Running Head: ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 1 Individual Level Characteristics that Affect the Association Between Dental Concerns and Problems Megan K. Hall, Jasmine A. Mack, MPH, and Linda B. Cottler, PhD, MPH, FACE University of Florida
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 2 Abstract Objective : This study estimates how demographic and socioeconomic factors, as well as access to care and use of drugs can influe nce the association between dental concerns and problems. Methods: Data was collected at the University of Florida through HealthStreet needs assessments from 2011 2017. Individual level characteristics and the expre ssion of dental concerns and problems were recorded for 2,319 people ; participants were stratified into four groups: concerns/ problems, concerns/no problems, no concerns/problems, and no concerns/no problems These typologies were then compared using a n adjusted multinomial logistic regression. Results: Nearly all demographic, access to care, and drug use variables were significantly associated with the typologies Nearly all parti cipan ts reported no concerns (89.5%); the most prevalent typology was no concerns with problems (47.4%). Conclusions: There is a need for improved oral health education and outreach among nearly all participants. Additional research that includes more participants and solicits a broader variety of dental problems could reduce bias This research shows the importance of implementing dental evaluations and interventions in the community in order to decrease patient concerns and problems and improve oral health.
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 3 Individual Level Characteristics That Affect the Association Between Dental Concerns and Problems There are a variety of factors that influence the prevalence of dental problems and dental concerns. It is critical for dental professionals to recognize the characteristics that affect a person's feelings between their oral health concerns and their oral health problems in order for them to provide the most effective care and educat ion. Understanding these patterns can help dental professionals to determine appropriate outreach and treatment methods for specific populations and patients. Introduction Significant literature has focused on the association between the presence of dental problems and factors such as socioeconomic status, demographics, access to care, and drug use. For example, research by Kim, Baker, Seirawan, and Crimmins (2012) argues th at in the United States, African Americans and people with low levels of education experience more oral health problems. Other research indicates that the utilization of preventative dental care decreases during periods of unemployment (Quinn, Catalano, & Felber, 2009). Also, research by Griffin, Jones, Brunson, Griffin, and Bailey (2012) suggests that the large presence of untreated dental diseases in older adults may indicate that older people have more difficultly accessing care to prevent and control or al disease. In relation to drug use, a cross sectional study conducted at a treatment center for drug addiction concluded that people who used crack and other illicit drugs had a poorer oral health related quality of life than people who did not use illi cit drugs (Antoniazzi, Zanatta, Ardenghi, & Feldens, 2017). Also, i n a study on the effects of drug use on oral health, Mohammadi et al. (2017) found that the total number of missing, decayed, and filled teeth were significantly higher among opioid users compared to non users Studies have also evaluated patient concerns for dental health in relationship with factors such as age and dental fear. Griffin et al. (2012) proposes that older people have lower
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 4 utilization of dental care due t o their lack of perceived need. This suggests that older people have less of a concern for their dental health due to the fact that they report less of a need for dental care than younger people. Also, people are less likely to express their dental health concerns if dental anxiety is prevalent. Research by Yildirim (2016) discusses the importance of limiting dental fear and concludes that women and young children show significantly higher Dental Fear Survey scores than men and older patients. Yildirim (201 6) also states that patients with low socioeconomic status and low education levels also have higher Dental Fear Survey scores. Therefore, these people may be less likely to express their dental concerns. Despite the importance of understanding the associ ation between patients' dental health concerns and problems, there is limited research that evaluates both dental concerns and dental problems together and the characteristics that affect their association. This is important because some people have concer ns and no problems and they should continue to be vigilant, while other people have problems and no concerns and they need to be educated. More thorough research on this topic is needed in order to understand how demographic and socioeconomic factors, as w ell as access to care and use of drugs, can influence the association between dental concerns and problems with a goal to improve dental care Aims and Hypotheses The purpose of this study was to evaluate the individual level characteristics that affect the association between community member's dental concerns and dental problems. We also aimed to understand how access to care and medical insurance, as well as perceived health status, affect patterns of dental concerns and dental problems. Lastly, we use d this research to assess the relationship between the use of marijuana and prescription pain medication and the presence of dental concerns and dental problems. We hypothesized that younger and more educated people will be more likely to have no problems and no concerns Also, people with less access to medical and dental care and lower perceived health will be more likely to have problems and concerns and people with greater
