A national sample of developmentally disabled adolescents with obesity and their utilization of preventive dental care services.

Background: Previous literature indicates that adolescents with developmental disabilities and obesity may have more oral health complications than healthy adolescents. However, dental care utilization among adolescents with developmental disabilities (DDs) and obesity is unclear. We investigated the differences in the utilization of preventive dental services between this high-risk group of adolescents and those with no DDs or obesity. Methods: Parent-reported data of adolescents 10-17 years (n = 68,942) from the 2016 to 2019 National Survey of Children's Health was used. In addition to descriptive and bivariate statistics, we ran three multiple logistic regression models guided by Andersen's Behavioral Model of Health Services Use, predicting the use of dental cleanings, fluoride treatments, and dental sealants. Results: Among adolescents with DDs and obesity, dental cleanings, fluoride treatments, and dental sealant utilization prevalence were 76%, 48%, and 21%, respectively. In comparison, adolescents with no DDs or obesity had a prevalence of 83%, 50%, and 19%, respectively. Multiple logistic regression analysis showed that adolescents with DDs and obesity did not significantly differ in their receipt of dental cleanings (p = .07), fluoride treatments (p = .55), and dental sealants (p = .23) compared to those with neither DDs nor obesity. Adolescents with DDs but no obesity were 22% and 30% more likely to receive fluoride treatments (p < .0001) and dental sealants (p < .0001), respectively. Conclusions: Fewer than half of adolescents with DDs and obesity utilized fluoride treatments, and less than one quarter utilized dental sealants but used all three preventive services at the same rate as those with no DDs or obesity. Implications: This study identified no differences in preventive dental care services utilization in adolescents with developmental disabilities (DDs) and obesity compared to those without DDs and obesity. However, the utilization of preventive dental services in this population is influenced by the federal poverty level and family background.

Association between oral health knowledge, perceived oral health related quality of life, perceived oral health status and emergency department and/or urgent care visit: Results from the multi-site oral health literacy study.

OBJECTIVES: To assess the link between oral health knowledge (OHK), self-perceived oral health, and emergency room (ER)/urgent care utilization for a dental problem. METHODS: Data were analyzed from a convenience sample of 790 adult participants who presented to two US dental schools and completed an interviewer-administered survey. Key independent variables were OHK assessed with the Comprehensive Measure of Oral Health Knowledge (CMOHK) instrument, self-perceived oral health status and quality of life determined using the General Oral Health Assessment Index (GOHAI) scores. The dependent variable was ER and/or urgent care utilization for a dental problem. Select sociodemographic variables such as age and gender were adjusted for in logistic regression models using SAS. RESULTS: 15.7% of the participants had ever visited an ER and/or urgent care for a dental problem. CMOHK scores were not significantly associated with visits to the ER and/or urgent care. In adjusted analysis, participants with unfavorable GOHAI scores were about three times as likely to have had an ER and/or urgent care visit (OR = 2.60, 95% CI: 1.66-4.09). Similarly, participants who were unsatisfied with their oral health were about twice as likely to have had an ER and/or urgent care visit (OR = 1.91, 95% CI: 1.21-3.00) as compared to those satisfied with their oral health status. CONCLUSION: Individuals unsatisfied with their oral health and those with unfavorable perceived oral health related quality of life could benefit from a greater awareness of dental service availability and extended hours including weekend hours at public dental clinics.

Dental care utilization among developmentally disabled adolescents experiencing difficulty with decayed teeth: A population-level study.

AIMS: To determine if adolescents with developmental disabilities (DDs) who experienced difficulty with dental caries differed by dental visits in the past 12 months and receipt of preventive services (fluoride treatment and dental sealants) during those visits compared to adolescents with no DDs or difficulty with dental caries. METHODS AND RESULTS: A cross-sectional study was conducted using data of 91 196 adolescents aged 10-17 years from the 2016-2020 National Survey of Children's Health. Descriptive and bivariate statistics and multivariable regression models were conducted. We derived the odds ratio for visiting a dental office (OR: 0.76, 95% CI: 0.57-1.03, p = .07), receiving fluoride treatments (OR: 1.20, 95% CI: 1.01-1.43, p = .04), and dental sealants (OR: 1.44, 95% CI: 1.19-1.75, p < .001) for DD adolescents who experienced difficulty with dental caries compared to adolescents with no DDs or difficulty with dental caries. CONCLUSIONS: DD adolescents who experienced difficulty with dental caries were more likely to receive fluoride treatments and sealants during dental visits but were equally likely to have a dental visit in the past 12 months than adolescents with no DDs or difficulty with dental caries.

