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Dental caries among children visiting a mobile dental clinic in South Central Kentucky: a pooled cross-sectional study
© Dawkins et al.; licensee BioMed Central Ltd. 2013
Received: 18 February 2013
Accepted: 15 April 2013
Published: 2 May 2013
Dental caries is one of the most common chronic childhood diseases affecting a large portion of children in the United States. The prevalence of childhood dental caries in Kentucky is among the highest in the nation. The purposes of this study are to (1) compare sociodemographic differences between caries and no caries groups and (2) investigate factors associated with untreated dental caries among children who visited a mobile dental clinic in South Central Kentucky.
Study subjects were children aged 6 to 15 years who participated in the school-based dental sealant program through the mobile dental clinic operated by the Institute for Rural Health at Western Kentucky University between September 2006 and May 2011 (n = 2,453). Descriptive statistics were calculated for sociodemographic factors (age, gender, race/ethnicity, insurance status, and urban versus rural residential location) and caries status. We used chi-square tests to compare sociodemographic differences of children stratified by caries and no caries status as well as three levels of caries severity. We developed a logistic regression model to investigate factors associated with untreated dental caries while controlling for sociodemographic characteristics.
The proportion of children having untreated dental caries was 49.7% and the mean number of untreated dental caries was 2.0. The proportion of untreated dental caries was higher in older children, children with no insurance and living in rural residential locations, and caries severity was also higher in these groups. Odds ratio indicated that older ages, not having private insurance (having only public, government-sponsored insurance or no insurance at all) and rural residential location were associated with having untreated dental caries after controlling for sociodemographic characteristics of children.
Untreated dental caries was more likely to be present in older children living in rural areas without insurance. Health interventionists may use this information and target rural children without having proper insurance in order to reduce geographic disparities in untreated dental caries in South Central Kentucky.
Oral health plays an important role in maintaining a healthy human body. Good oral health enhances our ability to perform a variety of oral and ingestive functions, such as speaking, chewing, and swallowing; however, oral diseases, ranging from untreated dental caries (tooth decay) to oral cancer, cause pain and disability for millions of Americans each year . In addition, poor oral health is associated with chronic diseases and ill health, such as cardiovascular disease and low-birth weight [2–4].
The Commonwealth of Kentucky exceeds the U.S. average for dental health problems as 13% of adults aged over 18 years are missing all of their teeth, compared to 6% nationally, placing Kentucky as the nation’s highest percentage of edentate (toothless) persons . The prevalence of dental abnormalities, such as untreated caries, is also high among children in Kentucky [6, 7]. Approximately 42.8% of Kentucky’s children before reaching the age of five have severe early childhood dental decay and 39.3% of these children have never visited a dentist . Moreover, tooth decay is the single most common chronic childhood disease affecting 20% of preschoolers, 50% of second graders and nearly 75% of 15 year olds in Kentucky .
Rural residents in Kentucky are less likely to have dental insurance, compared to urban residents, and not having any form of dental insurance is associated with childhood dental caries [10, 11]. Compared to rural areas, a greater proportion of residents living in urban areas have higher dental insurance coverage and dental care utilization rates but they do not necessarily have better dental health [11–13]. Various social and physical barriers to oral health care, such as no means of transportation to dental clinics and dentists not willing to accept Medicaid-insured children, are important issues related to poor dental health [14–16].
Governmental and non-governmental assistance programs, such as Medicaid, Kentucky Children’s Health Insurance Program (K-CHIP), and SMILE Kentucky, provide basic dental services for children from low income families. However, the utilization rate of dental services among Medicaid eligible children is low in Kentucky. Only 9.4% of Kentucky children eligible for Medicaid received early periodic screening, diagnosis, and follow-up treatment which was the lowest rate in the nation . Research suggests that some children, despite having dental insurance, are not always receiving dental care because their parents are not able to take their children to dentists or not motivated enough to seek dental care for their children [17, 18]. Untreated dental caries rates are high among children enrolled in public insurance, thus having government-assisted dental health insurance alone may not be fully effective in promoting better dental health .
