4)a,c 35.6 (26.5-44.8)a
Yes 16.7 (15.3-18.1)e 16.5 (14.2-18.7)a,e 23.3 (20.1-26.5)b,c,d,e 18.3 (15.6-21.0)a,d,e 13.5 (11.0-15.9)a,b,e
In past 12 months, delayed or did not get dental care due to the cost          
Yes 46.5 (42.3-50.7) 45.5 (39.1-51.9)a 52.5 (44.7-60.3)c 51.4 (44.5-58.4) 38.3 (29.3-47.2)a
No 15.6 (14.2-17.0) 15.2 (13.0-17.4) 22.4 (19.1-25.8) 16.1 (13.4-18.7) 14.7 (12.3-17.2)

Estimates by sociodemographic factors were based on weighted data from the pooled 2014/15 and 2017 Member Health Surveys, standardized to the age-sex distribution of the US in 2016; estimates by sex are only age-standardized. Estimates by dental insurance and cost factors were based on data from the 2017 survey.

a Significantly different (p < 0.05) from African-American/Blacks.

b Significantly different (p < 0.05) from Latinx.

c Significantly different (p < 0.05) from Whites.

d Significantly different (p < 0.05) from Asian American/Pacific Islanders.

e Significantly different (p < 0.05) from next closest level of this variable.

White = non-Hispanic White; Black = African-American/Black; Asian/PI = Asian American or Pacific Islander; CI = confidence interval.

Table 4. Logistic regression models predicting lack of preventive dental care in the prior 12 months

  Model 1 Model 2 Model 3
Effect OR 95% CI OR 95% CI OR 95% CI
Sex            
Female (Ref) (Ref) (Ref)
Male 1.58 (1.32-1.89) 1.58 (1.31-1.89) 1.63 (1.34-1.97)
Age            
Age 25-34 1.84 (1.40-2.43) 2.04 (1.54-2.70) 2.13 (1.58-2.87)
Age 35-49 1.25 (0.98-1.59) 1.40 (1.09-1.79) 1.41 (1.08-1.83)
Age 50-64 (Ref) (Ref) (Ref)
Age 66-75 1.09 (0.84-1.42) 0.93 (0.71-1.22) 1.03 (0.77-1.37)
Age 76-85 1.07 (0.82-1.41) 0.86 (0.65-1.15) 1.07 (0.78-1.46)
Race/ethnicity            
Black (Ref) (Ref) (Ref)
White 0.77 (0.62-0.96) 0.68 (0.54-0.84) 0.72 (0.57-0.90)
Latinx 0.64 (0.51-0.82) 0.60 (0.47-0.77) 0.65 (0.50-0.83)
Asian/PI 0.63 (0.49-0.81) 0.58 (0.45-0.75) 0.66 (0.51-0.870
Other 0.91 (0.40-2.10) 0.98 (0.44-2.19) 0.90 (0.39-2.11)
Education            
< High school graduate 3.15 (1.87-5.32) 3.09 (1.81-5.26) 2.92 (1.62-5.27)
High school graduate 2.14 (1.66-2.77) 2.07 (1.60-2.69) 2.09 (1.59-2.74)
Some college/AA degree 1.60 (1.29-1.98) 1.57 (1.26-1.94) 1.51 (1.21-1.90)
College graduate (Ref) (Ref) (Ref)
Household Income            
< $25,000 3.01 (2.17-4.17) 2.36 (1.70-3.30) 1.96 (1.38-2.79)
$25,000-$50,000 2.36 (1.84-3.04) 2.06 (1.59-2.66) 1.65 (1.26-2.16)
$50,000-$80,000 1.62 (1.27-2.06) 1.52 (1.19-1.94) 1.34 (1.04-1.73)
> $80,000 (Ref) (Ref) (Ref)
No insurance for preventive dental care 2.69 (2.16-3.35) 2.19 (1.74-2.76)
Cost barrier to dental care 3.38 (2.72-4.21)
C-statistic 0.70 0.72 0.75

Models are based on weighted survey data from the 2017 Member Health Survey only. C-statistics of 0.70-0.75 are considered a good model fit.

AA = Associate of Arts; Asian/PI = Asian American or Pacific Islander; CI = confidence interval; OR = odds ratio; Ref = reference.

Keywords: oral health care; total health care; dental care; social determinants; racial/ethnic disparities

Abbreviations: Asian/PI = Asian American/Pacific Islander; Black = African-American/Black; IRB = Institutional Review Board; KPNC = Kaiser Permanente Northern California; MHS = Member Health Survey; White = non-Hispanic White

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