Journal of Public Health Dentistry . ISSN 0022-4006
Dental procedures among children age birth to 20, United States, 1999 and 2009 Richard J. Manski, DDS, PhD, MBA1; Clemencia M. Vargas, DDS, PhD2; Erwin Brown, BS3; Kelly V. Carper, MEd4; Mark D. Macek, DDS, DrPH1; Leonard A. Cohen, DDS, MPH, MS1 1 2 3 4
Dental Public Health, University of Maryland School of Dentistry, Baltimore, MD, USA Orthodontics and Pediatric Dentistry, University of Maryland School of Dentistry, Baltimore, MD, USA Division of Survey Operations, Agency for Healthcare Research and Quality, Rockville, MD, USA Division of Statistical Research and Methods, Agency for Healthcare Research and Quality, Rockville, MD, USA
Keywords children; dental care; dental insurance; health care surveys; poverty; United States; MEPS; dental procedures. Correspondence Dr. Richard Manski, Dental Public Health, University of Maryland School of Dentistry, 650 W. Baltimore St., Baltimore, MD 21201. Tel.: 410-706-7245; Fax: 410-706-4031; e-mail: [email protected]. Richard J. Manski, Mark D. Macek, and Leonard A. Cohen are with Dental Public Health, University of Maryland School of Dentistry. Clemencia M. Vargas is with Orthodontics and Pediatric Dentistry, University of Maryland School of Dentistry. Erwin Brown is with the Division of Survey Operations, Agency for Healthcare Research and Quality. Kelly V. Carper is with the Division of Statistical Research and Methods, Agency for Healthcare Research and Quality. Received: 1/7/2014; accepted: 5/23/2014. doi: 10.1111/jphd.12065
Abstract Objective: To describe dental procedures received by US children and adolescents by poverty status and dental insurance coverage. Methods: Data for this analysis came from the 1999 and 2009 Medical Expenditure Panel Surveys. The primary outcome variable represented the types of dental procedures that were received during dental visits in the preceding year. Descriptive variables included dental insurance and poverty status. Analysis was restricted to children from birth to 20 years. Results: Overall, diagnostic (41.2 percent) and preventive (35.8 percent) procedures accounted for most of the procedures received by children from birth to 20 years of age, while restorative procedures accounted for just 5 percent. Children from lowincome families received a higher proportion of restorative procedures than children in higher-income families. The proportion of diagnostic and preventive services was lower among uninsured children than among publicly insured children. Orthodontic services, on the other hand, represented a greater percentage of these procedures among uninsured children than among publicly insured children. Discussion: The vast majority of procedures received by children from birth to 20 years were diagnostic and preventive. Most children with at least one dental visit received a diagnostic or preventive service. Between 1999 and 2009, the proportion of all services received accounted for by diagnostic or preventive services increased. However, the proportion in which each type of procedure was received by children who made at least one visit who received did not change.
Journal of Public Health Dentistry 75 (2015) 10–16
Introduction Dental caries, a potentially preventable disease, is the most common childhood disease in the United States (1). Regular dental visits are paramount for caries treatment, since caries is not a self-limiting or self-repairing disease, and prompt dental professional intervention is required to stop the downward spiral of the disease process. As disease complexity increases, there is a need for more specialized dental personnel and more complex dental care settings, including operating rooms for young children. Effectively, early dental visits reduce future expenditures (2), and preventive visits reduce subsequent nonpreventive or treatment visits (3). 10
The frequency of dental visits for children and adolescents should be based on dental needs, oral disease risk, and presence of medical conditions (4). The American Academy of Pediatric Dentistry recommends that children and adolescents make a dental visit at least once a year (4) for caries diagnosis and prevention. Moreover, they also recommend that the first dental examination should be at the time of eruption of the first tooth but not later than the first birthday (4). Recent reports indicate that dental care utilization by children (5), and particularly children covered by Medicaid (6), increased between 2000 and 2010. Although these reports bring hope, more needs to be done (6), considering that in 2004 only 45.4 percent of children from birth to 20 years of © 2014 American Association of Public Health Dentistry
R.J. Manski et al.
