key: cord-0765655-mn8zuyxw
authors: Burgette, Jacqueline M.; Weyant, Robert J.; Ettinger, Anna; Miller, Elizabeth; Ray, Kristin N.
title: What is the Association Between Income Loss During the COVID-19 Pandemic and Children’s Dental Care?
date: 2021-02-06
journal: J Am Dent Assoc
DOI: 10.1016/j.adaj.2021.02.001
sha: f2cbf3604280634f0ebdf96f6c2e33e3e91a6900
doc_id: 765655
cord_uid: mn8zuyxw

Background The degree to which children experience unmet need for dental care during the COVID-19 pandemic, and its association with pandemic-related household job or income loss, is unknown. Methods The authors performed a cross-sectional household survey of 348 families in Pittsburgh, PA during the week June 25 to July 2, 2020. Unmet need for child dental care and pandemic-related household job or income loss were assessed using caregiver self-report. Results Caregivers reported that the greatest unmet child health care need during the COVID-19 pandemic was dental care (16%) followed by medical care for a well visit or vaccination (5%). Approximately 40% of caregivers reported job loss or a decrease in household income due to the COVID-19 pandemic. We found a significant association between the probability of unmet child dental care and pandemic-related household job or income loss (P=.022). Losing a job or experiencing a decrease in income due to the COVID-19 pandemic was associated with unmet child dental care (Relative Risk, 1.77; 95% confidence interval, 1.08 to 2.88). Conclusions In our sample, three times as many households reported unmet dental care for a child compared to unmet medical care. Unmet child dental care was more common in households where pandemic-related job or income loss occurred. Practical Implications If unmet dental care continues as a result of the COVID-19 pandemic, non-traditional strategies for delivering dental care can be considered to improve access to dental care for children, such as teledentistry and oral health prevention services in primary care settings.

Access to dental care has been an ongoing challenge for American children even before the COVID-19 pandemic. [1] [2] [3] Dental caries (tooth decay) is the most common chronic disease among American youth 4 with a national prevalence of 45% in children ages 2 to 19. 4, 5 With decreased access to dental care, potential sequelae of unidentified or untreated child dental caries include pain, infection and poor academic performance. [1] [2] [3] 6 Decreased access to dental care can also lead to increased emergency room visits for acute dental pain 7-9 and serious life-threatening events. 10 To prevent dental caries in children, professional organizations -such as the American Academy of Pediatrics, 11 American Academy of Pediatric Dentistry, 12 American Dental Association 13 -advocate for a dental home to be established no later than 12 months of age.

Early dental visits are cost-effective 14 and state Medicaid programs have a federal mandate to cover the cost of child dental care within the Early and Periodic Screening, Diagnostic, and Treatment benefit. 15 However, even with the support of professional organizations and public insurance, many families describe insurmountable challenges to accessing dental care for their children. Cost remains the major barrier to receiving dental care that leads to unmet dental needs. 16 Although access to child dental care has grown for families with public insurance over the last few decades, inequitable access continues to be linked to socioeconomic status. [17] [18] [19] Additional barriers include difficulty finding a willing dental provider, 20-22 transportation [23] [24] and geographic proximity to dental providers. [25] [26] During the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) issued guidance for providing dental care, which "recommended that dental settings should J o u r n a l P r e -p r o o f prioritize urgent and emergency visits and delay elective visits and procedures to protect staff and preserve personal protective equipment and patient care supplies." 27 Additionally, the CDC recommended infection prevention and control practices during the COVID-19 pandemic, such as screening patients for signs and symptoms of COVID-19, physical distancing within the dental office and disinfection procedures. 27 These recommendations were put forth to decrease the risk of SARS-CoV-2 transmission during dental treatment and were supported by the American Dental Association, state dental societies, and departments of public health. Dental practices complied with CDC recommendations and reported a decrease in patient care, with over 95% of dental practices closing completely or opening only for emergency care by the end of April. 28 Since then, gradual re-opening has occurred nationally, with 30% of offices open in early May, 65% open in mid-May and 97% open in mid-June. 28 While dental practices may be "open," almost 64% were seeing lower patient volume than usual according to a survey in mid-June. 28 Additionally, dental practices that are open may be experiencing a backlog of dental visits, resulting in delayed visits for patients seeking dental care.

