JADA Continuing Education
Oral health status of rural adults in the United States
CLEMENCIA M. VARGAS, D.D.S., Ph.D.,
BRUCE A. DYE, D.D.S., M.P.H. and
KATHY L. HAYES, D.M.D., M.P.H.
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ABSTRACT
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Background. Many sociodemographic indicators of oral health disparity in the United States have been documented. Rural residence, however, has not been researched thoroughly, though it has been considered to be a potential indicator of disparity. The authors conducted this study to present information on the effects of rural residence on oral health in the United States.
Methods. The authors conducted their analyses using data from adults aged 18 to 64 years from the 1995, 1997 and 1998 National Health Interview Surveys and the Third National Health and Nutritional Examination Survey, 1988–94. The authors present national estimates for various oral health status indicators including dental insurance coverage, unmet care needs, frequency of dental visits, caries experience and prevalence of edentulism by rural/urban residence.
Results. The authors found that adults living in rural areas were more likely to report having unmet dental care needs and were less likely to have had a dental visit in the past year compared with adults living in urban areas. The prevalence of edentulism among rural adults was 16.3 percent—almost twice that of urban adults. Caries experience also was more likely to be greater among adults residing in rural areas.
Conclusions. Oral health disparities exist among U.S. adults living in rural and urban areas. Compared with urban residents, rural residents were less likely to report a dental visit in the past year and were more likely to be edentulous.
Practice Implications. By understanding the rural/urban differences in adult oral health status, practitioners, policy-makers and rural health advocates will have better information to use to promote activities that better meet the needs of rural adults in the United States.
It has been said that oral diseases such as periodontitis and dental caries are a "neglected epidemic" in the United States.1 This epidemic may be even greater among those for whom knowledge of the distribution of oral diseases has been limited. For example, little information exists on the oral health status of adults living in the rural areas of the United States. Although dated and sparse, the existing information indicates that oral health status disparity has existed between people living in urban and rural areas. For instance, results from the 1960–62 National Health Examination Survey indicated that the prevalence of edentulism among rural men was 18.7 percent compared with a prevalence of 15.3 percent for men residing in urban areas.2 For women residing in rural areas, the prevalence of edentulism was 21.5 percent compared with 18.9 percent for women living in urban areas.
While the lack of information on the oral health status of adults residing in the rural areas of the United States is troubling, awareness that there is a need to collect further information is increasing.
While the lack of information on the oral health status of adults residing in the rural areas of the United States is troubling, awareness that there is a need to collect further information is increasing. This is evident in the surgeon general’s report on oral health in the United States.3 In a call to action, the surgeon general has recognized the need for more oral health information to be available to address disparities among various groups within the United States, including rural populations.
The distribution of population by place of residence in the United States has been highly dynamic. Although the U.S. Census Bureau has reported that the overall rural population has declined continuously from 36.9 percent in 1960 to 24.8 percent in 1990,4 there are indications that the annual rate of population increase in some rural areas was more than three times greater in the 1990s compared with that of the 1980s.5 This selective increase in rural population has been attributed primarily to an out-migration from urban centers and to a reduction in the numbers of rural residents moving to metropolitan areas.5 An increase in the rural population usually brings economic benefits to rural businesses, but it also can stress other institutions concurrently, such as those involved in the delivery of health care services. Rural areas typically have fewer resources available for health care delivery systems than do urban areas. Therefore, the provision of health care, particularly dental care, to a growing population can be problematic because of the limited number of providers and facilities to serve the population.
Adults living in rural areas typically are self-employed, work in small businesses, are employed in part-time work or seasonal enterprises, and lack private insurance coverage.