age had made a dental visit in the previous year (7). Even though all children needed to make at least one dental visit per year to undergo diagnostic and preventive procedures, these visits were not equally distributed in the population; the percentage of children making a visit increased with family income, from 30.8 percent of children in poor families to 61.8 percent of children in higher-income families (7). The likelihood of having made a dental visit in the past year also depended on dental insurance coverage; 57.5 percent of children with private dental insurance, 34.1 percent of children with public dental insurance, and 27.5 percent of uninsured children had gone to the dentist in the previous year (7). Results from the National Health and Nutrition Examination Survey (NHANES) have consistently shown that children from low-income families are more likely to have untreated decay and less likely to have restorations than children from higher-income families (8). A previous report from the Medical Expenditure Panel Survey (MEPS) (7) indicated that while 82 percent of children underwent preventive procedures, only 20 percent underwent restorative procedures. However, this report did not present the distribution of procedures by poverty or dental insurance status. The purpose of this analysis is to describe the types of procedures undergone by US children and adolescents (aged birth to 20 years) in 2009 by poverty and dental insurance status. We will also determine whether there were any notable changes in the distribution of dental procedures received by children between 1999 and 2009. This study contributes to the dental public health literature by assessing whether dental insurance and poverty status affect the distribution of procedures as they do the distribution of dental visits.
Methods Data for this report came from the 1999 and 2009 iterations of the MEPS (9,10), a nationally representative survey of health-care use and expenses and insurance coverage in the United States. MEPS collects information about the specific health-care services that Americans use, how frequently the services are used, and how much they cost. It also collects data regarding dental insurance. From each selected household, one respondent typically reports information for all persons in the household. Survey data are representative of the civilian, noninstitutionalized household population of the United States. MEPS is sponsored by the Agency for Healthcare Research and Quality (AHRQ) with co-sponsorship by the National Center for Health Statistics (NCHS) from the Centers for Disease Control and Prevention (CDC). MEPS consists of three major survey elements: the Insurance Component, Medical Provider Component, and Household Component. The Household Component, used for this report, collects data about demographics, health conditions, © 2014 American Association of Public Health Dentistry
US children’s dental procedures in 1999 and 2009
health status, use of health-care services, health-care costs, and other related topics from a nationally representative sample of individuals and families in the US civilian noninstitutionalized population. The Household Component includes a “Dental Care” section that is the basis for this report and utilizes a panel design wherein survey respondents are followed for a 2-year period. Two panels are fielded concurrently, and data for a single calendar year are combined from the two overlapping panels to make annual estimates. Periodic interviews conducted during the two years make it possible to determine how changes in respondents’ health status, income, employment, and eligibility for insurance are related to use of services and payment for care. The MEPS sample is a subsample of households that participated in the previous year’s National Health Interview Survey (NHIS). The sampling design for the NHIS involves a multistage area probability approach with oversampling of selected populations, including Hispanics, African Americans, and Asians. A detailed description of the NHIS sampling methodology is available elsewhere (11). The primary outcome variable for this report described the types of dental procedures (services) that were received during dental visits in the past year. For this report, a dental visit refers to a visit to any type of dental practitioner, including general dentists, dental hygienists, dental technicians, and dental specialists. In order to ascertain information about what procedures were received during each dental visit, the MEPS questionnaire asks, “What did [you/person] have done during this visit?” If more than one procedure was received, the questionnaire also asks, “What else was done?” Respondents were shown cards listing corresponding responses from which to choose. Individual responses were grouped into the following procedure categories: diagnostic (examinations and radiographs), preventive (cleanings, fluoride treatments, dental sealants, and recall visits), restorative (fillings and inlays), prosthetic (crowns, bridges, fixed and removable dentures, denture repairs, and dental implants), periodontic (periodontal services only), endodontic (endodontic services only), oral surgery (oral surgery services only), orthodontic (orthodontic services only), and other (any other dental service not in the aforementioned categories). Similar procedures received during a single dental visit were grouped together. For example, if a respondent received three dental fillings during a particular visit, these three services were combined such that the respondent was said to have received one restorative procedure. Procedures that belonged to different categories were treated separately. For example, if a respondent received an examination, a dental cleaning, and a restoration during a particular visit, these three services would be counted as belonging to the diagnostic, preventive, and restorative categories, respectively. As a consequence of counting services in different categories for the same dental visit, the 11
US children’s dental procedures in 1999 and 2009
R.J. Manski et al.
