Abstract

We compared the extent to which having an intellectual or developmental disability was associated with rates at which Iowa Medicaid-enrolled children ages 3 to 8 had first dental checkups after an initial dental examination. We hypothesized that these children would have later first dental checkups than would children without an intellectual or developmental disability. Findings suggest no significant difference in the time to first dental checkup for children by intellectual or developmental disability status. Those who took over 12 months to see a dentist for their initial dental examination were 1.68 times as likely to have an earlier first dental checkup as children whose initial dental examination occurred within 4 months of being enrolled. Results suggest that having an intellectual or developmental disability is not associated with later first dental checkups for this population.

As highlighted in the Institute of Medicine's (2001) publication, Crossing the Quality Chasm, the timely receipt of health care services is critical in disease prevention.

Although dental visits were not explicitly mentioned in this report, the timing of dental recall examinations (e.g., prevention-oriented dental checkups that take place after an initial comprehensive dental examination) is important in preventing oral health problems in children, especially for those at increased risk for oral health problems. Timely dental checkups enable high-risk children to benefit from anticipatory guidance (Davies, Duxbury, Boothman, Davies, & Blinkhorn, 2005; Nainer & Mohammed, 2004; Pulitzer & Spencer, 2008; Zoning, Manheim, Assay, Cortellazzi, & Pereira, 2007) and preventive care, such as pit and fissure sealants and topical fluoride (Ahovuo-Saloranta, Hiiri, Norblad, Mäkelä, & Worthington, 2008; Marinho, Higgin, Logan, & Sheiham, 2003; Weintraub et al., 2006). Dental checkups also help to reduce the physical and social morbidities associated with untreated tooth decay, such as pain, local and systemic infection, school absences, and low self-esteem (Cunnion et al., 2010; Gift, Reisine, & Larach, 1992; Vargas, Macek, Goodman, & Wagner, 2005).

Health professionals believe that subgroups of children with an intellectual or developmental disability are at increased risk for poor oral health. Some of these children take prescription medications that contain high concentrations of sugar or lead to xerostomia (dry mouth)—factors associated with dental caries (Feigal, Jensen, & Mensing, 1981; Keene, Galasko, & Land, 2003). Many have highly cariogenic diets (Marshall, Eichenberger-Gilmore, Larson, Warren, & Levy, 2007; Nunn et al., 2009). Others have behavioral comorbidities that make it difficult for caregivers to brush the child's teeth and gums regularly with fluoridated toothpaste (Ferguson & Cinotti, 2009). On a provider-level, some dentists, citing inadequate training, are unwilling to see children with an intellectual or developmental disability (Casamassimo, Seale, & Ruehs, 2004). In addition, many such children are enrolled in state Medicaid dental programs, which introduces additional system-level barriers that make access to timely dental checkups difficult (Al Agili, Pass, Bronstein, & Lockwood, 2007; Mayer, Stearns, Norton, & Rozier, 2000; Nainar, 2000).

Children with an intellectual or developmental disability who have delayed dental checkups may be at increased risk for dental caries (Maurer, Boggs, Mourino, & Farrington, 1996). In a recent publication, Chi, Momany, Kuthy, Chalmers, and Damiano (2010) reported no difference in the likelihood of preventive dental care utilization for Iowa Medicaid-enrolled children ages 3 to 17 by intellectual or developmental disability status. One limitation of this study was the failure to adjust for overall health status. In another study in which this limitation was addressed, Chi, Momany, Jones, and Damiano (2011) found that newly Medicaid-enrolled children ages 3 to 8 with an intellectual or developmental disability in Iowa were significantly more likely to have later first dental visits than those without an intellectual or developmental disability (p  =  .04).

Even though timely dental checkups are important in preventing oral health problems, no investigators to date have compared the rates at which the first dental checkup takes place after the first comprehensive dental examination for Medicaid-enrolled children by intellectual or developmental disability status. The timing of the first dental checkup is important because it provides information on the initial periodicity with which children are visiting the dentist for preventive dental care. Without knowledge of the timing of first dental checkups for Medicaid-enrolled children, it is difficult to develop evidence-based clinical interventions and policies aimed at improving access to appropriate dental care for vulnerable children.