Adults living in rural areas typically are self-employed, work in small businesses, are employed in part-time work or seasonal enterprises, and lack private insurance coverage. The proportion of uninsured people is 20 percent higher in rural areas than it is in urban areas.6 It also has been reported that nearly 23 percent of uninsured adults have unmet dental care needs.7
Meeting dental care needs becomes increasingly challenging for people living in the rural United States. Not only is the distance to providers greater, but the dentist-to-person ratio in rural areas is significantly lower than that in urban areas (29 per 100,000 vs. 61 per 100,000, respectively).8 Consequently, the selection of dental providers in many rural areas is limited, and public resources directed toward maintaining a safety net of providers to help absorb costs associated with providing care to the uninsured often are underdeveloped. Because rural adults may encounter greater barriers to accessing dental care, the assumptions of increased untreated dental diseases and poorer oral health status have been perpetuated.
The purpose of this study is to present and describe differences among indicators of oral health status between rural and urban adults aged 18 to 64 years in the United States. Understanding the determinants and indicators of poor oral health is essential for the development and promotion of programs designed to improve the oral health status of adults in communities. Our goal is to provide the necessary groundwork for building a foundation for oral health surveillance, health policy development, and health promotion and disease prevention activities in rural areas of the United States in the 21st century.
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METHODS
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The data for this study are from several national surveys: the National Health Interview Survey, or NHIS, from 1995, 1997 and 1998; and the Third National Health and Nutrition Examination Survey, or NHANES III, 1988–94. These surveys were conducted by the National Center for Health Statistics, or NCHS, a component of the Centers for Disease Control and Prevention. Each survey used a complex sample design with over-sampling of special populations, and each survey was representative of the civilian, noninstitutionalized population of the United States.
NHIS collects sociodemographic and health data from face-to-face interviews using a stratified, multistage probability sample of households. The overall sample size of the NHIS each year is approximately 110,000 participants representing more than 45,000 households. Since the survey redesign in 1997, more than 30,000 people aged 18 years or older have been selected each year to receive a detailed questionnaire that includes oral health questions.
NHANES III collected sociodemographic and health data from personal interviews and examinations using a stratified, multistage probability sample of the noninstitutionalized civilian population. The overall sample size of NHANES III was approximately 38,000 participants. Trained dentists, who were calibrated periodically by the survey’s reference dental examiner, conducted dental examinations. The dental examination procedures have been described elsewhere.9 Details of the sampling design, survey operation and questionnaires for NHIS and NHANES III have been published.10,11
For the present study, we analyzed oral health–related variables from NHIS and NHANES III for the U.S. population 18 to 64 years of age. To increase the sample size, we combined data from NHIS 1997 and 1998. The number of people we included in the analyses varied by survey; the sample size of NHIS 1995 was 55,470 adults, the sample size for NHIS 1997 and 1998 was 55,250 adults, and the sample size for NHANES III was 14,366 adults. To maximize the use of available data, analyses for each variable included all cases with valid data for the specific variable.
Outcome variables.
We derived our outcome variables from the 1995, 1997 and 1998 NHIS and NHANES III. The outcome variables we used were dental insurance coverage, dental care utilization, caries experience and perception of oral health. We selected the source of the outcome variables based on the availability of the questions and sample size considerations to allow for more detailed analyses. Data on all types of dental insurance were available only from NHIS 1995 for all age groups (this was the only question on dental care included in the NHIS that year). Dental insurance coverage data were derived from multiple questions on source of dental coverage such that a person was categorized as either having "private" insurance (typically as an employer-provided benefit), having no insurance or having "public" insurance such as Medicaid.
The outcome variables used were dental insurance coverage, dental care utilization, caries experience and perception of oral health.
We measured dental care utilization as dental visits in the past year (NHIS 1997 and 1998) and pattern of visits (NHANES III). We preferred using data from NHIS 1997 and 1998 over data from NHANES III because of sample size considerations and because data from NHIS have been used regularly to determine dental care utilization. The question about dental visits in the past year was, "About how long has it been since you last saw or talked to a dentist? Include all types of dentists ... as well as dental hygienists." We analyzed patterns of dental care utilization from NHANES III. The question about frequency of dental visits was, "How often do you go to the dentist?" We collapsed the response categories "At least once a year" and "Every two years" into "Regular users." We classified those who responded "Whenever needed or no schedule" as "Episodic users." We did not include people who replied with other types of responses in these frequency of dental care analyses.
