Research Article ISSN 2639-9490

Oral Health & Dental Science

Evaluation of Barriers to Access Treatment for Gum Disease: A Cross-

sectional Study
Dorienne C. Taylor-Bishop1, Fatima Mncube-Barnes2*, Edmund Essah Ameyaw3, Paula Nesbitt4,
Gail Cherry-Peppers5 and Donna Grant-Mills6

Assistant Professor, Department of Restorative Dentistry,

1

Howard University College of Dentistry, Washington, USA.

Executive Director, Louis Stokes Health Sciences Library,

2

Howard University|501 W Street, NW, Washington, USA.

Research Coordinator, Louis Stokes Health Sciences Library,

3 *
Correspondence:
Howard University|501 W Street, NW, Washington, USA. Fatima Mncube-Barnes, Executive Director, Louis Stokes
Health Sciences Library, Howard University|501 W Street, NW,
Department of Comprehensive Care, Division Director of
4
Washington, USA.
Clinical Endodontics, Assistant Professor, Howard University
College of Dentistry, Washington, USA. Received: 29 Nov 2022; Accepted: 23 Dec 2022; Published: 27 Dec 2022

Associate Professor, Restorative Dentistry, Howard University

5

College of Dentistry, Washington, USA.

Professor and Associate Dean for Student Affairs, Howard

6

University College of Dentistry, Washington, USA.

Citation: Taylor-Bishop DC, Mncube-Barnes F, Ameyaw EE, et al. Evaluation of Barriers to Access Treatment for Gum Disease: A
Cross-sectional Study. Oral Health Dental Sci. 2022; 6(4); 1-8.

ABSTRACT
This study identified the specific factors which influence the treatment of gum disease. Specifically, the aims are to
examine i) the differences in the prevalence of self-reported periodontitis treatment in 2011–2012 and 2017–2018,
ii) the association between the background characteristics of respondents and treatment of gum disease, iii) the
effects of the background characteristics on the treatment of gum disease and iv) reasons for the lack of access to
dental care in 2011–2012 and 2017–2018.

Data from the National Health an Nutrition Examination Survery (NHANES) oral health questionnaires 2011-2012
and 2017-2018 were used. NHANES is a periodic survey conducted by the National Center for Health Statistics of
the Centers for Disease Control and Prevention. This data represents a stratified, multistage probability sample
of the civilian noninstitutionalized population in the 50 United States U.S) and the District of Columbia. Binary
multivariable logistic regression was used to examine the socioeconomic predictors of self-reported therapy for
gum disease. Compared to 2011-2012, more participants accessed oral health care services during 2017-2018,
resulting in fewer people seeking treatment for gum disease. Affordability and lack of dental health insurance
were the primary reasons for not receiving treatment for gum disease. Compared with Whites, Asians were more
likely to report having had treatment, followed by Hispanics and Blacks. Increasing oral health services for the
elderly could improve access to care related to periodontal disease in this cohort of patients. In addition, the
expansion of dental coverage with reduced out-of-pocket expenditure could improve access to dental services and
overall health.