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 5 access to care and higher perceived health will be more likely to have no probl ems and no concerns Lastly, we hypothesized that current and past users of prescription pain medication or marijuana will have lower rates of reported dental health concerns and have more dental problems than people who have never used. Method s Participan ts The participants for this study included HealthStreet members from North Central Florida. HealthStreet is a program at the University of Florida that focuses on improving the health of community members by assessing their health concerns, conditions, a nd research perceptions. The data was collected from 9,358 HealthStreet intake forms that each member completed from October 2011 August 2017. Only participants who answered all of the considered questions were included. Because the dental questions were added to the intake forms later in the collection process, the sample size was reduced to 2,319 participants. Variables Each participant completed an intake form that evaluated his or her individual level characteristics and determined whether or not they had dental concerns and dental problems. Dental concerns and problems. At the beginning of the assessment, participants were asked: "What are your top three health concerns?" They were considered to have dental con cern s if they mentioned "dental" or oral health" as one of their top three health concerns. The participants were also asked if they had ever been told they had, or had ever had a problem with dental health. If they answered "yes" to "dentures", "halitosis", "periodontal disease", "untreated cavities", "braces or retainer", or "other", then they were considered to have dental problems. Demographics.
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 6 To analyze the demographics and socioeconomic status, participants were asked their gender, age, ethnicity/race, education, employment, and whether or not they were Hispanic/Latinx Only participants that identified as male or female were included in the d ata. Age was analyzed categorically. Ethnicity/race was recorded as "Black/African American", "White", or "Other". Participants were identified as Hispanic/Latinx if they answered "yes" to the question on the intake form. Education was determined by whethe r the participant had a high school diploma, less than and high school diploma, or more than a high school diploma. Employment was re corded if the participants answered "yes" to having a full time or part time job. Access to care and healthcare utilizatio n. In order to analyze access to care and healthcare utilization, participants were asked if they had a physical or had seen a dentist within the past 12 months, if they had medical insurance, and their perceived health. Perceived health status was catego rized into two groups: "excellent/good" and "fair/poor". Drug use. The participants were also asked if they had ever used marijuana or prescription pain medications. They were given the o ptions "never", "past user", or "current user (past 30 days)". Anal yses All of the participants were separated into four groups : concerns/problems, no concerns/problems, concerns/no problems, and no concerns/no problems. The four groups were then compared in tables that evaluated the variables mentioned above. Chi square tests were performed and the data was interpreted as having a statistically significant difference at p < 0.05. The significant data determined from the tables was then used to perform a n adjusted mu ltinomial logistic regression analysis with the no concerns/no problems group as the reference. Each of the other groups (concerns/problems, no concerns/ problems, and
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 7 concerns/no problems) was compared to the reference group in or der to estimate the occurrence of dental concerns and dental problems based off of demographics/socioeconomic status access to care, and marijuana/prescription pain medication use. Results Typologies of Dental Concerns and Problems A significant proportion of participants reported no concerns (89.5%). Approximately equal proportions reported having (55.8%) and not having (44.2%) dental problems. The least prevalent typology had concerns but no problems (n =51, 2.2%) as shown in Table 1 Individual Level Characteristics by Dental Concern/Problem Typology Concerns and problems were analyzed for their association with individual level characteristics as shown in Table 2. N early all demographic, access to care, and drug use variables were significantly associated with dental concern and problem status ( p <0.05). Hispanic/Latinx status ( p =0.2680) and education ( p =0.1922) were statistically unassociated with typology. Specifically, a preponderance of young people was found among participants with no problems (columns C and D). Compared to the other groups, this group with no problems was also the most likely to report excellent or good health to be employed, and to have never used marijuana or prescription pain medications. Community members without oral health concerns ( columns B and D), compared to those with concerns, were more likely to be female. In contrast, p eople who had concerns (columns A and C) were least likely to have seen a dentist in the past 12 months and to have medical insur ance compared to their counterparts (columns B and D). Community members with both concerns and problems (column A) were most likely to be current or past marijuana users and were least likely to have had a physical in the past 12 months compared to the other groups. People with problems but no concerns (column B) were most likely to be the oldest participants (65 years of age and older), female, unemployed,
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 8 current or past users of prescription pain medications, and report fair or poor health status compared to the other groups. African Americans, compared to other races, were more likely to have concerns and no problems (column C) than a ny of the other typologies. Participants in the no concerns/no problems typology (column D) were most likely to report excellent or good perceived health and most likely to be employed compared to the other groups. They were also the least likely group to have not seen a dentist in the past 12 months (53.9% vs. 64.2% 82.4%) Adjusted Regression Predicting Dental Concern/Problem Typologies A djusted multinomial logistic regression was conducted with the no concerns and no problems group as the referent group (column D, Table 2). 95% confidence intervals were used and the odds ratio s (OR) estimated the influence that each variable (significant from the previous analysis) had on the likelihood of being in each of the other groups, compared to no concerns/no pro blems (see Table 3) The association between concern/problem typology and going to a den tist in the past 12 months was strong Participants who had not been to the dentist were more likely to have concerns/problems, no concerns/problems, and concerns/no problems compared to having no concerns/no problems (ORs = 2.0 9, 1.57, and 3.52 respectively) and was the only variable significantly associated across all three groups. After adjustment for other variables, concern/problem typology was associated with dr ug use. Compared to having no concerns and no problems, p eople who were currently using marijuana or had in the past, were between 72% and 86% more likely to have bo th concerns and problems. P eople who had used marijuana in the past were 24% more likely t o have no concerns and problems compared to the referent group, and people who reported current or past use o f prescription pain medications were 65% and 41% more li kely, respectively. Discussion
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 9 Our analysis shows a strong need for improved oral health education and outreach in the community. Nearly all participants reported no concerns with th eir dental health, regardless if they had problems or not. We found that the largest typology was pro blems but no concerns, which is surprising, suggesting that people are not concerned with their health status and are therefore less likely to seek treatment The results also concluded that African Americans are less likely to have problems but no concerns, which contradicts previous literature that showed that African Americans experience more oral health problems (Kim et al., 2012) The results from our analysis showed that African Americans were most common ly in the concerns/no problems group which shows that they are concerned with their oral health and should continue to be vigilant. In regards to employment, our research showed that people who are unemployed are more likely to have problems, regardless of their concerns. These results ar e similar t o previous research that states that preventative oral care decreases during periods of unemployment, which leads to more oral health problems (Quinn et al., 2009) Our findings showing that older people are more l ikely to have problems and no concerns and that younger people are more likely to have no problems and no concerns is consistent with studies that have shown that older people have a lower perceived need for dental care, despite the fact that they have mor e untreated dental diseases (Griffin et al., 2012). This suggests that older adults have more dental problems, but less concerns, perhaps because they have a lower perceived need compared to younger people. When compared to the group with no concerns and no problems, all of the other concern/problem typologies were less lik ely to have been to the dentist in the past 12 months suggesting that people who go to the dentist regularly are more likely to have no problems and no concerns. This is logical because going to the dentist frequently can prevent the occurrence of dental problems and also make patients less concerned because they know they are being treated effectively.