Hospital emergency department visits made by developmentally disabled adolescents with oral complications.

Purpose: We used Andersen's Behavioral Model in a cross-sectional study to determine the factors associated with utilization of the emergency department (ED), controlling for whether an adolescent has a developmental disability (DD) and one or more oral complications (toothaches, decayed teeth, bleeding gums, eating or swallowing problems). Methods: Data from the 2016-2019 National Survey of Children's Health (NSCH) was used for this secondary data analysis study. We used frequencies and percentages to describe the sample characteristics. Chi-square tests were used for bivariate analyses. Multivariable logistic regression modeling was conducted to predict ED visits by adolescents aged 10-17 controlling for predisposing, enabling, and need variables. Results: The sample consisted of 68,942 adolescents who were primarily male, non-Hispanic White, and born in the U.S. Parents reported that 69% of the adolescents had neither a DD nor an oral complication; 10% had no DD but experienced one or more oral complication; 16% had a DD but no oral complication; and 5% had both DDs and one or more oral complication. Adolescents with both a DD and an oral complication reported the highest level of ED visits at 33%, compared to 14% of adolescents with neither DD nor oral complication. Regression analysis showed that adolescents with a DD and oral complication (OR: 2.0, 95% CI: 1.64-2.54, p < 0.0001), and those with DDs but no oral complications (OR: 1.45, 95% CI: 1.25-1.68, p < 0.0001) were at higher odds of having an ED visit compared to those with neither a DD nor an oral complication. Not having a Medical Home increased the likelihood of ED visits by 14% (p = 0.02). Those with private insurance (OR: 0.63, 95% CI: 0.53-0.75, p < 0.0001) and those from a family where the highest level of education was some college and above (OR: 0.85, 95% CI: 0.73-0.98, p = 0.03) were less likely than their counterparts to have had an ED visit. Conclusion: Adolescents with DDs and oral complications utilize ED visits more frequently than those with neither DDs nor oral complications. Integrating the dental and medical health systems and incorporating concepts of a Patient-Centered Medical Home could improve overall health care and reduce ED visits for adolescents.

Oral Health in America: Implications for dental practice.

BACKGROUND: Important, but insufficient, gains have been achieved in access to and delivery of oral health care since the 2000 US surgeon general's report on oral health in America. Access to care has increased for children and young adults, but considerable work remains to meet the oral health care needs of all people equitably. The National Institutes of Health report, Oral Health in America: Advances and Challenges, reviews the state of the US oral health care system, achievements made since 2000, and remaining challenges. In this article, the authors highlight key advances and continuing challenges regarding oral health status, access to care and the delivery system, integration of oral and systemic health, financing of oral health care, and the oral health workforce. RESULTS: Public insurance coverage has increased since 2000 but remains limited for many low-income, minority, and older adult populations. The oral health care workforce has expanded to include new dental specialties and allied professional models, increasing access to health promotion and preventive services. Practice gains made by women and Asian Americans have not extended to other minority demographic groups. Oral health integration models are improving access to and delivery of patient-centered care for some vulnerable populations. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Coordinated policies and additional resources are needed to further improve access to care, develop dental insurance programs that reduce out-of-pocket costs to lower-income adults, and improve the integration of oral and medical health care delivery targeting a common set of patient-centered outcomes. Dental care professionals need to fully participate in meaningful and system-wide change to meet the needs of the population equitably.

Assessing oral health content in nondental professional association websites.

OBJECTIVES: Determine the prevalence and type of oral health (OH) content among nondental health professional associations' websites. METHODS: Fifty-nine organizations were selected from three lists of health professional associations and categorized as physician-, nurse- and other healthcare-related professions. Eight dental search terms were used on searchable websites. Six types of OH information were collected. Websites were assessed for any OH content and comparisons made. Frequencies, chi-square, and Fisher extract test statistics were calculated. RESULTS: Thirty-five (59 percent) of websites had any OH information content. Twenty (34 percent) had OH authored content, 10-19 percent had OH webpages, interest groups, or initiatives, CE courses or webinars, or curriculum information. The term "oral hygiene" gave the greatest yield and "dentistry" the least. No significant differences in existence of "Any OH content" was found between each organization type versus others. CONCLUSION: Many nondental professional associations could increase OH website content and education with assistance from dental organizations.