Caries experience was determined by the trained dentists’ clinical examinations in NHANES III. The data were presented using the decayed, missing and filled (permanent) teeth, or DMFT, index, and the percentage of adults with at least one carious tooth (NHANES III). Data for our analyses of edentulous people came from NHIS 1997 and 1998; analyses were limited to people 45 to 64 years of age. Periodontal status was approximated with the percentage of people with periodontal pockets of 4 to 5 millimeters.
Perception of oral health was approximated with the indicators of unmet dental care needs because the person could not afford treatment and self-reported dental status. Information on unmet dental care needs was collected in NHIS 1997 and 1998 using the question, "During the past 12 months, was there any time when you needed any of the following, but didn’t get it because you could not afford it? Eye care. Dental care. Mental care." The survey did not ask about other reasons for unmet dental care needs. Self-reported dental status was determined in NHANES III using the question, "How would you describe the condition of your natural teeth?"
Covariate selection.
The sociodemographic variable in which we were most interested was rural/urban residence. Although NHIS and NHANES III used different methodologies to classify place of residence, they both used U.S. Census Bureau guidelines to identify rural residences. Those guidelines identify a rural resident as a person living in a place that is not located within an urbanized area as defined by the U.S. Census Bureau and that has less than 2,500 inhabitants.12 Participants self-reported their race/ethnicity in both NHIS and NHANES III. Responses were collapsed into categories described as non-Hispanic white, non-Hispanic black, and Mexican-American in NHANES III or Hispanic in NHIS. While NHANES III oversampled Mexican-Americans and produced a small sample size of other Hispanics, NHIS provided a strong sample size for all Hispanics and a small sample size for Mexican-Americans. Therefore, to maximize the use of the available data, we restricted analyses of variables from NHANES III to Mexican-Americans and presented data from NHIS for all Hispanics. We excluded people from other racial/ethnic backgrounds from our race/ethnicity analyses because of their small sample size, but we did include them in all other analyses.
We determined poverty status by the ratio of the family income to an income threshold adjusted by family size and updated each year. For example, in 1997 a person living in a family of four with a family income of $16,400 or less was considered to be at or below 100 percent of the federal poverty level, or FPL. We defined different levels of poverty depending on the survey. The larger sample size of NHIS allowed us to classify poverty in three categories: poor (0–99 percent of the FPL), near poor (100–199 percent of the FPL) or nonpoor (200 percent or more of the FPL). The smaller sample of adults in NHANES III allowed us to classify poverty only as poor/near poor (less than 200 percent of the FPL) or nonpoor (200 percent or more of the FPL). We present sex analyses for selected variables.
Data analysis.
We used bivariate analyses to examine the relationships between rural and urban status among the selected sociodemographic and dental outcomes. We calculated all bivariate statistics using a statistical software package (SUDAAN, Release 7.0, Research Triangle Institute, Research Triangle Park, N.C.) that is designed to accommodate complex sample surveys in the calculation of standard error, or SE.13 We used sample weights to account for the unequal probability of selection and nonresponse of participants to produce prevalence estimates that allow for national representation. We present the results as percentages or means and their respective 95 percent confidence intervals, or CIs, to approximate statistical significance; CIs were calculated using the following formula: estimate ± (1.96 x SE). For confidentiality reasons, the urban/rural variable is not available in all the NCHS public release data files. Therefore, we conducted these analyses at NCHS’ Research Data Center.
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RESULTS
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Sociodemographic results (Table 1
) indicate that most rural residents aged 18 to 64 years in the United States were non-Hispanic white (88.1 percent). The portion of urban residents who were non-Hispanic whites was 70.7 percent. Urban residents were more likely to be non-poor than were rural residents (72.8 vs. 65.2 percent, respectively).
