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1.  Predictors of Dental Care Use: Findings from the National Longitudinal Study of Adolescent Health 
Objective
To examine longitudinal trends and associated factors in dental service utilization by adolescents progressing to early adulthood in the United States.
Data Source
The National Longitudinal Study of Adolescent Health from Waves I (1994-95), II (1996), III (2001-2002) and IV (2007-2008).
Study Design
This is a retrospective, observational study of adolescents' transition to early adulthood. We obtained descriptive statistics and performed logistic regression analyses to identify the effects of baseline and concurrent covariates on dental service utilization from adolescence to early adulthood over time.
Principal Findings
Dental service utilization within the prior 12 months peaked at age 16 (72%), gradually decreased until age 21 (57%), and thereafter remained flat. Whites and Asians had a 10-20 percentage points higher proportion of dental service utilization at most ages compared to Blacks and Hispanics. Dental service utilization at later follow-up visits was strongly associated with baseline utilization with OR= 10.7, 2.4 and 1.5 at the 1-year, 7-year and 13-year follow-ups respectively. These effects decreased when adjusted for current income, insurance and education. Compared to Whites, Blacks were consistently less likely to report any dental examination.
Conclusion
Dental service utilization was highest in adolescents. Gender, education, health insurance and income in young adulthood were significant predictors of reporting a dental examination. Blacks had lower odds of reporting a dental examination either as adolescents or as young adults.
doi:10.1016/j.jadohealth.2013.05.013
PMCID: PMC3805715  PMID: 23850156
Adolescents; dental service utilization; racial/ethnic minority; adulthood
2.  Racial/Ethnic Disparities in Receipt of Dental Procedures amongst Children Enrolled in Delta Dental Insurance in Milwaukee, Wisconsin 
Objectives
Most studies on the provision of dental procedures have focused on Medicaid enrollees known to have inadequate access to dental care. Little information on private insurance enrollees exists. This study documents the rates of preventive, restorative, endodontic, and surgical dental procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI) in Milwaukee.
Methods
We analyzed DDWI claims data for Milwaukee children aged 0–18 years between 2002 and 2008. We linked the ZIP-codes of enrollees to the 2000 US Census information to derive racial/ethnic estimates in the different ZIP- codes. We estimated the rates of preventive, restorative, endodontic, and surgical procedures provided to children in different racial/ethnic groups based on the population estimates derived from the US Census data. Descriptive and multivariable analysis was done using Poisson regression modeling on dental procedures per year.
Results
In seven years, a total of 266,380 enrollees were covered in 46 ZIP- codes in the database. Approximately, 64%, 44% and 49 % of White, African American and Hispanic children had at least one dental visit during the study period, respectively. The rates of preventive procedures increased up to the age of 9 years and decreased thereafter among children in all three racial groups included in the analysis. African American and Hispanic children received half as many preventive procedures as White children.
Conclusions
Our study shows that substantial racial disparities may exist in the types of dental procedures that were received by children.
doi:10.1111/j.1752-7325.2012.00366.x
PMCID: PMC4121860  PMID: 22970893
Dental procedures; healthcare disparities; race; dental insurance; dental care utilization; children; adolescents
3.  Patterns of dental service utilization following nontraumatic dental condition visits to the emergency department in Wisconsin Medicaid 
Objectives
To examine patterns of dental service utilization for adult Medicaid enrollees in Wisconsin following nontraumatic dental condition (NTDC) visits to the emergency department (ED).
Methods
This is a retrospective, observational study of claims for NTDC visits to the ED and dental service encounters from the Wisconsin Medicaid Evaluation and Decision Support database (2001–2009). We used competing risk models to predict probabilities of returning to the ED versus obtaining follow-up care from a dentist.
Results
We observed a 43 percent increase in the rate of NTDC visits to the ED, with most of this increase occurring from 2001 to 2005. Within 30 days of an NTDC visit to the ED, ~29.6 percent of enrollees will first visit a dentist office, while ~9.9 percent will return to the ED. Young to middle-aged adults (18 to <50 years) and enrollees living in counties with a lower supply of dental providers were more likely to return to the ED following a NTDC visit. Among the enrollees that first visited a dental office following an ED visit, 37.6 percent had an extraction performed at this visit.