The Evolving Role of Health Literacy in Improving Oral Health.

This chapter provides a review of the evolution of oral health literacy including its impact on oral health outcomes, the current status of oral health literacy initiatives and future research needs. Using the Healthy People 2010 definition, the chapter describes opportunities needed to improve oral health literacy among health providers as well as individuals/patients, communities and policy-makers. Studies of the two most prevalent dental diseasesâATdental caries and periodontal diseases - reveal that increasing the oral health literacy of the public and health care providers can play a major role in reducing these diseases. Increasing oral health literacy by creating access to accurate knowledge and supporting use of science-based preventive measures is essential. A major part of the chapter describes oral health literacy's influence in the integration of dental and medical care. The chapter provides an extensive list of research needed to further our understanding of the impact of oral health literacy on health disparities and the health of the population.

Bridging the dental-medical divide: Case studies integrating oral health care and primary health care.

BACKGROUND: The National Academies of Sciences, Engineering, and Medicine commissioned an environmental scan describing the status of health care integration of oral health and primary care services. METHODS: The authors conducted an environmental scan of US integration activities with publications from January 2000 through August 2017. They categorized services as preventive oral health services (POHS) provided by medical care providers, POHS provided by dental providers in nondental settings, preventive health services provided by dental providers, or care coordination using dedicated personnel and technology. The authors chose 4 programs as case studies and interviewed key personnel in each program. One case study illustrates each category of integrated services; additional examples describe category variation. RESULTS: The case study involving Into the Mouth of Babes illustrates medical professionals delivering POHS to children. The case study involving Grace Health presents dental hygienists embedded in the obstetrics-gynecology clinic to provide oral screening, prophylaxis, and education to pregnant women. At HealthPartners, medical care providers refer patients with diabetes to dentists and waive copays for periodontal care. The InterCommunity Health Network Coordinated Care Organization uses dedicated patient coordinators, technology, and coordinated payment and referral mechanisms to facilitate care. CONCLUSIONS: Integration of dental and medical care increased access to and coordination of patient care by means of offering health care services traditionally provided by the other profession. PRACTICAL IMPLICATIONS: Integration models demonstrate the incorporation of POHS by primary care professionals, the embedding of dental professionals into primary care clinics, and the incorporation of care coordination to increase the delivery of oral health care. Similarly, dentists identify and refer patients with medical needs or preventive gaps to medical homes.

Integrating Oral Health and Primary Care in the Changing Health Care Landscape.

The bi-directional relationship among oral health and other systemic diseases and conditions provides a strong rationale for integration of oral health and primary care practice. Patient care services may be coordinated across different times, places, and professional disciplines to provide a team approach to care for overall health.

The value of a combined word recognition and knowledge measure to understand characteristics of our patients' oral health literacy.

OBJECTIVE: The objective of the analysis was to examine the association between sociodemographic and dental understanding and utilization characteristics and lower oral health literacy (HL) and knowledge. METHODS: The cross-sectional Multicenter Oral Health Literacy Research Study (MOHLRS) recruited and interviewed 923 English-speaking, initial care-seeking adults. The questionnaire included participant sociodemographic characteristics, measures of the participant's understanding and utilization of dentistry, and two oral HL measures, the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D) and the Comprehensive Measure of Oral Health Knowledge (CMOHK), which were combined into a new composite HL and knowledge measure, the MOHLR-K. RESULTS: In adjusted multivariable analysis, persons who reported more understanding of dentist instructions had higher mean scores for all HL measures. Subjects reporting the highest level of understanding had greater scores by an average of 1.6 points for the MOHLR-K (95% CI: 0.85-2.40, P<.01), 2.11 points for REALMD-20 (95% CI: 0.75-3.48, P<.01) and 2.20 points for CMOHK (95% CI: 1.01-3.40, P<.01) after controlling for demographic and other dental understanding and utilization factors. Persons who reported history of tooth decay had higher MOHLR-K scores by an average of about 0.77 points (95% CI: 0.49-1.04, P<.01), higher REALMD-20 scores by 0.54 points (95% CI: 0.12-0.95, P=.01) and higher CMOHK scores by 1.22 points (95% CI: 0.82-1.63, P<.01) as compared to persons without tooth decay history after controlling for the other factors. Persons who had support all of the time for travel to the dentist had higher scores by an average of about 0.5 points for the MOHLR-K (95% CI: 0.04-0.96, P=.03) and about 0.89 points for the REALMD-20 (95% CI: 0-1.79, P=.05) as compared to subjects with no support after controlling for other factors. Report of periodontal history, financial challenges to delay a dental visit and dental utilization were not significantly associated with any of the HL measures once the other factors were adjusted for in the model. CONCLUSION: The analysis confirmed that pronunciation of medical and dental terms may not fully reflect comprehension and revealed that understanding both patients' sociodemographic and dental understanding and utilization factors, such as transportation to the dental office associated with lower oral HL and knowledge, could help the profession develop appropriate clear language programmes to improve access to dental care for vulnerable populations.