Table 2 shows dental insurance coverage by poverty status and rural/urban status. The percentage of adults with private dental insurance was higher among those residing in urban areas compared with those residing in rural areas (48.4 vs. 45.6 percent, respectively); this difference was not statistically significant. Total coverage by public insurance was low (5.3 percent). While poor people living in rural areas were significantly more likely to be uninsured for dental care than their poor urban counterparts (60.0 vs. 50.9 percent, respectively), there was little difference in being uninsured between near-poor and non-poor rural and urban residents.
Table 3 shows perceived oral health status as represented by unmet dental care needs and self-perception of "status of teeth" by urban/rural status and selected sociodemographic characteristics. Overall, the data indicate that rural adults were not more likely to report unmet dental care needs than were urban adults (10.8 vs. 9.8 percent, respectively). Women and non-Hispanic black rural residents, however, were more likely to report unmet dental care needs than their urban counterparts. The greatest percentages of adults who reported unmet dental care needs were the rural poor (21.6 percent) and the urban poor (18.8 percent). Although there was no significant difference between rural and urban residents who were poor, poor residents were nearly three times as likely to report unmet dental care needs as those who were nonpoor within the same place of residence. Findings from Table 3 also indicate that adults residing in rural areas reported poorer dental health more often than did those living in urban areas (32.7 vs. 31.8 percent, respectively); this difference was not statistically significant.
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TABLE 3 ORAL HEALTH STATUS FOR U.S. ADULTS 18–64 YEARS OLD BY SOCIODEMOGRAPHIC CHARACTERISTICS AND URBAN/RURAL STATUS.
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Findings for dental care utilization (Table 4, page 1678) include data on the prevalence of at least one dental visit in the past year and the pattern of visits. Overall, rural adults were less likely to have had a dental visit in the past year than were urban adults (58.3 vs. 65.8 percent, respectively). Although this pattern was consistent across sex and race/ethnicity subgroups, it was not significant for Hispanics. Furthermore, poor and nonpoor rural adults also were less likely to have had a dental visit in the past year than were urban adults with similar poverty statuses. Poor/near-poor people residing in rural areas were more likely to be episodic users of dental care than were poor/near-poor urban people (69.3 vs. 59.2 percent, respectively) and least likely to be regular users of dental care (25.2 vs. 34.3 percent, respectively). Regardless of place of residence, nonpoor adults were twice as likely to be regular users of dental care than were poor/near-poor adults.
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TABLE 4 DENTAL VISITS BY SOCIODEMOGRAPHIC CHARACTERISTICS AND URBAN/RURAL STATUS FOR U.S. ADULTS AGED 18–64 YEARS.
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Table 5 (page 1679) displays selected clinical oral health indicators by poverty status and rural/urban status. Rural adults tended to have more untreated dental caries than did their urban counterparts (31.7 vs. 25.2 percent, respectively). Although within each poverty subgroup the findings suggested trends toward a higher proportion of rural adults with untreated caries compared with urban adults, these trends did not reach statistical significance. Among all people, adults residing in rural areas were more likely to have a greater caries experience compared with those in urban areas. While nonpoor rural adults were more likely to have a higher DMFT score compared with their urban counterparts (13.9 vs. 12.7 percent, respectively), there was no significant difference among poor/near-poor adults regarding rural/urban status. We determined periodontal status by the presence of periodontal pockets measuring 4 to 5 mm. There was a trend for a higher percentage of periodontal pockets of 4 to 5 mm among rural adults than among urban adults, but it was not significant. A total of 27.9 percent of rural adults had periodontal pockets of 4 to 5 mm compared with 18.7 percent of adults living in urban areas. Adults 45 to 64 years of age residing in rural areas were almost twice as likely to be edentulous compared with adults in urban areas (16.3 vs. 8.8 percent, respectively). The prevalence of edentulism also was significantly greater among rural adults than among urban adults stratified by poverty status.