Mobile dental clinics are another strategy to provide dental health care. Unlike stationary dental clinics, mobile clinics provide greater physical access to dental care for medically underserved populations in poor urban and remote rural communities, and many existing mobile dental clinics offer basic services at lower or no cost to the user [20, 21]. School-based mobile dental programs are viable solutions to physical, financial, and structural barriers to dental care access for children [22, 23]. Thus, children with all types of social, economic, and cultural backgrounds within predetermined geographic areas may participate in school-based dental care .
The Institute for Rural Health (IRH) at Western Kentucky University (WKU) is a university-based multidisciplinary organization that collaborates with several departments across the university. A dental sealant program is provided to school-aged children at no cost to their parents or guardians through the Mobile Dental Unit that travels to participating schools throughout South Central Kentucky. With federal funding and a budget from WKU’s College of Health and Human Services, the IRH has been providing services since 2001. Roughly 4,000 children have received preventive dental care services and dental examinations since the inception of the program.
This research reports on a pooled cross-sectional secondary data analysis which examines untreated dental caries among school-aged children (6 to 15 years old) who participated in the dental sealant program and received oral examinations via the Mobile Dental Unit operated by the IRH from September 2006 to May 2011. We investigated the sociodemographic differences of children by caries status as well as the degree of caries severity, and examined factors associated with untreated dental caries among children living in South Central Kentucky.
Data were obtained from the Institute for Rural Health (IRH) at Western Kentucky University (WKU). We analyzed secondary data on children aged 6 to 15 years who participated in the dental sealant program provided by IRH clinicians through the Mobile Dental Unit (MDU). The staff consisted of a full-time dentist, and a full-time dental hygienist. Students enrolled in WKU’s Dental Hygiene program were supervised by the MDU clinicians and assisted with the dental procedures. The program was offered to primarily second and seventh grade students residing in South Central Kentucky because the first and second permanent molars appear around these ages . The event locations were scheduled in advance, and appointments were made through the school where the service was provided.
The selection of schools was based on the availability of the IRH’s financial resources and coordination with local schools. The IRH initially started providing dental services to medically underserved children in selected counties within the BRADD and gradually expanded to other schools within the service area. All schools within the IRH’s primary service areas, i.e., the BRADD or South Central Kentucky, were eligible to participate in the dental program. All services were provided at no cost to the parents or guardians of the children. All children, regardless of insurance status, were eligible to receive the services. All children who participated in the program underwent oral exams prior to dental sealant application.
Data collection procedure
All children were required to have a registration form completed by their parents or guardians prior to the service. The form included basic sociodemographic information, such as age, sex, race and ethnicity, new patient status, dental insurance coverage, and residential address. Parents or guardians were required to sign the general informed consent clause before the service was rendered to their children. The self-reported data on paper-based registration forms were transposed into a digital database by trained research assistants using Microsoft Access. Children who returned to the MDU more than once were excluded to avoid double counts.
Clinical data analyzed included the number of untreated dental caries. Dental caries is defined in a number of different ways in the literature . For the purpose of this study, dental caries was defined as clinically detectable bacterial infections on external surface layer of teeth which causes demineralization and destruction of the hard tissues . As part of the dental sealant program, oral examinations were performed by the IRH’s dentist and registered dental hygienist using a mirror, explorer, and air/water syringe in the fully equipped mobile dental unit. X-radiographs were not utilized. Dental hygiene students assisted the clinical staff during oral exams. Clinical data were entered into a separate table which was merged with the demographic data by patient ID. This research was approved by the Institutional Review Board at Western Kentucky University.
The objective of this research was threefold. First, the descriptive statistics for the sociodemographic characteristics of children were calculated. Age was categorized into four groups (6–7, 8–9, 10–12, and 13–15 year olds). For race and ethnicity, non-white children were categorized into one group because of the small sample size. Insurance status was categorized into (1) private (dental insurance), (2) public (government-supported, e.g. Medicaid, K-CHIP), and (3) no insurance. Residential location was categorized into urban (the Bowling Green, KY metropolitan area) and rural (non-metropolitan areas) status according to the OMB definition. The number of dental caries was categorized into at least one tooth with untreated caries and no teeth with caries.