Oral health conceptual knowledge and its relationships with oral health outcomes: Findings from a Multi-site Health Literacy Study.

OBJECTIVES: In 2010, a health literacy instrument designed to measure oral health conceptual knowledge was introduced. This developmental work was limited in that it included a relatively small and homogeneous study population and few oral health measures against which to test concurrent validity. The purpose of the present investigation is to expand upon the earlier work by utilizing a larger study sample and additional outcome variables. METHODS: Data for this report came from the Multi-site Oral Health Literacy Research Study (MOHLRS), a large, cross-sectional survey conducted at two university-based dental clinics in the United States. MOHLRS included multiple assessments administered during face-to-face interviews. Conceptual knowledge was measured with the Comprehensive Measure of Oral Health Knowledge (CMOHK). Questions about self-efficacy, utilization, and dental beliefs and attitudes were also asked. Covariates included recruitment site, age, gender, race/ethnicity, education level, and languages spoken. RESULTS: Overall, 18% of 909 adult participants exhibited "low" conceptual knowledge. CMOHK scores were significantly associated with three health literacy instruments, the REALM, Short-test of functional health literacy in adults (TOFHLA), and confidence filling out forms. In both bivariate and multivariable analyses, CMOHK scores were also significantly associated with dental beliefs and attitudes and self-efficacy to prevent both dental caries and periodontal disease. CMOHK scores were not associated with utilization, measured either as having a dental visit or a dental cleaning in the last year. CONCLUSIONS: The present investigation provides additional support for the CMOHK's validity. Researchers are encouraged to incorporate oral health conceptual knowledge into their theoretical frameworks, especially as it relates to beliefs and self-efficacy.

Did you know Medicare does not usually include a dental benefit? Findings from a multisite investigation of oral health literacy.

OBJECTIVES: Medicare does not usually include a dental benefit. Adults who are unaware of this fact risk unanticipated expenses after retirement. This report will explore the sociodemographic and oral health literacy determinants of this knowledge. METHODS: Data came from the Multi-Site Oral Health Literacy Research Study, a survey of patients presenting to two university dental clinics. Sociodemographic descriptors included age, sex, race/ethnicity, education level, and dental insurance status. Oral health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D). RESULTS: Only 34 percent of respondents knew the correct answer to the Medicare question. Knowledge was significantly associated with age, race/ethnicity, education level (bivariate only), and REALM-D score. CONCLUSIONS: Policymakers and those assisting in Medicare enrollment should ensure information regarding dental coverage is communicated in ways that individuals of varying literacy, language, and culture understand what is necessary to make appropriate decisions.

Oral Health Literacy and Measures of Periodontal Disease.

BACKGROUND: Existing evidence demonstrating a relationship between health literacy (HL) and periodontal health is insufficient to identify how providers can help patients manage periodontal disease. This study assesses associations between HL measures (word recognition, numeracy, and conceptual knowledge) and signs of periodontal disease. METHODS: This study included 325 new patients at a dental school clinic and employed an oral HL (OHL) survey, full-mouth radiographs, and clinical examination. Evaluations included the relationship between each HL measure versus number of teeth, bleeding score, plaque score, and periodontal severity with linear and ordinal logistic regression models before and after adjusting for covariates. RESULTS: Among HL measures, the Newest Vital Sign demonstrated a significant relationship with number of teeth and the Short Test of Functional Health Literacy in Adults showed a significant association with plaque score. The short Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALMD-20) showed participants who performed in the highest quartile had nearly two additional teeth, over 5.5% fewer bleeding sites, and nearly 9% fewer teeth with plaque after adjustment for demographic variables, smoking, and diabetes mellitus (DM). Participants who scored in the highest quartile of the Comprehensive Measure of Oral Health Knowledge (CMOHK) had nearly 9% less plaque. CONCLUSIONS: Two OHL instruments (REAMLD-20 and CMOHK) provided statistical associations with clinical measures of periodontal health at a level that could be considered of moderate clinical relevancy. Findings suggest dentists may wish to assess familiarity of their patients with dental terminology and knowledge of periodontal disease to provide education on oral hygiene, smoking, and DM.