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 1 of 8

Keywords Understanding what deters people from accessing dental care is
Periodontitis, Periodontal disease, Gum disease, Oral health, essential. Clinicians, researchers, and policymakers should devise
NHANES data. ways to improve dental insurance coverage, increase knowledge
and awareness of gum disease, and foster collaboration with
Introduction patients to reduce dental anxiety and fear, which leads to missing
Half of American adults aged over 30 have periodontitis. dental appointments.
Insufficient dental hygiene is a harbinger of oral bacteria that
causes dental caries, calculus, and gingivitis. Inadequate hygiene Methods
affects approximately three out of four American adults and can Dependent variables
advance to periodontitis, a more severe stage of the disorder [1]. The dependent variable was an oral health-related question that
Good oral health significantly contributes to one's overall well- asked participants if they had ever had treatment for gum disease
being. Since bi-annual dental visits are the norm for general oral (yes/no), such as scaling or root planing. Those who did not know
care, dentists should share information on preventing gum disease or had missing information were excluded from the study.
and associated comorbidities during these visits [2].
Exposure of Interest
Treatment for gum diseases differs across states, races, education, As listed in the National Health and Nutrition Examination Survey
and other subgroups. For example, among numerous studies, (NHANES) questionnaire on oral health, 11 reasons respondents
Burt and Eklund suggested there is less use of dental services by could not access dental care when needed were: 1) could not afford
males, ethnic/racial minorities, those with lower education, and it, 2) did not want to spend the money, 3) insurance did not cover,
those without dental insurance [3]. Other investigations suggested 4) dental office too far, 5) dental office not open at a convenient
geographic location as an essential factor [4-6]. People who live in time, 6) other dentists did not recommend, 7) afraid or did not like
more rural areas, both adults and children, had worse oral health the dentist, 8) unable to take time off from work, 9) too busy, 10)
than their urban counterparts [4] and may be less likely to utilize expected dental problems to go away, and 11) other. Individuals
oral health care services [6]. Other studies found that dental care who responded with "refused" or "do not know" were omitted
related to anxiety and fear affected dental care utilization [7,8]. [19,20].
Approximately 45% of the population in the U.S. have high levels
of anxiety and fear about dental care of sufficient intensity to lead Race Comparison Group
approximately close to 15% to avoid care [8,9]. Elevated dental Hispanics, Whites, Blacks, Asians, or Others were used as the
care-related anxiety or fear levels are associated with canceling comparison group in this analysis. The interview defined race as,
dental visits or failing to keep appointments [8]. Anxiety and fear "What race do you consider yourself to be?"
are more prevalent in dental care avoiders than in regulars [10].
These cited studies have impacted the understanding of dental care Other Covariates
treatment of periodontitis as a crucial component of improving Following previous research [21-25], the independent variables
oral health and well-being [11]. included age group, gender, annual household income, language,
marital status, education level, and 11 reasons participants could
Many studies worldwide have addressed the frequency and not access dental care. The gender classification was either male
determinants of oral healthcare utilization. Age, sex, urbanity, or female. Annual household income was grouped as $0–24,999,
education level, income level, employment, and health status, $25,000–54,999, or $55,000 and above. The language was
among others, have been associated with oral healthcare utilization categorized as English or Spanish. Marital status was categorized
in many studies globally [12-15]. However, published research on as married, no longer married, or never married. Education
associated factors in the treatment of gum disease and differences level was categorized as high school (had primary education or
in ever having had treatment for gum disease across specific year completed high school or GED) and some college, which included
groups in the U.S. is limited. In addition, background characteristics those identified as having some college, having an associate
differ in different parts of the world, which influences the treatment degree, or being college graduates or above.
of gum diseases differently [16-19].
Dataset and Design
This study aimed to identify the specific factors that influence gum The study utilized secondary data from the National Health and
disease treatment given the following hypotheses statements: Nutrition Examination Survey (NHANES) wave of data from
1) There is a difference in gum disease treatment between 2011– the 2011–2012 and 2017–2018. Both surveys used the same
2012 and 2017–2018. methodology. NHANES is an ongoing complex multistage
2) There is an association between background characteristics and survey that involves a series of cross-sectional surveys conducted
gum disease treatment. every two years [20]. It examines approximately 5,000 persons
3) There is a relationship between background characteristics and annually across the United States and is designed to be a nationally
treatment for gum disease. representative dataset of the civilian, noninstitutionalized U.S.
population. The survey collects data via household interviews of

