Quantitative data collection approaches in subject-reported oral health research: a scoping review.

BACKGROUND: This scoping review reports on studies that collect survey data using quantitative research to measure self-reported oral health status outcome measures. The objective of this review is to categorize measures used to evaluate self-reported oral health status and oral health quality of life used in surveys of general populations. METHODS: The review is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) with the search on four online bibliographic databases. The criteria include (1) peer-reviewed articles, (2) papers published between 2011 and 2021, (3) only studies using quantitative methods, and (4) containing outcome measures of self-assessed oral health status, and/or oral health-related quality of life. All survey data collection methods are assessed and papers whose methods employ newer technological approaches are also identified. RESULTS: Of the 2981 unduplicated papers, 239 meet the eligibility criteria. Half of the papers use impact scores such as the OHIP-14; 10% use functional measures, such as the GOHAI, and 26% use two or more measures while 8% use rating scales of oral health status. The review identifies four data collection methods: in-person, mail-in, Internet-based, and telephone surveys. Most (86%) employ in-person surveys, and 39% are conducted in Asia-Pacific and Middle East countries with 8% in North America. Sixty-six percent of the studies recruit participants directly from clinics and schools, where the surveys were carried out. The top three sampling methods are convenience sampling (52%), simple random sampling (12%), and stratified sampling (12%). Among the four data collection methods, in-person surveys have the highest response rate (91%), while the lowest response rate occurs in Internet-based surveys (37%). Telephone surveys are used to cover a wider population compared to other data collection methods. There are two noteworthy approaches: 1) sample selection where researchers employ different platforms to access subjects, and 2) mode of interaction with subjects, with the use of computers to collect self-reported data. CONCLUSION: The study provides an assessment of oral health outcome measures, including subject-reported oral health status and notes newly emerging computer technological approaches recently used in surveys conducted on general populations. These newer applications, though rarely used, hold promise for both researchers and the various populations that use or need oral health care.

Development of a parents' short form survey of their children's oral health.

BACKGROUND: Parents play an important role in their children's oral health behaviors, provide oral health access, initiate prevention, and coping strategies for health care. AIM: This paper develops a short form (SF) to assist parents to evaluate their children's oral health status using Patient-Reported Outcome Measurement Information System (PROMIS) framework that conceptualized health as physical, mental, and social components. DESIGN: Surveys of parents were conducted at dental clinics in Los Angeles County, together with an on-site clinical examination by dentists to determine clinical outcomes, Children's Oral Health Status Index (COHSI), and referral recommendations (RRs). Graded response models in item response theory were used to create the SF. A toolkit including SF, demographic information, and algorithms was developed to predict the COHSI and RRs. RESULTS: The final SF questionnaire consists of eight items. The square root mean squared error for the prediction of COHSI is 7.6. The sensitivity and specificity of using SF to predict immediate treatment needs (binary RRs) are 85% and 31%. CONCLUSIONS: The parent SF is an additional component of the oral health evaluation toolkit that can be used for oral health screening, surveillance program, policy planning, and research of school-aged children and adolescents from guardian perspectives.

Short form development for oral health patient-reported outcome evaluation in children and adolescents.

PURPOSE: Children and adolescents are vulnerable to dental problems and oral diseases. This paper presents the development of two multi-item self-report scales for use in assessing oral health status of children and adolescents. METHODS: Following the Patient-Reported Outcome Measurement Information System framework, survey questions were designed using a newly developed conceptual model. These items were administered to 334 children and adolescents (8-17 years) along with concurrent dental exams. Exploratory and confirmatory factor analyses were conducted and the item response theory graded response model was used to estimate item parameters and oral health status scores and to identify short-form items. The items were selected by high level of information and wide coverage of different domains to assess Child Oral Health Status Index (COHSI) and treatment referral recommendations (RR). RESULTS: The long form consists of 28 items. The short-form includes 12 items (8 for COHSI and 7 for RR with 3 common items).The intra-class correlations between long form and short-form were 0.90 for COHSI and 0.87 for RR. CONCLUSION: The short-forms provide a possible solution for the longstanding challenge of oral health evaluation for large populations of children and adolescents. The calibrated long form provides the foundation for computer adaptive test administration. These oral health assessment toolkits can be used for oral health screening, surveillance program, policy planning, and research.