Our primary objective in this study was to compare the rates at which Medicaid-enrolled children with and those without an intellectual or developmental disability had a first dental checkup after the first comprehensive dental examination. In addition, we sought to identify the factors associated with the rates at which Medicaid-enrolled children had their first dental checkup. On the basis of previous work showing that Medicaid-enrolled children with an intellectual or developmental disability had significantly later first dental visits (Chi et al., 2011), we tested the hypothesis that Medicaid-enrolled children with an intellectual or developmental disability would have later first dental checkups than would children without an intellectual or developmental disability. Furthermore, we hypothesized that other factors from our conceptual model would be important determinants of the time to first dental checkups for all Medicaid-enrolled children.

Method

Conceptual Model

We adapted a sociocultural oral health disparities model proposed by Patrick et al. (2006) as the conceptual model and evaluated factors from the following domains as potential determinants of the time to first dental checkup: (a) ascribed factors (intellectual or developmental disability status, age, sex, overall health status); (b) proximal factors (number of months to the first comprehensive dental examination, use of any restorative dental care after the first comprehensive dental examination but before the first dental checkup, use of preventive medical care); (c) immediate factors (whether there was a Medicaid-enrolled adult and/or sibling in the household); (d) intermediate factors (rurality); and (e) distal factors (whether the child lived in a dental Health Professional Shortage Area).

Study Design

We used administrative data from the Iowa Medicaid Program for this retrospective cohort study and received approval from the Institutional Review Board of the University of Iowa.

Data Source

We analyzed Iowa Medicaid enrollment and claims data from calendar years 2005–2007. The child was the unit of analysis. The enrollment files contained the child's unique identification number (used to link the files), age, sex, county of residence, and zip code at baseline. Baseline was defined as the child's first month of enrollment in the Iowa Medicaid Program in 2005. We used enrollment and medical claims files to identify intellectual or developmental disability status. The dental claims file contained information on all dental services received by the child and for which a claim was submitted by a dentist.

Study Population

We focused on children ages 3 to 8 who were newly enrolled in the Iowa Medicaid program in calendar year 2005 and had a first comprehensive dental examination from 2005 to 2007 (N  =  3,418). A child was classified as newly enrolled if he or she had no evidence of enrollment in the Iowa Medicaid Program in the 12 months prior to the first month of Medicaid enrollment in 2005. Children must have been enrolled for at least 6 months in 2005. We restricted our study to children in this age range because of the teeth present clinically (primary dentition or early mixed dentition consisting of primary teeth, permanent incisors, and first molars) and excluded children under age 3 years because most intellectual or developmental disabilities are identified after the third birthday (Council on Children with Disabilities, 2006; Pinto-Martin, Dunkel, Earls, Fliedner, & Landes, 2005). From the target study population, we excluded children living in institutions (n  =  17) to focus on those seeking dental care from community-based dentists and those enrolled in Medicaid through the foster care program (n  =  178) because these enrollees are known to have heterogeneous dental utilization patterns (Colthirst, Momany, Damiano, & Warren, 2009). We also excluded children who received any type of dental care before their first comprehensive dental examination (n  =  241). The final study population consisted of children who received a comprehensive dental examination after enrolling in the Iowa Medicaid program with no other dental care received prior to this first comprehensive dental examination (N  =  2,982).

Variables

Main predictor variable

The child's intellectual or developmental disabilities status (no/yes) was the main predictor variable. We used four of the five criteria described previously by Chi and colleagues (Chi et al., 2011; Chi et al., 2010) to operationalize intellectual or developmental disability status. These criteria were developed by a group of physicians, dentists, and developmental psychologists with extensive clinical experience treating children with intellectual or developmental disabilities at the University of Iowa Center for Disability and Development and program staff members at the Iowa Medicaid administrative office. We used both a categorical (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] medical diagnostic codes indicating a nonacquired cognitive deficit) and a noncategorical approach (participation in the state Home- and Community-Based Waiver Program for individuals with an intellectual or developmental disability, recipients of Targeted Case Management services for individuals with an intellectual or developmental disability, and children with evidence of an intellectual or developmental disability exception indicator as noted by a physician). We found these data in the child's eligibility and medical claims files from calendar year 2005.

Outcome variable

The outcome variable was the time to first dental checkup, defined as the rate at which the child's first dental checkup took place after the first comprehensive dental examination (see Figure 1). We used five-digit alphanumeric Current Dental Terminology codes (American Dental Association, 2005) to identify specific dental services from each child's dental claims files.

Figure 1.

Description of outcome variable (time to first dental checkup).

Figure 1.

Description of outcome variable (time to first dental checkup).