Conclusions
Almost one in five adult Medicaid enrollees will subsequently return to the ED following a previous NTDC visit. The provision of definitive care for these individuals appears to primarily consist of extractions.
doi:10.1111/j.1752-7325.2012.00364.x
PMCID: PMC4104605  PMID: 22882075
dental health services; dental care; emergency service; hospital; Medicaid
4.  Racial/Ethnic Variations in Emergency Department Wait Times for Nontraumatic Dental Condition Visits in the United States 
Background
Studies have documented an association between wait times in emergency departments (EDs) and quality of care for medical conditions, but little is known about trends and factors associated with wait times for nontraumatic dental condition (NTDC) visits in EDs. We examined trends in wait time and associated factors for NTDC visits in EDs in the United States.
Methods
We analyzed data from the National Hospital Ambulatory Medical Care survey for 1997 to 2007, with 2001-2002 excluded due to lack of wait time information. We used survey-weighted linear regression of log-transformed waiting time model for the wait time for NTDC visits.
Results
The geometric mean wait time for NTDC and non-NTDC visits was 29±1 and 25±0.6 minutes, respectively (p<0.0001). The geometric mean wait time for NTDC visits increased by 6% annually and from 20 minutes in 1997 to 37 minutes in 2007. Compared to Whites, Hispanics and Blacks had significantly longer wait times for NTDC visits (adjusted fold-difference [R] =1.2, 95% confidence interval [CI] = 1.13-1.31) and [R] = 1.3, [CI] = 1.29-1.38). Age, payer type, reason for visit and triaged category were significant predictors of wait time (R=2.3 and 2.4 for NTDC visits in triage category of 1-2 hours and >2-24hours respectively).
Conclusion
Nationally, wait times in EDs for NTDC visits increased over time. Hispanics (aged ≤ 33years old) and Blacks waited longer to receive care for NTDCs in EDs than Whites.
Practice Implication
Prolonged wait times for NTDC visits in emergency departments could adversely impact quality of care and patient outcomes.
PMCID: PMC3817612  PMID: 23813265
Emergency service; Dental service utilization; dental care
5.  Racial and Ethnic Disparities in Non-Traumatic Dental Condition Visits to Emergency Departments and Physicians’ Offices in the Wisconsin Medicaid Program 
Background
Non-traumatic dental condition (NTDC) visits frequently occur in emergency departments (EDs) and physicians’ offices (POs), but little is known about whether racial/ethnic disparities exist in Medicaid NTDC visit rates to EDs and POs.
Methods
All Medicaid dental claims in Wisconsin from 2001–2003 were analyzed to examine factors associated with NTDC visits to EDs and POs. Bivariable and multivariable analyses were performed; independent variables examined included race/ethnicity, age, gender, dental health professional shortage area (DHPSA) designation, and Urban Influence Code (UIC) for county of residence.
Results
956,774 NTDC visits made during 1,718,006 person-years were evaluated; 4.3% of visits occurred in EDs/POs. Native Americans, African-Americans, and enrollees of unknown race/ethnicity had the highest unadjusted ED/PO visit rates for NTDCs. African-Americans, Native-Americans, adults, and residence in partial or entire DHPSAs had significantly higher adjusted rates of NTDC visits to EDs. Significantly higher adjusted NTDC visit rates to POs were observed for Native-Americans, adults, and enrollees residing in entire DHPSAs, but African-Americans had a significantly lower adjusted rate.
Conclusions
Native Americans, those residing in entire DHPSAs, and adults have significantly higher risks of NTDC visits to EDs and POs; African-Americans are at increased risk of ED visits but at decreased risk of PO visits for NTDCs.
Clinical Implications
Reductions in Medicaid visits to EDs and POs and the associated costs might be achieved by improving dental care access and targeted educational strategies among minorities, DHPSA residents, and adults.
