OBJECTIVES

We sought to estimate the prevalence of oral health problems and receipt of preventive oral health (POH) services among children and youth with special health care needs (CYSHCN) and investigate associations with child- and family-level characteristics.

METHODS

We used pooled data from the 2016–2018 National Survey of Children’s Health. The analytic sample was limited to children 1 to 17 years old, including 23 099 CYSHCN and 75 612 children without special health care needs (non-CYSHCN). Parent- and caregiver-reported measures of oral health problems were fair or poor teeth condition, decayed teeth and cavities, toothaches, and bleeding gums. POH services were preventive dental visits, cleanings, tooth brushing and oral health care instructions, fluoride, and sealants. Bivariate and multivariable logistic regression analyses were conducted.

RESULTS

A higher proportion of CYSHCN than non-CYSHCN received a preventive dental visit in the past year (84% vs 78%, P < .0001). Similar patterns were found for the specific preventive services examined. However, CYSHCN had higher rates of oral health problems compared with non-CYSHCN. For example, decayed teeth and cavities were reported in 16% of CYSHCN versus 11% in non-CYSHCN (P < .0001). In adjusted analyses, several factors were significantly associated with decreased prevalence of receipt of POH services among CYSHCN, including younger or older age, lower household education, non-English language, lack of health insurance, lack of a medical home, and worse condition of teeth.

CONCLUSIONS

CYSHCN have higher rates of POH service use yet worse oral health status than non-CYSHCN. Ensuring appropriate use of POH services among CYSHCN is critical to the reduction of oral health problems.

What’s Known on This Subject:

Children/youth with special health care needs are more likely to experience barriers to oral health services than those without special health care needs. Prior research has focused on access to oral health care in general, rather than specific services.

What This Study Adds:

Using recent data from the National Survey of Children’s Health, we examined children and youth with special health care needs’ receipt of specific preventive oral health services, including annual preventive dental visits, cleanings, instruction on tooth brushing, fluoride treatments, and sealants.

Children and youth with special health care needs (CYSHCN) are “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”1  Approximately 19% of children and youth <18 years of age (∼13.6 million) in the United States are estimated to have special health care needs.2  Dental caries is the most prevalent oral health problem in US children; NHANES data reveal that 16% of children have untreated caries.3,4  Although published national estimates on dental caries specifically among CYSHCN are unavailable, smaller clinical studies reveal they are more likely to have dental caries than those without special health care needs (non-CYSHCN).4  Risk factors associated with dental caries among CYSHCN include frequent use of sugar-containing liquid medicines and dependence on a caregiver for regular oral hygiene.5,6  Within this population, the most common oral diseases are gingivitis and periodontal disease,7  which are associated with a lack of routine oral hygiene. Oral health care, including preventive services delivered at home or at a health care facility, is critical for promoting good oral health among CYSHCN.8 

National data reveal that only 29% of need for dental health practitioners nationwide is currently being met.9  CYSHCN in particular face numerous barriers to oral health services leading to unmet dental needs, including the inability to find a dentist as well as dental staff who are comfortable with caring for CYSHCN. Although the majority of CYSHCN are seen by general dentists, the pediatric dentistry subspecialty, which requires 2 years of additional training beyond dental school focusing on the unique needs of children, provides the skill sets necessary to care for CYSHCN. There are only ∼7600 practicing pediatric dentists in the United States, which is inadequate to care for all CYSHCN.10,11  In addition, there are financial barriers resulting from Medicaid reimbursement rates that are below the usual and customary fees. Although many CYSHCN have Medicaid insurance for dental and oral health care, the demand for these services among Medicaid enrollees often exceeds the number of available providers.12,13  As of 2016, only 39% of general practice dentists and 66% of pediatric dentists participated in Medicaid and/or Children’s Health Insurance Program.14  Child- and family-level barriers include the child’s fear of dentists, the child’s inability to cooperate during oral examinations, other health care needs deemed more urgent, and parent or caregiver health literacy.15 

Most data available on dental caries or other oral health conditions among CYSHCN are based on parent- or caregiver-reported measures.5  Studies focused on oral health care and oral health status among CYSHCN have been conducted by using data from previous iterations of the National Survey of Children’s Health (NSCH) and the National Survey of Children with Special Health Care Needs.1618  These studies, however, were focused on access to dental and oral health care as well as forgone care, rather than receipt of specific preventive services. Starting in 2016, the NSCH began collecting data on certain preventive services (including cleanings and prophylaxis, instruction on tooth brushing, fluoride treatments, and sealants).19  Therefore, the aims with this study are to use recent NSCH data to (1) estimate the prevalence of oral health problems (oral health status) and receipt of preventive oral health (POH) services (use) in the past year among CYSHCN, (2) compare oral health status and POH care use of CYSHCN versus non-CYSHCN, and (3) investigate associations between CYSHCN’s receipt of POH services and various individual and contextual factors as characterized by the Andersen behavioral model of health services use.

The Andersen model is a conceptual framework that has been extensively applied to a broad range of health services and health conditions and that organizes the factors that lead to health care service use into 3 broad categories: predisposing, enabling, and need-related.2023  Predisposing factors include demographic characteristics (eg, age, sex) as well as social factors (eg, education level). Enabling factors include financial factors (eg, insurance, income) and organizational factors (eg, regular source of health care). Need factors include self-perceptions of general health status and illness symptoms as well as professional assessments of patient health status.

We analyzed data from the NSCH, an annual nationally representative survey of children and youth aged 0 to 17 years across the 50 US states and the District of Columbia.24,25  The Maternal and Child Health Bureau, within the Health Resources and Services Administration, provides direction and funding for the survey, and the US Census Bureau conducts the survey. Survey respondents include parents or other caregivers (hereinafter referred to as “parents”) familiar with the child’s health and health care needs. For the current analysis, we combined 3 years of data (2016–2018),26,27  excluding children <1 year of age. Overall response rates ranged from 37% to 43%, depending on the year; the interview completion rate (proportion of households with children who completed a questionnaire) ranged from 70% to 78%. We applied sampling weights to account for nonresponse and reduce the magnitude of bias2830  and conducted poststratification adjustment to ensure sociodemographic subgroups were appropriately represented in the estimates. Additional information regarding the survey’s methodology is available elsewhere.3133  Because the NSCH data are publicly available and deidentified, the study did not qualify as human subjects research and was not subject to review by an institutional review board.34 

The total analytic sample size was 98 711 children and youth ages 1–17 years, including 23 099 CYSHCN. We identified CYSHCN using responses to the CYSHCN Screener, a brief instrument that assesses 5 domains of qualifying health needs, operationalized as (1) functional limitations (alone or in combination with other qualifying needs); (2) prescription medication use; (3) elevated use or need of medical, mental health, or educational services; (4) use of specialized therapies, such as physical, occupational, or speech therapy; and (5) ongoing emotional, developmental, or behavioral conditions requiring treatment or counseling.35  To qualify as CYSHCN, a child must experience at least 1 of the 5 domains, as a result of a health or medical condition with a duration of at least 12 months.

Oral health status measures were based on parent reports about their child’s current condition of teeth and past-year frequent or chronic decayed teeth and cavities, toothaches, and bleeding gums. Measures of POH care use in the past year were preventive dental visit, cleaning, instructions on tooth brushing and oral health care, fluoride treatment, and sealants (among those 6–17 years).

We selected several covariates on the basis of data availability and existing literature and organized them according to the Andersen framework.3645  Predisposing factors included age, sex, race and ethnicity, household education, household language, and urban or rural residence. Enabling factors included parent general health status, parent mental and emotional health status, family poverty status, current insurance status and type, and receipt of care within a medical home (composed of 5 care components: personal doctor or nurse, usual source of care when sick, family-centered care, ease of referrals, care coordination).46  Need factors included total number of current conditions or disorders (out of a list of 26 chronic physical conditions and mental, emotional, or developmental disorders), type of special health care need, and overall condition of teeth.

We limited analyses to children and youth 1 to 17 years except for receipt of sealants, which was limited to those 6 to 17 years, consistent with clinical practice guidelines.47,48  We conducted bivariate analyses to describe sample characteristics and obtain the prevalence of the oral health status and preventive service use, stratified by CYSHCN status. We also conducted bivariate analyses to examine the unadjusted prevalence rates of each POH service among CYSHCN, by the predisposing, enabling, and need factors, and then ran multivariable logistic regressions to assess the relationship between each preventive service and all independent variables. Model results are reported as adjusted prevalence rate ratios and 95% confidence intervals (CIs) comparing the effect of each independent variable on the relative prevalence of each outcome measure, controlling for all other independent variables.

We dropped observations with missing or unknown data from the analyses. Sex, race, ethnicity, and household poverty were imputed during weighted procedures. More information is available elsewhere about the imputation methods.4951  All analyses were weighted on the basis of the survey’s sampling design to produce estimates that were nationally representative. We used Stata SE version 15 (StataCorp, College Station, TX).