Patient-Reported oral health outcome measurement for children and adolescents.

BACKGROUND: Oral health is an important component of daily functioning and well-being. A comprehensive patient-reported oral health measure is needed to gauge the impact of oral health status on children and adolescents. This study aims to develop oral health item banks and associated short-form surveys for children and adolescents 2-17 year olds. METHODS: Using children and adolescents, ages 2-17 years, selected from diverse dental sites in Greater Los Angeles Area, we propose to develop state-of-the-science methods to create oral health item banks to effectively measure oral health outcomes for children and adolescents. Methods include a literature review of existing measures, focus groups, cognitive interviews, drafting and field testing of survey items, and evaluation of the psychometric properties of the measures. RESULTS: Based on the systematic literature search and focus groups, we identified core (physical health, mental health, and social function domains) and peripheral (e.g., need and access) oral health domains. We then drafted survey items and revised them based on 66 cognitive interviews (27 children/adolescents and 39 parents) with 39 families. The revised items will be administered in a field test of 500 children and adolescents ages 2-17, and their parents. CONCLUSIONS: The qualitative methods used in the initial phases of the project (focus group and cognitive interviews) are the initial steps in the development of oral health item banks and associated short-form surveys for children and adolescents. The oral health items can potentially be used to create effective computerized adaptive test and/or create ad hoc short forms targeting specific areas of oral health to survey large populations of children with much less cost compared with traditional clinical oral health examination.

Child and adolescent perceptions of oral health over the life course.

PURPOSE: To elicit perceptions of oral health in children and adolescents as an initial step in the development of oral health item banks for the Patient-Reported Oral Health Outcomes Measurement Information System project. METHODS: We conducted focus groups with ethnically, socioeconomically, and geographically diverse youth (8-12, 13-17 years) to identify perceptions of oral health status. We performed content analysis, including a thematic and narrative analysis, to identify important themes. RESULTS: We identified three unique themes that the youth associated with their oral health status: (1) understanding the value of maintaining good oral health over the life course, with respect to longevity and quality of life in the adult years; (2) positive association between maintaining good oral health and interpersonal relationships at school, and dating, for older youth; and (3) knowledge of the benefits of orthodontic treatment to appearance and positive self-image, while holding a strong view as to the discomfort associated with braces. CONCLUSIONS: The results provide valuable information about core domains for the oral health item banks to be developed and generated content for new items to be developed and evaluated with cognitive interviews and in a field test.

Development of short forms for screening children's dental caries and urgent treatment needs using item response theory and machine learning methods.

OBJECTIVES: Surveys can assist in screening oral diseases in populations to enhance the early detection of disease and intervention strategies for children in need. This paper aims to develop short forms of child-report and proxy-report survey screening instruments for active dental caries and urgent treatment needs in school-age children. METHODS: This cross-sectional study recruited 497 distinct dyads of children aged 8-17 and their parents between 2015 to 2019 from 14 dental clinics and private practices in Los Angeles County. We evaluated responses to 88 child-reported and 64 proxy-reported oral health questions to select and calibrate short forms using Item Response Theory. Seven classical Machine Learning algorithms were employed to predict children's active caries and urgent treatment needs using the short forms together with family demographic variables. The candidate algorithms include CatBoost, Logistic Regression, K-Nearest Neighbors (KNN), Naïve Bayes, Neural Network, Random Forest, and Support Vector Machine. Predictive performance was assessed using repeated 5-fold nested cross-validations. RESULTS: We developed and calibrated four ten-item short forms. Naïve Bayes outperformed other algorithms with the highest median of cross-validated area under the ROC curve. The means of best testing sensitivities and specificities using both child-reported and proxy-reported responses were 0.84 and 0.30 for active caries, and 0.81 and 0.31 for urgent treatment needs respectively. Models incorporating both response types showed a slightly higher predictive accuracy than those relying on either child-reported or proxy-reported responses. CONCLUSIONS: The combination of Item Response Theory and Machine Learning algorithms yielded potentially useful screening instruments for both active caries and urgent treatment needs of children. The survey screening approach is relatively cost-effective and convenient when dealing with oral health assessment in large populations. Future studies are needed to further leverage the customize and refine the instruments based on the estimated item characteristics for specific subgroups of the populations to enhance predictive accuracy.