Third, factors associated with untreated dental caries were examined using multivariate logistic regression. Covariates included in the model were age, gender, race and ethnicity, insurance status, and residential location. Multicollinearity may apply to explanatory variables that are collinear . Our logistic regression analysis identified that multicollinearity was not an issue with explanatory variables used in this research. Odds ratio (OR) estimates were summarized with 95% confidence intervals (CI). All analyses were carried out using SAS version 9.2.
Descriptive statistics (n = 2453)
Race and ethnicity
White and non-white
Sociodemographic differences of children by caries status
Age, years (n = 2426)
Gender (n = 2415)
Race and ethnicity (n = 2426)
Insurance coverage (n = 2264)
Residential location (n = 2426)
Sociodemographic characteristics of children by multiple caries categories
0 (No caries)
1 to 2
Odds ratios for untreated dental caries (n = 2032)
OR, 95% CI
Age, years (ref. 6 to 7)
8 to 9
1.00 [0.83, 1.21]
10 to 12
1.03 [0.70, 1.51]
13 to 15
1.53 [1.08, 2.15]
Gender (ref. female)
1.19 [0.99, 1.41]
Race/ethnicity (ref. White)
0.95 [0.73, 1.23]
Insurance (ref. no insurance)
0.51 [0.38, 0.69]
0.83 [0.62, 1.12]
Residential location (ref. urban)
1.28 [1.06, 1.55]
Our results were consistent in all stages of analysis, which indicated that age, insurance coverage, and residential location were important factors related to untreated dental caries in school-aged children in South Central Kentucky. Older children were more likely to have untreated caries than younger children. Health interventionists may use this information to prevent dental problems in older children. It is during childhood that habits begin to form and the earlier children start to learn good oral habits the greater the impact it will have on them later in life . Messages about practicing good oral health habits can be reinforced during childhood development through providing dental education regularly. In addition, children in schools begin to make their own decisions and choices on what to eat [34, 35]. School children are exposed to opportunities inside or outside school settings to purchase sugary beverages or snacks through vending machines . Frequent consumption of sugary foods, along with poor dental hygiene may explain the higher prevalence of untreated dental caries among the older school children [37, 38].
In Kentucky, Medicaid Dental Programs are offered to eligible children under the age of 21 and the coverage includes basic services, such as oral exams, x-rays, emergency visits, and fillings . In this study, however, public or government-sponsored dental insurance plans seemed to have little impact on having less untreated dental caries. Children covered through private dental insurance had fewer dental caries compared to children with no insurance. This finding is consistent with other studies documenting that children with Medicaid and CHIP have higher prevalence of dental diseases compared to children with private insurance [40, 41]. Children with Medicaid and public assistance insurance may have limited access to and utilization of dental care due to various social, economic, and cultural reasons that prevent them from seeking dental care . Particularly, persistent poverty and low income may be directly or indirectly affecting children’s dental health .
This research showed significant urban–rural disparities in untreated dental caries, characterizing poor dental health among rural children. Contrary to our findings, national level studies suggest no differences in caries lesions and caries experiences between urban and rural children . This may be related to a number of factors. First, different definitions and indices of caries and dental conditions may be used in various research settings [27, 44]. Second, urban versus rural areas may be defined differently. A study from Louisville, Kentucky, for example, showed that children living in the Louisville metro area, defined by the city zip codes, were more likely to have untreated caries compared to children living outside the metro area . Other research uses the metropolitan area-based definition which includes suburban or fringe counties of a metropolitan area as ‘urban’ . Thus, different results may be obtained based on how urban and rural residential locations are defined and who resides in such locations. Lastly, it is important to note the possibility of data aggregation. Compared to national level studies, geographically disaggregated data may unmask subnational health disparities, thus, it is likely to see spatial variability of health events using data at the local level .