Approximately 20% of the children and youth 1 to 17 years were CYSHCN (Table 1). There were significant differences between CYSHCN and non-CYSHCN, with respect to age, sex, race and ethnicity, household language, parent general health and mental and emotional health, family poverty ratio, insurance status and type, and receipt of health care in a medical home (P < .0001 for all). Almost 48% of CYSHCN had 3 or more current conditions or disorders. Approximately 30% of CYSHCN qualified based solely on use of medications, 27% had both medication and service use, and 18% had service use only, with the remaining 26% having functional limitations.

TABLE 1

Characteristics of Children 1–17 Year, by Special Health Care Needs Status, 2016–2018 NSCH

Children With Special Health Care Needs (n = 23 099)Children Without Special Health Care Needs (n = 75 612)P (CSHCN Versus Non-CSHCN)
Weighted %95% CIWeighted %95% CI
Total 19.6 19.1–20.1 80.4 79.9–80.9 — 
Predisposing factors      
 Age, y      
  1–5 17.1 16.0–18.2 31.4 30.6–32.2 <.0001 
  6–8 17.5 16.3–18.7 17.6 17.0–18.3 — 
  9–11 21.1 20.0–22.4 17.3 16.7–18.0 — 
  12–15 29.2 27.9–30.6 22.5 21.8–23.1 — 
  16–17 15.1 14.1–16.2 11.2 10.7–11.7 — 
 Sex      
  Male 57.9 56.4–59.4 49.4 48.6–50.3 <.0001 
  Female 42.1 40.6–43.6 50.6 49.7–51.4 — 
 Race and ethnicity      
  Hispanic 21.5 20.0–23.1 25.8 24.9–26.7 <.0001 
  Non-Hispanic Black 17.4 16.1–18.8 12.3 11.7–12.9 — 
  Non-Hispanic other 9.1 8.4–9.8 11.1 10.7–11.5 — 
  Non-Hispanic white 52.0 50.5–53.5 50.8 50.0–51.6 — 
 Highest household education      
  Less than high school 8.6 7.4–9.9 9.5 8.8–10.3 .0566 
  High school 21.1 19.8–22.6 19.1 18.4–19.9 — 
  More than high school 70.3 68.7–71.9 71.4 70.5–72.2 — 
 Primary household language      
  English 91.4 90.2–92.6 84.0 83.2–84.8 <.0001 
  Non-English 8.6 7.4–9.8 16.0 15.2–16.8 — 
 Urban or rural residence      
  MSA 75.0 74.0–75.9 75.9 75.5–76.4 .0491 
  Not MSA 10.8 10.2–11.5 9.9 9.6–10.3 — 
  Suppressed 14.2 13.6–14.9 14.2 13.9–14.4 — 
Enabling factors      
 Parent or caregiver general health status      
  Excellent or very good 55.6 54.1–57.1 70.8 70.0–71.6 <.0001 
  Good 30.9 29.5–32.3 23.2 22.5–24.0 — 
  Fair or poor 13.5 12.3–14.8 6.0 5.5–6.4 — 
 Parent or caregiver mental or emotional health status      
  Excellent or very good 65.1 63.6–66.6 80.3 79.6–81.0 <.0001 
  Good 25.2 23.8–26.5 16.1 15.4–16.7 — 
  Fair or poor 9.7 8.7–10.8 3.6 3.3–4.0 — 
 Family poverty ratio      
  <100% FPL 24.2 22.6–25.9 19.6 18.8–20.4 <.0001 
  100%–199% FPL 23.0 21.6–24.5 21.8 20.9–22.7 — 
  200%–399% FPL 27.5 26.7–28.2 27.5 26.7–28.2 — 
  ≥400% FPL 27.8 26.6–29.0 31.2 30.5–31.9 — 
 Current insurance status or type      
  Private only 48.7 47.3–50.2 60.3 59.4–61.1 <.0001 
  Public only 39.7 38.1–41.2 29.1 28.3–30.0 — 
  Private + public 7.5 6.7–8.4 3.7 3.4–4.1 — 
  Uninsured 4.1 3.6–4.8 6.9 6.4–7.4 — 
 Personal doctor or nurse      
  Yes 79.8 78.4–81.1 70.5 69.7–71.3 <.0001 
  No 20.2 18.9–21.6 29.5 28.7–30.3 — 
 Usual source of care when sick      
  Yes 82.0 80.7–83.2 76.5 75.7–77.3 <.0001 
  No 18.0 16.8–19.3 23.5 22.7–24.3 — 
 Family-centered care (when needed)      
  Yes 82.6 81.1–83.9 87.6 86.9–88.3 <.0001 
  No 17.4 16.1–18.9 12.4 11.7–13.1 — 
 No problems getting referrals (when needed)      
  Not difficult or no problem 73.3 71.0–75.6 83.1 81.0–85.0 <.0001 
  Difficult or problem 26.7 24.4–29.0 16.9 15.0–19.0 — 
 Care coordination (when needed)      
  Yes 60.7 59.1–62.3 76.7 75.7–77.7 <.0001 
  No 39.3 37.7–40.9 23.3 22.3–24.3 — 
 Medical home (previous 5 components rolled up)      
  Yes 42.8 41.4–44.3 49.5 48.7–50.3 <.0001 
  No 57.2 55.7–58.6 50.5 49.7–51.3 — 
Need factors (CSHCN only)      
 No. conditions or disordersa      
  0 7.1 6.4–7.8 — — — 
  1 22.3 21.1–23.5 — — — 
  2 22.9 21.7–24.2 — — — 
  3+ 47.7 46.2–49.2 — — — 
 Type of special health care need      
  Functional limitation 26.2 24.8–27.7 — — — 
  Medication only 29.0 27.8–30.3 — — — 
  Service use only 18.0 16.9–19.3 — — — 
  Medication and service use 26.7 25.5–28.0 — — — 
Children With Special Health Care Needs (n = 23 099)Children Without Special Health Care Needs (n = 75 612)P (CSHCN Versus Non-CSHCN)
Weighted %95% CIWeighted %95% CI
Total 19.6 19.1–20.1 80.4 79.9–80.9 — 
Predisposing factors      
 Age, y      
  1–5 17.1 16.0–18.2 31.4 30.6–32.2 <.0001 
  6–8 17.5 16.3–18.7 17.6 17.0–18.3 — 
  9–11 21.1 20.0–22.4 17.3 16.7–18.0 — 
  12–15 29.2 27.9–30.6 22.5 21.8–23.1 — 
  16–17 15.1 14.1–16.2 11.2 10.7–11.7 — 
 Sex      
  Male 57.9 56.4–59.4 49.4 48.6–50.3 <.0001 
  Female 42.1 40.6–43.6 50.6 49.7–51.4 — 
 Race and ethnicity      
  Hispanic 21.5 20.0–23.1 25.8 24.9–26.7 <.0001 
  Non-Hispanic Black 17.4 16.1–18.8 12.3 11.7–12.9 — 
  Non-Hispanic other 9.1 8.4–9.8 11.1 10.7–11.5 — 
  Non-Hispanic white 52.0 50.5–53.5 50.8 50.0–51.6 — 
 Highest household education      
  Less than high school 8.6 7.4–9.9 9.5 8.8–10.3 .0566 
  High school 21.1 19.8–22.6 19.1 18.4–19.9 — 
  More than high school 70.3 68.7–71.9 71.4 70.5–72.2 — 
 Primary household language      
  English 91.4 90.2–92.6 84.0 83.2–84.8 <.0001 
  Non-English 8.6 7.4–9.8 16.0 15.2–16.8 — 
 Urban or rural residence      
  MSA 75.0 74.0–75.9 75.9 75.5–76.4 .0491 
  Not MSA 10.8 10.2–11.5 9.9 9.6–10.3 — 
  Suppressed 14.2 13.6–14.9 14.2 13.9–14.4 — 
Enabling factors      
 Parent or caregiver general health status      
  Excellent or very good 55.6 54.1–57.1 70.8 70.0–71.6 <.0001 
  Good 30.9 29.5–32.3 23.2 22.5–24.0 — 
  Fair or poor 13.5 12.3–14.8 6.0 5.5–6.4 — 
 Parent or caregiver mental or emotional health status      
  Excellent or very good 65.1 63.6–66.6 80.3 79.6–81.0 <.0001 
  Good 25.2 23.8–26.5 16.1 15.4–16.7 — 
  Fair or poor 9.7 8.7–10.8 3.6 3.3–4.0 — 
 Family poverty ratio      
  <100% FPL 24.2 22.6–25.9 19.6 18.8–20.4 <.0001 
  100%–199% FPL 23.0 21.6–24.5 21.8 20.9–22.7 — 
  200%–399% FPL 27.5 26.7–28.2 27.5 26.7–28.2 — 
  ≥400% FPL 27.8 26.6–29.0 31.2 30.5–31.9 — 
 Current insurance status or type      
  Private only 48.7 47.3–50.2 60.3 59.4–61.1 <.0001 
  Public only 39.7 38.1–41.2 29.1 28.3–30.0 — 
  Private + public 7.5 6.7–8.4 3.7 3.4–4.1 — 
  Uninsured 4.1 3.6–4.8 6.9 6.4–7.4 — 
 Personal doctor or nurse      
  Yes 79.8 78.4–81.1 70.5 69.7–71.3 <.0001 
  No 20.2 18.9–21.6 29.5 28.7–30.3 — 
 Usual source of care when sick      
  Yes 82.0 80.7–83.2 76.5 75.7–77.3 <.0001 
  No 18.0 16.8–19.3 23.5 22.7–24.3 — 
 Family-centered care (when needed)      
  Yes 82.6 81.1–83.9 87.6 86.9–88.3 <.0001 
  No 17.4 16.1–18.9 12.4 11.7–13.1 — 
 No problems getting referrals (when needed)      
  Not difficult or no problem 73.3 71.0–75.6 83.1 81.0–85.0 <.0001 
  Difficult or problem 26.7 24.4–29.0 16.9 15.0–19.0 — 
 Care coordination (when needed)      
  Yes 60.7 59.1–62.3 76.7 75.7–77.7 <.0001 
  No 39.3 37.7–40.9 23.3 22.3–24.3 — 
 Medical home (previous 5 components rolled up)      
  Yes 42.8 41.4–44.3 49.5 48.7–50.3 <.0001 
  No 57.2 55.7–58.6 50.5 49.7–51.3 — 
Need factors (CSHCN only)      
 No. conditions or disordersa      
  0 7.1 6.4–7.8 — — — 
  1 22.3 21.1–23.5 — — — 
  2 22.9 21.7–24.2 — — — 
  3+ 47.7 46.2–49.2 — — — 
 Type of special health care need      
  Functional limitation 26.2 24.8–27.7 — — — 
  Medication only 29.0 27.8–30.3 — — — 
  Service use only 18.0 16.9–19.3 — — — 
  Medication and service use 26.7 25.5–28.0 — — — 