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TABLE 5 SELECTED CLINICAL ORAL HEALTH INDICATORS BY POVERTY AND URBAN/RURAL STATUS FOR U.S. ADULTS AGED 18 TO 64 YEARS.
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DISCUSSION
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In this study of people who were representative of the U.S. population aged 18 to 64 years, we found that rural/urban residency influences a person’s oral health status. Adults living in rural areas were more likely to be edentulous and were more likely to have experienced dental caries. Furthermore, rural adults were less likely to have had a dental visit in the past 12 months. These findings may reflect a combination of inadequate availability and access to timely dental care.
Although the prevalence of edentulism and dental caries experience is greater among rural adults, our analyses did not find a significant difference between rural and urban adults in the prevalence of untreated caries. This may be the result of more rural people’s electing to have their symptomatic teeth extracted instead of restored. Because our findings suggest that poor rural adults are more likely to be uninsured and episodic users of dental care, the cost and availability of dental care may be an important predictor for the increased prevalence of tooth loss in rural areas. It also has been reported that most people with unmet dental care needs do not seek care because of financial concerns.7 Findings from our current study indicate that women and non-Hispanic blacks who reside in rural areas are more likely to have unmet dental care needs than are their urban counterparts.
The prevalence of edentulism has important considerations for both oral health policy-makers and practitioners. It has been reported that the proportion of people with complete tooth loss has declined in the past 25 years across all age groups with edentulism being most prevalent among poor people.14 Our findings indicate that 10 percent of all people 45 to 64 years of age are edentulous. Among people in that age range who were poor and resided in rural areas, however, the prevalence of edentulism was 24.5 percent—2.5 times higher than the prevalence in the general population. Thus, we conclude that an important sociodemographic risk factor for tooth loss for adults 45 to 64 years of age is being poor and residing in a rural area simultaneously. Further reduction in the prevalence of tooth loss may require policy-makers to re-examine existing presumptions about preventing edentulism. This may involve the development of new or modified oral health promotion activities specifically targeted toward rural adults, which should be tested and evaluated for efficacy.
For dental clinicians, greater tooth loss in rural areas among people with fewer resources may translate into more rural adults having greater needs for removable dental prosthetics and lesser needs for fixed prosthetics than urban adults. Because lost teeth have been associated with poorer diets and diminished chewing ability, which may affect overall health,3 complete tooth loss without appropriate replacement can be viewed as a form of dental disability. Thus, as rural adults age and the prevalence of edentulism among them increases disproportionately compared with urban adults, the quality of life for older adults residing in rural areas may diminish disproportionately as a result of increased dental disability compared with their urban counterparts.
The capacity to deliver oral health care to rural adults in the United States may be diminishing. Not only is the ratio of dentists to 100,000 population in rural areas nearly 50 percent less than that of urban areas,8 but the number of active dentists in the United States has continued to decrease over the past decade from 59.1 per 100,000 to 53.7 per 100,000.3 Furthermore, as student indebtedness increases, fewer recently graduated dentists will establish practices in lower-income communities.3 To attract dental providers to underserved areas, a Health Professional Shortage Area, or HPSA, designation for both rural and urban areas can be made; opportunities that could be available to providers in HPSAs include special scholarships, loan repayment programs and grants. Nevertheless, it has been reported that 94 percent of the dental care needs in HPSAs are unmet.3 These work force issues may continue to exacerbate the already existing disparity in oral health status between adults residing in rural areas and urban areas. Because our findings indicate that a significant difference exists between poor rural and urban adults with no insurance or regardless of the pattern of dental visits (that is, those who are either episodic or regular users), the reduced availability of dental providers may have a greater impact on the poorer oral health status of rural adults than on that of urban adults independent of financial barriers to access of dental care.