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 2 of 8

all the participants, followed by a physical examination of most sociodemographic variables and the question Ever had treatment
of them in a mobile examination center (MEC). This survey is for gum disease? Furthermore, ii) the reasons respondents did
approved by the National Center for Health Statistics (NCHS) not access dental care (i.e., affordability, accessibility, proximity,
Research Ethics Review Board (ERB). Detailed information about behavioral attitude, dental phobia, and doctor's referral). An
sampling and procedures is available on the NHANES website Exact McNemar's test was used to assess significant differences
[20]. in response to Ever had treatment for gum disease? During 2011–
2012 and 2017–2018. The binary logistic regression was used to
The 2011–2012 cycle consisted of 9,756 participants, including examine the socioeconomic predictors of self-reported gum disease
children and adults. For this study, those under the Age of 30 and treatment; variables with p<.05 were considered significant and
over 79 (n=4,799) were not analyzed. We further excluded twenty- included in the model.
nine participants with missing data (including "do not know" and
"refused") for our primary outcome variable, "Ever had treatment Results
for gum disease," Once these exclusion criteria were applied, the Using data from the NHANES oral health questionnaire 2011-
final sample for this study was 4,157. Whereas 2017–2018 had 2012; 2017-2018, we assessed the association between the
8,897 participants. Applying the same exclusion criteria (excluding sociodemographic variables and the question ever had treatment
4156 participants under the Age of 30 and over the Age of 79 and for gum disease (yes/no)? Table 1 shows the characteristics of the
20 participants who were missing the outcome variable) resulted participants by self-reported treatment for gum disease. Significant
in 4,299 participants. differences were observed in all races/ethnicity between the
2011–2012 and 2017–2018 groups on those who answered yes
IBM® SPSS software (version 26) was used for the analysis to the question Ever had treatment for gum disease? In addition,
[26]. Descriptive statistics were used to describe the in 2017–2018, the results showed a 50% decrease in those who
respondents' background characteristics. The chi-square test of needed gum disease treatment.
independence examined the following: i) association between the

Table 1: Respondents' Characteristics by Yes/No to self-reported Treatment of Gum Disease.

2011-2012 2017-2018
Background characteristics No. of No. of
Yes No Total Yes No Total
Persons Persons
Age % % % %
30-39 19 81 100 956 22 78 100 827
40-49 27 73 100 890 28 72 100 869
50-59 25 75 100 905 29 71 100 1,106
60-69 28 72 100 901 29 71 100 780
70-79 22 78 100 505 24 76 100 194
Gender
Male 23 77 100 2,199 24 76 100 2,282
Female 23 77 100 2,307 26 74 100 2,439
Annual House Income ($)
0-24,999 19 81 100 1,380 20 80 100 1,079
25,000-54,999 24 76 100 1,160 23 77 100 1,245
55,000 and over 27 73 100 1,731 29 71 100 1,911
Language
English 23 77 100 3,952 23 77 100 4,180
Spanish 29 71 100 554 36 64 100 541
Marital Status
Married 75 25 100 2,751 26 74 100 2,912
No longer Married 79 21 100 1,185 24 76 100 1,270
Never Married 76 24 100 563 19 81 100 533
Education level (20+)
HS 20 80 100 2,145 22 78 100 2,078
Some college 27 73 100 2,359 27 73 100 2,631
Race
Hispanic 73 27 100 909 32 68 100 1,022
White 80 20 100 1,717 18 82 100 1,678
Black 77 23 100 1,167 26 74 100 1,102
Asian 72 28 100 606 30 70 100 691
Other including multiracial 79 22 100 107 22 78 100 228

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 3 of 8

The results suggest fewer respondents were treated for gum marital status, education, and race/ethnicity were all significantly
disease compared with 2011–2012. For example, in 2011–2012, different (p<.05) among the self-reported gum disease treatments.
80% of 1,717 Whites responded affirmatively to the question
compared with 18% of 1,678 in 2017–2018, a difference of 80%. Table 3 shows the predictors of Ever had treatment for gum disease
Furthermore, 77% of 1,167 Blacks responded yes in 2011–2012, for both the 2011–2012 and 2017–2018 NHANES surveys. The
whereas in 2017–2018, only 26% of 1,102 Blacks responded yes, logistic regression model included Age, race/ethnicity, annual
a 68% difference. household income, education, and language. Gender was excluded
from the model because it was not significant. Individuals with an
As shown in Table 2, the participants who said yes to Ever had annual income of $55,000 and above have higher odds of receiving
treatment for gum disease, totaled 1,013 in 2011–2012 and 1,108 treatment for gum disease. For both groups, i.e., 2011–2012 and
in 2017–2018. In both groups, there were more women (50.8%, 2017–2018, participants who had a household income of $55,000
53.1%) than men (49.2%, 46.9%), and the proportion of married and above were more likely (OR=1.46; 95% CI: 1.20, 1.77; 2011–
people was higher (64.4%, 66.3%) than unmarried. In addition, 2012; OR=1.46; 95% CI: 1.19, 1.78; 2017–2018) to have reported
most participants had attended some college (59.7%, 62.1%) ever having treatment for gum disease, in contrast to households
and had income levels of $55,000 and above (47.2%, 52.2%); with income of $0–$24,999. Compared with the 30–39 age group,
Hispanics constituted 23.9% and 29.0%, compared with Whites 40–79 was more likely to have ever had treatment for gum disease.
(31.0%, 23.6%), Blacks (26.1%, 24.2%), and Asians (16.8%, For example, in 2017–2018, the 60–69 age group had higher odds
18.9%). The chi-square test's Age, annual household income, (OR=1.71; 95% CI: 1.36, 2.14; 2011–2012; OR=2.06; 95% CI:

