The decision to seek preventive dental care has been found to be associated with several factors. In a study of dental checkup frequency among adults, Woolfolk and colleagues² found that infrequent preventive visits were associated with four factors: having a lower income level, being male, not having found a dental office for usual care and feeling anxiety regarding dental care.² In a study that examined the use of dental preventive care services, Yu and colleagues³ found that 32 percent of respondents reported never having had a dental examination, and 2 percent reported never having had any preventive care. They also found that factors such as lack of insurance, income, education, sex and ethnicity were predictors of lack of professional preventive care.³ A study of preventive visits by children and adolescents showed income to be a deciding factor for children’s and adolescents’ accessing preventive care.⁴ Results indicated that children and adolescents in lower income groups had fewer visits for preventive care than did children in higher income groups.⁴

The use of preventive dental services appears to be increasing.^5,6 In a study comparing data from a 10-year period, Brennan and colleagues⁶ found an increase in preventive and maintenance visits from 20.9 percent in 1983 to 1984 to 25.2 percent in 1993 to 1994. In a more recent study, Macek and colleagues⁵ reported that slightly more than 39 percent of children reported having had a diagnostic or preventive visit during 1996.

While numerous studies have examined various factors associated with receiving preventive care, Brown and Lazar⁷ completed a study that focused on the providers of preventive care. According to Brown and Lazar, dental hygienists were more likely to provide care in larger group practices, in practices of younger dentists and in practices with younger patients.⁷ In addition, practices employing dental hygienists were more likely to provide preventive procedures than practices not employing hygienists.⁷ Interestingly, this study also showed that practices employing dental hygienists performed fewer oral surgical, prosthetic and restorative procedures.⁷

The purpose of this article is to further examine the role of preventive care services in the context of practitioner type and to estimate the extent to which these services are provided by dentists or dental hygienists by analyzing data from the 1996 Medical Expenditure Panel Survey(MEPS).⁸

During 1996, approximately 86 million Americans had had at least one visit to dental care providers nationwide for preventive care treatment.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The 1996 MEPS is the third in a series of nationally representative health surveys of the U.S. community-based population that is sponsored by the Agency for Healthcare Research and Quality (AHRQ). The MEPS collects health care expenditure, use and payment source data, along with socioeconomic, demographic and health insurance data. The target for the 1996 MEPS was a sample of 10,500 households that had participated in the 1995 National Health Interview Survey (NHIS). To collect health expenditure and use data for 1996, members of each MEPS household were interviewed in person three times during an approximate 18-month period. The combined NHIS response rate and full-year 1996 response rate of the MEPS sample through the third round was 70 percent.⁸

The focus of this analysis is on preventive dental use and type of provider. Preventive visits are defined as any visit that incorporates one or more of the following dental procedures: prophylaxes, fluoride treatments and sealants.¹ Provider types are defined as "dental hygienist" or "dentist." "Dentist" is defined as any provider type not specifically identified as "hygienist" (see Manski and Moeller¹). More than one type of provider may have been identified on an event record.⁹ Specifically, national estimates are provided for the civilian noninstitutionalized population of the United States and include preventive dental visitation and provider categories for each of several socioeconomic and demographic categories. We computed all estimates and standard errors reported here, taking into account the complex sampling design of MEPS, through use of the software package SUDAAN (Release 6.40, Research Triangle Institute, Research Triangle Park, N.C.).¹⁰

	RESULTS

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The 1996 MEPS involved 21,571 total participants, representing 268,905,490 noninstitutionalized U.S. civilians. Of these, slightly more than one-fourth (6,595) of all participants representing 75,326,027 civilians were younger than 18 years of age. Approximately one-half of all participants were female (51 percent, n = 11,282), 35 percent (n = 7,545) of all participants were nonwhite and almost 40 percent (n = 8,628) of all participants reported that they were from families with low incomes.

The figure and Tables 1 through 3 (pages 223–226) provide national estimates for preventive dental visits by socioeconomic and other demographic variables. The figure shows the percentage of the population who had had a preventive dental visit during 1996, by race and provider type. While African-American and Hispanic respondents were much more likely (P > .05) to report having visited a dentist for preventive care, whites were more likely (P > .05) to receive similar care from a hygienist.

View larger version (55K): [in this window] [in a new window]   Figure. Preventive dental visits, by provider type and patients’ race/ethnicity. Source: Agency for Healthcare Research and Quality, Center for Cost and Financing Studies.9

Table 2 shows the total population that had had a preventive visit and total population and percentage of the population that had had a preventive visit during 1996, by provider type and several socioeconomic and other demographic variables. Overall, the rate of utilization was similar among respondents reporting having had a preventive care visit to a dentist or to a hygienist (42.7 percent and 46.0 percent, respectively, P > .05). Poorer respondents, nonwhite respondents, respondents residing in large metropolitan areas and respondents without dental insurance were more likely (P < .05) to report having had a preventive dental care visit to a dentist than a similar visit to a hygienist. On the other hand, female respondents, white respondents, respondents aged 19 to 64 years, respondents with a higher income, respondents with dental insurance, respondents residing in a small metropolitan area and respondents with more education were more likely (P < .05) to report having had a preventive dental care visit to a hygienist than having had a similar visit to a dentist. We observed no significant difference (P > .05) in the distribution of preventive care visits to dentists or hygienists among the oldest and youngest respondents, respondents residing in nonmetropolitan areas and male respondents.