MSA, metropolitan statistical area. —, not applicable.

a

Includes the following conditions and disorders: allergies, arthritis, asthma, brain injury, blood disorders, cerebral palsy, cystic fibrosis, diabetes, Down syndrome, epilepsy, severe or frequent headaches, heart condition, hearing problems and deafness, vision problems and blindness, anxiety, attention-deficit/hyperactivity disorder, autism spectrum disorder, behavioral and conduct problems, depression, developmental delay, intellectual disability, learning disability, speech and language disorder, Tourette's syndrome, other genetic or inherited condition, and other mental health condition.

CYSHCN were more likely than non-CYSHCN to have poor oral health (P < .0001 for all; Table 2). Specifically, the prevalence of teeth in fair or poor condition was twice as high among CYSHCN as non-CYSHCN (10% vs 4.5%), and CYSHCN had higher rates of decayed teeth and cavities (16% vs 11%), toothaches (6% vs 3.5%), and bleeding gums (4% vs 1.4%), compared with non-CYSHCN.

TABLE 2

Oral Health Status and POH Care Use, by Special Health Care Needs Status (1–17 Year), 2016–2018 NSCH

Children With Special Health Care Needs (n = 23 099)Children Without Special Health Care Needs (n = 75 612)P (CSHCN Versus Non-CSHCN)
Weighted %95% CIWeighted %95% CI
Oral health status      
 Teeth in fair or poor condition 10.2 9.1–11.4 4.5 4.1–4.9 <.0001 
 Cavities or decayed teeth, past year 15.6 14.4–16.9 10.8 10.3–11.4 <.0001 
 Toothaches, past year 6.1 5.2–7.2 3.5 3.2–3.8 <.0001 
 Bleeding gums, past year 4.0 3.3–4.8 1.4 1.2–1.7 <.0001 
POH care use      
 Preventive dental visit, past year 84.0 82.7–85.3 78.2 77.5–78.9 <.0001 
 Cleaning, past year 77.8 76.4–79.1 70.0 69.2–70.8 <.0001 
 Instructions on tooth brushing, past year 49.6 48.2–51.1 40.9 40.1–41.7 <.0001 
 Fluoride treatment, past year 53.0 51.5–54.5 43.3 42.5–44.1 <.0001 
 Sealant, past year (6–17 y) 24.4 23.0–25.8 21.3 20.5–22.1 .0001 
Children With Special Health Care Needs (n = 23 099)Children Without Special Health Care Needs (n = 75 612)P (CSHCN Versus Non-CSHCN)
Weighted %95% CIWeighted %95% CI
Oral health status      
 Teeth in fair or poor condition 10.2 9.1–11.4 4.5 4.1–4.9 <.0001 
 Cavities or decayed teeth, past year 15.6 14.4–16.9 10.8 10.3–11.4 <.0001 
 Toothaches, past year 6.1 5.2–7.2 3.5 3.2–3.8 <.0001 
 Bleeding gums, past year 4.0 3.3–4.8 1.4 1.2–1.7 <.0001 
POH care use      
 Preventive dental visit, past year 84.0 82.7–85.3 78.2 77.5–78.9 <.0001 
 Cleaning, past year 77.8 76.4–79.1 70.0 69.2–70.8 <.0001 
 Instructions on tooth brushing, past year 49.6 48.2–51.1 40.9 40.1–41.7 <.0001 
 Fluoride treatment, past year 53.0 51.5–54.5 43.3 42.5–44.1 <.0001 
 Sealant, past year (6–17 y) 24.4 23.0–25.8 21.3 20.5–22.1 .0001 

CYSHCN had higher rates of POH care use than non-CYSHCN (≤.0001 for all; Table 2). Eighty-four percent of CYSHCN had a past-year preventive dental visit, compared with 78% of non-CYSHCN. Although rates of the following specific preventive services were lower for both populations, compared with the prevalence of past-year visits, they were still higher among CYSHCN than non-CYSHCN: teeth cleanings (78% vs 70%), instructions on tooth brushing (50% vs 41%), fluoride treatments (53% vs 43%), and sealants (24% vs 21%).

Several predisposing, enabling, and need factors were significantly associated with POH care among CYSHCN (Table 3). Child age, race and ethnicity, household education, and primary language were consistently associated with receipt of specific POH services (although race and ethnicity was not associated with sealants). Parent general health was associated with all preventive services except fluoride treatment or sealants, whereas parental mental and emotional health was associated with preventive visits and cleaning. Moreover, family poverty ratio, child insurance status and type, and having a medical home were associated with receipt of all POH services except sealants. In addition, 3 of the 5 medical home care components (having a personal doctor or nurse, having a usual source of care when sick, and having family-centered care) were associated with receipt of POH services. Type of special health care need and condition of teeth were associated with all POH services except sealants. Number of conditions or disorders was associated with cleanings and fluoride treatment only.

TABLE 3

Prevalence of Receipt of POH Services in the Past Year Among Children with Special Health Care Needs (1–17 Year), 2016–2018 NSCH