Table 2: Respondent Characteristics by Background Characteristics by Self-Reported Gum Disease For 2011-2012, 2017-2018-Year Groups
2011-2012 2017-2018
Background characteristics
Yes No P-value Yes No P-value
Age % % % %
30-39 18.4 24.5 14.6 21.8
40-49 23.4 20.8 18.3 19.1
50-59 22.5 21.5 22.2 21.0
60-69 24.7 20.7 30.3 23.9
70-79 11.1 12.5 14.5 14.3
1013 3,144 0.000 1108 3,191 0.00
Gender
Male 49.2 49.0 46.9 48.9
Female 50.8 51.0 53.1 51.1
N 1013 3,144 0.213 1,108 3,191 0.213
Annual House Income ($)
0-24,999 25.3 33.3 20.7 25.8
25,000-54,999 27.2 26.7 27.1 29.8
55,000 and over 47.5 40.1 52.2 44.4
N 969 2,983 0.000 994 2,862 0.000
Language
English 84.4 88.1 82.8 89.6
Spanish 15.6 11.9 17.2 10.0
N 1013 3,144 0.000 1,108 3,191 0.000
Marital Status
Married 64.4 62.1 66.3 62.3
No longer Married 22.7 24.5 24.6 24.6
Never Married 12.9 13.4 9.1 13.2
N 1,013 3,139 0.001 1106 3,187 0.000
Education level (20+)
HS 40.3 48.5 37.9 45.0
Some college 59.7 51.5 62.1 55.0
N 1,013 3,143 0.000 1,104 3,187 0.000
Race
Hispanic 23.9 20.1 29.0 20.9
White 31.0 36.9 23.6 35.4
Black 26.1 27.3 24.2 24.1
Asian 16.8 13.2 18.9 14.4
Other including multi racial 2.3 2.5 4.4 5.3
N 1,013 3,144 0.000 1,108 3,191 0.000

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 4 of 8

Table 3: Binary Logistic Regression of Treatment of Gum Disease
2011-2012 2017-2018
Treatment For Gum Disease
Odds Ratio 95% CI Odds Ratio 95% CI
Age Group
30-39 REF REF
40-49 1.471 (1.174, 1.844) 1.352 (1.053, 1.737)
50-59 1.512 (1.205, 1.898) 1.647 (1.296, 2.095)
60-69 1.705 (1.361, 2.136) 2.059 (1.635, 2.592)
70-79 1.388 (1.054, 1.828) 1.871 (1.430, 2448)
Race
White REF REF
Hispanic 1.208 (0.911, 1.601) 1.713 (1.329, 2.208)
Black 1.193 (0.984, 1.446) 1.536 (1.248, 1.890)
Asian 1.553 (1.238, 1.949) 1.831 (1.457, 2.301)
Other 1.091 (0.665, 1.792) 1.375 (0.957, 1.976)
Annual Household Income
$0-$24,999 REF REF
$25000-$54,999 1.324 (1.083, 1.619) 1.140 (0.922, 1.410)
$55,000 and over 1.461 (1.204, 1.773) 1.458 (1.192, 1.783)
Adult Education
High School REF REF
Some College 1.407 (1.191, 1.663) 1.488 (1.258, 1.760)
Language
Spanish REF REF
English 0.620 (0.449, 0.857) 0.515 (0.381, 0.697)

Figure 1: Reasons Why Respondents Could Not Access Dental Care.