There are other factors that may be associated with higher prevalence of untreated dental caries in rural areas. Rural areas are prone to dentist shortage as the number of practicing dentists is projected to start declining in 2014 due to mass retirement of older dentists, while dental schools are producing fewer graduates, and some dentists are not willing to practice in rural areas . Dental caries experience among children was lower in fluoridated communities than in non-fluoridated communities . While some households with private well water supplies have excessive fluoride exposure, other households have lower fluoride levels, and many rural communities lack optimally fluoridated water supplies [49, 50]. An additional factor to consider is the fact that residents of rural communities may have differing levels of knowledge, attitudes, and beliefs about oral health compared to urban residents which may impact caries outcomes [12, 51].
There was no racial/ethnic difference in untreated dental caries in South Central Kentucky. The National Survey of Children’s Health, however, reports suboptimal dental health among the minority groups compared to non-Hispanic white children . The majority of the non-white children in our study lived in urban areas (72%). Urban children, however, had less untreated dental caries even after controlling for racial/ethnic difference. The variation from the national trend in our study area should deserve greater attention and further research is needed to explain the absence of racial/ethnic disparities in untreated caries in South Central Kentucky.
This study was subject to several limitations. First, the sample size for the non-white groups was small, thus, we were not able to perform our analyses using more specific racial and ethnic groups than non-white. Recruiting children in non-white groups is an inherent problem in Kentucky because the percent of black and Hispanic residents, for example, is well below the national average . In addition, our analyses did not include a more direct measure of socioeconomic status, such as family income which may impact children’s dental health. To compensate for this lack of data, we included insurance status and rural location as surrogates for family income.
A pooled cross-sectional analysis did not allow the same population to be observed over the study time periods. We were only able to assess sociodemographic differences of children by caries status. Following the same children from elementary schools to middle schools may provide more complete and accurate estimates of untreated dental caries and greater insights into the progression of dental health problems due to advanced age.
In this study, untreated dental caries served as the indicator of poor dental health. Other commonly used indices, such as the decayed-missing-filled teeth (DMFT) index, was not used because not all data were available. Using other indices may produce different results. In addition, we examined untreated dental caries by reporting odds ratios rather than other statistical methods such as prevalence ratios. It is preferable to estimate prevalence ratios instead of odds ratios in cross-sectional studies when disease is common . Odds ratio, however, is a standard and practical method that fits the model with maximum likelihood estimates and requires fewer assumptions than prevalence ratio does [54, 55]. Thus, our study is consistent with other epidemiological studies reporting odds ratios controlling for other factors.
Lastly, this research was conducted using a convenience sample of children whose parents had agreed to have their children participate in the dental sealant program provided by the mobile unit in schools. Children who participated in the program may have social, economic, and cultural traits that are different from ones who did not. The IRH targets medically underserved children, but all second and seventh grade children in participating schools were eligible to receive preventive dental care services regardless of their socioeconomic status. During the dental screening, however, some children were not cooperative and did not finish the complete procedures and/or examinations. In addition, we pooled samples from five academic years (September 2006 to May 2011) to increase sample sizes and statistical reliability. We excluded returned children to avoid double counts in all analyses.
Older ages, public insurance or no insurance, and rural residential location were important factors associated with having untreated dental caries in school-aged children in South Central Kentucky. Gender and race/ethnicity, however, were not significant factors associated with untreated dental caries. This information may be useful in planning school-based dental programs and target children in rural areas without dental insurance in order to reduce dental health disparities.
Financial support for this research was provided by the Research & Creative Activities Program (RCAP I) from the Office of Sponsored Program at WKU (# 12–8018). ED was supported in part by the MAP provided by the Office of Graduate Studies and Research. We would like to thank Matthew Hunt, MA, Bonny Petty, RDH and Chandra Ellis-Griffith, RN, MSN for their helpful comments on earlier drafts of this manuscript.