Preventive Dental VisitCleaningInstructions on Tooth BrushingFluoride TreatmentSealant (6–17 y)
Weighted %95% CIPWeighted %95% CIPWeighted %95% CIPWeighted %95% CIPWeighted %95% CIP
Predisposing factors                
 Age, y                
  1–5 65.5 61.8–69.1 <.0001 51.6 48.0–55.2 <.0001 36.3 33.0–39.8 <.0001 35.4 32.0–38.9 <.0001 — — .0005 
  6–8 87.3 83.5–90.3 — 80.8 76.9–84.2 — 54.5 50.6–58.4 — 56.3 52.4–60.2 — 26.9 24.0–30.2 — 
  9–11 89.0 86.1–91.4 — 83.9 80.9–86.4 — 57.5 54.3–60.6 — 59.9 56.6–63.0 — 27.4 24.8–30.2 — 
  12–15 88.2 85.9–90.1 — 84.9 82.6–87.0 — 52.4 49.7–55.1 — 57.5 54.8–60.2 — 23.9 21.9–26.1 — 
  16–17 86.3 83.5–88.8 — 81.7 78.4–84.6 — 42.7 39.1–46.5 — 51.0 47.3–54.6 — 18.0 14.4–22.4 — 
 Sex                
  Male 83.0 81.2–84.7 .0711 76.7 74.8–78.5 .0611 50.1 48.1–52.1 .4759 53.0 51.0–54.9 .9182 24.6 22.9–26.5 .6887 
  Female 85.4 83.5–87.2 — 79.3 77.3–81.2 — 49.0 46.7–51.3 — 53.1 50.8–55.4 — 24.1 22.0–26.3 — 
 Race and ethnicity                
  Hispanic 81.0 76.5–84.8 .0184 74.5 70.1–78.5 .0001 41.8 37.7–46.0 <.0001 48.7 44.4–53.0 <.0001 23.5 19.8–27.8 .8287 
  Non-Hispanic Black 81.6 77.8–84.9 — 72.3 68.2–76.1 — 45.3 40.8–49.8 — 44.2 39.8–48.7 — 25.0 20.9–29.7 — 
  Non-Hispanic other 85.0 81.7–87.9 — 78.5 74.9–81.7 — 51.0 47.0–55.0 — 53.8 49.8–57.8 — 26.1 22.5–30.0 — 
  Non-Hispanic white 85.9 84.7–87.1 — 80.9 79.6–82.2 — 54.1 52.6–55.6 — 57.6 56.2–59.1 — 24.3 22.9–25.7 — 
 Highest household education                
  Less than high school 71.1 61.7–78.9 <.0001 64.1 55.3–72.0 <.0001 32.7 25.8–40.4 <.0001 33.7 27.2–40.9 <.0001 16.8 12.2–22.6 .0071 
  High school 80.4 77.4–83.0 — 71.2 67.8–74.4 — 42.8 38.9–46.8 — 46.4 42.5–50.3 — 22.6 19.0–26.6 — 
  More than high school 86.8 85.6–87.9 — 81.6 80.3–82.8 — 54.0 52.5–55.5 — 57.7 56.2–59.2 — 26.0 24.6–27.5 — 
 Primary household language                
  English 85.0 83.8–86.2 .0008 79.1 77.7–80.3 <.0001 51.3 49.8–52.7 <.0001 55.0 53.5–56.4 <.0001 25.1 23.7–26.5 .0100 
  Non-English 73.8 65.3–80.9 — 64.9 57.0–72.1 — 32.2 25.7–39.5 — 32.1 25.8–39.2 — 16.0 11.0–22.6 — 
 Urban or rural residence                
  MSA 83.6 81.9–85.2 .0018 77.5 75.7–79.1 .0001 50.1 48.2–52.0 .0002 52.5 50.6–54.3 <.0001 24.1 22.4–25.9 .0313 
  Not MSA 82.3 79.6–84.6 — 74.4 71.5–77.1 — 43.4 40.4–46.4 — 48.9 45.8–52.1 — 22.3 19.5–25.4 — 
  Suppressed 87.7 86.1–89.2 — 82.2 80.3–84.0 — 51.9 49.6–54.2 — 59.1 56.9–61.4 — 27.5 25.3–29.7 — 
Enabling factors                
 Parent or caregiver general health status                
  Excellent or very good 86.4 84.8–87.9 .0007 80.5 78.8–82.1 .0001 51.5 49.7–53.3 .0236 54.4 52.5–56.3 .2396 24.0 22.4–25.6 .6117 
  Good 82.2 79.3–84.7 — 76.3 73.4–78.9 — 48.7 45.9–51.5 — 52.6 49.7–55.4 — 24.3 22.0–26.8 — 
  Fair or poor 80.0 76.0–83.4 — 71.9 67.5–75.9 — 44.7 39.7–49.8 — 50.4 45.4–55.3 — 26.3 21.3–32.0 — 
 Parent or caregiver mental or emotional health status                
  Excellent or very good 85.9 84.4–87.3 .0024 79.6 77.9–81.1 .0174 50.3 48.6–52.0 .4525 53.5 51.8–55.3 .2205 23.3 21.8–24.8 .1370 
  Good 81.2 77.9–84.1 — 75.4 72.1–78.4 — 47.9 44.8–51.1 — 51.5 48.3–54.7 — 25.9 23.2–28.8 — 
  Fair or poor 80.6 76.0–84.5 — 74.9 70.1–79.1 — 50.8 44.9–56.7 — 56.9 51.2–62.4 — 28.4 22.2–35.5 — 
 Family poverty ratio                
  <100% FPL 80.6 77.5–83.7 <.0001 71.7 68.2–75.1 <.0001 42.5 38.6–46.5 <.0001 45.1 41.3–49.0 <.0001 23.1 19.6–26.7 .3211 
  100%–199% FPL 80.2 76.7–83.7 — 73.3 69.7–76.8 — 43.9 40.3–47.5 — 49.2 45.5–52.8 — 22.7 19.0–26.3 — 
  200%–399% FPL 84.5 82.3–86.8 — 79.8 77.4–82.2 — 51.4 48.8–54.1 — 55.5 52.9–58.0 — 25.1 22.4–27.8 — 
  ≥400% FPL 89.8 88.1–91.5 — 85.1 83.3–87.0 — 59.0 56.8–61.1 — 60.9 58.8–63.1 — 26.2 24.0–28.4 — 
 Current insurance status or type                
  Private only 88.4 87.1–89.7 <.0001 84.3 82.8–85.6 <.0001 56.5 54.9–58.2 <.0001 59.7 58.0–61.4 <.0001 24.5 23.0–26.1 .9470 
  Public only 80.3 77.6–82.8 — 72.5 69.8–75.1 — 43.2 40.4–46.0 — 47.3 44.4–50.1 — 25.1 22.5–27.8 — 
  Private + public 86.2 82.1–89.4 — 78.3 73.8–82.3 — 53.2 47.5–58.8 — 54.9 49.2–60.4 — 23.8 17.4–31.7 — 
  Uninsured 66.4 58.2–73.6 — 58.8 51.0–66.1 — 30.4 24.2–37.4 — 34.4 28.0–41.5 — 23.1 16.7–31.1 — 
 Personal doctor or nurse                
  Yes 86.5 85.3–87.6 <.0001 80.6 79.2–81.8 <.0001 52.2 50.6–53.8 <.0001 55.7 54.2–57.3 <.0001 25.9 24.3–27.5 .0003 
  No 74.1 69.8–77.9 — 66.7 62.5–70.6 — 40.3 36.7–44.0 — 42.3 38.7–46.0 — 19.4 16.7–22.4 — 
 Usual source of care when sick                
  Yes 85.9 84.5–87.2 <.0001 80.3 78.8–81.6 <.0001 52.4 50.8–54.0 <.0001 55.5 53.8–57.1 <.0001 25.8 24.3–27.4 .0001 
  No 76.4 72.6–79.9 — 67.8 63.8–71.5 — 39.1 35.3–43.1 — 42.7 38.9–46.6 — 18.5 15.7–21.8 — 
 Family-centered care (when needed)                
  Yes 86.7 85.4–88.0 <.0001 80.8 79.4–82.1 <.0001 53.2 51.6–54.7 .0013 57.7 56.1–59.2 <.0001 26.0 24.6–27.6 .3042 
  No 77.0 72.5–80.9 — 70.1 65.6–74.2 — 45.2 40.7–49.8 — 45.1 40.7–49.6 — 23.4 19.1–28.4 — 
 No problems getting referrals (when needed)                
  Not difficult or no problem 83.0 80.6–85.2 .1122 75.7 73.1–78.1 .1486 49.6 46.9–52.4 .0295 53.7 51.0–56.4 .1039 26.9 24.3–29.8 .7176 
  Difficult or problem 78.7 73.2–83.3 — 71.6 66.2–76.5 — 43.2 38.3–48.3 — 48.8 43.6–54.0 — 25.8 20.6–31.8 — 
 Care coordination (when needed)                
  Yes 86.9 85.0–88.6 .0623 80.7 78.7–82.5 .0715 52.7 50.6–54.8 .4804 57.6 55.5–59.7 .0608 25.7 23.8–27.7 .7750 
  No 84.4 82.3–86.3 — 78.0 75.8–80.1 — 51.5 48.9–54.1 — 54.4 51.8–57.0 — 25.2 22.6–28.1 — 
 Medical home (previous 5 components rolled up)                
  Yes 88.5 87.0–89.9 <.0001 83.3 81.6–84.8 <.0001 54.5 52.4–56.5 <.0001 58.5 56.4–60.5 <.0001 25.8 24.0–27.7 .0741 
  No 80.7 78.7–82.6 — 73.8 71.7–75.7 — 46.0 44.0–48.1 — 49.0 46.9–51.1 — 23.3 21.4–25.4 — 
Need factors                
 No. conditions or disorders                
  0 79.7 75.3–83.5 .0748 70.6 65.4–75.3 .0057 43.8 38.8–48.8 .1502 42.1 37.3–46.9 <.0001 20.2 15.4–26.1 .1088 
  1 82.6 79.5–85.4 — 77.0 74.0–79.9 — 49.3 46.3–52.3 — 50.1 47.1–53.1 — 22.5 19.8–25.4 — 
  2 85.9 83.4–88.1 — 80.5 77.9–82.9 — 50.5 47.5–53.6 — 54.8 51.8–57.8 — 23.9 21.0–27.0 — 
  3+ 84.5 82.4–86.3 — 77.9 75.8–79.9 — 50.2 48.0–52.5 — 55.2 52.9–57.4 — 25.9 24.0–28.0 — 
 Type of special health care need                
  Functional limitation 80.3 76.9–83.3 <.0001 73.3 69.9–76.4 <.0001 46.0 42.8–49.3 .0028 50.5 47.2–53.9 .0024 23.5 20.3–26.9 .5459 
  Medication only 87.1 85.4–88.7 — 81.5 79.5–83.3 — 52.2 49.9–54.6 — 55.1 52.7–57.5 — 23.5 21.4–25.7 — 
  Service use only 79.4 76.0–82.5 — 72.4 68.9–75.7 — 47.0 43.4–50.7 — 48.8 45.1–52.5 — 26.1 22.5–30.0 — 
  Medication and service use 87.5 85.1–89.6 — 81.9 79.4–84.1 — 52.1 49.4–54.8 — 56.1 53.3–58.8 — 25.1 22.9–27.5 — 
 Condition of teeth                
  Excellent or very good 87.3 86.0–88.5 <.0001 81.5 80.0–82.8 <.0001 51.7 50.1–53.3 .0046 55.9 54.3–57.5 <.0001 25.3 23.8–26.9 .3260 
  Good 79.4 76.2–82.2 — 72.0 68.6–75.1 — 46.5 43.0–50.0 — 48.9 45.4–52.5 — 22.3 19.4–25.5 — 
  Fair or poor 73.8 67.2–79.4 — 67.7 61.4–73.5 — 43.8 38.0–49.8 — 44.3 38.4–50.4 — 24.3 19.1–30.4 — 