Comparing Well-Tested Health Literacy Measures for Oral Health: A Pilot Assessment.

There has been growing national concern over the low health literacy of Americans and, coinciding with this, a growing importance placed on measuring health literacy. Health literacy is the ability to access, understand, and use information to make health decisions. Health literacy in an oral health context means access to accurate information about oral health, understanding the risks of neglecting oral care, and calculating the chances of getting periodontal disease. This exploratory study compared the 3 most popular and well-tested health literacy measures in an oral health setting. Using a survey of dental patients from safety net dental clinics in two states, we explored differences and similarities between health literacy measures as they pertained to oral health perceptions and oral self-efficacy. Findings indicated that the three health literacy measures were not interchangeable and had differential effects on data collected, which suggested differential relationships with oral health perceptions and outcomes.

Assessing health literacy and oral health: preliminary results of a multi-site investigation.

OBJECTIVES: To introduce a multi-site assessment of oral health literacy and to describe preliminary analyses of the relationships between health literacy and selected oral health outcomes within the context of a comprehensive conceptual model. METHODS: Data for this analysis came from the Multi-Site Oral Health Literacy Research Study (MOHLRS), a federally funded investigation of health literacy and oral health. MOHLRS consisted of a broad survey, including several health literacy assessments, and measures of attitudes, knowledge, and other factors. The survey was administered to 922 initial care-seeking adult patients presenting to university-based dental clinics in California and Maryland. For this descriptive analysis, confidence filling out forms, word recognition, and reading comprehension comprised the health literacy assessments. Dental visits, oral health functioning, and dental self-efficacy were the outcomes. RESULTS: Overall, up to 21% of participants reported having difficulties with practical health literacy tasks. After controlling for sociodemographic confounders, no health literacy assessment was associated with dental visits or dental caries self-efficacy. However, confidence filling out forms and word recognition were each associated with oral health functioning and periodontal disease self-efficacy. CONCLUSIONS: Our analysis showed that dental school patients exhibit a range of health literacy abilities. It also revealed that the relationship between health literacy and oral health is not straightforward, depending on patient characteristics and the unique circumstances of the encounter. We anticipate future analyses of MOHLRS data will answer questions about the role that health literacy and various mediating factors play in explaining oral health disparities.

Developing a flexible core Dental Public Health curriculum for predoctoral dental and dental hygiene schools.

OBJECTIVE: The curriculum for graduating dental and dental hygiene students must prepare them to contribute to the improvement or maintenance of health for individual patient's and the public's health. The objective is to describe the background for and the process used to develop a core Dental Public Health Curriculum for such students. METHODS: The process used was to solicit and review existing dental public health curriculum in dental and dental hygiene schools; review curriculum for other health professionals; identify the themes needed to frame the curriculum; select usable materials and identify gaps in existing curricular materials; and develop appropriate curriculum materials that would embody the competencies developed for undergraduate dental and dental hygiene education. RESULTS: Twenty-three topics were identified as embodying the eight competencies. Based on these topics, six courses, Principles of Dental Public Health, Evidence-Based Dentistry, Ethics and Dental Public Health, Dental Public Health Policy and Advocacy, Oral Health Promotion and Disease Prevention, and Oral Health Literacy and Dental Public Health, were prepared. Each course includes syllabus, PowerPoint presentations, student assignments and activities, instructor guide, and classroom discussion points. Depending on the hours available in the existing curriculum at the dental or hygiene school, lecture presentations and take home assignments/discussions may be used independently or in combination with presentations from other courses. In addition, individual discussions and activities may be used to integrate dental public health materials into other courses. CONCLUSION: A flexible curriculum is available at the AAPHD website to enable the incorporation of DPH topics into the curriculum.