Table 3 provides the total number of visits and the number of preventive visits per person for people with a preventive visit during 1996, by provider type and several socioeconomic and other demographic variables. During 1996, Americans made almost 125 million visits to dental providers nationwide for preventive care treatment. While slightly less than one-half (58.5 million) of all preventive dental visits were provided by a dentist, approximately 66 million (53.1 percent) preventive dental visits were provided by dental hygienists. Overall, Americans who reported having had a preventive dental visit during 1996 reported greater (P < .05) rates of preventive visits to hygienists than to dentists. No significant difference (P > .05) was observed in the rate of preventive care visits to dentists or hygienists among the oldest respondents, black respondents, Hispanic respondents, poor and low-income respondents and respondents with some or no schooling.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
MEPS data provide nationally representative estimates and include data elements that describe specific dental visits by provider and treatment type for each of several demographic and socioeconomic categories. Additionally, the MEPS data establish a baseline for rates of preventive dental care utilization for the U.S. population by provider type.

While these data and analyses are useful, they do have limitations. For instance, treatment and provider data are self-reported. Self-reported data are less accurate than those collected by observation or by dental record abstraction, which potentially limits the usefulness of these data. Adding to this potential recall bias is the fact that patients sometimes are unable to differentiate between a dentist, dental hygienist or dental assistant during a typical visit. On the other hand, the recall period for the MEPS is relatively short compared with those of other national surveys.¹¹

Nonetheless, results show that respondents who were female, older (18 years and older), white, from a higher socioeconomic background, with more education, who live in suburban and rural areas and who have dental insurance coverage were more likely to obtain care in a dentist’s office from a dental hygienist than a dentist for their preventive oral health visits. The total number of preventive visits also was higher for dental hygienists than for dentists. This could be the result of a greater number of preventive visits per person as well as the higher numbers of respondents whose demographic profile makes them more likely to access the oral health care system and to utilize dental hygienists for their preventive services. These results also could be a reflection of the socioeconomic status of the region or neighborhoods in which the practice is located. The policy implications of these results do not speak to the necessity of employing dental hygienists nor to the quality of the preventive product of a particular practice or practitioner type, but rather to a practice’s level of productivity.

The American Dental Association 1996 Survey on Dental Practice did not find any differences in the socioeconomic backgrounds of the patients selecting care by varying dental practice types.

Interestingly, those people more likely to obtain care from a dental hygienist for their preventive oral health visits (that is, white ethnic background, higher family income, higher educational status and dental insurance coverage) are essentially the same people who are more likely to access the oral health care system.¹² One exception to this observation is the category of people residing in nonmetropolitan areas. In this analysis, respondents residing in nonmetropolitan areas reported an increase in the likelihood of receiving preventive care services from a dental hygienist rather than a dentist.

This analysis raises a number of questions about people’s choices and opportunities with respect to the acquisition of dental care services. Some patient-initiated referrals also may be influenced by the presence of a particular dental hygienist.

The American Dental Association 1996 Survey on Dental Practice assessed the employment practices of dentists.^14,15 The survey reported that larger and more established dental practices are more likely to employ at least one dental hygienist and more likely to employ a higher number of dental hygienists.¹⁴ Furthermore, solo and new dental practices were less likely to employ a full-time or part-time dental hygienist than were independent and nonsolo practices. The differential between dentists in solo and nonsolo practices was especially large with regard to employment of full-time dental hygienists and the number of dental hygienists per practice.¹⁴ Interestingly, the ADA survey did not find any differences in the socioeconomic backgrounds of the patients selecting care by varying dental practice types.

Results of the analysis in this study provide further reflection of dental work force capacity needs and the supply and distribution of dentists and dental hygienists needed to match the demand for their services. The U.S. Bureau of Labor Statistics (BLS), reported that while approximately 152,000 dentists were available to provide oral health care services during 2000, the numbers of dentists expected to practice will increase at a slower rate than the average for all occupations through 2010 despite a possible need to replace an aging work force.^16,17 Similarly, the BLS projects that through 2010 the employment of dental hygienists will grow at a faster rate than the average for all occupations in response to an increasing demand for oral health care.¹⁶ This increased demand for oral health services will occur because future age cohorts—especially those from the "baby boom" generation, which is projected to grow by 81 percent between 1999 and 2030—are expected to be healthier, retain more natural teeth, be from higher socioeconomic and educational backgrounds, and have more expansive dental insurance coverage.^18,19 Interestingly, while 147,000 dental hygienists were employed in 2000, approximately 60 percent were in practice part time.¹⁶

	CONCLUSION

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Recently, national attention has focused on the productivity of dental offices in an attempt to estimate future dental work force needs.²⁰ The proper use of technology in addition to a well-managed office staff, including dental hygienist providers, boosts the productive output of all dental services in a dentist’s practice, including preventive dental visits. An implication of this analysis is that, as Beazoglou and colleagues²⁰ concluded, "accurate estimates of changes in dentists’ productivity are important in evaluating the adequacy of the number of dentists to meet the demand for dental services." This analysis of the MEPS data furthers an understanding of the delivery and utilization of preventive dental services and suggests a need for additional research to better clarify and predict emerging important trends in dental work force capacity.