Preventive Dental VisitCleaningInstructions on Tooth BrushingFluoride TreatmentSealant (6–17 y)
Weighted %95% CIPWeighted %95% CIPWeighted %95% CIPWeighted %95% CIPWeighted %95% CIP
Predisposing factors                
 Age, y                
  1–5 65.5 61.8–69.1 <.0001 51.6 48.0–55.2 <.0001 36.3 33.0–39.8 <.0001 35.4 32.0–38.9 <.0001 — — .0005 
  6–8 87.3 83.5–90.3 — 80.8 76.9–84.2 — 54.5 50.6–58.4 — 56.3 52.4–60.2 — 26.9 24.0–30.2 — 
  9–11 89.0 86.1–91.4 — 83.9 80.9–86.4 — 57.5 54.3–60.6 — 59.9 56.6–63.0 — 27.4 24.8–30.2 — 
  12–15 88.2 85.9–90.1 — 84.9 82.6–87.0 — 52.4 49.7–55.1 — 57.5 54.8–60.2 — 23.9 21.9–26.1 — 
  16–17 86.3 83.5–88.8 — 81.7 78.4–84.6 — 42.7 39.1–46.5 — 51.0 47.3–54.6 — 18.0 14.4–22.4 — 
 Sex                
  Male 83.0 81.2–84.7 .0711 76.7 74.8–78.5 .0611 50.1 48.1–52.1 .4759 53.0 51.0–54.9 .9182 24.6 22.9–26.5 .6887 
  Female 85.4 83.5–87.2 — 79.3 77.3–81.2 — 49.0 46.7–51.3 — 53.1 50.8–55.4 — 24.1 22.0–26.3 — 
 Race and ethnicity                
  Hispanic 81.0 76.5–84.8 .0184 74.5 70.1–78.5 .0001 41.8 37.7–46.0 <.0001 48.7 44.4–53.0 <.0001 23.5 19.8–27.8 .8287 
  Non-Hispanic Black 81.6 77.8–84.9 — 72.3 68.2–76.1 — 45.3 40.8–49.8 — 44.2 39.8–48.7 — 25.0 20.9–29.7 — 
  Non-Hispanic other 85.0 81.7–87.9 — 78.5 74.9–81.7 — 51.0 47.0–55.0 — 53.8 49.8–57.8 — 26.1 22.5–30.0 — 
  Non-Hispanic white 85.9 84.7–87.1 — 80.9 79.6–82.2 — 54.1 52.6–55.6 — 57.6 56.2–59.1 — 24.3 22.9–25.7 — 
 Highest household education                
  Less than high school 71.1 61.7–78.9 <.0001 64.1 55.3–72.0 <.0001 32.7 25.8–40.4 <.0001 33.7 27.2–40.9 <.0001 16.8 12.2–22.6 .0071 
  High school 80.4 77.4–83.0 — 71.2 67.8–74.4 — 42.8 38.9–46.8 — 46.4 42.5–50.3 — 22.6 19.0–26.6 — 
  More than high school 86.8 85.6–87.9 — 81.6 80.3–82.8 — 54.0 52.5–55.5 — 57.7 56.2–59.2 — 26.0 24.6–27.5 — 
 Primary household language                
  English 85.0 83.8–86.2 .0008 79.1 77.7–80.3 <.0001 51.3 49.8–52.7 <.0001 55.0 53.5–56.4 <.0001 25.1 23.7–26.5 .0100 
  Non-English 73.8 65.3–80.9 — 64.9 57.0–72.1 — 32.2 25.7–39.5 — 32.1 25.8–39.2 — 16.0 11.0–22.6 — 
 Urban or rural residence                
  MSA 83.6 81.9–85.2 .0018 77.5 75.7–79.1 .0001 50.1 48.2–52.0 .0002 52.5 50.6–54.3 <.0001 24.1 22.4–25.9 .0313 
  Not MSA 82.3 79.6–84.6 — 74.4 71.5–77.1 — 43.4 40.4–46.4 — 48.9 45.8–52.1 — 22.3 19.5–25.4 — 
  Suppressed 87.7 86.1–89.2 — 82.2 80.3–84.0 — 51.9 49.6–54.2 — 59.1 56.9–61.4 — 27.5 25.3–29.7 — 
Enabling factors                
 Parent or caregiver general health status                
  Excellent or very good 86.4 84.8–87.9 .0007 80.5 78.8–82.1 .0001 51.5 49.7–53.3 .0236 54.4 52.5–56.3 .2396 24.0 22.4–25.6 .6117 
  Good 82.2 79.3–84.7 — 76.3 73.4–78.9 — 48.7 45.9–51.5 — 52.6 49.7–55.4 — 24.3 22.0–26.8 — 
  Fair or poor 80.0 76.0–83.4 — 71.9 67.5–75.9 — 44.7 39.7–49.8 — 50.4 45.4–55.3 — 26.3 21.3–32.0 — 
 Parent or caregiver mental or emotional health status                
  Excellent or very good 85.9 84.4–87.3 .0024 79.6 77.9–81.1 .0174 50.3 48.6–52.0 .4525 53.5 51.8–55.3 .2205 23.3 21.8–24.8 .1370 
  Good 81.2 77.9–84.1 — 75.4 72.1–78.4 — 47.9 44.8–51.1 — 51.5 48.3–54.7 — 25.9 23.2–28.8 — 
  Fair or poor 80.6 76.0–84.5 — 74.9 70.1–79.1 — 50.8 44.9–56.7 — 56.9 51.2–62.4 — 28.4 22.2–35.5 — 
 Family poverty ratio                
  <100% FPL 80.6 77.5–83.7 <.0001 71.7 68.2–75.1 <.0001 42.5 38.6–46.5 <.0001 45.1 41.3–49.0 <.0001 23.1 19.6–26.7 .3211 
  100%–199% FPL 80.2 76.7–83.7 — 73.3 69.7–76.8 — 43.9 40.3–47.5 — 49.2 45.5–52.8 — 22.7 19.0–26.3 — 
  200%–399% FPL 84.5 82.3–86.8 — 79.8 77.4–82.2 — 51.4 48.8–54.1 — 55.5 52.9–58.0 — 25.1 22.4–27.8 — 
  ≥400% FPL 89.8 88.1–91.5 — 85.1 83.3–87.0 — 59.0 56.8–61.1 — 60.9 58.8–63.1 — 26.2 24.0–28.4 — 
 Current insurance status or type                
  Private only 88.4 87.1–89.7 <.0001 84.3 82.8–85.6 <.0001 56.5 54.9–58.2 <.0001 59.7 58.0–61.4 <.0001 24.5 23.0–26.1 .9470 
  Public only 80.3 77.6–82.8 — 72.5 69.8–75.1 — 43.2 40.4–46.0 — 47.3 44.4–50.1 — 25.1 22.5–27.8 — 
  Private + public 86.2 82.1–89.4 — 78.3 73.8–82.3 — 53.2 47.5–58.8 — 54.9 49.2–60.4 — 23.8 17.4–31.7 — 
  Uninsured 66.4 58.2–73.6 — 58.8 51.0–66.1 — 30.4 24.2–37.4 — 34.4 28.0–41.5 — 23.1 16.7–31.1 — 
 Personal doctor or nurse                
  Yes 86.5 85.3–87.6 <.0001 80.6 79.2–81.8 <.0001 52.2 50.6–53.8 <.0001 55.7 54.2–57.3 <.0001 25.9 24.3–27.5 .0003 
  No 74.1 69.8–77.9 — 66.7 62.5–70.6 — 40.3 36.7–44.0 — 42.3 38.7–46.0 — 19.4 16.7–22.4 — 
 Usual source of care when sick                
  Yes 85.9 84.5–87.2 <.0001 80.3 78.8–81.6 <.0001 52.4 50.8–54.0 <.0001 55.5 53.8–57.1 <.0001 25.8 24.3–27.4 .0001 
  No 76.4 72.6–79.9 — 67.8 63.8–71.5 — 39.1 35.3–43.1 — 42.7 38.9–46.6 — 18.5 15.7–21.8 — 
 Family-centered care (when needed)                
  Yes 86.7 85.4–88.0 <.0001 80.8 79.4–82.1 <.0001 53.2 51.6–54.7 .0013 57.7 56.1–59.2 <.0001 26.0 24.6–27.6 .3042 
  No 77.0 72.5–80.9 — 70.1 65.6–74.2 — 45.2 40.7–49.8 — 45.1 40.7–49.6 — 23.4 19.1–28.4 — 
 No problems getting referrals (when needed)                
  Not difficult or no problem 83.0 80.6–85.2 .1122 75.7 73.1–78.1 .1486 49.6 46.9–52.4 .0295 53.7 51.0–56.4 .1039 26.9 24.3–29.8 .7176 
  Difficult or problem 78.7 73.2–83.3 — 71.6 66.2–76.5 — 43.2 38.3–48.3 — 48.8 43.6–54.0 — 25.8 20.6–31.8 — 
 Care coordination (when needed)                
  Yes 86.9 85.0–88.6 .0623 80.7 78.7–82.5 .0715 52.7 50.6–54.8 .4804 57.6 55.5–59.7 .0608 25.7 23.8–27.7 .7750 
  No 84.4 82.3–86.3 — 78.0 75.8–80.1 — 51.5 48.9–54.1 — 54.4 51.8–57.0 — 25.2 22.6–28.1 — 
 Medical home (previous 5 components rolled up)                
  Yes 88.5 87.0–89.9 <.0001 83.3 81.6–84.8 <.0001 54.5 52.4–56.5 <.0001 58.5 56.4–60.5 <.0001 25.8 24.0–27.7 .0741 
  No 80.7 78.7–82.6 — 73.8 71.7–75.7 — 46.0 44.0–48.1 — 49.0 46.9–51.1 — 23.3 21.4–25.4 — 
Need factors                
 No. conditions or disorders                
  0 79.7 75.3–83.5 .0748 70.6 65.4–75.3 .0057 43.8 38.8–48.8 .1502 42.1 37.3–46.9 <.0001 20.2 15.4–26.1 .1088 
  1 82.6 79.5–85.4 — 77.0 74.0–79.9 — 49.3 46.3–52.3 — 50.1 47.1–53.1 — 22.5 19.8–25.4 — 
  2 85.9 83.4–88.1 — 80.5 77.9–82.9 — 50.5 47.5–53.6 — 54.8 51.8–57.8 — 23.9 21.0–27.0 — 
  3+ 84.5 82.4–86.3 — 77.9 75.8–79.9 — 50.2 48.0–52.5 — 55.2 52.9–57.4 — 25.9 24.0–28.0 — 
 Type of special health care need                
  Functional limitation 80.3 76.9–83.3 <.0001 73.3 69.9–76.4 <.0001 46.0 42.8–49.3 .0028 50.5 47.2–53.9 .0024 23.5 20.3–26.9 .5459 
  Medication only 87.1 85.4–88.7 — 81.5 79.5–83.3 — 52.2 49.9–54.6 — 55.1 52.7–57.5 — 23.5 21.4–25.7 — 
  Service use only 79.4 76.0–82.5 — 72.4 68.9–75.7 — 47.0 43.4–50.7 — 48.8 45.1–52.5 — 26.1 22.5–30.0 — 
  Medication and service use 87.5 85.1–89.6 — 81.9 79.4–84.1 — 52.1 49.4–54.8 — 56.1 53.3–58.8 — 25.1 22.9–27.5 — 
 Condition of teeth                
  Excellent or very good 87.3 86.0–88.5 <.0001 81.5 80.0–82.8 <.0001 51.7 50.1–53.3 .0046 55.9 54.3–57.5 <.0001 25.3 23.8–26.9 .3260 
  Good 79.4 76.2–82.2 — 72.0 68.6–75.1 — 46.5 43.0–50.0 — 48.9 45.4–52.5 — 22.3 19.4–25.5 — 
  Fair or poor 73.8 67.2–79.4 — 67.7 61.4–73.5 — 43.8 38.0–49.8 — 44.3 38.4–50.4 — 24.3 19.1–30.4 — 