Pilot testing a predoctoral dental public health curriculum: reporting process and outcomes.

OBJECTIVES: The purpose of this study was to pilot test the predoctoral dental public health (DPH) curriculum developed by the American Association of Public Health Dentistry (AAPHD) in various US dental schools and dental hygiene programs. METHODS: Following the Lewy's theoretical framework, we used all three curriculum tryout methods (laboratory tryout, pilot tryout, and field tryout) for the pilot testing process. Open-ended questions on the structure, presentation, and content of the curriculum were sent to faculty pilot testing the DPH curriculum to obtain critical feedback and comments. RESULTS: Between Summer 2013 and Spring 2015, the curriculum was pilot tested in nine dental schools and seven dental hygiene programs with over 1,300 students. The majority of the comments from the faculty were favorable. Positive comments about the structure of the curriculum focused on the well-organized nature of the curriculum, the value of the instructor guide and speaker notes, rubrics, and the flow of the presentations. In terms of the content, faculty commented on the wide range of public health issues covered and the clarity of course and lecture objectives. Negative comments dealt with the level of detail, some confusing assignments, and outdated data. Problems identified in pilot testing were corrected in the final DPH curriculum. CONCLUSIONS: The curriculum was successfully utilized in varied formats and well received. Through AAPHD, this standardized DPH core curriculum is now available for widespread use at dental schools and dental hygiene programs.

Developing core dental public health competencies for predoctoral dental and dental hygiene students.

Dental professionals are an "underutilized" workforce, when it comes to advocating for prevention and wellness in populations. The goal of this HRSA-funded project is to develop dental public health (DPH) competencies and curriculum for US predoctoral dental and dental hygiene programs. These competencies and accompanying curriculum are designed to better prepare the oral health workforce to meet the needs of the entire population, including the chronically underserved, those challenged by poor health literacy, or communities encountering barriers to accessing oral health care. By increasing the DPH competency of all graduating dental providers, in population-based approaches to preventing oral diseases rather than the existing exclusive focus on treatment, the number of providers who can respond to a population or the public's unmet needs and challenges, both in private practices and publicly supported clinics, will increase. This paper describes the competency development process and the eight competencies that were identified.

The association of patients' oral health literacy and dental school communication tools: a pilot study.

The aim of this pilot study was to assess adult patients' ability to read and understand two communication tools at the University of California, Los Angeles, School of Dentistry: the dental school clinic website and a patient education brochure pertaining to sedation in children that was written by dental school personnel. A convenience sample of 100 adults seeking treatment at the school's general dental clinic during 2012-13 completed a health literacy screening instrument. They were then asked to read clinic educational and informational materials and complete a survey. Analyses were conducted to determine the association between the subjects' oral health literacy and sociodemographics and their ability to locate and interpret information in written oral health information materials. SMOG and Flesch-Kincade formulas were used to assess the readability level of the electronic and written communication tools. The results demonstrated an association between these adults' oral health literacy and their dental knowledge and ability to navigate health information website resources and understand health education materials. Health literacy was not associated with age or gender, but was associated with education and race/ethnicity. The SMOG Readability Index determined that the website and the sedation form were written at a ninth grade reading level. These results suggest that dental schools and other health care organizations should incorporate a health-literate approach for their digital and written materials to enhance patients' ability to navigate and understand health information, regardless of their health literacy.

The association between oral health literacy and failed appointments in adults attending a university-based general dental clinic.

OBJECTIVES: The purpose of this study is to determine the association between personal characteristics, a person's oral health literacy, and failing to show for dental appointments at a university dental clinic. METHODS: A secondary data analysis was conducted on data collected from 200 adults at a university dental clinic between January 2005 and December 2006. In the original study, an oral health literacy instrument, the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D), was administered, sociodemographic and health information seeking behavior was gathered, and electronic records were reviewed. RESULTS: Descriptive and bivariate analyses and a classification and regression tree (CART) analysis were conducted. Seeking health information through fewer sources vs. multiple sources was the strongest predictor of failing to show. The subjects' oral health literacy, as measured by the REALM-D List 3 score, was the next most significant variable. Classification and regression tree analyses also selected gender, chief complaint, age, and payment type as predictor variables. CONCLUSIONS: Multiple factors contribute to failing to show for dental appointments. However, individuals who use fewer sources of oral health information, a subset of health literacy skills, are more likely to fail to show for dental appointments.