Inadequate dental service use in rural communities can have important clinical consequences. Although the five-year survival rate for oropharyngeal cancer is nearly 50 percent, most oral cancers respond favorably to early treatment.15 Consequently, it has been suggested that oral cancer examinations should be conducted regularly among high-risk people.16,17 However, a difference in the prevalence of men and women having had a dental visit in the past year by rural/urban residency implies that adults residing in rural areas have fewer opportunities to receive a periodic oral cancer screening. Fewer dental visits by rural adults also may affect adversely the national objective to reduce mortality from oropharyngeal cancers as described in Healthy People 2010.18
The lack of statistically significant differences between rural and urban populations found in the oral health clinical indicators may be associated with a potential that not enough rural people living in remote areas were covered because of survey design and sampling error. Consequently, a limitation of this study could be that estimates from NHANES III did not have sufficient statistical power to represent nonadjacent rural areas compared with rural locations adjoining urban centers. Furthermore, not all rural communities are poor, and the number of affluent rural communities is increasing as the prosperity of some metropolitan centers extends into adjacent rural areas—producing an evening-out of the data at the national level. In addition, although a state’s overall rural socioeconomic characteristics are an important indicator of health status among its residents, rural/urban differences in general health care are not consistent among states.19
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CONCLUSION
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This is the first report to document selective indicators for adult oral health status by rural residency in the United States. The results of our analyses indicate that rural/urban differences in oral health status maybe not be related only to poverty. However, poverty significantly influences the difference between rural and urban adults on the frequency of dental visits and the prevalence of edentulism. Complete tooth loss occurs significantly more often in rural areas, which may profoundly affect a rural person’s quality of life.
Improving access to dental care and increasing dental care utilization in rural areas may require a renewed oral health care policy approach directed toward rural areas of the United States involving dental practitioners, policy-makers, advocates and other rural health stakeholders. If progress is to be made toward increasing tooth retention and improving oral health in the United States, additional research in dental health services and disease prevention need to be undertaken to elucidate the underlying causes that promote rural/urban oral health disparity.
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FOOTNOTES
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Dr. Vargas is an assistant professor, Department of Pediatric Dentistry, University of Maryland Dental School, Baltimore, 666 W. Baltimore, Room 3-E-11, Baltimore, Md. 21201-1586, e-mail "cnv001{at}dental.umaryland.edu". Address reprint requests to Dr. Vargas.
Dr. Dye is a dental epidemiology officer, U.S. Public Health Service, National Health and Nutritional Examination Survey program, Center for Disease Control and Prevention/National Centers for Health Statistics, Hyattsville, Md.
Dr. Hayes is a senior program management officer, Health Resources and Services Administration, Rockville, Md.
Support for this study was provided to Dr. Vargas from Health Resources and Services Administration contract 00-0499(P).
Portions of this article were presented at the annual meeting of the National Rural Health Association, Dallas, May 2001.
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REFERENCES
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- Kelly J, Van Kirk L, Garst C. Total loss of teeth in adults, United States: 1960–62. Hyattsville, Md.: National Center for Health Statistics; 1973. Vital and Health Statistics; series 11, no. 27.
- U.S. Public Health Service, Office of the Surgeon General, National Institute of Dental and Craniofacial Research. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, U.S. Public Health Service; 2000. NIH publication 00–4713.
- U.S. Census Bureau. Population 1790 to 1990. Available at: "www.census.gov/population/censusdata/table-4.pdf". Accessed Oct. 4, 2001.
- Johnson KM. The rural rebound. Washington: Population Reference Bureau; 1999.
- National Rural Health Association. Access to health care for the uninsured in rural and frontier America. Available at: "www.nrharural.org/pagefile/issuepapers/ipaper15.html". Accessed Oct. 29, 2002.
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The Importance of Place of Residence: Examining Health in Rural and Nonrural Areas
Am J Public Health,
October 1, 2004;
94(10):
1682 - 1686.
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ABSTRACT
METHODS