Before the COVID-19 pandemic, dental care was the greatest unmet health care need among children in the United States. [29] [30] The aim of this study was to determine the degree to which children in the study population were reported to have unmet need for dental care during the COVID-19 pandemic and whether that reported unmet need was associated with pandemicrelated household job or income loss given access barriers associated with loss of employerprovided dental insurance and income. In this cross-sectional study, we did not assess whether there was a change in unmet dental needs due to the pandemic; rather, we sought to report the level of unmet dental needs descriptively at one point in time. We hypothesized that dental care would be the greatest unmet child health care need, consistent with literature prior to the J o u r n a l P r e -p r o o f pandemic. 29-30 Additionally, we hypothesized that families reporting household job loss or decreased income related to COVID-19 would have higher rates of unmet child dental needs compared to families not reporting job loss or decreased income.

In April 2020, a partnership of pediatricians, child health researchers, public health and social service organizations developed a repeated cross-sectional survey, the Family Strengths Survey (FSS), 31 as part of an ongoing academic-community collaborative called "The Pittsburgh

Study." The goal of the FSS was to understand the experiences of families in Western Pennsylvania week-by-week during the COVID-19 pandemic with the recruitment and data collection procedures described in a previous publication. 32 The FSS used an opt-in nonprobability design to recruit adults living in Western Pennsylvania with children less than 18 years-old living in their household through list-servs, social media posts, local newspaper, radio coverage, and texts and emails. Consistent with American Association for Public Opinion Research reporting guidelines for survey recruitment using an opt-in nonprobability panel, the participation rate was not reported because the sampling frame was unknown. 33, 34 Participants were asked to complete the FSS weekly using an online Qualtrics survey tool or by phone in English or Spanish. They completed the online Qualtrics survey or phone survey anonymously with the option of opting into the chance to win a $100 gift card distributed weekly. Core survey questions were included in this weekly repeated cross-sectional study. Supplemental questions were added to the survey each week on a one-time basis in response to emerging concerns. This cross-sectional analysis focused on questions added on a one-time basis during the week of June 25 to July 2, 2020, approximately three months after the pandemic started, which elicited responses from caregivers about unmet child health care needs over the prior three months. The University of Pittsburgh Institutional Review Board deemed this project exempt.

The dependent variable, unmet child dental care, was measured using questions from the National Survey of Children's Health. The caregiver reported whether dental care was needed and not received by a child in the household. Survey respondents were asked "During the past 3 months, was there any time when this child needed health care but it was not received? By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services." 35 If the caregiver answered positively, they were asked "Which types of care were not received? Check all that apply" with the following seven options: Medical Care for a child's illness or problem, Medical Care for a check-up or well check or shots, Dental Care, Vision Care, Hearing Care, Mental Health Services, and Other. 35 This question, as replicated from the National Survey of Children's Health, does not specify the reason for unmet dental care. Unmet dental care was a binary variable defined as a positive response to selecting "Dental Descriptive statistics and graphics were used to explore the distribution of sociodemographic characteristics of the sample, including the relative risk of unmet child dental care if a household experienced job loss or decrease in income due to the COVID-19 pandemic. All analyses were conducted using STATA 15 (StataCorp, College Station, TX).

In this cross-sectional household survey in Western Pennsylvania, 86% of caregivers identified as Non-Hispanic White, 66% reported a household pre-pandemic income of greater than $75,000, and the mean family composition was two parents and three children (Table 1) .

Approximately 40% (138/348, 95% CI 35-45%) of caregivers in the study reported a job loss or decrease in household income due to the COVID-19 pandemic.