- Preventing cavities, gum disease, tooth loose, and oral cancers at a glance.http://www.cdc.gov/chronicdisease/resources/publications/AAG/doh.htm,
- Boggess KA, Beck JD, Murtha AP, Moss K, Offenbacher S: Maternal periodontal disease in early pregnancy and risk for a small-for-gestational-age infant. Am J Obstet Gynecol. 2006, 194 (5): 1316-1322. 10.1016/j.ajog.2005.11.059.View ArticlePubMedGoogle Scholar
- Haraszthy VI, Zambon JJ, Trevisan M, Zeid M, Genco RJ: Identification of periodontal pathogens in atheromatous plaques. J Periodontol. 2000, 74 (10): 1554-1560.View ArticleGoogle Scholar
- DeRossi SS, Sollecito TP: The oral-medical disease connection: pregnancy, cardiovascular disease, and diabetes. Compend Contin Educ Dent. 2012, 33 (6): 406-414.PubMedGoogle Scholar
- Childress MT, Smith-Mello M: Foresight: Kentucky's oral health poses challenges. Long Term Policy Research Center. 2007, Frankfort, KY,http://www.e-archives.ky.gov/pubs/LPRC/foresighno50.pdf, 50,Google Scholar
- Haelthy Kentucky Smiles: A lifetime of oral health. Statewide oral health strategic plan: the commonwealth of Kentucky, 2006. 2006, Frankfort, KY: Kentucky Department for Public HealthGoogle Scholar
- A Project of the Child and Adolescent Health Management Initiative.http://www.childhealthdata.org/home,
- Kentucky Oral Health Summit.http://chfs.ky.gov/dph/mch/cfhi/kohs.htm,
- Henry RG: Kentucky's Dental Access Summit. 2001, Lexington, KY: Kentucky Dental Health CoalitionGoogle Scholar
- Lu N, Samuels ME, Kletke PR, Whitler ET: Rural–urban differences in health insurance coverage and patterns among working-age adults in Kentucky. J Rural Health. 2010, 26 (2): 129-138. 10.1111/j.1748-0361.2010.00274.x.View ArticlePubMedGoogle Scholar
- Kandel EA, Richards JM, Binkley CJ: Childhood caries in the state of Kentucky, USA: a cross-sectional study. BMC Oral Health. 2012, 12 (38):Google Scholar
- Heaton IJ, Smith TA, Raybould TP: Factors influencing use of dental services in rural and urban communities: considerations for practitioners in underserved areas. J Dent Educ. 2004, 68 (10): 1081-1089.PubMedGoogle Scholar
- Byck GR, Walton SM, Cooksey JA: Access to dental care services for Medicaid children: variations by urban/rural categories in Illinois. J Rural Health. 2002, 18 (4): 512-520. 10.1111/j.1748-0361.2002.tb00918.x.View ArticlePubMedGoogle Scholar
- Kelly SE, Binkley CJ, Neace WP, Gale BS: Barriers to care-seeking for children's oral health among low-income caregivers. Am J Public Health. 2005, 95 (8): 1345-1351. 10.2105/AJPH.2004.045286.View ArticlePubMedPubMed CentralGoogle Scholar
- Davis EE, Deinard AS, Maiga EW: Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room. J Public Health Dent. 2010, 70 (3): 205-210. 10.1111/j.1752-7325.2010.00166.x.View ArticlePubMedGoogle Scholar
- Mofidi M, Rozier RG, King RS: Problems with access to dental care for Medicaid-insured children: what caregivers think. Am J Public Health. 2002, 92 (1): 53-58. 10.2105/AJPH.92.1.53.View ArticlePubMedPubMed CentralGoogle Scholar
- Larsen CD, Larsen MD, Handwerker LB, Kim MS, Rosenthal M: A comparison of urban school- and community-based dental clinics. J Sch Health. 2009, 79 (3): 116-122. 10.1111/j.1746-1561.2008.00395.x.View ArticlePubMedGoogle Scholar
- Amin MS: Utilization of dental services by children in low-income families in Alberta. J Can Dent Assoc. 2011, 77 (b57):Google Scholar
- Brickhouse TH, Rozier RG, Slade GD: Effects of enrollment in Medicaid versus the State Children's health insurance program on kindergarten children's untreated dental caries. Am J Public Health. 2008, 98 (5): 876-881. 10.2105/AJPH.2007.111468.View ArticlePubMedPubMed CentralGoogle Scholar