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 5 of 8

Table 4: Reasons Why Respondents Could Not Access Dental Care by Race/Ethnicity
Hispanic White Black Asian Other Hispanic White Black Asian Other
2011-2012 2017-2018
% % % % % % % % % %
Could not afford 68.4 60.7 57.8 53.8 41.2 44.9 47.5 45.1 30.8 38.3
Did not want to spend the money 3.1 4.9 3.2 4.5 5.9 1.9 6.2 3.6 5.5 7.4
Insurance did not cover 10.4 14.2 13.2 15.2 20.0 19.4 19.0 18.6 22.6 22.2
Dental office too far 1.2 1.5 1.7 0.0 4.7 3.6 2.0 3.6 3.4 3.7
office does not open at convenient time 1.6 1.8 1.7 3.8 7.1 1.9 1.6 2.7 2.7 1.9
Other dentist did not recommend 0.0 0.0 0.0 0.0 0.0 0.9 0.8 0.9 0.0 0.0
Afraid or did not like dentist 3.5 4.7 4.1 3.8 4.7 3.7 6.4 4.7 3.4 3.1
Unable to take time off from work 2.0 3.5 3.6 4.5 5.9 4.9 3.1 5.5 6.2 4.9
Too busy 2.4 2.4 4.0 4.5 3.5 5.0 3.8 2.9 9.6 4.9
Expected dental problems 2.0 1.1 1.5 3.8 2.4 3.9 3.8 5.2 7.5 4.3
Other 5.3 5.3 9.2 6.1 4.7 9.9 5.9 7.3 8.2 9.3
Total 100 100 100 100 100 100 100 100 100 100
Number of Participants 490 550 531 132 85 535 612 559 146 162

1.64, 2.59; 2017–2018) than age group 30-39 to have reported indicated by 10) did not think anything serious was wrong and
Ever had treatment for gum disease. expected dental problems to disappear. The questionnaire did not
elaborate on 11) other reasons.
Compared with Whites, members of racial/ethnic minority groups
(Hispanic, Blacks, Asians, and others) had higher odds of ever As illustrated in Table 4, some items related to affordability,
having had treatment for gum disease in 2011–2012 and 2017– anxiety, or fear of the dentist were in the top five out of 11. Table
2018. In all racial groups, the 2017–2018 group odds were slightly 4 shows the chi-square cross-tabulation results of the variation
higher than those in 2011–2012. Asians had higher odds (OR=1.6; in access to dental care by background characteristics. Of the 11
95% CI: 1.24, 1.95; 2011–2012; OR=1.8; 95% CI: 1.46, 2.30; surveyed reasons, not being able to afford was key to not accessing
2017–2018) than Whites of Ever having had treatment for gum treatment for gum disease; could not afford was highly rated
disease. Hispanics had higher odds (OR=1.2; 95% CI: 0.91, 1.60; (>50%) by respondents across all races/ethnicities, followed by
2011-2012; OR= 1.7, 95% CI: 1.33, 2.21; 2017-2018) than Whites insurance did not cover, other, afraid or did not like dentist, and
of Ever having had treatment for gum disease. Blacks had higher too busy.
odds (OR=1.2; 95% CI: 0.98, 1.45; 2011-2012; OR=1.5; 95% CI:
1.25, 1.89; 2017-2018) than Whites of ever having had treatment Discussion
for gum disease. Other sociodemographic variables were not When compared with overall well-being, oral health is often
included in the model. undervalued. However, oral health is about much more than
just healthy teeth. The mouth links the body to the digestive
Overall, more respondents had treatment for gum disease in 2017- and respiratory tracts. Research suggests that oral bacteria and
2018 than in 2011-2012. Participants who responded "yes "to the inflammation associated with periodontitis contribute to
having dental care increased from 92.7 percent to 94.1 percent. the following: cardiovascular disease, type 2 diabetes mellitus,
Participants who had never had treatment decreased from 7.4 rheumatoid arthritis, inflammatory bowel disease, Alzheimer's
percent to 5.9 percent. An exact McNemar's Test determined a disease, nonalcoholic fatty liver disease, and certain cancers
statistically significant difference in the proportion of those who [19,22,27]. Luckily, gum disease is preventable. Therefore,
said yes to having had gum disease treatment in 2011-2012 and policymakers should expand dental coverage to improve overall
2017-2018. (p=0.000). health.