We considered a child to have had a comprehensive dental examination if Current Dental Terminology Codes D0150 or D0110 appeared in his or her dental claims files after initially enrolling in the Iowa Medicaid program in 2005. To be included, the child must have had no evidence of any other previous dental care received prior to this first comprehensive dental examination. We identified the child's first dental checkup by Current Dental Terminology Codes D0120 or D0150, which had to appear anytime after the first comprehensive dental examination. To account for the effect of provider switching, the two dental checkups must have been filed by the same dentist.

Model covariates

We included three ascribed factors: age at baseline (continuous variable), sex (female/male), and overall health status (healthy/any acute condition but no chronic condition/any chronic condition). We defined overall health status using the 3M Clinical Risk Grouping methodology (Hughes, 2004), in which medical claims data are used and children are classified into one of the following mutually exclusive, hierarchical core health status groups: healthy, acute condition, single minor chronic condition, minor chronic condition in multiple systems, single dominant or moderate chronic condition, significant chronic condition in multiple systems, dominant chronic condition in three or more systems, malignancy, and catastrophic chronic condition. Children from the first core health status group were classified as healthy; those from the second group were classified as having any acute condition but no chronic condition; and the remaining children were classified as having any chronic condition.

We also included three proximal factors: the number of months to the first comprehensive dental examination (<4, 4 to 6, 7 to 12, >12), whether the child received any restorative dental care after the first comprehensive dental examination but before the first dental checkup (no/yes), and whether the child utilized preventive medical care in 2005 (no/yes). Children who received any restorative care (defined by Current Dental Terminology Codes D1510-D1550, D2110-D2394, D2930-D4342, D7110-D7140, D9420) on the same date as the first dental checkup were classified as not having received restorative dental care, unless such care was received after the date of the first dental checkup (in which case the child was classified as having received restorative care). We made this decision to ensure that the first dental checkup was initiated as a preventive visit rather than because of a dental problem (e.g., toothache, broken filling, tooth abscess). In addition, we included two immediate factors (whether the child lived in a household with a Medicaid-enrolled adult and whether there was another Medicaid-enrolled sibling in the household); one intermediate factor (rurality of the child's county of residence at baseline as a four-level categorical variable based on the 2003 U.S. Department of Agriculture Rural-Urban Continuum Codes: metropolitan, urban adjacent to metropolitan, urban not adjacent to metropolitan, rural); and one distal factor (whether the child lived in a Dental Health Professional Shortage Area at baseline).

Statistical Analysis

We used chi-square and t tests to assess for statistical differences in proportions and means, respectively. We constructed Kaplan-Meier survival curves and used the log-rank test to identify the relationship between intellectual or developmental disability status and the time to first dental checkup (α  =  .05), which are two approaches that adjust for censoring but not for other model covariates. We assessed for collinearity between covariates measuring similar domains (e.g., rurality and Dental Health Professional Shortage Area). There was no evidence of collinearity. We tested the proportional hazards assumption for each model covariate with time-dependent variables. No variables violated the proportional hazards assumption. We also tested for an interaction between the two immediate variables (having a Medicaid-enrolled sibling and/or adult from the household). Because this interaction failed to reach statistical significance, it was excluded from the final regression models. We constructed multiple variable Cox proportional hazards regression models (α  =  .05). Two additional regression models were constructed to adjust for potential correlation between subjects from the same household and children seen by the same dentist. Because this adjustment did not affect the hazard ratios, we only reported hazards ratios from the unadjusted model. We analyzed all data using SAS 9.2 for Windows (PROC LIFETEST and PROC PHREG statements).

Results

Descriptive Data

There were 2,982 children ages 3 to 8 in our study who were newly enrolled in Iowa Medicaid. About 1.3% of children (n  =  39) were identified with an intellectual or developmental disability (see Table 1). On average, these children were enrolled in Medicaid 5 months longer than those without an intellectual or developmental disability (29.7 and 24.6, respectively), although this difference was not significant. In addition, significantly larger proportions of children without an intellectual or developmental disability were healthy compared with children with such a disability (86.4% and 41%, respectively; p < .0001). Significantly larger proportions of children without an intellectual or developmental disability had another Medicaid-enrolled sibling (81.6%) or adult (60.2%) in the household than did those with an intellectual or developmental disability (48.7% and 30.8%, respectively).

