National Trends in Pediatric Dental Needs and Use by Special Health Care Needs Status: An Observational Study Using the National Survey of Children’s Health, 2016–2022

Children with special health care needs (SHCNs) experience more unmet health care needs compared with children without SHCNs, meaning that they are less likely to receive needed health care.¹ They are 4 times as likely to have unmet health care needs in the previous year than peers without SHCNs,¹ with dental care being the second most common unmet health care need.² Children with SHCNs also have higher rates of oral health problems,^3,4 with gingivitis and periodontal disease being highly prevalent.⁵ Multilevel factors, including chronic health conditions, insurance type, poverty experience, family structure, rurality, and residing in a health professional shortage area, are associated with greater unmet dental needs among this population.^6–11 Foregone dental care can result in preventable adverse consequences¹² and compromise quality of life.¹³ 

Despite increased foregone dental care and relatively poorer oral health status, children with SHCNs have historically demonstrated high levels of dental service use. Studies have generally shown that use of dental services is similar to or even greater than that by children without SHCNs.^14–17 For example, children with SHCNs with developmental disorders (DD) have higher overall use of dental visits than children without DD.¹⁶ In contrast, other studies have indicated that, in certain populations or contexts, children with SHCNs are less likely to have preventive dental care.^18,19 In Washington, young children with SHCNs enrolled in the Medicaid Access to Baby and Child Dentistry program were less likely to receive preventive services.¹⁸ Another study investigated use patterns in the months leading up to and including the prevaccine period of the COVID-19 pandemic.¹⁹ In adjusted models, children with SHCNs were less likely to have a preventive dental visit than children without SHCNs.

The COVID-19 pandemic had a profound impact on access to and use of health care services. Analyzing current trends in unmet dental care needs and dental use of children with SHCNs compared with children without SHCNs provides valuable insights into understanding disparities, especially due to inequities resulting from the pandemic, as well as their underlying drivers. Between 2016 and 2020, there was a significant rise in children diagnosed with anxiety and depression, decreased physical activity, and decreased care for mental and emotional well-being.³ These factors were exacerbated during the pandemic, along with a decline in preventive medical and dental care visits.

Using data from the National Survey of Children’s Health (2016–2022), we aimed to do the following: (1) compare oral health-related measures (ie, oral health status, unmet dental care needs, and dental use) between a national sample of children with and without SHCNs; and (2) assess trends in these oral health–related measures and ascertain whether the findings are consistent over time. Previous studies comparing dental access between these populations have focused on a shorter time-period or on specific oral health measures. These studies have lacked a long-term, inclusive understanding of how oral health status, unmet dental care needs, and dental use patterns have evolved over time. A comprehensive analysis contrasting trends in oral health needs and dental use patterns between children with and without SHCN over 7 years, including the pandemic period, may inform development of targeted intervention programs and policies and help shape future research efforts.

Through this cross-sectional study, we evaluated publicly available pooled data from 2016 to 2022 from the National Survey of Children’s Health (NSCH), a nationally representative sample of noninstitutionalized children in the United States. We identified variables of interest from the topical questionnaire, which was completed by a parent or caregiver familiar with the sampled child’s health. In 2023, the Maternal and Child Health Bureau began to address differences in race reporting options between the NSCH and the American Community Survey; survey administrators revised the imputation and weighting by race and ethnicity for the 2022 NSCH.²⁰ These enhancements were applied retroactively to data from 2016 to 2021. Additional details on the survey methodology are described elsewhere.^21,22 We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for reporting observational studies.²³ The study was deemed exempt by the Harvard Faculty of Medicine Institutional Review Board (23–0799).

We assessed the following 2 categories of dental measures: (1) parent- or caregiver-reported oral health needs and (2) dental use.

We assessed parent- or caregiver-reported oral health needs in the following 3 different ways: (1) fair/poor condition of teeth, (2) dental problems, and (3) unmet dental care needs. We derived the “fair/poor condition of teeth” variable from the question “How would you describe the condition of this child’s teeth?” Responses included excellent, very good, good, fair, and poor. We dichotomized the variable as fair/poor condition of teeth versus excellent/very good/good. Second, “dental problems” are based on the question “During the past 12 months, has this child had frequent or chronic difficulty with any of the following?” Responses included toothaches, bleeding gums, and decayed teeth or cavities. Each of these became an individual binary variable. In addition, we treated the responses collectively by combining them into an indicator variable if the parent reported at least 1 of any of the problems. Third, we derived the variable “unmet dental care needs” as a measure of foregone dental care from the question “During the past 12 months, was there any time when this child needed health care, but it was not received?” A follow-up question asked respondents to specify which types of care were not received, and response options included medical care, dental care, vision care, mental health services, and other. We categorized the variable as an indicator variable based on a positive response to an endorsement of unmet dental care.