Socio-behavioral predictors of self-reported oral health-related quality of life.

PURPOSE: To examine the relationship between social and financial support, behavioral and sociodemographic variables, and oral health-related quality of life (OHRQoL) in a national probability sample. METHODS: The National Health and Nutrition Examination Survey (NHANES) 2003-2004 data system was used; there were 12,761 persons selected for the sample, 10,122 of those were interviewed (79.3 %). Oral health-related quality of life, the outcome measure, was evaluated using seven items derived from the 14-item NHANES Oral Health Impact Profile (OHIP) included in the home interview. The aggregated OHRQoL scores ranged from 7 to 28. We included only adults, aged 20 and older, who self-reported their alcohol use during home interview (n = 5,014). Independent variables were social and financial support, and behavioral variables (smoking and alcohol use), with sociodemographic variables as covariates. Multiple linear regression analysis used weighted data representing 124 million persons. RESULTS: Lack of financial support reduced OHRQoL, but not social support. Smoking reduced OHRQoL, but not alcohol use. Compared to ages 20-24, persons aged 24-44 and aged 45-64 had significantly lower OHRQoL scores, but persons aged 65+ did not. Latinos' OHRQoL scores were lower than those of whites; there were no differences between whites and other ethnic groups. CONCLUSION: The model provides insights into the perception of OHRQoL in that oral health related to the ability to pay for care. Those in the middle years (24-64) rate their OHRQoL lower than do their younger cohorts; there is no difference in OHRQoL between the young and the old.

Oral health status and the epidemiologic paradox within Latino immigrant groups.

BACKGROUND: According to the United States census, there are 28 categories that define "Hispanic/Latinos." This paper compares differences in oral health status between Mexican immigrants and other Latino immigrant groups. METHODS: Derived from a community-based sample (N = 240) in Los Angeles, this cross-sectional study uses an interview covering demographic and behavioral measures, and an intraoral examination using NIDCR epidemiologic criteria. Descriptive, bivariate analysis, and multiple regression analysis were conducted to examine the determinants that are associated with the Oral Health Status Index (OHSI). RESULTS: Mexican immigrants had a significantly higher OHSI (p < .05) compared to other Latinos. The multilinear regression showed that both age and gender (p < .05), percentage of untreated decayed teeth (p < .001), number of replaced missing teeth (p < .001), and attachment loss (p < .001) were significant. CONCLUSIONS: Compared with the other Latino immigrants in our sample, Mexican immigrants have significantly better oral health status. This confirms the epidemiologic paradox previously found in comparisons of Mexicans with whites and African Americans. In this case of oral health status the paradox also occurs between Mexicans and other Latinos. Therefore, when conducting oral health studies of Latinos, more consideration needs to be given to differences within Latino subgroups, such as their country of origin and their unique ethnic and cultural characteristics.

Investigating Perceptions of Teachers and School Nurses on Child and Adolescent Oral Health in Los Angeles County.