MSA, metropolitan statistical area. —, not applicable.

After adjusting for all covariates, several factors remained significantly associated with receipt of POH care among CYSHCN (Table 4). CYSHCN in the youngest (1–5 years) and oldest (16–17 years) age categories had decreased prevalence of receipt of POH care, relative to those 12 to 15 years. In addition, CYSHCN from households with a high school education or less had decreased prevalence of preventive services, relative to CYSHCN from households with more education. CYSHCN from non-English households also had decreased prevalence of preventive services, compared with English-language households. Although few significant associations between race and ethnicity and receipt of POH services remained after adjustment, Hispanic CYSHCN had decreased prevalence of tooth brushing instruction and non-Hispanic Black CYSHCN had decreased prevalence of fluoride treatment, compared with non-Hispanic white CYSHCN. Fair or poor parental mental or emotional health (versus excellent or very good) was associated with increased prevalence of tooth brushing instructions and fluoride treatment; however, parent general health status was no longer associated with receipt of preventive services after accounting for covariates. In addition, there were few adjusted associations between family poverty ratio and receipt of preventive services, with the exception that CYSHCN <200% of the federal poverty level (FPL) had decreased prevalence of tooth brushing instructions, compared with CYSHCN ≥400% FPL. Lack of health insurance (versus private insurance) was associated with decreased prevalence of most POH services, whereas having (versus not having) a medical home was associated with increased prevalence of preventive services. There were no adjusted associations between type of special health care need and receipt of preventive services; however, CYSHSN with 2 or more conditions or disorders had increased prevalence of fluoride treatment, and CYSHCN with teeth in less than excellent or very good condition had decreased prevalence of preventive dental visits, cleanings, and fluoride treatment.

TABLE 4

Adjusted Prevalence Rate Ratios for Receipt of POH Services in the Past Year among Children With Special Health Care Needs (1–17 Year), 2016–2018 NSCH

