key: cord-0980727-xsjvjudn
authors: Lyu, Wei; Wehby, George L.
title: Effects of the COVID-19 Pandemic on Children’s Oral Health and Dental Care Use
date: 2022-02-25
journal: J Am Dent Assoc
DOI: 10.1016/j.adaj.2022.02.008
sha: 4812e93c1efb7b9a3441562e2ca2b28d7f957b95
doc_id: 980727
cord_uid: xsjvjudn

Background The Coronavirus Disease 2019 (COVID-19) pandemic led to early restrictions on access to dental care and social distancing requirements. This study examines the early effects of the COVID-19 pandemic on children’s oral health and access to dental care in the United States. Methods Using nationally representative data from the National Survey of Children’s Health, we compare several measures of children’s oral health and dental care use early during the pandemic in 2020, and one year earlier. Logistic (multinomial or binary) regression models are estimated adjusting for several child/household covariates and state fixed effects. Similar comparisons are estimated for 2019 relative to 2018 to evaluate pre-pandemic trends. Results Children in 2020 were 16% (relative risk ratio or RRR=0.84, 95% CI: 0.75,0.93) less likely to have excellent dental health as perceived by parents and 75% (RRR=1.75, 95% CI: 1.14,2.67) more likely to have poor dental health than 2019. Also, children in 2020 had higher risk for bleeding gums (odds ratio or OR=1.46, 95% CI:1.16,1.85). The likelihood of having a dental visit in the past 12 months was 27% (OR=0.73, 95% CI:0.65,0.82) lower in 2020 including lower likelihood for preventive visits. The 2020-2019 differences were observed across demographic and socioeconomic subgroups. There were no such differences between 2019 and 2018. Conclusions There was widespread decline in children’s oral health status and access to dental care early during the COVID-19 pandemic.

The Coronavirus Disease 2019 (COVID- 19) pandemic has posed significant challenges 25 to children's health. [1] [2] [3] Several COVID-19 mitigation policies were declared in the United States 26 beginning in March and April 2020 including lockdowns and closure of schools and businesses. 4 

One consequence of these closures and social distancing measures was disrupting children's 28 access to health care services. 5, 6 Children's oral health status is likely one of the more adversely 29 affected domains of children's health due to early imposed restrictions on access to dental 30 services. [7] [8] [9] However, there is little empirical evidence on the magnitude of changes in children's 31 oral health status and use of dental services during the COVID-19 pandemic. This study aims to 32 provide evidence on this question. 33 In March 2020, the Centers for Diseases Control and Prevention and the American Dental 34 Association recommended that dental offices postpone elective procedures and only provide 35 emergency care 10, 11 due to concerns about COVID-19 exposure during treatment. [12] [13] [14] Most 36 states also imposed their own restrictions on services at dental offices in the first few months of 37 the pandemic. 15 These restrictions along with social distancing measures likely resulted in many 38 parents having to postpone dental care for their children during the pandemic particularly for 39 preventive care and non-emergency treatments. Even though most dental clinics have reopened 40 since June 2020, over 60% reported lower patient volume than usual or closed by the end of 41 2020, and nearly 40% reported lower volume or closed as recently as October 2021. 16 