This study reports the results of focus groups with school nurses and teachers from elementary, middle, and high schools to explore their perceptions of child and adolescent oral health. Participants included 14 school nurses and 15 teachers (83% female; 31% Hispanic; 21% White; 21% Asian; 14% African American; and 13% Others). Respondents were recruited from Los Angeles County schools and scheduled by school level for six one-hour focus groups using Zoom. Audio recordings were transcribed, reviewed, and saved with anonymization of speaker identities. NVivo software (QSR International, Melbourne, Australia) was used to facilitate content analysis and identify key themes. The nurses' rate of "Oral Health Education" comments statistically exceeded that of teachers, while teachers had higher rates for "Parental Involvement" and "Mutual Perception" comments. "Need for Care" was perceived to be more prevalent in immigrants to the United States based on student behaviors and complaints. "Access to Care" was seen as primarily the nurses' responsibilities. Strong relationships between community clinics and schools were viewed by some as integral to students achieving good oral health. The results suggest dimensions and questions important to item development for oral health surveys of children and parents to address screening, management, program assessment, and policy planning.

Using a Machine Learning Algorithm to Predict the Likelihood of Presence of Dental Caries among Children Aged 2 to 7.

BACKGROUND: Dental caries is the most common chronic childhood infectious disease and is a serious public health problem affecting both developing and industrialized countries, yet it is preventable in most cases. This study evaluated the potential of screening for dental caries among children using a machine learning algorithm applied to parent perceptions of their child's oral health assessed by survey. METHODS: The sample consisted of 182 parents/caregivers and their children 2-7 years of age living in Los Angeles County. Random forest (a machine learning algorithm) was used to identify survey items that were predictors of active caries and caries experience. We applied a three-fold cross-validation method. A threshold was determined by maximizing the sum of sensitivity and specificity conditional on the sensitivity of at least 70%. The importance of survey items to classifying active caries and caries experience was measured using mean decreased Gini (MDG) and mean decreased accuracy (MDA) coefficients. RESULTS: Survey items that were strong predictors of active caries included parent's age (MDG = 0.84; MDA = 1.97), unmet needs (MDG = 0.71; MDA = 2.06) and the child being African American (MDG = 0.38; MDA = 1.92). Survey items that were strong predictors of caries experience included parent's age (MDG = 2.97; MDA = 4.74), child had an oral health problem in the past 12 months (MDG = 2.20; MDA = 4.04) and child had a tooth that hurt (MDG = 1.65; MDA = 3.84). CONCLUSION: Our findings demonstrate the potential of screening for active caries and caries experience among children using surveys answered by their parents.

Computerized adaptive testing and short form development for child and adolescent oral health patient-reported outcomes measurement.

OBJECTIVES: To develop computerized adaptive testing (CAT) and short forms of self-report oral health measures that are predictive of both the children's oral health status index (COHSI) and the children's oral health referral recommendation (COHRR) scales, for children and adolescents, ages 8-17. MATERIAL AND METHODS: Using final item calibration parameters (discrimination and difficulty parameters) from the item response theory analysis, we performed post hoc CAT simulation. Items most frequently administered in the simulation were incorporated for possible inclusion in final oral health assessment toolkits, to select the best performing eight items for COHSI and COHRR. RESULTS: Two previously identified unidimensional sets of self-report items consisting of 19 items for the COHSI and 22 items for the COHRR were administered through CAT resulting in eight-item short forms for both the COHSI and COHRR. Correlations between the simulated CAT scores and the full item bank representing the latent trait are r = .94 for COHSI and r = .96 for COHRR, respectively, which demonstrated high reliability of the CAT and short form. CONCLUSIONS: Using established rigorous measurement development standards, the CAT and corresponding eight-item short form items for COHSI and COHRR were developed to assess the oral health status of children and adolescents, ages 8-17. These measures demonstrated good psychometric properties and can have clinical utility in oral health screening and evaluation and clinical referral recommendations.

Development of toolkits for detecting dental caries and caries experience among children using self-report and parent report.