Of the 348 families who participated in the survey in the week June 25 to July 2, 2020, caregivers reported that the greatest unmet child health care need during the last three months during the COVID-19 pandemic was "Dental Care" (n=54, 16%, 95% CI 12-20%), followed by "Medical Care for a check-up or well check or shots" (n=18, 5%, 95% CI 3-8%), "Mental Health Services" (n=12, 3%, 95% CI 2-6%), "Vision Care" (n=9, 3%, 95% CI 1-5%), "Medical Care for a child's illness or problem" (n=8, 2%, 95% CI 1-4%), "Other" (n=6, 2%, 95% CI 1-4%) and "Hearing Care" (n=2, 1%, 95% CI 0-2%) ( Figure 1 ). In our sample, caregivers reported that a child in their household needed dental care over three times more often than a child needed medical care for a well visit or vaccination ( Figure 1 ). We did not find that families without J o u r n a l P r e -p r o o f unmet child dental care were different than those with unmet child dental care (P>0. 19 ) except for one characteristic: household job loss or decrease in income due to the COVID-19 pandemic (p=0.022) ( Table 1 , Table 2 ). The risk of unmet child dental care in a household that experienced job loss or decrease in income due to the COVID-19 pandemic was 21% (29/138) compared to 12% in household that did not experienced job loss or decrease in income due to the COVID-19 pandemic (25/210).

Losing a job or experiencing a decrease in income due to the COVID-19 pandemic was associated with a greater risk of unmet child dental care (Relative Risk =1.77, 95% CI 1.08-2.88).

We found a significant association between caregiver-reported unmet child dental care and job loss or decreased income in the household due to the COVID-19 pandemic. Similar to before the COVID-19 pandemic, 29-30 unmet dental care was the greatest unmet child health care need. In our sample, unmet child dental care was more common than unmet medical care with a prevalence of 16%, and considerably higher than the national prevalence of unmet child dental care among youth aged 1 to 17 years-old (2%) prior to the pandemic. 36 Before the COVID-19 pandemic, more Americans reported financial barriers to receiving dental care compared to any other type of health care. 16 Although we do not know the specific reasons for the unmet dental care, it is possible that the high levels of unmet dental need could reflect routine preventive care or greater need for treatment resulting from dental caries. The national and independent nonprofit organization, FAIR Health, found that dental caries rose from the fifth-to the fourth-most common dentalrelated diagnosis in hospital emergency rooms from January and February 2020 to March and April 2020. 38 They also found that dental service utilization for those with private insurance fell 76% in March 2020 and 81% in April 2020 compared to the same months in the previous year for children age 14 and younger. 38 The COVID-19 pandemic has also resulted in limited access to comprehensive dental treatment under general anesthesia for children, 39,40 which could result in unmet dental care needs.

Our findings highlight the impact of the COVID-19 pandemic for all families in the study, whether they receive care in America's private or public dental health care system. [1] [2] [3] 17, 41 In the private dental care delivery system, private dental practices serve approximately twothirds of Americans and are financed by employer-provided commercial dental benefits with high out-of-pocket dental health care expenses compared to overall out-of-pocket health spending. [1] [2] [3] 17, 41 In the public dental care delivery system, the dental safety net systemincluding Federally Qualified Health Centers, school-based health centers, and academic dental institutions -strives to cover dental care for the remaining one-third of Americans who may be underserved due to income, lack of dental insurance, rural location, and systematic disadvantage due to race, ethnicity and immigration status. [2] [3] 41 Notably, there was no difference in pandemicrelated job loss or loss of income across the different levels of household income (data not shown), so the acute change of the COVID-19 pandemic impacted unmet dental for children across the entire study population.

For families in the private dental health care system, changing family financial circumstances may have rendered high out-of-pocket dental health care expenses no longer affordable, resulting in unmet child dental care. Therefore, our results call attention to the consequences of financing of oral health services through employee-sponsored dental insurance and fee-for-service care. A restructuring of the oral health delivery system would be needed to promote oral health even in times of changing financial situations, such as a pandemic.