PMCID: PMC3817617  PMID: 19047672
Medicaid; racial/ethnic disparities; non-traumatic dental conditions; emergency department; DHPSAs
6.  Nontraumatic dental condition-related visits to emergency departments on weekdays, weekends and night hours: findings from the National Hospital Ambulatory Medical Care survey 
Objective
To determine whether the rates of nontraumatic dental condition (NTDC)-related emergency department (ED) visits are higher during the typical working hours of dental offices and lower during night hours, as well as the associated factors.
Methods
We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997 through 2007 using multivariate binary and polytomous logistic regression adjusted for survey design to determine the effect of predictors on specified outcome variables.
Results
Overall, 4,726 observations representing 16.4 million NTDC-related ED visits were identified. Significant differences in rates of NTDC-related ED visits were observed with 40%–50% higher rates during nonworking hours and 20% higher rates on weekends than the overall average rate of 170 visits per hour. Compared with 19–33 year olds, subjects < 18 years old had significantly higher relative rates of NTDC-related ED visits during nonworking hours [relative rate ratio (RRR) = 1.6 to 1.8], whereas those aged 73 and older had lower relative rates during nonworking hours (RRR = 0.4; overall P = 0.0005). Compared with those having private insurance, Medicaid and self-pay patients had significantly lower relative rates of NTDC visits during nonworking and night hours (RRR = 0.6 to 0.7, overall P < 0.0003). Patients with a dental reason for visit were overrepresented during the night hours (RRR = 1.3; overall P = 0.04).
Conclusion
NTDC-related visits to ED occurred at a higher rate during nonworking hours and on weekends and were significantly associated with age, patient-stated reason for visit and payer type.
doi:10.2147/CCIDE.S49191
PMCID: PMC3770522  PMID: 24039453
dental health services; dental care; emergency service; toothache
7.  MEDICATIONS PRESCRIBED IN EMERGENCY DEPARTMENTS FOR NONTRAUMATIC DENTAL CONDITION VISITS IN THE UNITED STATES 
Medical Care  2012;50(6):508-512.
Background
Prior research has documented factors associated with non-traumatic dental condition (NTDC) visits to emergency departments (EDs), but little is known about the care received by patients in EDs for NTDC visits.
Objective
We examined national trends in prescription of analgesics and antibiotics in EDs for NTDC visits in the United States.
Research Design
We analyzed data from the National Hospital Ambulatory Medical Care survey for 1997 to 2007. We used a multivariable logistic regression model to examine factors associated with receiving analgesics and antibiotics for NTDC visit in EDs.
Results
Overall 74% received at least one analgesic, 56% at least one antibiotic and 13% received no medication at all during an NTDC visit to the ED. The prescription of medications at EDs for NTDC visits steadily increased over time for analgesics (OR=1.11/year, p=<.0001) and antibiotics (OR=1.06/year, p<0.0001). In the multivariable analysis, self-pay patients had significantly higher adjusted odds of receiving antibiotics, while those with non-dental reason for visit and children (0–4 years) had significantly lower adjusted odds of receiving a prescription for antibiotics in EDs for NTDC visits. Children 0–4 years, adults 53–72 years and older adults (73 years and older) had lower adjusted odds (p<0.001) of receiving analgesics.
Conclusions
Nationally, analgesic and antibiotic prescriptions for NTDC visits to EDs have increased substantially over time. Self-pay patients had significantly higher odds of being prescribed antibiotics. Adults over 53 years and especially those 73 years and older had significantly lower odds of receiving analgesics in EDs for NTDC visits.
doi:10.1097/MLR.0b013e318245a575
PMCID: PMC3353147  PMID: 22584886
Nontraumatic dental conditions; Emergency Department; Medications
8.  Nontraumatic Oral Health Classification for Alternative Use of Syndromic Data 
Objective
To develop a nontraumatic oral health classification that could estimate the burden of oral health-related visits in North Carolina (NC) Emergency Departments (EDs) using syndromic surveillance system data.