Table 1

Descriptive Data by Group by Intellectual or Developmental Disability (IDD) Status and Total Study Population of Newly Medicaid-Enrolled Children (N  =  2,982)

Descriptive Data by Group by Intellectual or Developmental Disability (IDD) Status and Total Study Population of Newly Medicaid-Enrolled Children (N  =  2,982)
Descriptive Data by Group by Intellectual or Developmental Disability (IDD) Status and Total Study Population of Newly Medicaid-Enrolled Children (N  =  2,982)
Table 1

Continued

Continued
Continued

Dental Utilization

About 53% of children without and 43.6% of children with an intellectual or developmental disability had their first comprehensive dental examination within 6 months of being in the Medicaid program (see Table 1). Overall, 14.7% of newly Medicaid-enrolled children had at least one restorative dental visit between the first comprehensive dental examination and first dental checkup. Less than 8% of children with an intellectual or developmental disability received restorative dental care.

Table 2 displays the cumulative proportions of children with a first dental checkup at specified time intervals unadjusted for model covariates but adjusted for censoring. About 42% of all children had a first dental checkup within 6 months of the first comprehensive dental examination. This proportion increased to 77% by year one, with nearly all children having a dental checkup within 31 months of the first comprehensive dental examination. Among children with an intellectual or developmental disability, 40% and 73% had a dental checkup within 6 months and one year of the first comprehensive dental examination, respectively. These rates were slightly higher for children without an intellectual or developmental disability (42% and 77%, respectively). Over the entire study period, however, the difference in the time to first dental checkup for children with and those without an intellectual or developmental disability failed to reach statistical significance, as depicted in the Kaplan-Meier survival curves (see Figure 2). In addition, there appeared to be significant differences in the time to first dental checkup based on the number of months to the first comprehensive dental examination (p < .0001) and whether there was a Medicaid-enrolled adult in the household (p  =  .04).

Figure 2.

Kaplan–Meier survival curves for newly Medicaid-enrolled children in Iowa identified with (solid line) and without an intellectual or developmental disability (dotted line) in 2005 and number of months to the first dental checkup (log–rank test: p  =  .87).

Figure 2.

Kaplan–Meier survival curves for newly Medicaid-enrolled children in Iowa identified with (solid line) and without an intellectual or developmental disability (dotted line) in 2005 and number of months to the first dental checkup (log–rank test: p  =  .87).

Table 2

Cumulative Proportions of Children With First Dental Checkup by Time Intervals* (N  =  2,982)

Cumulative Proportions of Children With First Dental Checkup by Time Intervals* (N  =  2,982)
Cumulative Proportions of Children With First Dental Checkup by Time Intervals* (N  =  2,982)
Table 2

Continued

Continued
Continued

Cox Proportional Hazard Regression Models

After adjusting for model covariates (see Table 3), we found no significant difference in the time to first dental checkup by intellectual or developmental disability status. The only factor that appeared to be statistically significant was the number of months to the first comprehensive dental examination. Compared with children whose first comprehensive dental examination took place within 4 months of being in the Medicaid program, those with a first comprehensive dental examination after more than 12 months of being in the Medicaid program were 1.68 times as likely to have an earlier first dental checkup (p < .0001). In other words, children who took the longest to see a dentist for their first comprehensive examination were significantly more likely to have an earlier first dental checkup than those who got in quickly for their first comprehensive examination. One immediate factor, having a Medicaid-enrolled adult in the household, approached statistical significance (p  =  .064).

Table 3

Final Multiple Variable Cox Proportional Hazards Regression Model for Time to First Dental Checkup (N  =  2,982)

Final Multiple Variable Cox Proportional Hazards Regression Model for Time to First Dental Checkup (N  =  2,982)
Final Multiple Variable Cox Proportional Hazards Regression Model for Time to First Dental Checkup (N  =  2,982)
Table 3

Continued

Continued
Continued

Discussion

This study is the first in which researchers compared the rates at which the first dental checkup took place for newly Medicaid-enrolled children with and those without an intellectual or developmental disability. Timely dental checkups are important, especially for children at risk for oral health problems, because dentists can intervene with preventive care and less invasive restorative treatments when necessary. During dental checkups, caregivers of these children are supposed to receive anticipatory guidance, which reinforces positive oral health care practices that can benefit their child. We hypothesized that newly Medicaid-enrolled children with an intellectual or developmental disability would have later first dental checkups than children without an intellectual or developmental disability. However, our regression models revealed no significant difference in the time to first dental checkups by intellectual or developmental disability status. The only factor that was significantly related to earlier first dental checkups was the number of months it took for the child to receive their first comprehensive dental examination. Children who received a first comprehensive dental examination more than 12 months after being in the Medicaid program were 1.68 times as likely to have an earlier first dental checkup as did children who received a first comprehensive dental examination within 4 months.