In light of the financial barriers to child dental care for households that access dental care through the dental safety net system, the Centers for Medicare and Medicaid Services is continuing to bolster the second tier of the dental health care system with a continuation of the Oral Health Initiative, which helps states provide access to dental and oral health services for children enrolled in Medicaid and the Children's Health Insurance Program. 42 For both the private and public dental health care systems, there are opportunities to improve access to dental care for American children, including teledentistry, 43-46 a focus on caries prevention strategies including topical fluoride and sealants 47,48 and minimally-invasive dental services that do not generate aerosols. 49 These evidence-based strategies offer opportunities to enhance care in general, but specifically during the current pandemic where physical distancing and avoidance of aerosolizing procedures are important.

Additionally, there are a myriad interprofessional opportunities to promote child oral health by engaging non-dental health professionals -including physicians, social workers, dietitian nutritionists, and community health workers -to educate families on child oral health knowledge and prevention practices. 44,51 With less unmet child medical care compared to dental care in our sample, the delivery of preventive oral health services during medical visits 50-54 may be a strategy to overcome the barriers to child preventive dental care during the pandemic.

Finally, we can combat the increased need for child dental care by focusing on preventing dental caries in children. The current pandemic is a call to action to re-invigorate our efforts in primary prevention for oral health, with a particular focus on solutions that promote oral health for all Americans regardless of employment or income. 55

Limitations. This study had several limitations. Our results may be subject to reporting bias and measurement error due to the use of self-reported data and lack of specificity on unmet dental care. For example, unmet dental care could be for a dental prophylaxis or an untreated and emergent dental trauma. The results also may not be generalizable, particularly because this study was a convenience sample comprised of mostly white families with high incomes. Finally, this study is cross-sectional, which does not allow for causal inference between income and unmet child dental care.

Conclusions. Three months into the COVID-19 pandemic, we found that dental care was the greatest unmet health care need among children, with more households reporting unmet child dental care compared to unmet child medical care in our sample. Additionally, unmet child dental care was more common in households where pandemic-related job or income loss occurred. If unmet dental care continues as a result of the COVID-19 pandemic, non-traditional strategies for delivering dental care may need to be considered to improve access to dental care for American children, such as teledentistry and oral health prevention services delivered in primary care settings. Additionally, an investment in dental public health efforts in needed to decrease the burden of dental disease and potentially decrease the level of unmet dental care among American children during the COVID-19 pandemic. Finally, the COVID-19 pandemic has provided a stress on the financial system that supports the delivery of dental services, 348 Note: + Unmet child dental care is defined as caregiver-reported needed dental care that was not receive by a child in the household. ǂ Household Job Loss or Decrease in Income Due to the COVID-19 Pandemic is defined by the caregiver's positive response to the question, "Have you or another adult in your household lost your job or experienced a decrease in income because of the COVID pandemic?" Losing a job or experiencing a decrease in income due to the COVID-19 pandemic was associated with a greater risk of unmet child dental care (Relative Risk=1.77, 95% CI 1.08-2.88). Q6 Thank you for being willing to complete this survey --here are details about the survey, which we are inviting you to take this week and every week during the pandemic:

COVID-19 (the Coronavirus) has challenged all of us. We are conducting this research because parents and adult caregivers are vital for ensuring children continue to thrive during these tough times. We want to learn about what has been helpful for you and your family. Are there resources we should share with others? We also want to help families connect to resources and supports. We are asking parents or expecting parents to answer questions about their family and the resources available in their communities. If you agree to complete the survey, your responses are anonymous. You can skip questions. You can stop any time. Taking the survey will not affect your receipt of services. Each week 5 people who complete the survey will be randomly selected to receive $100. We expect to have about 500 people complete the survey every week, so your chance of receiving $100 is about 1 in 100.

At the end of the survey, you have the choice to enter your name and contact information to get more information about resources and to answer the survey again in the future. This information is never linked to your answers to the survey.

