Households’ age, country of birth, and marital status, stronger predictor variables than education in the prevalence of dental sealants, restorations, and caries among US children 5–19 years of age, NHANES 2005–2010

The preponderance of evidence attests that children’s oral health is associated with multiple biological and sociodemographic factors. Likewise, income and education are frequently associated with health status globally. Households’(HHs) sociodemographic characteristics influence on children’s oral health frequently include race, income, education, and health insurance coverage [1‐4]. Maternal health and marital status, birth place, work and living environments, and social support also play a significant role in children’s access to dental care [5, 6]. Households’ income and education directly correlate with children’s access to preventive and restorative dental care and indirectly with dental caries or decay [1, 7, 5, 8]. Most studies using examination data representative of the U.S. population e.g., National Health and Nutrition Examination Survey (NHANES) frequently include HHs income and education to measure associations with children’s oral health. These studies do not simultaneously measure associations that include HHs variables such as; age, gender, citizenship, country of birth, marital status, family size, with the prevalence of dental sealants, restorations, and caries in children [9, 10]. The aim of this study is to use data representative of the U.S. population to determine if households (HHs) age, birth country, and marital status, are reliable predictors as HHs education for the prevalence of dental sealants, restorations, and caries in U.S. children 5 to 19 years of age.

From the study sample of children 5–19 years of age (n = 9151), 51.1% were males, 32, 33.91 and 34.09%, were 5–9, 10–14, 15–19 years of age respectively, and 20.5% lived under 100% of the Federal Poverty Level (FPL) (Table 1). The study HHs sample (n = 31, 034) included 54.7% males, 47.9% in the age range 30–49, 26.6% with a college or above education, 14.9% living below 100% of the FPL, 11.4% never married, 56.4% had a family size of 1–3 members, 82.8% had health insurance, and 92.2% were US citizens. Mexican Americans and other Hispanics HHs had the highest proportion of persons living under 100% of the FPL, with less than a 9th grade education, no health insurance and a non-citizen status. HHs from Other Race/Multiracial had the highest percentage of being married or living with a partner, Mexican Americans, Non-Hispanic White, and Other Hispanic ranked 2nd, 3rd, and 4th (Table 2).

In bivariate analysis, sealants were more prevalent among children from HHs with spouses with a college or above education (40.2%), HHs with a college or above education (39.9%), non-Hispanic White HHs (34.4%), HHs ages 50–59 (33.9%), and ages 30–49 (32.9%), and HHs with insurance (32.6%). Children from non-citizen HHs had the lowest sealant prevalence (20%). Children from HHs of Mexican-American ancestry and birth place had the highest prevalence of restored teeth (51.9%) and (50.3%) respectively. A college education or above for both the HHs and their spouses resulted in the lowest prevalence of restored teeth (32.9%) and (34%) respectively in children. Children’s caries prevalence was higher among non-citizens and uninsured HHs (30.1%) and (27.9%), and lowest in children from HHs and spouses with college of above education (6.9%) (Table 3).

After adjusting for HHs health insurance, citizenship, family size, and children’s age categories, the odds of children having sealants were higher among HHs with a college education or above OR 2.05 [1.54.-2.73] vs. HHs with a < 9th grade, in HHs ages 39–49 (OR 1.78 [1.41–2.24) vs. 18–29 years of age, and in HHs spouses with a college education and above OR 1.71 [1.14–2.56] vs. HHs with a < 9th grade. Lowest odds for sealant were among children from HHs of non-Hispanic Black ancestry 0.60 [0.48–0.75]. The odds of having restored teeth were higher in children of HHs born in Mexico 1.74 [1.44–2.10], never married HHs 1.21 [1.02–1.43] and those widowed/divorced/separated 1.18 [1.01–1.39]. Lowest in HHs with college or above education 0.46 [0.33–0.63]. The highest odd for caries was among children from HHs that were never married 1.91 [1.47–2.48]. Children from female HHs had an OR of 1.26 (1.06–1.50) for caries when compared to male HHs. Children living in HHs with a college education 0.31 [0.22–0.43] had the lowest odds for caries (Table 4).

Results from this study indicate that after controlling for health insurance, citizenship, family size, and children age categories, having HHs with ages 30–49 could significantly have higher odds of a child receiving dental sealants than HHs spouses with a college education or above. HHs birth place increased the odds of children’s experiencing dental restorations more than HHs with college education. HHs with a marital status “Never Married” provided the highest odds for dental caries in children.

To the best of the author’s knowledge, this study is the first to use recent NHANES data to measure the associations between HHs gender, age categories, marital status, country of birth, and the prevalence of children’s dental sealants, restorations, and caries. The findings in this study agree with other research that reports disparities in Mexican-American and Black or African-American children’s prevalence of caries and dental sealants [13‐15]. Similar to the present study researchers have found positive associations between children prevalence of dental sealants and parents with higher educational attainment and having dental insurance [16‐18]. Bivariate analysis in the present study confirms that the prevalence of children’ dental sealants, restorations, and caries was higher in homes where females HHs (owns or rents house) when compared to male HHs. After adjusting for covariates, female HHs only significantly increased the odds of children having caries. Although not significant, children from female HHs had slightly higher odds for sealants and restorations. Higher health literacy among female HHs and a better understanding of the value of prevention (sealants) may explain the present study findings on children’s dental sealants. After adjusting for race, education, age, and number of children, female oral health literacy has been associated with better reported oral health status [19].

In the present study the highest odds of having children with dental caries were linked to HHs that never married followed by HHs widows/separated/divorced (Table 4). The high risk of caries in children has been associated with single-parent households [20‐22]. Authors using NHANES data reported that even though disparities in caries prevalence may be decreasing across racial and ethnic groups, only non-Hispanic Black children 15 year of age experienced a significant decrease in caries experience [23]. These findings differ from the present study where in Non-Hispanic Black HHs the odds of children’s dental caries were 40% higher when compared to children’s odds from “Mexican American” HHs. In a systematic review on parental influences on the development of caries in children aged 0–6 years, the age of the mother had no clear effect on the risk of caries in children [24]. Similarly the present study did not find significant associations between HHs ages 50–59 and the odds of children having caries. However both of these studies findings differ from a longitudinal study where caregivers age was associated with new non-cavitated caries lesions in children 2–5 years of age [25].

The present study was not able to measure the influence of HHs oral health literacy on children’s dental indicators. Caregivers’ oral health literacy has been associated with children oral health status [26, 27]. NHANES data on fluoride products as dietary supplements are not linked to subjects participating in the oral health BSE and the confounding effects of fluoride on the prevalence of restorations and caries could not be measured in the present study. Underreporting of caries or tooth decay may result in NHANES studies since the BSS does not include radiographs that can detect interproximal lesions. In the United States (US), poverty is measured by the Federal Poverty Level (FPL). During 2010, families living at the US 100% of Federal Poverty Level were consider poor if their annual income was $10,830 for one person, $14,570 for two persons, and $22,050 for 4 persons. In 2014, US median income was higher among those aged 45 to 54 and married couples, and more females and persons without a high school diploma lived in poverty [28]. Worldwide poverty is measured differently from the US. Age, marital status, and education effects on poverty might not be similar to the US. Results from this study could possibly not be valid in other countries.

HHs age, marital status, and gender, could contribute to a better understanding of the root causes of oral health disparities in children. Knowledge of the aforementioned HHs characteristics impact on children’s access to dental services could help providers identify families with children who are at a greater risk for caries or not benefiting from preventive dental services. Tailored outreach, case management, and patient education interventions could help families and providers to work on strategies to improve children’s oral health.