Although not directly comparable, in a previous study on dental checkups, Maurer et al. (1996) reported that 64% of patients ages 2 to 46 years (M  =  14.2) with a handicap such as mental retardation, cerebral palsy, epilepsy, or an orthopedic problem had a checkup within 12 months. This proportion is about 13% less than the proportion of children in our study with a dental checkup within 12 months (77%). In addition, 55.3% of newly Medicaid-enrolled children ages 3 to 8 in our study had a comprehensive dental examination followed by a dental checkup (2,982/5,391), whereas 12.6% of Medicaid-enrolled children less than 21 years of age in New Hampshire received two dental examinations (Chi & Milgrom, 2009). There are no other published studies to which we can compare our findings on rates of first dental checkups for newly Medicaid-enrolled children by intellectual or developmental disability status.

We have three potential explanations of our failure to detect a difference in the time to first dental checkups for Medicaid-enrolled children by intellectual or developmental disability status. First, it may be that once a newly Medicaid-enrolled child sees a dentist for the first time and is not referred to another dentist, two traits shared by children in this study, having an intellectual or developmental disability is a less important determinant of the timing of subsequent dental checkups. Second, 41% of the children with an intellectual or developmental disability were classified as healthy, a relatively large subgroup of children who may be similar to those without an intellectual or developmental disability. Dental utilization for these children could have skewed the outcome measure for children with an intellectual or developmental disability toward unity. However, we reanalyzed our data after excluding these healthy children with an intellectual or developmental disability and found that the adjusted hazard ratios remained the same, making this explanation unlikely. Third, although the difference was not statistically significant, 7.7% of children with an intellectual or developmental disability received restorative treatment after the first comprehensive dental examination but before the first dental checkup compared to 14.8% of children without an intellectual or developmental disability (see Table 1). This difference suggests that children with an intellectual or developmental disability may have had less need for restorative care, in which case we would expect similar rates of first dental checkup by intellectual or developmental disability status.

Other Determinants of the Time to First Dental Recall Examination for All Children

Ascribed factors

In addition to intellectual or developmental disability status, we examined three ascribed factors: age, sex, and overall health status. We failed to detect a significant difference by age in the time to first dental checkup. This finding is inconsistent with previous findings that younger Medicaid-enrolled children are significantly more likely to have later first dental visits than those who are older (Chi et al., 2011). Disregarding statistical significance, the directions of the hazard ratios reveal that children ages 3, 4, or 5 were less likely to have earlier first dental checkups than were 8-year-olds. We also found no differences by sex or overall health status. Although there is no reason to expect heterogeneous dental utilization by sex, it is unclear why children with a chronic condition were no less likely to have earlier first dental checkups than were healthy children, given that children in the former group have other health care needs that may be higher priority than oral health. The relationship between overall health status and dental utilization for Medicaid-enrolled children warrants further investigation.

Proximal factors

There were three proximal factors included in our models: use of primary medical care, number of months to the first comprehensive dental examination, and whether the child received any restorative dental care after the first comprehensive dental examination but before the first dental checkup. The only factor that was significant was the number of months to the first comprehensive dental examination. Even then, only children who had a first comprehensive dental examination more than 12 months from the time of enrollment into the Iowa Medicaid program were significantly more likely to have earlier first dental checkups than were children with a first comprehensive dental examination less than 4 months from enrollment. Although it is possible that this difference was due to chance (type I error), another explanation is that the presence of risk factors for dental caries, such as inflamed gums and white spot lesions (reversible cavities), might have prompted dentists to assign these children to more frequent dental checkups. In addition, caregivers who postpone the child's first visit may learn about the importance of periodic dental checkups and, subsequently, be more vigilant about taking their child to the dentist for regular checkups. As for the other two proximal factors, we believe the explanation for a lack of statistical significance is that the first dental comprehensive examination may be the single most important determinant of the timing of the first dental checkup.