- Gardner T, Gavaza P, Meade P, Adkins DM: Delivering free healthcare to rural Central Appalachia population: the case of the Health Wagon. Rural Remote Health. 2012, 12 (2035):Google Scholar
- Mobile Health Map.http://www.mobilehealthmap.org/,
- Skillman SM, Doescher MP, Mouradian WE, Brunson DK: The challenge to delivering oral health services in rural America. J Public Health Dent. 2010, 70 (Supple 1): S49-57.View ArticlePubMedGoogle Scholar
- Jackson DM, Jahnke LR, Kerber L, Nyer G, Siemens K, Clark C: Creating a successful school-based mobile dental program. J Sch Health. 2007, 77 (1): 1-6. 10.1111/j.1746-1561.2007.00155.x.View ArticlePubMedGoogle Scholar
- Albert DA, McManus JM, Mitchell DA: Models for delivering school-based dental care. J Sch Health. 2005, 75 (5): 157-161.View ArticlePubMedGoogle Scholar
- Ekstrand KR, Christiansen J, Christiansen ME: Time and duration of eruption of first and second permanent molars: a longitudinal investigation. Community Dent Oral Epidemiol. 2003, 31 (5): 344-350. 10.1034/j.1600-0528.2003.00016.x.View ArticlePubMedGoogle Scholar
- Update of statistical area definitions and guidance on their uses. 2009, Washington, D.C.: Executive Office of the President, Office of Management and Budget,http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf,
- Pitts NB: Modern concepts of caries measurement. J Dent Res. 2004, 83 (Spec No C): C43-47.View ArticlePubMedGoogle Scholar
- Kidd EAM, Fejerskov O: What constitutes dental caries? histopathology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res. 2004, 83 (Spec Iss C): C35-C38.View ArticlePubMedGoogle Scholar
- Ferreira SH, Beria JU, Kramer PF, Feldens EG, Feldens CA: Dental caries in 0- to 5-year-old Brazilian children: prevalence, severity, and associated factors. Int J Paediatr Dent. 2007, 17 (4): 289-296. 10.1111/j.1365-263X.2007.00831.x.View ArticlePubMedGoogle Scholar
- Gherunpong S, Sheiham A, Tsakos G: A sociodental approach to assessing children's oral health needs: integrating an oral health-related quality of life (OHRQoL) measure into oral health service planning. Bull Qorld Health Organ. 2006, 84 (1): 36-42.View ArticleGoogle Scholar
- Peres MA, de Oliveira Latorre Mdo R, Sheiham A, Peres KG, Barros FC, Hernandez PG, Maas AM, Romano AR, Victora CG: Social and biological early life influences on severity of dental caries in children aged 6 years. Community Dent Oral Epidemiol. 2005, 33 (1): 53-63. 10.1111/j.1600-0528.2004.00197.x.View ArticlePubMedGoogle Scholar
- Allison PD: Logistic Regression Using SAS: Theory and Applications. 2012, Cary, NC: SAS Institute, Inc., 2Google Scholar
- Bertness J, Holt K: Promoting Oral Health in Schools: A Resource Guide. 2009, Washington, D.C: U.S. Department of health and Human Services, Health Resources and Services AdministrationGoogle Scholar
- Warash BG, Fitch C, Bodnowich K: Snack choices: helping young children make decisions. J Fam Consum Sci. 2003, 95 (2): 60-64.Google Scholar
- Blinkhorn AS, Roberts BP, Duxbury JT: The ability of young children to influence adults in the choice of sugary foods and drinks. Health Educ J. 2003, 62 (3): 210-219. 10.1177/001789690306200303.View ArticleGoogle Scholar
- Price J, Murnan J, Bradena M: Soft drink vending machines in schools: a clear and present danger. Am J Health Behav edu. 2006, 37 (5): 306-314.View ArticleGoogle Scholar