The unemployment rise early in the pandemic might have also reduced access to dental 43 care due to loss of income and employer-sponsored coverage for 6.9 million dependents by June 44 2020. 17 Children were more likely to experience unmet dental care than medical care during the 45 pandemic, especially in families with pandemic-related job or income losses. 9 Among privately 46 J o u r n a l P r e -p r o o f insured children, the use of dental care also rebounded at a slower rate than insured adults after 47 the reopening. 18 Limited access to and delayed dental care are critical risk factors for worsened 48 children's oral health. 19-22 49 School closures during the pandemic likely also had adverse effects on children's oral 50 health. In 2020, most schools closed or changed to remote instruction. School closures disrupted 51 children's access to school-based dental care programs offered in some schools. In 2021, there 52 were nearly 2000 school-based health centers, about 16% of which provide onsite dental services 53 to thousands of students annually. 23 analyses. Descriptive statistics for the main sample are presented in Appendix Table 1 . Outcomes were measures of the child's oral health or dental care use. The first outcome 92 was dental health as perceived by parents (or other responding primary caregivers) on a Likert 93 scale (excellent, very good, good, fair, or poor). The second outcome was based on a question 94 about whether the child had frequent or chronic difficulty with oral health problems over the past 95 12 months including toothaches, bleeding gums, or decayed teeth. We coded a binary (0/1) 96 indicator for reporting any of these problems, and separate binary indicators for each of these 97 problems. Utilization of dental services was measured by two variables based on the survey 98 questions: 1-a binary indicator for whether the child had any dental visits in the past 12 months; 99 and 2-a three-category variable for whether the child had none, one, or two or more preventive 100 dental visits in the past 12 months. The questionnaire defined a preventive dental visit as one 101 involving any of the following services: dental check-up, dental cleaning, dental sealant, or For the two multi-category ordered outcomes, dental health as perceived by parents (from 115 excellent to poor) and the number of preventive dental visits, an ordered logistic regression was 116 first considered. However, the proportional odds assumption was rejected based on the Brant 117 test. 32 Therefore, the model for these two outcomes was estimated using multinominal logistic 118 regression (which drops the proportional odds assumption). For binary outcomes (any dental 119 problem, any dental visit), a binary logistic regression was used. Regression models were 120 estimated using the survey sampling weights to obtain nationally representative estimates.

The model was estimated first for the total sample. Additional models were estimated for 122 demographic and socioeconomic subgroups to evaluate potential differences. In those analyses, 123 the regression models were estimated by child's age (age 1-5, 6-11, and 12-17 years), gender, 124 race/ethnicity (non-Hispanic White versus Hispanic or non-White), family income (<200%, 200-125 399%, and ≥400% FPL) and insurance status (publicly insured versus not).

Oral Health 128 Figure 1 reports the relative risk ratios (RRRs) and their 95% confidence intervals from 129 the multinomial logistic regression for the child's dental health as perceived by parents (on five 130 categories from excellent to poor with good as the reference category) comparing 2020 to 2019. and those without public insurance coverage ( Table 1 ). The increase in bleeding gum likelihood 168 was largest among children 1-5 years (Table 2) , also largest when adding infants age 0 169 (Appendix Table 2 ). All subgroups had statistically significant declines in dental care use in 170 2020 (Table 3) . first year. These findings are consistent with other studies in the UK, Israel, and Brazil, which 184 also showed that the COVID-19 pandemic was significantly associated with reduced access to 185 dental care and poorer oral health status among children. 26, [33] [34] [35] 186 Improving children's oral health and access to dental care has long been a desired policy 

The study has some data limitations. Because all measures of children's oral health and 222 access to dental care in the NSCH are reported by parents (or for a small proportion by other 223 caregivers), there is the possibility for measurement error. However, it is unlikely that any 224 measurement error is different before and after the COVID-19 pandemic. Therefore, any 225 measurement error is unlikely to bias the magnitude of differences between survey years but can 226 inflate the variance of estimates (i.e., wider confidence intervals and higher p-values). Another 227 issue is that all outcomes except for the dental health as perceived by parents cover the past 12 228 J o u r n a l P r e -p r o o f months. Therefore, it is possible that some of the responses to these questions in 2020 capture the 229 pre-pandemic period. However, since the NSCH data were collected between July 2020 and 230 January 2021 (at least 4 months after the pandemic was declared in March and following the 231 early lockdowns and business including dental practice closures), these questions are likely to In conclusion, the study provides evidence of widespread decline in oral health status and 238 access to dental care among children in the United States early during the COVID-19 pandemic.

These findings highlight the need to monitor these trends through timely data collection and to sample includes children between ages 1 and 17 years. The relative risk ratios (dots) and 95% confidence 4 intervals (bars) were obtained from multinomial logistic regression estimates for the child's dental health 5

as perceived by parents (on five categories from excellent to poor with good as the reference category) 6

with separate regressions for comparing 2020 to 2019 and comparing 2019 to 2018. The model used data 7

from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, 8 race/ethnicity, highest education of parents, number of children, marital status, any employment, income 9

as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the 10 NSCH sampling weights to yield national representative estimates. 11 All models used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for 17

age, gender, race/ethnicity, highest education of parents, number of children, marital status, any 18 employment, income as a percentage of the federal poverty level, and state fixed effects. The model was 19

weighted by the NSCH sampling weights to yield national representative estimates. 20 The sample includes children between ages 1 and 17 years. The relative risk ratios and 95% confidence intervals in brackets were obtained from multinomial logistic regression estimates for the child's dental health as perceived by parents (on five categories from excellent to poor with good as the reference category) with separate regressions for comparing 2020 to 2019 and comparing 2019 to 2018. The model used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, race/ethnicity, highest education of parents, number of children, marital status, any employment, income as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the NSCH sampling weights to yield national representative estimates. *p<0.1, **p<0.05, ***p<0.01 