number of procedures undergone by an individual could be greater than the number of dental visits he or she made. The main descriptor variables were dental insurance status (private, public, uninsured) and poverty status [
Dental procedures among children age birth to 20, United States, 1999 and 2009 Richard J. Manski, DDS, PhD, MBA1; Clemencia M. Vargas, DDS, PhD2; Erwin Brown, BS3; Kelly V. Carper, MEd4; Mark D. Macek, DDS, DrPH1; Leonard A. Cohen, DDS, MPH, MS1 1 2 3 4
Dental Public Health, University of Maryland School of Dentistry, Baltimore, MD, USA Orthodontics and Pediatric Dentistry, University of Maryland School of Dentistry, Baltimore, MD, USA Division of Survey Operations, Agency for Healthcare Research and Quality, Rockville, MD, USA Division of Statistical Research and Methods, Agency for Healthcare Research and Quality, Rockville, MD, USA
Keywords children; dental care; dental insurance; health care surveys; poverty; United States; MEPS; dental procedures. Correspondence Dr. Richard Manski, Dental Public Health, University of Maryland School of Dentistry, 650 W. Baltimore St., Baltimore, MD 21201. Tel.: 410-706-7245; Fax: 410-706-4031; e-mail: [email protected]. Richard J. Manski, Mark D. Macek, and Leonard A. Cohen are with Dental Public Health, University of Maryland School of Dentistry. Clemencia M. Vargas is with Orthodontics and Pediatric Dentistry, University of Maryland School of Dentistry. Erwin Brown is with the Division of Survey Operations, Agency for Healthcare Research and Quality. Kelly V. Carper is with the Division of Statistical Research and Methods, Agency for Healthcare Research and Quality. Received: 1/7/2014; accepted: 5/23/2014. doi: 10.1111/jphd.12065
Abstract Objective: To describe dental procedures received by US children and adolescents by poverty status and dental insurance coverage. Methods: Data for this analysis came from the 1999 and 2009 Medical Expenditure Panel Surveys. The primary outcome variable represented the types of dental procedures that were received during dental visits in the preceding year. Descriptive variables included dental insurance and poverty status. Analysis was restricted to children from birth to 20 years. Results: Overall, diagnostic (41.2 percent) and preventive (35.8 percent) procedures accounted for most of the procedures received by children from birth to 20 years of age, while restorative procedures accounted for just 5 percent. Children from lowincome families received a higher proportion of restorative procedures than children in higher-income families. The proportion of diagnostic and preventive services was lower among uninsured children than among publicly insured children. Orthodontic services, on the other hand, represented a greater percentage of these procedures among uninsured children than among publicly insured children. Discussion: The vast majority of procedures received by children from birth to 20 years were diagnostic and preventive. Most children with at least one dental visit received a diagnostic or preventive service. Between 1999 and 2009, the proportion of all services received accounted for by diagnostic or preventive services increased. However, the proportion in which each type of procedure was received by children who made at least one visit who received did not change.
Journal of Public Health Dentistry 75 (2015) 10–16
Introduction Dental caries, a potentially preventable disease, is the most common childhood disease in the United States (1). Regular dental visits are paramount for caries treatment, since caries is not a self-limiting or self-repairing disease, and prompt dental professional intervention is required to stop the downward spiral of the disease process. As disease complexity increases, there is a need for more specialized dental personnel and more complex dental care settings, including operating rooms for young children. Effectively, early dental visits reduce future expenditures (2), and preventive visits reduce subsequent nonpreventive or treatment visits (3). 10
The frequency of dental visits for children and adolescents should be based on dental needs, oral disease risk, and presence of medical conditions (4). The American Academy of Pediatric Dentistry recommends that children and adolescents make a dental visit at least once a year (4) for caries diagnosis and prevention. Moreover, they also recommend that the first dental examination should be at the time of eruption of the first tooth but not later than the first birthday (4). Recent reports indicate that dental care utilization by children (5), and particularly children covered by Medicaid (6), increased between 2000 and 2010. Although these reports bring hope, more needs to be done (6), considering that in 2004 only 45.4 percent of children from birth to 20 years of © 2014 American Association of Public Health Dentistry
R.J. Manski et al.