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 10 Information on the use of drugs showed that people who were current users of prescrip tion pain medications and past users of marijuana showed a higher prevalence of problems despite their concerns. This is consistent with research that claims that illicit drug users have poorer oral health (Mohammadi et al., 2017) One can speculate that current users of prescription pain medication show less concern, despite problems, because the drugs mask pain, making treatment less of a priority. W e can conclude that our hypothesis that younger people will be less likely to have problems and concerns is correct, but there was no significant difference in education across the groups The results were also consistent with our hypothesis that people with less access to medical and dental care would be more likely to have problems and concerns. But, accord ing to the data, people with fair/low perceived health state that they do have dental problems, but dental health is not one of their top three health concerns. This suggests that this population should be educated on the importance of oral health on overa ll wellbeing. Lastly, we were able to support our hypothesis that current users of pr escription pain medications would be more likely to have problems and less likely to have concerns than people who had never used, but past users of marijuana were more likely to have both concerns and problems. Notwithstanding the strengths of this study, there were a few limitations. First, d ue to the later addition of the dental questions to the intake form the sample size was reduced, with only 51 (2.2%) in the conc erns/no problems typology and 193 (8.3%) in the concerns/ problems typology This sample reduction may have limited the ability to find associations and statistical significance. Still, the sample was 2,319 overall, which is a sizable group for this first a nalysis. Secondly, the question about concerns was open ended. When asked about their top three health concerns, dental concerns may not have been salient unless they were currently experiencing problems. This could have led to misclassification bias. Thir dly dental problems that we asked about omitted temporomandibular joint (TMJ) dysfunction, treated cavities, root canals, broken or missing teeth, and others which could also lead to bias
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 11 To ou r knowledge this is the first paper that analyzes how individual characteristics influence the association between dental concerns and dental problems and the strengths outweigh the limitations. We believe that this research promotes the significance of surveyi ng th e community's feeling s about dental health. The results show the importance of implementing dental interventions and evaluations among HealthStreet community members in order to increase patient education about oral health and access to care. It encourages the use of preventative measures in order to decrease both dental concerns and dental problems and therefore improve oral health among community members. Acknowledgements This r esearch was supported by the University of Florida Clinical and Translational Science Institute, which is supported in part by the NIH National Center for Advancing Translational Sciences under award number UL1TR001427. The content is solely the responsibility of the authors and does not necessarily represent the offic ial views of the National Institutes of Health. We would also like to thank HealthStreet staff and volunteers for making this research possible.