We assessed dental use through report of any dental visit in the past 12 months, including the number of preventive visits. We derived the dichotomous variable “any dental visit” from the question “During the past 12 months, did this child see a dentist or other oral health care provider for any kind of dental or oral health care?” This captured preventive, treatment, and urgent visits. A follow-up question for children who had seen a dentist or oral health provider in the prior 12 months asked “If yes, during the past 12 months, did this child see a dentist or other oral health care provider for preventive dental care, such as check-ups, dental cleanings, dental sealants, or fluoride treatments?” We categorized responses as 0, 1, or ≥2 preventive visits.

Children with SHCN status (yes/no) was an existing variable identifying children with SHCNs, as defined by the validated Children with Special Health Care Needs Screener.²⁴ The Screener identifies children with SHCNs based on parent or caregiver report of need or use of prescription medications, services, and/or specialized therapies; functional difficulties; and emotional, developmental, or behavioral problems for which treatment or counseling is needed.²⁴ These questions reflect the Maternal and Child Health Bureau definition and are used in multiple national surveys.

Covariates were specified a priori based on established literature; we used the Andersen Model²⁵ to categorize these as enabling, predisposing, and need-related factors. Predisposing factors were age, sex, race and ethnicity, family structure, count of children with SHCNs in household, highest household education, nativity of parents and caregivers, primary household language, and geographic region. Enabling factors included parent or caregiver general health status, parent or caregiver mental health status, family poverty ratio (FPR), child health insurance status, and past-year preventive medical visit. Need-related factors were examined through presence of a developmental disorder, as previously defined.²⁶ 

We completed analyses in accordance with the NSCH complex sampling design. We appended NSCH data for 7 years (2016–2022) into 1 data frame, including a variable reflecting survey year. The final data included children aged 1 to 17 years with complete information regarding the variables of interest, and observations with missing data were excluded. Our final 7-year pooled study cohort was 208 448 children (Supplemental Figure 1, Figure 1).

We adjusted survey weights to produce 7-year estimates from 2016 to 2022.²⁷ Sex and race and ethnicity were imputed using hot-deck imputation, and FPR was multiple-imputed using sequential regression methods.²² To account for this in the analysis, we designated the data as a multiple-imputed data set.²⁸ For the initial analysis (Tables 1 and 2), we stratified the data by children with SHCN status and calculated weighted percentages and associated 95% CIs. χ² tests were used to assess differences between children with and without SHCNs. For the trends analysis (Table 3 and Figures 1 and 2), we calculated weighted prevalence estimates and associated 95% CIs reflecting each year and the outcomes of interest among children with and without SHCNs. We calculated the absolute and relative differences in each outcome over the 7-year period, and absolute differences were calculated based on the differences in outcomes between 2016 and 2022. To calculate statistical significance of trends from 2016 to 2022, we ran logistic regression analyses considering year as a continuous variable and adjusting for age, sex, race and ethnicity, and FPR (Table 3). To understand a more granular level of the overall trends observed, we created an additional model examining the outcomes of unmet dental care needs and any dental visit in the past year. We looked at the significance between each year-over-year period (Table 4). These comparisons were performed by sub-setting the data to the 2-year timeframe of interest, and then we again ran adjusted logistic regression analyses considering year as a continuous variable. We performed all analyses using Stata/MP version 18.0 (StataCorp LLC).²⁹ 

We describe the study sample in Table 1, which includes children with and without SHCNs. Table 2 looks at these same children with a focus on their specific oral health care needs, as well as their use of dental services. As previously discussed, the NSCH uses a sophisticated sampling and weighting process for the selection of survey subjects and the treatment of the data collected from them. These techniques maximize the likelihood that the differences between these two populations, ie, with and without SHCNs, are real.

The demographics (Table 1) for the families with children with SHCNs show the following: a greater proportion (45.1% vs. 31.0%) of children with SHCNs belong to the older age group (ie, aged 12–17 years); are male (56.9% vs 49.4%); and primarily spoke English (92.5% vs 86.8%). A higher proportion of children with SHCNs endorsed a single-mother family structure (22.8% vs 14.6%), whereas a lower proportion without SHCNs resided in a 2-parent household (66.2% vs 77.8%). Although percentages of Black families were higher in the group with SHCNs (15.9% vs 11.4%), percentages of Asian (2.3% vs 4.6%) and Hispanic families (20.8% vs 23.9%) were lower. Children with SHCNs have a higher proportion (20.5% vs 15.1%) belonging to the income category below 100% FPR, as well as the public-only insurance category (36.9% vs. 26.6), compared with children without SHCNs. A higher proportion of parents who have children with SHCNs reported their overall physical (13.0% vs 5.5%) and mental health (10.7% vs 4.5%) as fair or poor.