age had made a dental visit in the previous year (7). Even though all children needed to make at least one dental visit per year to undergo diagnostic and preventive procedures, these visits were not equally distributed in the population; the percentage of children making a visit increased with family income, from 30.8 percent of children in poor families to 61.8 percent of children in higher-income families (7). The likelihood of having made a dental visit in the past year also depended on dental insurance coverage; 57.5 percent of children with private dental insurance, 34.1 percent of children with public dental insurance, and 27.5 percent of uninsured children had gone to the dentist in the previous year (7). Results from the National Health and Nutrition Examination Survey (NHANES) have consistently shown that children from low-income families are more likely to have untreated decay and less likely to have restorations than children from higher-income families (8). A previous report from the Medical Expenditure Panel Survey (MEPS) (7) indicated that while 82 percent of children underwent preventive procedures, only 20 percent underwent restorative procedures. However, this report did not present the distribution of procedures by poverty or dental insurance status. The purpose of this analysis is to describe the types of procedures undergone by US children and adolescents (aged birth to 20 years) in 2009 by poverty and dental insurance status. We will also determine whether there were any notable changes in the distribution of dental procedures received by children between 1999 and 2009. This study contributes to the dental public health literature by assessing whether dental insurance and poverty status affect the distribution of procedures as they do the distribution of dental visits.
Methods Data for this report came from the 1999 and 2009 iterations of the MEPS (9,10), a nationally representative survey of health-care use and expenses and insurance coverage in the United States. MEPS collects information about the specific health-care services that Americans use, how frequently the services are used, and how much they cost. It also collects data regarding dental insurance. From each selected household, one respondent typically reports information for all persons in the household. Survey data are representative of the civilian, noninstitutionalized household population of the United States. MEPS is sponsored by the Agency for Healthcare Research and Quality (AHRQ) with co-sponsorship by the National Center for Health Statistics (NCHS) from the Centers for Disease Control and Prevention (CDC). MEPS consists of three major survey elements: the Insurance Component, Medical Provider Component, and Household Component. The Household Component, used for this report, collects data about demographics, health conditions, © 2014 American Association of Public Health Dentistry
US children’s dental procedures in 1999 and 2009
health status, use of health-care services, health-care costs, and other related topics from a nationally representative sample of individuals and families in the US civilian noninstitutionalized population. The Household Component includes a “Dental Care” section that is the basis for this report and utilizes a panel design wherein survey respondents are followed for a 2-year period. Two panels are fielded concurrently, and data for a single calendar year are combined from the two overlapping panels to make annual estimates. Periodic interviews conducted during the two years make it possible to determine how changes in respondents’ health status, income, employment, and eligibility for insurance are related to use of services and payment for care. The MEPS sample is a subsample of households that participated in the previous year’s National Health Interview Survey (NHIS). The sampling design for the NHIS involves a multistage area probability approach with oversampling of selected populations, including Hispanics, African Americans, and Asians. A detailed description of the NHIS sampling methodology is available elsewhere (11). The primary outcome variable for this report described the types of dental procedures (services) that were received during dental visits in the past year. For this report, a dental visit refers to a visit to any type of dental practitioner, including general dentists, dental hygienists, dental technicians, and dental specialists. In order to ascertain information about what procedures were received during each dental visit, the MEPS questionnaire asks, “What did [you/person] have done during this visit?” If more than one procedure was received, the questionnaire also asks, “What else was done?” Respondents were shown cards listing corresponding responses from which to choose. Individual responses were grouped into the following procedure categories: diagnostic (examinations and radiographs), preventive (cleanings, fluoride treatments, dental sealants, and recall visits), restorative (fillings and inlays), prosthetic (crowns, bridges, fixed and removable dentures, denture repairs, and dental implants), periodontic (periodontal services only), endodontic (endodontic services only), oral surgery (oral surgery services only), orthodontic (orthodontic services only), and other (any other dental service not in the aforementioned categories). Similar procedures received during a single dental visit were grouped together. For example, if a respondent received three dental fillings during a particular visit, these three services were combined such that the respondent was said to have received one restorative procedure. Procedures that belonged to different categories were treated separately. For example, if a respondent received an examination, a dental cleaning, and a restoration during a particular visit, these three services would be counted as belonging to the diagnostic, preventive, and restorative categories, respectively. As a consequence of counting services in different categories for the same dental visit, the 11
US children’s dental procedures in 1999 and 2009
R.J. Manski et al.
number of procedures undergone by an individual could be greater than the number of dental visits he or she made. The main descriptor variables were dental insurance status (private, public, uninsured) and poverty status [