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Notes: The sample includes children between ages 1 and 17 years. The odds ratios and 95% confidence intervals in brackets were obtained from logistic regression for any of the following oral health problems: toothaches, bleeding gums, or decayed teeth; and for each problem separately, comparing 2020 to 2019 and comparing

All models used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, race/ethnicity, highest education of parents, number of children, marital status, any employment, income as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the NSCH sampling weights to yield national representative estimates. *p<0.1, **p<0using Data from 2018-2020 National Survey of Child's Health

Appendix Figure 1. Differences (Relative Risk Ratios with 95% Confidence Intervals) in Children's Dental Health Perceived by Parents between 2020 and 2019 and between

Differences (Odds Ratios and 95% Confidence Intervals) in Children's Oral Health Problems between 2020 and

Differences (Odds Ratios or Relative Risk Ratios and 95% Confidence Intervals) in Children's Use of Dental Visits between 2020 and

Relative Risk Ratios or Odds Ratios with 95% Confidence Intervals) in Children's Oral Health and Use of Dental Visits between 2020 and

Appendix Figure 1 . Differences (Relative Risk Ratios with 95% Confidence Intervals) in Children's Dental Health Perceived by Parents between 2020 and 2019 and between 2019 and 2018, Children Aged 0- 17 Years Notes: The relative risk ratios (dots) and 95% confidence intervals (bars) were obtained from multinomial logistic regression estimates for the child's dental health perceived by parents (on five categories from excellent to poor with good as the reference category) with separate regressions for comparing 2020 to 2019 and comparing 2019 to 2018. The model used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, race/ethnicity, highest education of parents, number of children, marital status, any employment, income as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the NSCH sampling weights to yield national representative estimates.Appendix Figure 2 . Differences (Odds Ratios and 95% Confidence Intervals) in Children's Oral Health Problems between 2020 and 2019 and between 2019 and 2018, Children Aged 0-17 YearsNotes: The odds ratios (dots) and 95% confidence intervals (bars) were obtained from logistic regression for any of the following oral health problems: toothaches, bleeding gums, or decayed teeth; and for each problem separately, comparing 2020 to 2019 and comparing 2019 to 2018. All models used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, race/ethnicity, highest education of parents, number of children, marital status, any employment, income as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the NSCH sampling weights to yield national representative estimates. Notes: The odds ratios (dots) and 95% confidence intervals (bars) were obtained from logistic regression for any dental visits comparing 2020 to 2019 and comparing 2019 to 2018. The relative risk ratios (dots) and 95% confidence intervals (bars) were obtained from multinomial logistic regression estimates for number of preventive dental visits (on three categories of none, one, or 2 or more visits with no visit as reference group) comparing 2020 to 2019 and comparing 2019 to 2018. All models used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, race/ethnicity, highest education of parents, number of children, marital status, any employment, income as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the NSCH sampling weights to yield national representative estimates.Appendix Notes: The relative risk ratios and 95% confidence intervals in brackets were obtained from multinomial logistic regression estimates for the child's dental health as perceived by parents (on five categories from excellent to poor with good as the reference category) and number of preventive dental visits on three categories of none, one, or 2 or more visits with no visit as reference group) with separate regressions for comparing 2020 to 2019 and comparing 2019 to 2018. The odds ratios and 95% confidence intervals in brackets were obtained from logistic regression for any of the following oral health problems: toothaches, bleeding gums, or decayed teeth; for each problem separately; and any dental visits comparing 2020 to 2019 and comparing 2019 to 2018. All models used data from 2018-2020 waves of National Child Health Survey (NSCH) and adjusted for age, gender, race/ethnicity, highest education of parents, number of children, marital status, any employment, income as a percentage of the federal poverty level, and state fixed effects. The model was weighted by the NSCH sampling weights to yield national representative estimates. *p<0.1, **p<0.05, ***p<0.01