Preventive Dental VisitCleaningInstructions on Tooth BrushingFluoride TreatmentSealant (6–17 y)
aPRRa95% CIsaPRR95% CIsaPRR95% CIsaPRR95% CIsaPRR95% CIs
Predisposing factors           
 Age, y (reference: 12–15)b           
  1–5 0.75a 0.70–0.80a 0.61a 0 0.56–0.67a 0.72a 0.64–0.80a 0.64a 0.56–0.71a — — 
  6–8 1.00 0.96–1.04 0.97 0.92–1.01 1.07 0.98–1.16 1.00 0.92–1.08 1.15 0.98–1.32 
  9–11 1.02 0.99–1.06 1.01 0.97–1.04 1.13a 1.04–1.22a 1.08 1.00–1.15 1.19a 1.04–1.35a 
  16–17 0.98 0.95–1.02 0.98 0.94–1.02 0.80a 0.72–0.89a 0.90a 0.82–0.98a 0.77a 0.59–0.95a 
 Sex (reference: female)           
  Male 0.98 0.96–1.01 0.99 0.95–1.02 1.00 0.93–1.06 0.98 0.92–1.04 0.98 0.86–1.10 
 Race and ethnicity (reference: non-Hispanic white)           
  Hispanic 1.02 0.98–1.06 1.02 0.97–1.07 0.88a 0.79–0.99a 1.02 0.93–1.11 1.12 0.91–1.33 
  Non-Hispanic Black 1.00 0.97–1.04 0.98 0.93–1.03 0.93 0.83–1.03 0.86a 0.76–0.95a 1.10 0.88–1.32 
  Non-Hispanic other 1.02 0.99–1.06 1.02 0.98–1.07 1.01 0.92–1.09 1.02 0.93–1.10 1.08 0.91–1.24 
 Highest household education (reference: more than high school)           
  Less than high school 0.90a 0.81–0.99a 0.88a 0.78–0.98a 0.78a 0.61–0.96a 0.69a 0.53–0.84a 0.65a 0.42–0.88a 
  High school 0.96a 0.92–0.99a 0.93a 0.89–0.97a 0.87a 0.78–0.95a 0.86a 0.78–0.94a 0.86 0.68–1.03 
 Primary household language (reference: English)           
  Non-English 0.96 0.88–1.04 0.93 0.83–1.03 0.82a 0.66–0.99a 0.70a 0.55–0.85a 0.62a 0.40–0.84a 
 Urban or rural residence (reference: MSA)           
  Not MSA 0.99 0.96–1.02 0.96 0.92–1.01 0.88a 0.81–0.96a 0.93 0.85–1.01 0.95 0.80–1.10 
  Suppressed 1.04a 1.01–1.06a 1.04a 1.01–1.07a 1.02 0.96–1.08 1.09a 1.04–1.15a 1.17a 1.04–1.29a 
Enabling factors           
 Parent or caregiver general health status (reference: excellent or very good)           
  Good 1.00 0.97–1.03 1.00 0.97–1.04 1.02 0.95–1.10 1.05 0.98–1.12 0.99 0.86–1.13 
  Fair or poor 0.99 0.94–1.04 0.98 0.91–1.04 0.95 0.83–1.06 1.03 0.90–1.15 1.06 0.80–1.31 
 Parent or caregiver mental or emotional health status (reference: excellent or very good)           
  Good 0.97 0.94–1.01 0.99 0.95–1.03 1.00 0.92–1.08 0.99 0.91–1.06 1.13 0.96–1.30 
  Fair or poor 0.99 0.93–1.05 1.02 0.95–1.09 1.16a 1.01–1.304a 1.16a 1.02–1.30a 1.24 0.90–1.59 
 Family poverty ratio (reference: ≥400% FPL)           
  <100% FPL 0.99 0.95–1.04 0.98 0.93–1.04 0.88a 0.77–0.98a 0.94 0.83–1.04 0.84 0.64–1.04 
  100%–199% FPL 0.97 0.93–1.02 0.98 0.92–1.03 0.90a 0.81–0.98a 0.98 0.90–1.06 0.83 0.66–1.00 
  200%–399% FPL 0.97 0.94–1.00 0.98 0.95–1.02 0.93 0.86–1.00 0.96 0.90–1.03 0.93 0.80–1.05 
 Current insurance status or type (reference: private only)           
  Public only 0.99 0.95–1.02 0.96 0.92–1.01 0.91a 0.83–0.99a 0.93 0.85–1.01 1.22a 1.02–1.42a 
  Private + public 1.03 0.98–1.07 1.00 0 0.94–1.06 1.08 0.95–1.20 1.02 0.90–1.13 1.12 0.79–1.44 
  Uninsured 0.85a 0.76–0.94a 0.81a 0.70–0.91a 0.66a 0.51–0.81a 0.69a 0.55–0.82a 1.20 0.80–1.59 
 Medical home (reference: no)           
  Yes 1.05a 1.02–1.07a 1.07a 1.04–1.10a 1.12a 1.05–1.19a 1.13a 1.07–1.20a 1.11 0.99–1.22 
Need factors           
 No. conditions or disorders (reference: 0)           
  1 1.02 0.96–1.07 1.03 0.96–1.11 1.04 0.90–1.17 1.07 0.93–1.20 1.00 0.72–1.28 
  2 1.04 0.98–1.10 1.06 0.99–1.13 1.06 0.92–1.20 1.16a 1.01–1.30a 1.13 0.80–1.46 
  3+ 1.05 0.99–1.11 1.05 0.98–1.13 1.10 0.96–1.25 1.21a 1.06–1.36a 1.19 0.85–1.53 
 Type of special health care need (reference: medication only)           
  Functional limitation 0.96 0.93–1.00 0.96 0.91–1.00 0.92 0.83–1.01 0.94 0.85–1.02 0.91 0.73–1.10 
  Service use only 0.97 0.93–1.00 0.96 0.91–1.01 0.95 0.86–1.04 0.94 0.85–1.02 1.02 0.85–1.20 
  Medication and service use 1.00 0.97–1.04 1.00 0.96–1.05 1.00 0.92–1.08 1.00 0.93–1.07 1.02 0.87–1.16 
 Condition of teeth (reference: excellent or very good)           
  Good 0.92a 0.89–0.96a 0.91a 0.87–0.95a 0.96 0.88–1.04 0.93 0.85–1.00 0.90 0.77–1.04 
  Fair or poor 0.90a 0.83–0.96a 0.89a 0.82–0.96a 0.97 0.84–1.09 0.85a 0.73–0.97a 0.92 0.68–1.16 
Preventive Dental VisitCleaningInstructions on Tooth BrushingFluoride TreatmentSealant (6–17 y)
aPRRa95% CIsaPRR95% CIsaPRR95% CIsaPRR95% CIsaPRR95% CIs
Predisposing factors           
 Age, y (reference: 12–15)b           
  1–5 0.75a 0.70–0.80a 0.61a 0 0.56–0.67a 0.72a 0.64–0.80a 0.64a 0.56–0.71a — — 
  6–8 1.00 0.96–1.04 0.97 0.92–1.01 1.07 0.98–1.16 1.00 0.92–1.08 1.15 0.98–1.32 
  9–11 1.02 0.99–1.06 1.01 0.97–1.04 1.13a 1.04–1.22a 1.08 1.00–1.15 1.19a 1.04–1.35a 
  16–17 0.98 0.95–1.02 0.98 0.94–1.02 0.80a 0.72–0.89a 0.90a 0.82–0.98a 0.77a 0.59–0.95a 
 Sex (reference: female)           
  Male 0.98 0.96–1.01 0.99 0.95–1.02 1.00 0.93–1.06 0.98 0.92–1.04 0.98 0.86–1.10 
 Race and ethnicity (reference: non-Hispanic white)           
  Hispanic 1.02 0.98–1.06 1.02 0.97–1.07 0.88a 0.79–0.99a 1.02 0.93–1.11 1.12 0.91–1.33 
  Non-Hispanic Black 1.00 0.97–1.04 0.98 0.93–1.03 0.93 0.83–1.03 0.86a 0.76–0.95a 1.10 0.88–1.32 
  Non-Hispanic other 1.02 0.99–1.06 1.02 0.98–1.07 1.01 0.92–1.09 1.02 0.93–1.10 1.08 0.91–1.24 
 Highest household education (reference: more than high school)           
  Less than high school 0.90a 0.81–0.99a 0.88a 0.78–0.98a 0.78a 0.61–0.96a 0.69a 0.53–0.84a 0.65a 0.42–0.88a 
  High school 0.96a 0.92–0.99a 0.93a 0.89–0.97a 0.87a 0.78–0.95a 0.86a 0.78–0.94a 0.86 0.68–1.03 
 Primary household language (reference: English)           
  Non-English 0.96 0.88–1.04 0.93 0.83–1.03 0.82a 0.66–0.99a 0.70a 0.55–0.85a 0.62a 0.40–0.84a 
 Urban or rural residence (reference: MSA)           
  Not MSA 0.99 0.96–1.02 0.96 0.92–1.01 0.88a 0.81–0.96a 0.93 0.85–1.01 0.95 0.80–1.10 
  Suppressed 1.04a 1.01–1.06a 1.04a 1.01–1.07a 1.02 0.96–1.08 1.09a 1.04–1.15a 1.17a 1.04–1.29a 
Enabling factors           
 Parent or caregiver general health status (reference: excellent or very good)           
  Good 1.00 0.97–1.03 1.00 0.97–1.04 1.02 0.95–1.10 1.05 0.98–1.12 0.99 0.86–1.13 
  Fair or poor 0.99 0.94–1.04 0.98 0.91–1.04 0.95 0.83–1.06 1.03 0.90–1.15 1.06 0.80–1.31 
 Parent or caregiver mental or emotional health status (reference: excellent or very good)           
  Good 0.97 0.94–1.01 0.99 0.95–1.03 1.00 0.92–1.08 0.99 0.91–1.06 1.13 0.96–1.30 
  Fair or poor 0.99 0.93–1.05 1.02 0.95–1.09 1.16a 1.01–1.304a 1.16a 1.02–1.30a 1.24 0.90–1.59 
 Family poverty ratio (reference: ≥400% FPL)           
  <100% FPL 0.99 0.95–1.04 0.98 0.93–1.04 0.88a 0.77–0.98a 0.94 0.83–1.04 0.84 0.64–1.04 
  100%–199% FPL 0.97 0.93–1.02 0.98 0.92–1.03 0.90a 0.81–0.98a 0.98 0.90–1.06 0.83 0.66–1.00 
  200%–399% FPL 0.97 0.94–1.00 0.98 0.95–1.02 0.93 0.86–1.00 0.96 0.90–1.03 0.93 0.80–1.05 
 Current insurance status or type (reference: private only)           
  Public only 0.99 0.95–1.02 0.96 0.92–1.01 0.91a 0.83–0.99a 0.93 0.85–1.01 1.22a 1.02–1.42a 
  Private + public 1.03 0.98–1.07 1.00 0 0.94–1.06 1.08 0.95–1.20 1.02 0.90–1.13 1.12 0.79–1.44 
  Uninsured 0.85a 0.76–0.94a 0.81a 0.70–0.91a 0.66a 0.51–0.81a 0.69a 0.55–0.82a 1.20 0.80–1.59 
 Medical home (reference: no)           
  Yes 1.05a 1.02–1.07a 1.07a 1.04–1.10a 1.12a 1.05–1.19a 1.13a 1.07–1.20a 1.11 0.99–1.22 
Need factors           
 No. conditions or disorders (reference: 0)           
  1 1.02 0.96–1.07 1.03 0.96–1.11 1.04 0.90–1.17 1.07 0.93–1.20 1.00 0.72–1.28 
  2 1.04 0.98–1.10 1.06 0.99–1.13 1.06 0.92–1.20 1.16a 1.01–1.30a 1.13 0.80–1.46 
  3+ 1.05 0.99–1.11 1.05 0.98–1.13 1.10 0.96–1.25 1.21a 1.06–1.36a 1.19 0.85–1.53 
 Type of special health care need (reference: medication only)           
  Functional limitation 0.96 0.93–1.00 0.96 0.91–1.00 0.92 0.83–1.01 0.94 0.85–1.02 0.91 0.73–1.10 
  Service use only 0.97 0.93–1.00 0.96 0.91–1.01 0.95 0.86–1.04 0.94 0.85–1.02 1.02 0.85–1.20 
  Medication and service use 1.00 0.97–1.04 1.00 0.96–1.05 1.00 0.92–1.08 1.00 0.93–1.07 1.02 0.87–1.16 
 Condition of teeth (reference: excellent or very good)           
  Good 0.92a 0.89–0.96a 0.91a 0.87–0.95a 0.96 0.88–1.04 0.93 0.85–1.00 0.90 0.77–1.04 
  Fair or poor 0.90a 0.83–0.96a 0.89a 0.82–0.96a 0.97 0.84–1.09 0.85a 0.73–0.97a 0.92 0.68–1.16 