- Mobley C, Marshall TA, Milgrowm P, Coldwell SE: The contribution of dietary factors to dental caries and disparities in caries. Acad Pediatr. 2009, 9 (6): 410-414. 10.1016/j.acap.2009.09.008.View ArticlePubMedPubMed CentralGoogle Scholar
- Harris R, Nicoll AD, Adair PM, Pine CM: Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2001, 21 (1 Supple): 71-85.Google Scholar
- Department for Medicaid Services: Dental Services. 2012, Frankfort, KY: Kentucky Cabinet for Health and Family Services,http://www.chfs.ky.gov/dms, 12,Google Scholar
- GAO: Oral Health: Efforts under way to improve children's access to dental services, but sustained attention needed to address ongoing concerns. Edited by: Office USGA. 2010, Washington, D.C: The Government Accountability OfficeGoogle Scholar
- Edelstein BL: Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr. 2002, 2 (2 Suppl): 141-147.View ArticlePubMedGoogle Scholar
- Bagramian RA, Garcia-Godoy F, Volpe AR: The global increase in dental caries. A pending public health crisis. Am J Dent. 2009, 21 (1): 3-8.Google Scholar
- Vargas CM, Ronzio CR, Hayes KL: Oral health status of children and adolescents by rural residence, United States. J Rural Health. 2003, 19 (3): 260-268. 10.1111/j.1748-0361.2003.tb00572.x.View ArticlePubMedGoogle Scholar
- Marshall TA, Levy SM, Broffitt B, Warren JJ, Eichenberger-Gilmore JM, Burns TL, Stumbo PJ: Dental caries and beverage consumption in young children. Pediatrics. 2003, 112: e184-e191. 10.1542/peds.112.3.e184.View ArticlePubMedGoogle Scholar
- Eberhardt MS, Pamuk ER: The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health. 2004, 94 (10): 1682-1686. 10.2105/AJPH.94.10.1682.View ArticlePubMedPubMed CentralGoogle Scholar
- Johnson PJ, Call KT, Blewett LA: The importance of geographic data aggregation in assessing disparities in American Indian prenatal care. Am J Public Health. 2010, 100 (1): 122-128. 10.2105/AJPH.2008.148908.View ArticlePubMedPubMed CentralGoogle Scholar
- Collier R: United States faces dentist shortage. Can Med Assoc J. 2009, 181 (11): E253-E254. 10.1503/cmaj.109-3086.View ArticleGoogle Scholar
- Gillcrist JA, Brumley DE, Blackford JU: Community fluoridation status and caries experience in children. J Public Health Dent. 2001, 61 (3): 168-171. 10.1111/j.1752-7325.2001.tb03385.x.View ArticlePubMedGoogle Scholar
- Graves JM, Daniell W, James F, Milgrom P: Estimating fluoride exposure in rural communities: a case study in Western Washington. Wash State J Public Health Prac. 2009, 2 (2): 22-31.Google Scholar
- NRHA: Meeting oral health care needs in rural America. National Rural Health Association. vol April 2005. 2005, Kansas City, MO: National Rural Health AssociationGoogle Scholar
- Patrick DL, Lee RS, Nucci M, Grembowski D, Jolles CZ, Milgrom P: Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health. 2006, 6 (Suppl 1): S4-10.1186/1472-6831-6-S1-S4.View ArticlePubMedPubMed CentralGoogle Scholar
- Dietrich T, Culler C, Garcia RI, Henshaw MM: Racial and ethnic disparities in children's oral health: the National Survey of Children's Health. J Am Dent Assoc. 2008, 139 (11): 1507-1517.View ArticlePubMedGoogle Scholar
- State and County Quick Facts.http://quickfacts.census.gov/qfd/states/21000.html,
- Petersen MR, Deddens JA: A comparison of two methods for estimating prevalence ratios. BMC Med Res Methodol. 2008, 8 (9):Google Scholar
- Pearce N: Effect measures in prevalence studies. Environ Health Perspect. 2004, 112 (10): 1047-1050. 10.1289/ehp.6927.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6831/13/19/prepub
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