OBJECTIVES: To develop child- and parent-reported toolkits for active caries and caries experience in children and adolescents, ages 8-17. METHODS: A sample of 398 child/parent dyads recruited from 12 dental practices in Los Angeles County completed a computer-assisted survey that assessed oral health perceptions. In addition, children received a dental examination that identified the presence or absence of active caries and caries experience. A Multiple Adaptive Regression Splines model was used to identify a subset of survey items associated with active caries and caries experience. The splines and coefficients were refined by generalized cross-validation. Sensitivity and specificity for both dependent variables were evaluated. RESULTS: Eleven child self-reported items were identified that had sensitivity of 0.82 and specificity of 0.45 relative to active caries. Twelve parent-reported items had a sensitivity of 0.86 and specificity of 0.50. Seven child self-reported items had a sensitivity of 0.86 and specificity of 0.34, and 11 parent-reported items had a sensitivity of 0.86 and specificity of 0.47 for caries experience. CONCLUSIONS: The survey items identified here are useful in distinguishing children with and without active caries and with and without caries experience. This research presents a path towards using children's and their parents' reports about oral health to screen for clinically determined caries and caries exposure. The items identified in this study can be useful when clinical information is unavailable.

Characteristics of dentists providing dental care to publicly insured patients.

OBJECTIVE: This study aims to identify the practice and patient care characteristics of dentists who provide care to publicly insured patients, beyond currently available existing information, which is typically limited to demographics of such dentists. METHODS: A cross-section of dentists in private practices in California was surveyed, with a 46 percent average adjusted response rate. The sample included 3,180 generalists or specialists who provided general care in private practice. Characteristics of dentists who provided care to publicly insured patients were examined in descriptive analyses. The independent association of dentist characteristics with the provision of any care and the provision of care to a significant number of publicly insured patients were examined in logistic regression analyses. RESULTS: Over 40 percent of dentists saw public patients. Regression analyses revealed that dentists who spent more time in periodontic and surgical care, saw more walk-in patients, had multilingual capacity, accepted reduced fees, had more minority patients, had fewer hygienists, or had multiple practice locations were more likely than those without such characteristics to provide care to publicly insured patients. CONCLUSIONS: Dentists who care for publicly insured patients appear to have practices that are different from those who do not, in terms of delivery of patient care and practice structure. Such differences have implications for the access to and quality of dental health care of publicly insured patients. The success of public programs and policies aimed at ensuring access to dental care depends on ability and willingness of dentists to accommodate public patients' needs.

Qualitative methods in the development of a parent survey of children's oral health status.

BACKGROUND: Parents' perceptions of their 8-17-year-old children's oral health status were assessed using a sample from diverse dental clinics in Greater Los Angeles County to identify constructs for a survey instrument. METHODS: Focus groups with 29 parents or guardians were conducted to identify themes that informed development of survey items. The draft items were administered to a different group of 32 parents or guardians in cognitive interviews, and revised for subsequent field-testing. RESULTS: Thematic and narrative analyses were performed after the focus groups and key lay-oriented dimensions were uncovered, notably the relationship between oral health, systemic health and the life course. In the cognitive interviews, parents entered multiple responses to questions related to the look of their child's teeth, and their overall perception of tooth color. Parents also assessed their child's fear or discomfort with the dental experience, and other social and psychological concerns related to oral health status. The temporal dimensions of certain items were specified; for example, oral pain and mood items were revised to include duration of the symptom or mood state. As parents tended to confuse oral health maintenance and prevention, these two related concepts were separated into two items. Based on the qualitative work, we revised items in preparation for a field test. CONCLUSIONS: As a PRO measurement study, qualitative research informed a field test survey to assess factors associated with oral health status and the individual's perceptions and subjective views of these constructs for eventual item development for epidemiological and clinical use.

Oral white patches in a national sample of medical HIV patients in the era of HAART.