aPRR, adjusted prevalence rate ratio; MSA, metropolitan statistical area. —, not applicable.

a

Indicates a statistically significant difference compared with the reference group at α = .05.

b

Each reference group has an aPRR = 1.00.

Our findings indicate that CYSHCN have higher rates of POH care use than non-CYSHCN despite having worse oral health status. CYSHCN’s poor oral health status may relate to their specific medical condition, poor understanding of oral hygiene practices, and poor manual dexterity, resulting in limited ability to perform self-care. Oral health treatments may be complex, requiring several appointments. In addition, because of their significant health needs, CYSHCN may have increased exposure to health care providers, leading to referrals for POH services.52  In other words, the higher rates of oral health care use may be in response to CYSHCN’s worse oral health status yet remain insufficient to meet their needs. Ensuring appropriate use of POH services among CYSHCN is critical to the reduction of primary and permanent dentition caries, gingivitis, and periodontal disease.53  Yet, children with chronic conditions may encounter more difficulty in finding dentists who are comfortable providing dental care.5,9  Whereas 95% of pediatric dentists treat CYSHCN,54  only 10% of general dentists do.55  Few general dentists report regularly treating CYSHCN, having hands-on educational experiences with CYSHCN in dental school, or feeling equipped to manage patients’ unique needs,5557  highlighting the importance of dental workforce training that meets the needs of CYSHCN.58 

Overall, the associations identified in this study are consistent with previous work examining preventive dental care among CYSHCN.59  As with the general child population,19  we found that the youngest CYSHCN were less likely to receive POH services. CYSHCN with parents with lower levels of education, and those from non-English households, were also less likely to receive POH services, as similarly reported among the general population.19  These findings highlight the importance of empowering parents by improving their oral health knowledge, providing referrals to dental care resources, and advocating for improved oral health care among CYSHCN.58 

Findings revealed that CYSHCN with a medical home were more likely to receive POH services. The National Standards for Systems of Care for Children and Youth with Special Health Care Needs recognizes that CYSHCN must have access to specialty services, facilitated through a medical home that coordinates care to meet medical, dental, and social-emotional needs.60  We found that 1 in 6 CYSHCN did not have a preventive dental visit in the past year. Given ongoing efforts to improve the health care system to better serve the health care needs of CYSHCN,52  this finding highlights missed opportunities to ensure all CYSHCN receive the necessary oral health care to prevent oral disease, such as integrating POH care (and dental coordinators) into medical homes.6163 

In addition, uninsured CYSHCN were less likely to receive POH services compared with their privately insured counterparts, but there were mixed findings regarding the impact of public insurance: publicly insured CYSHCN had decreased prevalence of tooth brushing instruction, increased prevalence of sealants, and no differences in preventive dental visits, cleanings, and fluoride, relative to privately insured CYSHCN. Previous research has revealed that publicly insured children (including CYSHCN) have similar levels of access to and use of dental care compared with those with private insurance, despite public insurance plans having better coverage for dental services.64,65  Although Medicaid has always covered pediatric dental health services as an Early and Periodic Screening, Diagnostic, and Treatment benefit, long-standing concerns with low rates of use prompted federal recommendations and efforts to increase visit rates, including for POH services.66  Expanding eligibility for Medicaid, however, is not sufficient to improve outcomes for CYSHCN.67  Possible insurance-based strategies for further improving oral health care access include assuring that dental and oral health coverage meets the specific needs of CYSHCN, such as covering more complex or hospital-based procedures; improving reimbursement rates for oral health services; and creating innovative systems of care using the Medicaid waiver process (eg, dental clinics specializing in the care of CYSHCN).58 

The findings pertaining to sealants stand in contrast with other POH services examined. Specifically, we found no associations between sealants and race and ethnicity, family poverty ratio, or current insurance status or type. This may be explained by school-based dental sealant programs, which have targeted students in low socioeconomic areas, providing a cost-effective intervention to increase the prevalence of sealants and reduce caries among low-income children.6870  The majority of children, however, still lack sealants across all racial and ethnic, income, age, and disability status groups.68,71 

There are several study limitations to consider. First, estimates are based on parent reports, which may be subject to recall or reporting bias. In particular, parents may not be aware of specific oral health services received by adolescents if they do not accompany them into the examination room during their visit, which may lead to underreporting. In contrast, parent-reported estimates are generally higher than those produced from claims-based data,7274  possibly because of a “telescoping effect” whereby parents recall distant events (such as a dental visit) as being more recent. No clinical validation studies have been conducted to assess the extent of bias in parental reports of oral health care; however, other national surveys that rely on self-report have been used to estimate oral health care use.75,76  Parent-reported measures of oral health status are also subjective in nature, particularly the qualitative assessment of the child’s condition of teeth. Although this measure has not been previously validated, it has been used in the NSCH since 2003, and previous studies have found that it is associated with race and ethnicity,36  insurance type,65  socioeconomic status,39  and special health care needs,77  all in the expected directions. In addition, the results for fluoride treatment should be interpreted with caution. The American Dental Association generally recommends fluoride treatment of children at elevated risk for caries; however, it also advises professional judgment in assessing patients’ risk status when considering the net benefits of such treatment.78  The NSCH did not allow us to ascertain characteristics of children (eg, access to fluoridated water, use of fluoridated toothpaste) that would indicate elevated risk. As a result, our estimates of the prevalence of fluoride treatment may underestimate the prevalence among children with an indicated need, because we included all children regardless of need in the denominator. Additional research is needed to study optimal fluoride strategies for special needs populations, including CYSHCN with specific health conditions. Finally, the NSCH only collects information about oral health services provided by dentists or other oral health care providers; services provided by primary care providers, such as pediatricians, are not captured by the survey. The US Preventive Services Task Force and the American Academy of Pediatrics’ Bright Futures Guidelines both recommend that primary care clinicians provide POH services to infants and children, including fluoride treatment and supplementation and oral hygiene education.79,80  Future research is needed to examine the provision of oral health services provided to children, including CYSHCN, in primary care settings.

In this study, we highlight the importance of a comprehensive approach for ensuring access to POH services among CYSHCN. Such an approach should endeavor to adequately train oral health professionals; improve parents’ oral health knowledge and skills to prevent oral disease; establish a medical home that fully enables care coordination among medical, dental, and other social services; and provide adequate dental and oral health care coverage through public and private insurance.

Dr Canto and Ms Vodicka conceptualized and designed the study, drafted the Introduction and Discussion sections of the manuscript, and reviewed and revised the manuscript; Dr Lebrun-Harris conducted the data analysis, drafted the Methods and Results sections of the manuscript, and reviewed and revised the manuscript; Drs Mann and Kinsman provided guidance on the study design and data analysis, and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The views expressed in this article are those of the authors and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US government.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-050886.

     
  • CI

    confidence interval

  •  
  • CYSHCN

    Children and youth with special health care needs

  •  
  • FPL

    Federal poverty level

  •  
  • NSCH

    National Survey of Children’s Health

  •  
  • POH

    preventive oral health

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.