In Table 2, we compare oral health needs and use between the 2 populations. Overall, children with SHCNs had significantly higher occurrence (9.8% vs 3.8%) of fair/poor oral health status, dental problems (19.3% vs 12.3%), and unmet dental care needs (3.1% vs 1.1%). Children with SHCNs also had significantly higher percentage of any dental visits (87.0% vs 81.8%), and receipt of 2 or more preventive dental visits in the previous 12 months (57.9% vs 55.1%). However, children without SHCN had a significantly higher percentage of 1 past-year preventive visit (42.4% vs 39.1%). These differences are all statistically significant.

In the initial descriptive statistics components of the analysis, we pooled data for 7 years and treated the combined data as 1 cross-sectional view of the population (Tables 1 and 2). However, we were concerned regarding consistency over these findings over time because some of the included years, especially 2020, saw substantial barriers to care due to the COVID-19 pandemic. Figure 1, Tables 3 and 4 show trends comparisons over time for 2 oral health measures, ie, parent/caregiver-reported fair/poor oral health and dental problems for both populations. Although not statistically significant, over the 7-year study period, the percentage of reported dental problems (eg, bleeding gums, toothache, and/or cavities) among children with SHCNs increased from 17.9% in 2016 to a peak of 20.7% in 2019 and decreased to 19.1% by 2022. Similarly, the percentage of fair/poor oral health among children with SHCNs increased from 8.6% in 2016 to peak at 10.7% in 2019 before returning to 8.7% in 2021 and then increased to 9.5% in 2022. Comparatively, the percentage of both oral health measures among children without SHCN remained flat during the study period and did not increase significantly in 2019 or 2020. These within-population trends are not significant for either population. Regardless, the between-population differences (Table 2) for these 2 oral health measures among children do remain significant over the 7-year period.

Figure 2, Tables 3 and 4 show trends over time for use measured by unmet dental care needs and whether a dental visit occurred. Among children with SHCN, the prepandemic period between 2016 and 2018 saw a slight, non-statistically significant decrease (ie, 88.9% to 87.1%) in all dental visits, followed by a significant drop to 83.8% in 2020. This was followed by a slight, non-statistically significant increase to 85.4% in 2021. By 2022, dental visits among children with SHCNs had increased to 87.6%, which was a significant increase from 2020. Among children without SHCNs, the percentage of dental visits decreased significantly from 81.2% in 2016 to 79.9% in 2020. By 2022, the percentage of all dental visits among children without SHCNs had rebounded to 82.7%. Although the decline in absolute terms is not that large, what is concerning is the lack of rebound to prepandemic levels in 2022 among children with SHCNs, although dental visits did fully recoup among their peers without SHCNs. However, the CIs were relatively wide, which indicated uncertainty with the estimate.

The test of trends for any dental visit among children with SHCNs was statistically significant for the 7-year study period (Table 3). The sequential year-over-year comparisons (Table 5, Supplementary Figure 1) show that this finding was driven by the large drop in dental use between 2019 and 2020, despite a significant increase from 2021 to 2022. Among children without SCHNs, although the test of trends for the 7-year period was not significant (Table 4), the sequential year-over-year comparisons (Table 6, Supplemental Figure 1) shows that there was a significant increase in dental visits between 2016 and 2017, a significant drop between 2019 and 2020, and a significant rebound from 2021 to 2022. Over the 7-year period, the percentage of children with SHCNs who had unmet dental needs increased significantly between 2019 and 2020, from 2.6% to 4.3%, and decreased to 2.3% by 2022 (Table 3). Comparatively, the percentage of children without SHCNs who had unmet dental needs did not change significantly over time.