Immediate factors

We examined two immediate factors: whether the child had a Medicaid-enrolled sibling or a Medicaid-enrolled adult in the household. Both variables, as well as the interaction between the two variables, failed to reach statistical significance. However, the adult variable approached significance, p  =  .06, suggesting that children with a Medicaid-enrolled adult may be less likely to have earlier first dental checkups. Households with a Medicaid-enrolled adult are among the lowest income families in Medicaid. This economic vulnerability may be associated with caregiver health beliefs and behaviors that lead to poor dental utilization. As a result, children from these households may experience additional barriers to timely dental checkups, such as high caregiver stress, unreliable transportation, and inability of the primary caregiver to take time off from work. Given the link between caregiver and child dental utilization (Grembowski, Spiekerman, & Milgrom, 2008) and the importance of monitoring the oral health of vulnerable children, the relationship between immediate factors and the timing of first dental checkups requires further clarification.

Intermediate factor

We examined the role of one intermediate factor, rurality of the child's county of residence, and failed to detect statistically significant differences across the four rurality subgroups. This finding conflicts with previous work suggesting that children living in rural areas have greater problems accessing dental care (DeVoe, Krois, & Stenger, 2009). An explanation for our finding is that rurality may be a less important determinant of the timing of first dental checkups once a child is able to establish a dental home by having a first comprehensive dental examination.

Distal factor

There was one distal factor in our models: whether the child lived in a Dental Health Professional Shortage Area. The explanation for the lack of statistical significance is similar to the explanation for our intermediate factor (rurality).

Overall conceptual model

It appears that the adapted Patrick et al. model on oral health disparities was not sufficient in helping us to identify the determinants of first dental checkups for Medicaid-enrolled children. The more important finding, in the context of previous findings, is that the determinants of utilization for different types of dental care (first comprehensive dental examinations and first dental checkups) are heterogeneous. Our work underscores the complexity of modeling dental utilization for vulnerable children. Additional conceptual work may be necessary to link use of different types of dental care into a single theoretical framework, which can then be used to develop policies and clinical interventions aimed at improving access to appropriate types of dental care for all Medicaid-enrolled children.

There are three limitations with the current study. First, our findings can only be generalized to newly Medicaid-enrolled children ages 3 to 8 years. It is possible that the relationship between intellectual or developmental disability status and the time to first dental checkup is different for older Medicaid-enrolled children. Second, we were unable to include in our regression models behavioral measures, such as caregiver attitudes, knowledge, and beliefs regarding dental checkups, which are presumed to be important determinants of disparities in access to dental care in Patrick et al.'s model on oral health disparities. Future researchers should collect primary data from caregivers of Medicaid-enrolled children and assess the role behavioral factors have on the time to first dental checkups. Third, the lack of clinical data for children precluded an assessment of the level of dental treatment need for children in the study. We included a restorative treatment variable in our model and assumed that children who needed dental treatment received it, although this assumption could not be verified. For this reason, in the future investigators should collect clinical data in order to assess the extent to which the dental checkups are subsequently associated with lower levels of unmet dental need. It may be that children at risk for oral health problems, such as Medicaid enrollees with an intellectual or developmental disability, may need to see a dentist more frequently to ensure that an adequate level of preventive care is provided and to reinforce positive oral health-related practices among caregivers.

In conclusion, our findings suggest no difference in the time to first dental checkups for newly Medicaid-enrolled children with and those without an intellectual or developmental disability. The only factor associated with earlier first dental checkups was greater length of time to the first comprehensive dental examination (over 12 months). It is encouraging that all children in our study eventually had a first dental checkup. However, one fifth of children had their first dental checkup longer than one year after the first comprehensive dental examination. If the longer periodicity of dental checkups was based on lower risk for developing caries and other oral health problems, our findings might reflect appropriate use of dental care services. However, it is likely that many of these children had delayed first dental checkups and could have benefitted from preventive care provided earlier and more frequently, highlighting the larger problem that subgroups of Medicaid-enrolled children have in terms of access to timely dental checkups. Future work should be focused on constructing additional conceptual models on dental utilization to help researchers identify the determinants of dental checkups, especially for children at increased risk for oral health problems. This knowledge can then be used to develop clinical interventions and periodicity policies aimed at improving the oral health for the most vulnerable child Medicaid enrollees.

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Author notes

Editor-in-charge: Steven J. Taylor

Authors

Donald L. Chi, DDS, PhD (e-mail: dchi@uw.edu), Oral Health Sciences, University of Washington, Seattle, WA 98195. Elizabeth T. Momany, PhD, and Peter C. Damiano, DDS, Public Policy Center; Michael P. Jones, PhD, Biostatistics; and Raymond Kuthy, DDS, Preventive and Community Dentistry, University of Iowa, Iowa City, IA 52242.