Introduction
Lack of access to regular dental care often results in costly, oral health visits to EDs that could otherwise have been prevented or managed by a dentist (1). Most studies on oral health-related visits to EDs have used a wide range of classifications from different databases, but none have used syndromic surveillance data. The volume, frequency, and included details of syndromic data enabled timely burden estimates of nontraumatic oral health visits for NC EDs.
Methods
Literature review, input by subject matter experts (SMEs), and analysis of syndromic data was used to create the nontraumatic oral health classification. BioSense, a near real-time, national-level, electronic health surveillance system was the source of the NC ED syndromic data. Visits with at least one oral health-related ICD-9-CM code were extracted for NC fiscal years 2008–2010. Univariate analyses of chief complaint (CC) and final diagnosis data along with SME consultation were used to determine the CC substrings and ‘white list’ of ICD-9-CM codes used as inclusion criteria to classify visits as oral health-related. These analyses and consultations also determined the trauma-related codes and substrings used to exclude visits.
Results
Table 1 shows all nontraumatic oral health-related ICD-9-CM codes used for the characterization. Codes likely related to the types of dental emergencies that routine dental care could not have prevented were excluded. Approximately 275,000 patient records were evaluated to determine the CC substrings. The final CC substrings chosen (Table 1) represented over 56% of visits in the candidate record dataset. Over 334,000 BioSense patient records were evaluated, and SMEs reviewed the 32 ICD-9-CM codes that co-occurred most commonly in visits containing oral health-related ICD-9-CM codes to determine which co-occurring ICD-9-CM codes (white list, Table 1) could be present and still maintain the main reason for the visit as an oral health-related problem. Trauma-related visit criteria used for exclusion were derived from a subset of BioSense sub-syndromes (Falls; Fractures and dislocation; Injury, NOS; Sprains and strains; and Motor vehicle traffic accidents) and from selected CC substrings (‘assault’, ‘fight’, and ‘brawl’).
In summary, an ED visit had a nontraumatic oral health classification if it contained 1) an oral health-related CC substring with no trauma-related ICD-9-CM codes or CC substrings or 2) an oral health-related ICD-9 code accompanied by no oral health-related or trauma-related CC substrings and with no other diagnosis codes except for those on the whitelist.
Conclusions
There is increasing demand to determine ways to use syndromic surveillance data in an alternative way for population health surveillance. This use of BioSense data provided a practical classification of patient records for the tracking of nontraumatic oral health-related visits to NC EDs. Visit estimates created using this classification in combination with other pertinent information could prove useful to policymakers when deciding upon resource allocation aimed at reducing this unnecessary burden on the NC ED system. The large volume of records in syndromic surveillance systems offers substantial weight of evidence for alternative use in epidemiological studies; however, accurate classification of records is required to select cases of interest. While data volume precludes validation of every included record, a combination of human expertise and data analysis can provide credible classification criteria.
PMCID: PMC3692904
Syndromic Surveillance; Oral Health; Emergency Departments
9.  Rural–urban differences in dental service use among children enrolled in a private dental insurance plan in Wisconsin: analysis of administrative data 
BMC Oral Health  2012;12:58.
Background
Studies on rural–urban differences in dental care have primarily focused on differences in utilization rates and preventive dental services. Little is known about rural–urban differences in the use of wider range of dental procedures. This study examined patterns of preventive, restorative, endodontic, and extraction procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI).
Methods
We analyzed DDWI enrollment and claims data for children aged 0-18 years from 2002 to 2008. We modified and used a rural and urban classification based on ZIP codes developed by the Wisconsin Area Health Education Center (AHEC). We categorized the ZIP codes into 6 AHEC categories (3 rural and 3 urban). Descriptive and multivariable analysis using generalized linear mixed models (GLMM) were used to examine the patterns of dental procedures provided to children. Tukey-Kramer adjustment was used to control for multiple comparisons.