The NHANES oral health questionnaire included 11 reasons The reviewed NHANES questionnaire on oral health assessed
the respondents could not access dental care, as displayed in 11 reasons participants could not access dental care. Healthcare
Figure 1. Affordability included traditional barriers to healthcare utilization barriers on affordability, dentophobia, and others were
utilization: 1) could not afford the cost, 2) did not want to spend among the top five. Regardless of ethnicity, could not afford was
money, and 3) insurance did not cover recommended procedures. rated highly by all races/ethnicities, especially in 2011–2012,
Other barriers included 4) being too busy, 5) the dental office is with approximately 20% decrease in 2017–2018. Interestingly,
not open at convenient times, 6) the dental office being too far insurance did not cover, was rated lower in 2011–2012, and
away, and 7) being unable to take time off work. Dental anxiety or increased slightly in 2017–2018. This difference conforms to results
dentophobia was indicated by 8) being afraid or not liking dentists. from other studies [28]. Respondents answering "other reasons"
The doctor's referral meant 9) another dentist recommended not did not elaborate upon the specific impediments experienced in
doing it. Finally, low perceived need showed a behavioral attitude receiving treatment for periodontal disease. Their answers would

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 6 of 8

have clarified and identified unknown impediments in receiving References
treatments. 1. American Academy of Periodontology. 2020.
2. https://www.perio.org/consumer/cdc-study.htm
Oral health disparities are determined mainly by race/ethnicity,
Age, and household income [12-15,28]. In their study on oral 3. Holmstrup P, Damgaard C, Olsen I, et al. Comorbidity
diseases and social determinants of health, researchers found a of periodontal disease: two sides of the same coin? An
consistent association between socioeconomic status (income, introduction for the clinician. J Oral Microbiol. 2017; 9:
occupation, and educational level) and the prevalence and 1332710.
severity of oral diseases [21-25,28,29,30]. Similar to our findings, 4. Burt BA, Eklund SA. Dentistry, dental practice, and the
another study examining the risk factors for treating gum disease community: Elsevier Health Sciences. 2005.
between adult Asian and Hispanic groups found that respondents 5. Krause DD, May WL, Cossman J, et al. An analysis of oral
answering, "could not afford" and "insurance was not covered", health disparities and access to services in the Appalachian
were impediments rated highly by both racial/ethnic group region Prepared for Appalachian Regional Commission. 2012.
[25,28].
6. McNeil DW, Hayes SE, Randall CL, et al. Depression and the
rural environment are associated with poor oral health among
This study shows the need for affordable dental care coverage and
pregnant women in Northern Appalachia. Behav Modif. 2016;
services to ensure increased overall health support across all races/
40: 325-340.
ethnicities in the U.S. Understanding why people cannot access
dental care is crucial for preventive care and unmet needs. 7. Vargas CM, Dye BA, Hayes KL. Oral health status of rural
adults in the United States. J Am Dent Assoc. 2002; 133:
Limitations 1672-1681.
This cross-sectional study does not deduce causality or temporal 8. Al Johara A. Factors affecting utilization of dental health
relationship. The included population was limited to adults aged services and satisfaction among adolescent females in Riyadh
30 years and older. It did not include institutionalized persons, City. Saudi Dental Journal. 2010; 22: 19-25.
such as older adults in nursing home settings and adults in prisons, 9. McNeil DW, Randall CL. Dental fear, and anxiety associated
which may introduce selection bias. The Centers for Disease with oral health care: Conceptual and clinical issues.
Control and Prevention diagnosis of periodontitis–American Behavioral Dentistry. 2014.
Academy of Periodontology requires a periodontal examination. 10. Dionne RA, Gordon SM, McCullagh LM, et al. Assessing the
Thus, using this definition for self-reported NHANES data need for anesthesia and sedation in the general population. J
could lead to misclassification. While this study examined why Am Dent Assoc. 1998; 129: 1111-1119.
respondents could not access dental care when needed, we could
not examine the reasons ever to use dental care. Reasons for never 11. Gatchel RJ, Ingersoll BD, Bowman L, et al. The prevalence of
using dental care are more likely to capture "preventive" dental dental fear and avoidance: a recent survey study. J Am Dent
visits than needed dental services. Reasons why respondents Assoc. 1983; 107: 609-610.
could not access dental care when dental care was "needed" may 12. Spencer AJ, Harford JE. Oral health of Australians: National
reflect more urgent and immediate characteristics of participants planning for oral health improvement. 2001.
unlikely to get dental care. We also examined the two common 13. Šiljak S, Janković J, Marinković J, et al. Dental service
reasons for not accessing dental care – "cannot afford the cost" utilisation among adults in a European developing country:
and "insurance does not cover." The inability to distinguish fndings from a national health survey. Int Dent J. 2019; 69:
between the two was pointed out as a limitation by Marchi et 200-206.
al. [25]. The use of logistic regression controlled the effect of 14. Santoso CMA, Bramantoro T, Nguyen MC, et al. Factors
confounding (internal validity). afecting dental service utilisation in Indonesia: a population-
based multilevel analysis. Int J Environ Res Public Health.
Conclusion 2020; 17: 5282.
This study shows the need for affordable dental care coverage and
15. Herkrath FJ, Vettore MV, Werneck GL. Contextual and
services in ensuring increased overall health and wellness across
individual factors associated with dental services utilisation
all races/ethnicities in the U.S. Expansion of dental coverage with
by Brazilian adults: a multilevel analysis. PLoS ONE. 2018;
reduced out-of-pocket health expenditure could improve access to
13: 1-17
dental services and overall health.
16. Rezaei S, Woldemichael A, Zandian H, et al. Dental healthcare
Ethics Approval for data usage service utilisation and its determinants in West Iran: a cross-
This article has been prepared per the STROBE statement for sectional study. Int Dent J. 2018; 68: 176-182
reporting observational studies and was determined exempt by the 17. Reda SF, Reda SM, Murray Thomson W, et al. Inequality in
Institutional Review Board at our institution. utilization of dental services: a systematic review and meta-
analysis. Am J Public Health. 2018; 108: e1-7.

