Oral Health Status Has Improved for Children, but Some Gaps in Treatment Access Persist

Children and adolescents in the U.S. have made substantial oral health gains in recent years while the prevalence of dental disease in adults has remained fairly constant, with an increase in the number of seniors with decay, according to a September 2019 report by the Centers for Disease Control and Prevention (CDC). But a separate new analysis presents a more nuanced picture of progress, with a mix of gains and losses in terms of long-standing disparities among white, black, and Mexican American populations, and between higher- and lower-income groups.

Dr. Scott Tomar, director of institutional analysis and evaluation at the University of Florida College of Dentistry, conducted this analysis and used data from the CDC report to identify whether relative disparities for children and adults increased or decreased between different income and race/ethnicity groups over two time periods: 1999-2004 and 2011-16.

Of Tomar’s 48 comparisons between groups defined by race/ethnicity or poverty status, the disparities gap narrowed over time for 42 percent of them, widened for 37 percent, and stayed the same for 21 percent. What remained constant between the two time periods were the persistent disparities in oral health status between white and other racial/ethnic groups and between higher- and lower-income groups of all ages.

“While the gaps have narrowed for some indicators, they have widened for many others, and equity in oral health status remains elusive. We can and should do better,” Tomar said.

Following is a closer look at what the CDC and Tomar found.

For 2- to 5- year-olds:

Overall: Prevalence of decay in primary teeth decreased by 5 percentage points to 23 percent. White, Mexican American, and lower-income children experienced declines, while black and higher-income children saw no change.

Disparity gaps: Compared with white children, relative disparities widened for black and Mexican American children because gains by whites outpaced those of the other groups. However, the gap narrowed between higher- and lower-income children.

Overall: Untreated decay decreased by nearly 50 percent to reach 10 percent for this age group. All racial/ethnic and income groups saw substantial improvements.

Disparity gaps: Disparity gaps widened between blacks and whites and for Mexican Americans relative to whites. They also widened between higher- and lower-income groups. Relative disparities increased by race/ethnicity and income despite gains by all groups because black, Mexican American, and low-income children started with much higher prevalence of disease than whites and higher-income children.

For 6- to 11-year-olds:

Overall: The prevalence of decay in permanent teeth decreased by 4 percentage points to 17 percent. Only white, Mexican American, and high-income children experienced declines; among black and low-income children, there was no significant change.

Disparity gaps: Relative disparities increased between whites and Mexican Americans despite Mexican Americans experiencing the largest percentage point decline among all racial/ethnic groups. The gap widened because Mexican Americans started at a much higher prevalence of decay. Disparities also increased between white and black youth and between higher- and lower- income groups. 

Overall: There was a decrease for untreated decay from 8 to 5 percent. Only Mexican American and lower-income groups experienced declines; other groups saw no significant changes.

Disparity gaps: Relative disparities narrowed between whites and Mexican Americans, and higher- and lower-income youth, because of the large declines experienced by Mexican American and lower-income groups. Relative disparities increased between whites and blacks because although the changes were small within each group, the differences when taken together were enough to widen the gap.

Dental sealants

Progress has been particularly strong in use of dental sealants, which are thin coatings placed on the chewing surfaces of permanent teeth to prevent decay. All race/ethnicity and income groups saw significant gains on this measure, and the racial and income disparity gaps narrowed. Sealant prevalence increased from 31 to 42 percent for 6- to 11-year-olds and from 38 to 48 percent for 12- to 19-year-olds. Across both age groups, blacks saw an increase of at least 10 percentage points and Mexican American and low-income youth had gains of 16 percentage points or more.

For 20- to 64-year-olds:

Overall: Decay experience declined modestly (2 percentage points) but remained high at 90 percent. Only white and higher-income adults experienced declines, while the other groups saw no significant changes.

Disparity gaps: The disparity gap between whites and Mexican Americans narrowed because whites began with a higher prevalence of decay from 1999 to 2004. The gaps between blacks and whites and between higher- and lower-income groups did not change.

Overall: The prevalence of untreated decay remained about the same (26 percent). No race/ethnicity or income group experienced significant changes.

Disparity gaps: Relative disparities decreased between white and black adults, and between white and Mexican American adults, because although the changes were small within each group,  the differences were enough to narrow the gap when taken together. The gap remained constant between income groups.

For seniors (age 65-plus):

Overall: Decay experience increased by 3 percentage points to 96 percent. Whites and adults in both higher- and lower- income groups experienced significant increases in decay, while blacks and Mexican Americans saw no significant changes.

Disparity gaps: There were no significant changes in relative disparities from 1999 to 2004 and from 2011 to 2016.

Overall: Untreated decay remained relatively constant at about 16 percent. Higher-income seniors were the only group to significantly improve; the other groups did not experience significant changes.

Disparity gaps: The relative disparity between whites and blacks decreased because the small changes within each group  were enough to narrow the gap when taken together. Blacks saw a larger decline than whites. The disparity gap increased between income groups.  

The CDC report and Tomar’s analysis highlight the consequences of a U.S. dental coverage and delivery system that is failing large segments of the population. A number of policy options can help improve this situation. About 30 percent of working-age adults and 60 percent of seniors lack dental insurance. To date, 14 states have not adopted the Affordable Care Act’s Medicaid expansion. Expanding coverage for low-income adults, along with a more generous adult Medicaid dental benefit, would help increase access, as would adding dental coverage to Medicare. And states can do more to help the dental care delivery system extend its reach to underserved populations. These efforts include removing unnecessary state-level rules that block dental hygienists from working in community settings and expanding the use of dental therapists, who can offer basic restorative care at a lower cost to the delivery system.

Jane Koppelman is a senior manager and Allison Corr is an officer with The Pew Charitable Trusts’ dental campaign.