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 12 References Antoniazzi, R. P., Zanatta, F. B., Ardenghi, T. M., & Feldens, C. A. (2017). The use of crack and other illicit drugs impacts oral health related quality of life in Brazillians. Oral Diseases doi:10.1111/odi.12786 Griffin, S. O., Jones, J. A., Brunson, D., Griffin, P. M., & Bailey, W. D. (2012). Burden of Oral Disease Among Older Adults and Implications for Public Health Priorities. American Journal of Public Health 102 (3), 411 418. http://doi.org/10.2105/AJPH.2011.300362 Kim, J. K., Baker, L. A., Seirawan, H. and Crimmins, E. M. (2012). Prevalence of oral health problems in U.S. adults, NHANES 1999 2004: exploring differences by age, education, and race/ethnicity. Special Care in Dentistry, 32: 234 241. doi:10.1111/j.1754 4505.2012.00280.x Mohammadi, T. M., Hasheminejad, N., Salari, H. R., Rostamizade h, M. R., & Najafipour, H. (2017). Association between Tooth Loss and Opium Addiction: Results of a Community Based Study on 5900 Adult Individuals in South East of Iran in 2015. Journal of International Society of Preventive & Community Dentistry 7 (4), 1 86 190. http://doi.org/10.4103/jispcd.JISPCD_189_17 Quinn, B. C., Catalano, R. A., & Felber, E. (2009). The Effect of Community Level Unemployment on Preventive Oral Health Care Utilization. Health Services Research 44 (1), 162 181. http://doi.org/10.1111 /j.1475 6773.2008.00901.x Yildirim, T. T. (2016). Evaluating the Relationship of Dental Fear with Dental Health Status and Awareness. Journal of Clinical and Diagnostic Research!: JCDR 10 (7), ZC105 ZC109. http://doi.org/10.7860/JCDR/2016/19303.8214
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 13 Tables Table 1 : Typologies of Dental Concerns and Problems Note. DDS= dental Table 2 : Individual Level Characteristics by Dental Concern/Problem Typology Total n=2,319 A: Concerns/ Problems n=193 B: No Concerns/ Problems n=1100 C: Concerns/ No Problems n=51 D: No Concerns/ No Problems n=975 p values Total 2319 (100%) 193 (14.9%) 1100 (47.4%) 51 (2.2%) 975 (42.0%) Gender 0.0050* Female 1561 (67.3%) 117 (60.6%) 778 (70.7%) 31 (60.8%) 635 (65.1%) Male 758 (32.7%) 76 (39.4%) 322 (29.3%) 20 (39.2%) 340 (34.9%) Age <0.0001* 18 34 573 (24.7%) 45 (23.3%) 223 (20.3%) 15 (29.4%) 290 (29.7%) 35 44 313 (13.5%) 33 (17.1%) 129 (11.7%) 7 (13.7%) 144 (14.8%) 45 64 1040 (44.9%) 98 (50.8%) 516 (46.9%) 25 (49.0%) 401 (41.1%) 65+ 393 (17.0%) 17 (8.8%) 232 (21.1%) 4 (7.8%) 140 (14.4%) Ethnicity/Race: <0.0001* Black/African American 1139 (49.1%) 106 (54.9%) 473 (43.0%) 37 (72.6%) 523 (53.6%) White 1040 (44.9%) 77 (39.9%) 561 (51.0%) 10 (19.6%) 392 (40.2%) Other 140 (6.0%) 10 (5.2%) 66 (6.0%) 4 (7.8%) 60 (6.2%) Hispanic/Latin x 213 (9.2%) 11 (5.7%) 104 (9.5%) 3 (5.9%) 95 (9.8%) 0.2680 Education 0.1922 < High School 395 (17.0%) 34 (17.6%) 200 (18.2%) 8 (15.7%) 153 (15.7%) High School Diploma 813 (35.1%) 80 (41.5%) 370 (33.6%) 22 (43.1%) 341 (35.0%) > High School 1111 79 530 21 481 No DDS Problems Yes DDS Problems Total No DDS Concerns 975 (42.0%) 1100 (47.4%) 2075 (89.5%) Yes DDS Concerns 51 (2.2%) 193 (8.3%) 244 (10.5%) Total 1026 (44.2%) 1293 (55.8%) 2319 (100%)