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 7 of 8

18. Lo ECM, Tan HP. Cultural challenges to oral healthcare Carolina, Chapel Hill, USA), Gordon Douglass (Past
implementation in elders. Gerodontology. 2014; 31: 72-76. President, American Academy of Periodontology), Roy Page
19. McGrath C. The use of Traditional Chinese Medicine in (University of Washington. Prevalence of periodontitis in
managing oral health—Hong Kong: one country, two systems. adults in the United States: 2009 and 2010. J Dent Res. 2012;
Int Dent J. 2005; 55: 302-306. 91: 914-920.
26. Nguyen T. Risk Factors for Treatment of Gum Disease
20. Tranby EP, Jacob M, Kelly A, et al. State of Oral Health
Among Asian AND Hispanic Adult Groups. California State
Equity in America 2021 Research Report 1: A Coming
University San Marcos in partial fulfilment of the requirements
Surge in Oral Health Treatment Needs — Pandemic-related
for the degree of Master of Public Health, 2018.
events appear poised to create a spike in oral disease among
adults. Boston, MA: CareQuest Institute for Oral Health 27. IBM Corp. Released 2019. IBM SPSS Statistics for Windows,
Advancement. 2021. Version 26.0. Armonk, NY: IBM Corp
21. http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. 28. Hajishengallis G, Chavakis T. Local and systemic mechanisms
linking periodontal disease and inflammatory comorbidities.
22. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance- Nature Reviews Immunology. 2021; 28: 1-5.
hcf.html.
29. Gupta A, Feldman S, Perkins RB, et al. Predictors of dental
23. https://www.improvediagnosis.org/improvedx-newsletter/ care use, unmet dental care need, and barriers to unmet need
improvedx-july-2020/missed-and-delayed-diagnoses-of-non- among women: results from NHANES, 2011 to 2016. Journal
covid-conditions-collateral-harm-from-a-pandemic. of public health dentistry. 2019; 79: 324-333.
24. Luo H, Wu B. Self-Awareness of 'Gum Disease' Among U.S. 30. Centers for Disease Control and Prevention, Oral Health
Adults. Journal of Public Health Management and Practice: Disparities. 2020
JPHMP. 2017; 23: e1-e7. 31. Peres MA, Macpherson LMD, Weyant RJ, et al. Oral Diseases:
25. Eke PI, Dye BA, Wei L, et al. CDC Periodontal Disease A Global Public Health Challenge. The Lancet. 2019; 394:
Surveillance workgroup: James Beck (University of North 249-260.

© 2022 Taylor-Bishop DC, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License

Oral Health Dental Sci, 2022 Volume 6 | Issue 4 | 8 of 8