OBJECTIVES: Several types of HIV-related oral mucosal conditions have been reported to occur during the course of HIV disease progression. Of these, few may be manifested as 'white' lesions and many are noticeable to the patient. This paper examines the relationships between social, behavioral and medical aspects of HIV infection and reporting an occurrence of oral white patches (OWP) by HIV-infected patients. METHODS: The subjects are participants in all three interviews in the HIV Cost and Services Utilization Study (HCSUS). The subjects were selected using a three-stage probability sampling design. The multivariate analysis is based on 2109 subjects with nonmissing binary outcome variable for all three waves representing a national sample of 214 000 individuals. The multivariate model was fitted using generalized estimating equations (GEE) by implementing the XTGEE command in STATA. RESULTS: We estimate that 75 000 persons (35%) reported at least one incident of OWP, of these 14 000 reported having OWP during all three interviews, and that the rate of reporting declined over the three HCSUS waves. The multivariate analysis showed seven variables that were significant predictors of at least one report of OWP. CONCLUSIONS: Compared with persons on HAART therapy, patients on other regimens or taking no antiviral medications were 23-46% more likely to report an incident of OWP. Compared with whites, African Americans were 32% less likely to report OWP, while current smokers were 62% more likely than nonsmokers. Being diagnosed with AIDS and having CD4 counts less than 500 significantly increased the likelihood of reporting OWP.

Oral health findings for HIV-infected adult medical patients from the HIV Cost and Services Utilization Study.

BACKGROUND: The HIV Cost and Services Utilization Study (HCSUS) was conducted by a consortium of private and government institutions centered at the RAND Corp. to provide national estimates of adult medical patients who are HIV-positive. This article presents descriptive oral health findings from that study. METHODS: The National Opinion Research Center (NORC) conducted four interviews of a nationally representative sample of adults with HIV who made a medical visit for regular care in early 1996. This article uses data from the second interview conducted between December 1996 and July 1997. The authors constructed analytical weights for each respondent so the 2,466 interviewees represented a population of 219,700. RESULTS: Most adult medical patients with HIV rated their oral health as at least "good," but 12 percent (representing a population of 25,300) rated it as "poor." Xerostomia was the most commonly reported symptom (37 percent) to arise in the time since the previous interview. Twenty-nine percent had a dental benefit under Medicaid and 23 percent had private insurance. Eighteen percent had not revealed their HIV status to the dentist they usually saw. CONCLUSIONS: National data on adult medical patients with HIV provide a context for local or convenience sample studies and can help give direction to public health and public policy programs directed to the oral health needs of this population. CLINICAL IMPLICATIONS: The attitudes and beliefs of adult HIV patients should be taken into account in the creation of community health education programs and continuing education for dentists. Medicaid programs should include adult dental benefits.

National estimates of out-of-pocket dental costs for HIV-infected users of medical care.

BACKGROUND: Out-of-pocket costs for U.S. dental care in 1996 were dollar 157 per person at the poverty level and dollar 229 for people with higher incomes. This article examines out-of-pocket expenditures for dental care in HIV-infected patients who took part in the HIV Cost and Services Utilization Study (HCSUS), conducted by a consortium of private and government institutions centered at the RAND Corp. METHODS: The HCSUS used a probability sampling design. The authors used a weighted sample of 2,466 HCSUS respondents to estimate the national population of HIV-infected users of medical care. The patients were asked to report how much they had spent on their dental care in the preceding 12 months, including payments made by them, their family or their friends--but not by insurance companies--for their dental care. RESULTS: In 1996, 135,000 HIV-infected subjects spent dollar 20.5 million on dental care, averaging dollar 152 per user. Whites spent dollar 220, African-Americans dollar 55 and Hispanics dollar 101. People receiving dental care from private dentists spent dollar 232 compared with dollar 7 spent by those who received care in AIDS clinics. CONCLUSIONS: More than one-half of the HIV-infected users of medical care identified private dentists as their source of dental care and spent the vast majority of the dollar 20.5 million. The remaining subjects identified public dental programs as their source of care and had low expenditures. The explanation for these low expenditures is the subsidization of public programs and the likelihood that fewer and less costly services are provided by such programs. PRACTICE IMPLICATIONS: Dentists should be aware of out-of-pocket funds spent by the HIV-infected population in private practices and public programs. Any policy change reducing public funding may result in higher out-of-pocket costs for disadvantaged groups or in increasing disparities in access to dental services.