Our study aim was to compare differences in oral health needs and dental use between children with and without SHCNs and to assess trends over the last 7 years to better understand how these patterns have evolved and changed over time. The study period included 2020, ie, the early period of the pandemic, when access to dental services was very limited for all. Overall, we found that children with SHCNs had significantly worse oral health status, more dental problems, and greater unmet dental care needs compared with their peers without SHCNs. There was also a significant decrease in children receiving dental services in 2020 regardless of special needs status; however, the decrease for children with SHCNs was more pronounced (5.7% vs 4.3% for children without SHCNs). Prior studies have reported pandemic-related reductions in children’s use of both medical and dental services.³⁰ The pandemic adversely impacted US children’s oral health status and access to dental care.^30–33 Between 2019 and 2020 there were significant increases in parents reporting unmet medical and dental care needs for all US children aged 1 to 17 years, but this was highest for unmet dental care needs.³⁰ 

In terms of access to dental care, other studies have found that certain populations were more acutely affected than others, especially the youngest children and families with lower parental education levels.³⁰ Children’s oral health status was also notably worse in 2020 compared with the period before the pandemic, a pattern that persisted through 2021.³² These differences were amplified among certain demographic and socioeconomic subgroups in 2021, notably Hispanic or non-white children, as well as children living in families with incomes below 200% of the federal poverty level.³² Interestingly, our study found a higher proportion of Hispanic families in the group without SHCNs. Kranz et al³³ showed that there were no increases in racial and ethnic disparities in children’s dental visits or oral health outcomes during the pandemic, although prepandemic disparities persisted.

As highlighted in our study, children with SHCNs were one of the subgroups that experienced more pronounced negative oral health outcomes during the COVID-19 pandemic. Although our study did not investigate contributory factors, there are a few reasons why the pandemic might have affected children with and without SHCNs differently. Caregivers of children with SHCNs might have been more cautious about seeking dental care due to underlying health conditions that could heighten the risk of severe illness from COVID-19. This caution could have led to delayed or avoided dental visits for their child with SHCNs. In addition, families of children with SHCNs might need more support in navigating health care systems. During the pandemic, disruptions in community resources and support networks could have made it harder for these families to keep dental appointments. Although there was subsequent improvement in self-reported unmet dental care needs, the percentage of dental visits metric did not fully recover to prepandemic levels among children with SHCNs. In contrast, dental visits did fully recoup among their peers without SHCNs. This disparity could signify that barriers to dental care disproportionately impacted children with SHCNs and persisted before and after the pandemic peak. However, it is important to note that neither children with nor those without SHCNs experienced a rebound to prepandemic numbers in terms of receiving at least 2 preventive dental visits per year. Because the overall number of dental visits did increase in 2022 from prepandemic levels among children without SHCNs, that suggests that those visits are for dental treatment beyond routine preventive care, which is consistent with reduced access to preventive care during the pandemic.

Although we considered children with SHCNs as individuals, they often exist within a family comprising children with and without SHCNs. Among households of children with SHCNs, 27.4% reported having 2 children with SHCNs, and 8.8% reported having at least 3 children with SHCNs. Maintaining good oral health is a family activity, from daily toothbrushing to routine dental check-ups. Children with SHCNs, as well as and their families, may present with a variety of challenges to receiving routine dental care, including physical, psychological, and behavioral. For children with SHCNs, these gaps in care may magnify other existing problems that these children experience, including difficulty with nutrition and pain.³⁴ Poor nutrition in children may result in poor tooth development, which will exacerbate these problems into adulthood³⁵ and may ultimately affect overall health and quality of life.

This study has several limitations. The NSCH relies on caregiver self-report and does not verify actual receipt of dental care or include objective clinical measures. Our findings could therefore be subject to reporting inaccuracy. Caregivers were more likely to report specific dental problems (bleeding gums, toothache, and/or cavities) than to endorse their child’s oral health status as fair or poor. This could be related to the caregiver’s perception that fair/poor oral health is considered pejorative, whereas cavities are more ubiquitous among children and therefore more neutral. Future studies could explore how parents’ perceptions influence children’s oral health status and parents’ responses to survey questions. The study population comprised a noninstitutionalized population of children and may not be generalizable to all US children, including youth in boarding homes or institutionalized settings. Given the cross-sectional nature of the NSCH data, causality cannot be inferred.

Children with SHCNs require good oral health care, which starts at home and includes accessible, comprehensive dental care. They do not always receive either and are more likely to be impacted by externalities such as a pandemic. This study highlighted the oral health disparities between children with and without SHCNs throughout the study period. Although the entire population was impacted by COVID-19, children with SHCNs were more adversely impacted. Even by 2022, although there was improvement of unmet dental care needs, dental service use had not recovered from the pandemic.

The authors would like to acknowledge Jane Barrow, MS, for initial conceptualization of the study and compilation of the research team and Fan Bi, MS, for code review and statistical support in the data analysis.

DD

developmental disorders

FPR

family poverty ratio

NSCH

National Survey of Children’s Health

SHCN

special health care needs.