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 14 (47.9%) (40.9%) (48.2%) (41.2%) (49.3%) Unemployed 1498 (64.6%) 130 (67.4%) 786 (71.5%) 33 (64.7%) 549 (56.3%) <0.0001* Have not had a physical within past 12 months 651 (28.1%) 78 (40.4%) 293 (26.6%) 18 (35.3%) 262 (26.9%) 0.0005* Have not seen a dentist within past 12 months 1419 (61.2%) 146 (75.7%) 706 (64.2%) 42 (82.4%) 525 (53.9%) <0.0001* Does not have medical insurance 714 (30.8%) 83 (43.0%) 312 (28.4%) 22 (43.1%) 297 (30.5%) 0.0002* Perceived Health <0.0001* Excellent/Good 1395 (60.2%) 108 (56.0%) 587 (53.4%) 34 (66.7%) 666 (68.3%) Fair/Poor 924 (39.8%) 85 (44.0%) 513 (46.6%) 17 (33.3%) 309 (31.7%) Marijuana 0.0001* Never 1119 (48.3%) 65 (33.7%) 515 (46.8%) 31 (60.8%) 508 (52.1%) Past User 831 (35.8%) 89 (46.1%) 411 (37.4%) 13 (25.5%) 318 (32.6%) Current User (past 30 days) 369 (15.9%) 39 (20.2%) 174 (15.8%) 7 (13.7%) 149 (15.3%) Prescription Pain Medication <0.0001* Never 1022 (44.1%) 78 (40.4%) 416 (37.8%) 26 (51.0%) 502 (51.5%) Past User 990 (42.7%) 87 (45.1%) 507 (46.1%) 20 (39.2%) 376 (38.6%) Current User (past 30 days) 307 (13.2%) 28 (14.5%) 177 (16.1%) 5 (9.8%) 97 (10.0%) Note. indicates significant p values
ASSOCIATION BETWEEN DENTAL CONCERNS AND PROBLEMS 15 Table 3 : Adjusted Regression Predicting Dental Concern/Problem Typologies Note. indicates significant p values Adjusted Multinomial Logistic Regression Concerns/ Problems vs. No Concerns/No Problems ( n= 193 vs. 975) No Concerns/ Problems vs. No Concerns/No Problems ( n= 1100 vs. 975) Concerns/No Problems vs. No Concerns/No Problems ( n= 51 vs. 975) aOR (95% CI) p value aOR (95% CI) p value aOR (95% CI) p value Gender Female vs Male 1.00 (0.72, 1.40) 0.9932 1.42 (1.16, 1.73) 0.0006* 0.78 (0.42, 1.44) 0.4295 Race/Ethnicity African American vs White 1.00 (0.71, 1.41) 0.9924 0.65 (0.54, 0.79) <0.0001* 2.38 (1.14, 4.97) 0.0213* Other vs White 0.92 (0.45, 1.92) 0.8314 0.81 (0.55, 1.19) 0. 2827 2.40 (0.71, 8.07) 0. 1582 Age 35 44 vs 18 34 1.34 (0.81, 2.22) 0.2511 1.07 (0.79, 1.46) 0. 6637 0.84 (0.33, 2.13) 0. 7056 45 64 vs 18 34 1.37 (0.91, 2.06) 0.1363 1.38 (1.10, 1.75) 0.0067* 1.09 (0.55, 2.19) 0.8049 65+ vs 18 34 0.94 (0.50, 1.80) 0.8591 1.76 (1.29, 2.40) 0.0003* 0.68 (0.21, 2.25) 0.5282 Unemployed vs Employed 1.46 (1.02, 2.09) 0.0382* 1.59 (1.29, 1.95) <0.0001* 1.37 (0.72, 2.59) 0.3388 Perceived Health Fair/Poor vs Good/Excellent 1.25 (0.89, 1.74) 0.2008 1.54 (1.26, 1.87) <0.0001* 0.84 (0.45, 1.58) 0.5956 Have not had a physical in the last 12 months vs Have had a physical in the last 12 months 1.52 (1.08, 2.16) 0.0180* 1.03 (0.83, 1.27) 0.8253 1.16 (0.61, 2.18) 0.6501 Have not been to a dentist in the last 12 months vs Have been to a dentist in the last 12 months 2.09 (1.43, 3.07) 0.0002* 1.57 (1.29, 1.92) <0.0001* 3.52 (1.62, 7.66) 0.0015* Does not have medical insurance vs Has medical insurance 1.10 (0.77, 1.57) 0.5900 0.87 (0.70, 1.08) 0.2083 1.26 (0.67, 2.36) 0.4800 Prescription Pain Medication Current User vs Never 1.64 (0.98, 2.74) 0.0577 1.65 (1.22, 2.22) 0.0 010* 1.18 (0.42, 3.29) 0. 7539 Past User vs Never 1.42 (0.99, 2.02) 0.0551 1.41 (1.15, 1.72) 0. 0009* 1.37 (0.73, 2.59) 0. 3299 Marijuana Current User vs Never 1.72 (1.08, 2.74) 0.0225* 1.30 (0.99, 1.71) 0.0644 0.59 (0.24, 1.45) 0. 2498 Past User vs Never 1.86 (1.28, 2.68) 0.0 010* 1.24 (1.00, 1.52) 0. 0463* 0.60 (0.30, 1.20) 0. 1455