This research study is being done by researchers at the University of Pittsburgh and Children's Hospital of Pittsburgh with help from the United Way, Allegheny County Health Department and the Department of Health and Human Services. Let's get started. And thanks again for your time and your answers. Food assistance (including food banks, school distribution sites, WIC, SNAP, food boxes) (1) Transportation assistance (such as MATP) (2) Medical care including emergency room, urgent care, primary care, and other health care services (3) Outpatient therapy services (such as physical therapy (PT), occupational therapy (OT, and speech/language therapy) (4)

Medications, medical supplies, and durable medical equipment (DME) (5) Rehabilitation or early intervention services (6) Home health services (such as home health aides and home nursing) and respite care (7) Baby supplies like diapers, formula, and wipes (8) Unemployment benefits (9) Cash assistance (10) Child care (11) Family support services (like parenting support or advice, handling challenging behaviors) (12)

Mental health or behavioral health care (13) Substance use disorder treatment (14) Housing support (15) Financial support for utilities (16) Education support for children or special education services, including an Individualized Education Plan (IEP) or 504 plan (17) None of the Time (1) Some of the Time (2) Most of the Time (1) I'm worried about affording testing (4) I'm not sure I would be given a test (5) I'm not sure the test can be trusted (6) Other (7) o No, none of us have tried to get tested (1) o No, one of us (or more) tried to get tested but was not able to (4) o Yes and we are awaiting results (5) o Yes and the test showed the person tested did NOT have COVID-19 (negative) (6) o Missed shots/vaccines but not because of COVID-19. (5) Page Break Q85 In the past 7 days, were members of your household treated unfairly or badly because of the color of their skin, language, accent, or because they come from a different country or culture?

o Yes (1) o No (2) Q84 How often do you feel that racial/ethnic groups who are not white, such as African Americans and Latinos, are discriminated against in your neighborhood or workplace?

o Never (1) o Rarely (2) o Sometimes (3) o Often (4) Q93 How comfortable do you feel talking to your child(ren) about race/racism? o Very comfortable (1) o Somewhat comfortable (4) o Neither comfortable nor uncomfortable (5) o Somewhat uncomfortable (6) o Very uncomfortable (7) o I choose not to talk to my child(ren) about race/racism at this time / at their current age Q25 What do you identify as your race(s)? Please select ALL that apply.

American Indian or Alaska Native (1) Black or African American (2) Asian or Pacific Islander (3) White (4) Biracial or Multiple races (5) Some other race: (6) ________________________________________________

Prefer not to answer (7) Q70 Do any of the children in your household identify as different race(s) or ethnicity than your own? o Yes (1) o No (4) Q28 Is English the primary language spoken in your home? o No change (1) o Lost job in past week (2) o Found new employment in past week (3) Q39 Did your household have a change in income in the past week? (Include income from a job, from unemployment, and any other sources) o No change (1) o Less income this week compared to last week (2) o More income this week compared to last week (3) 

United States Department of Health and Human Services. Oral health in America: A report of the surgeon general

Institute of Medicine and National Research Council. Improving access to oral health care for vulnerable and underserved populations

Oral Health in America: Removing the Stain of Disparity

Prevalence of total and untreated dental caries among youth: United States

Prevalence of untreated decay in primary teeth (dt) among youths 2-11 years of age, by selected characteristics: United States, National Health and Nutrition Examination Survey

The impact of oral health on the academic performance of disadvantaged children

Early and Periodic Screening, Diagnostic, and Treatment

Dental Care Presents The Highest Level Of Financial Barriers, Compared To Other Types Of Health Care Services

A tale of two safety nets

Trends in paediatric dental caries by poverty status in the United States

Trends in dental caries in children and adolescents according to poverty status in the United States from 1999 through

How willing are dentists to treat young children?: a survey of dentists affiliated with Medicaid managed care in New York City

Infant oral health care: a survey of general dentists, pediatric dentists, and pediatricians in Virginia

Access to dental care for children in the United States: a survey of general practitioners

Barriers to care-seeking for children's oral health among low-income caregivers

Rapid-cycle community assessment of health-related social needs of children and families during COVID-19. Acad Pediatr

Computing response metrics for online panels

Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 2019 National Survey of Children's Health

National Survey of Children's Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB)

Nearly Two-Thirds of U.S. Households Struck By COVID-19 Face Financial Trouble