Dental public health in California: a mixed picture.

Californians face significant dental public health problems. To address these problems, state government, professional organizations, and philanthropic entities in some areas have joined forces. Major issues such as fluoridation, access to care, and the role of the Dental Board of California are examined in terms of the varying roles these critical segments play in affecting the oral health of Californians. This issue of the Journal is dedicated to an examination of public health dentistry in California. While often thought of as innovative and at the "cutting-edge," the state presents a mixed picture of publicly funded oral health programs. Public health concerns sometimes take a lower priority or are overlooked by state government in an era of cutbacks. California lags behind other states in many public goods crucial to the overall quality of life of its residents. This dichotomy is evident in dental public health as it is in education, general health, and air quality. This paper assesses selected dental public health programs, identifying those where innovations have occurred and other program areas where the state has inadequately addressed the dental public health needs of its population.

Assessing the contribution of the dental care delivery system to oral health care disparities.

OBJECTIVES: Existing studies of disparities in access to oral health care for underserved populations often focus on supply measures such as number of dentists. This approach overlooks the importance of other aspects of the dental care delivery system, such as personal and practice characteristics of dentists, that determine the capacity to provide care. This study aims to assess the role of such characteristics in access to care of underserved populations. METHODS: We merged data from the 2003 California Health Interview Survey and a 2003 survey of California dentists in their Medical Study Service Areas (MSSAs). We examined the role of overall supply and other characteristics of dentists in income and racial/ethnic disparities in access, which was measured by annual dental visits and unmet need for dental care due to costs. RESULTS: We found that some characteristics of MSSAs, including higher proportions of dentists who were older, white, busy or overworked, and did not accept public insurance or discounted fees, inhibited access for low-income and minority populations. CONCLUSIONS: These findings highlight the importance of monitoring characteristics of dentists in addition to traditional measures of supply such as licensed-dentist-to-population ratios. The findings identify specific aspects of the delivery system such as dentists' participation in Medicaid, provision of discounted care, busyness, age, race/ethnicity, and gender that should be regularly monitored. These data will provide a better understanding of how the dental care delivery system is organized and how this knowledge can be used to develop more narrowly targeted policies to alleviate disparities.

The impact of HIV on oral health and subsequent use of dental services.

OBJECTIVE: This study examined differences in health and access to dental services among a nationally representative sample of patients with HIV using Andersen's Behavioral Model of Health Services Use. METHODS: This investigation is a longitudinal study that used structural equation modeling to analyze data from the HIV Cost and Services Utilization Study, a probability sample of 2,864 adults under treatment for HIV infection. Key predisposing variables included sex, drug use, race/ethnicity, education, and age. Enabling factors included income, insurance, and regular source of care. Need factors included mental, physical, and oral health. Dependent variables included whether a respondent utilized dental services and number of visits. RESULTS: More education, dental insurance, usual source of dental care, and poor oral health predicted a higher probability of having a dental visit. African Americans, Hispanics, those exposed to HIV through drug use or heterosexual contact, and those in poor physical health were less likely to have a dental visit. Of those who visited dental professionals, older persons, those with dental insurance, and those in worse oral health had more visits. African Americans and persons in poor mental health had fewer visits. CONCLUSIONS: Persons with more HIV-related symptoms and a diagnosis of AIDS have a greater need for dental care than those with fewer symptoms and without AIDS, but more pressing needs for physical and mental health services limit their access to dental services. Providers should better attend to the oral health needs of persons with HIV who are in poor physical and mental health.