Results
Approximately, 50%, 67% and 68 % of enrollees in inner-city Milwaukee, Rural 1 (less than 2500 people), and suburban-Milwaukee had at least one annual dental visit, respectively. Children in inner city-Milwaukee had the lowest utilization rates for all procedures examined, except for endodontic procedures. Compared to children from inner-city Milwaukee, children in other locations had significantly more preventive procedures. Children in Rural 1-ZIP codes had more restorative, endodontic and extraction procedures, compared to children from all other regions.
Conclusions
We found significant geographic variation in dental procedures received by children enrolled in DDWI.
doi:10.1186/1472-6831-12-58
PMCID: PMC3548684  PMID: 23259637
Oral health; Urban; Rural; Dental care for children; Dental Insurance; Health services accessibility
10.  Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States 
Objective
We examined trends and patient characteristics for non-traumatic dental condition (NTDC) visits to emergency departments (EDs), and compared them to other ED visit types, specifically non-dental ambulatory care sensitive conditions (non-dental ACSCs) and non-ambulatory care sensitive conditions (non-ACSCs) in the United States.
Methods
We analyzed data from the National Hospital Ambulatory Medical Care survey (NHAMCS) for 1997 to 2007. We performed descriptive statistics and used a multivariate multinomial logistic regression to examine the odds of one of the three visit types occurring at an ED. All analyses were adjusted for the survey design.
Results
NTDC visits accounted for 1.4% of all ED visits with a 4% annual rate of increase (from 1.0% in 1997 to 1.7% in 2007). Self-pay patients (32%) and Medicaid enrollees (27%) were over-represented among NTDC visits compared to non-dental ACSC and non-ACSC visits (P < 0.0001). Females consistently accounted for over 50% of all types of ED visits examined. Compared to whites, Hispanics had significantly lower odds of an NDTC visit versus other visit types (P < 0.0001). Blacks had significantly lower odds of making NDTC visits when compared to non-dental ACSC visits only (P < 0.0001). Compared to private insurance enrollees, Medicaid and self-pay patients had 2–3 times the odds of making NTDC visits compared to other visit types.
Conclusion
Nationally, NTDC visits to emergency departments increased over time. Medicaid and self-pay patients had significantly higher odds of making NDTC visits.
doi:10.2147/CCIDEN.S28168
PMCID: PMC3652363  PMID: 23674919
emergency service; dental disease; adults; dental utilization
11.  Increased Children's Access to Fluoride Varnish Treatment by Involving Medical Care Providers: Effect of a Medicaid Policy Change 
Health Services Research  2009;44(4):1144-1156.
Background
In 2004, the State of Wisconsin introduced a change to their Medicaid Policy allowing medical care providers to be reimbursed for fluoride varnish treatment provided to Medicaid enrolled children.
Objective
To determine the extent by which a state-level policy change impacted access to fluoride varnish treatment (FVT) for Medicaid enrolled children.
Data Source
The Electronic Data Systems of Medicaid Evaluation and Decision Support database for Wisconsin from 2002 to 2006.
Study Design
We analyzed Wisconsin Medicaid claims for FVT for children between the ages of 1 and 6 years, comparing rates in the prepolicy period (2002–2003) to the period (2004–2006) following the policy change.
Principal Findings
Medicaid claims for FVT in 2002–2003 totaled 3,631. Following the policy change, claims for FVT increased to 28,303, with 38.0 percent submitted by medical care providers. FVT rates increased for children of both sexes and all ages, rising from 1.4 per 1,000 person-years of enrollment in 2002–2003 to 6.6 per 1,000 person-years in 2004–2006. Overall, 48.6 percent of the increase in FVT was attributable to medical care providers. The largest increase was seen in children 1–2 years of age, among whom medical care providers were responsible for 83.5 percent of the increase.
Conclusions
A state-level Medicaid policy change was followed by both a significant involvement of medical care providers and an overall increase in FVT. Children between the ages of 1 and 2 years appear to benefit the most from the involvement of medical care providers.
doi:10.1111/j.1475-6773.2009.00975.x
PMCID: PMC2739021  PMID: 19453390
Medicaid-enrolled children; oral health disparities; fluoride varnish treatment; medical care providers; policy change
12.  Provision of Fluoride Varnish Treatment by Medical and Dental Care Providers: Variation by Race/Ethnicity and Levels of Urban Influence 
Background
In 2004, Wisconsin Medicaid policy changed to allow medical care providers to be reimbursed for fluoride varnish treatment (FVT) to children’s teeth to improve access and utilization. To date, no study has been published on whether geographic and racial/ethnic variation in the provision of FVT in response to this policy change exists.
Objective
To examine the association of rates of FVT for children enrolled in Wisconsin Medicaid with race/ethnicity, Urban Influence Codes (UIC), and Dental Health Professional Shortage Area (DHPSA) designation based on county of residence.
Methods
A retrospective, pre-post design was used based on FVT claims for children in the Wisconsin Medicaid program from 2002 to 2006. Poisson Regression Models were used to evaluate the association of rates of FVT claims with race/ethnicity, UIC, and DHPSA designation.
Results
The rate of FVT claims varied by resident county-type according to UIC and DHPSA designation, age, and race/ethnicity. Post policy, the largest increases were observed for Native Americans residing in none DHPSA counties, enrollees living in rural counties and for Hispanics living in partial and entire DHPSA counties. African-Americans residing in partial DHPSA and metropolitan counties displayed the lowest rates of FVT claims.
Conclusions
Overall access and utilization of fluoride varnish treatment increased, but substantial racial/ethnic and geographic variation in the provision of FVT for children enrolled in Wisconsin Medicaid was observed. Future policies should incorporate measures that will specifically address the racial and geographic variations identified in this study.
doi:10.1111/j.1752-7325.2010.00168.x
PMCID: PMC2967666  PMID: 20459463
Fluoride varnish treatment; Children; Ethnic groups; Health services accessibility
13.  Pilot survey of oral health-related quality of life: a cross-sectional study of adults in Benin City, Edo State, Nigeria 
BMC Oral Health  2005;5:7.
Background
Oral health studies conducted so far in Nigeria have documented prevalence and incidence of dental disease using traditional clinical measures. However none have investigated the use of an oral health-related quality of life (OHRQoL) instrument to document oral health outcomes. The aims of this study are: to describe how oral health affects and impacts quality of life (QoL) and to explore the association between these affects and the oral health care seeking behavior of adults in Benin City, Edo State, Nigeria.
Methods
A cross-sectional survey recruited 356 adults aged 18–64 years from two large hospital outpatient departments and from members of a university community. Closed-ended oral health questionnaire with "effect and impact" item-questions from OHQoL-UK© instrument was administered by trained interviewers. Collected data included sociodemographic, dental visits, and effects and impact of oral health on QoL. Univariate and bivariable analyses were done and a chi-square test was used to test differences in proportions. Multivariable analyses using ANOVA examined the association between QoL factors and visits to a dentist.
Results
Complete data was available for 83% of the participants. About 62% of participants perceived their oral health as affecting their QoL. Overall, 82%, 63%, and 77% of participants perceived that oral health has an effect on their eating or enjoyment of food, sleep or ability to relax, and smiling or laughing, respectively. Some 46%, 36%, and 25% of participants reported that oral health impact their daily activities, social activities, and talking to people, respectively. Dental visits within the last year was significantly associated with eating, speech, and finance (P < 0.05). The summary score for the oral health effects on QoL ranged from 33 to 80 with a median value of 61 (95% CI: 60, 62) and interquartile range of 52–70. Multivariable modeling suggested a model containing only education (F = 6.5, pr>F = 0.0111). The mean of effects sum score for those with secondary/tertiary education levels (mean = 61.8; 95% CI: 60.6, 62.9) was significantly higher than those with less than secondary level of education (mean = 57.2; 95% CI: 57.2, 60.6).
Conclusion
Most adults in the study reported that oral health affects their life quality, and have little/no impact on their quality of life. Dental visits within the last year were associated with eating, speech, and finance.
doi:10.1186/1472-6831-5-7
PMCID: PMC1190187  PMID: 16042806

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