Dental Services Use Among Adults With Disabilities: Results From the 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey

Abstract

Objectives:

People with disabilities face many challenges in accessing dental care. We compared disparities in dental care patterns (ie, dental visits for preventive care or treatment) between adults with and without hearing, seeing, mobility, self-care, cognition, or independent living disabilities.

Methods:

We analyzed data from the 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey (NHANES). For outcome variables, we included self-reported dental visit (yes/no) and preventive dental visit (yes/no) within the past year. NHANES asked participants whether they had serious difficulty in conducting any of the following 6 activities: hearing, seeing, mobility, self-care, cognition, or independent living; participants who answered yes to any of these activities were classified as disabled. Our analytic sample included 11 288 adult respondents aged ≥20 years. We used multiple logistic regression to assess the association between disability status—measured by any disability (yes/no), the 6 types of disabilities (yes/no), and the number of disabilities—and the outcome variables, with P ≤ .05 indicating significance.

Results:

Respondents with disabilities were less likely than those without a disability to have a preventive dental visit (adjusted odds ratio = 0.67; 95% CI, 0.59-0.77). Respondents with disabilities in mobility, self-care, or independent living were significantly less likely than those without any disability to have a dental visit. In addition, adults with more disabilities were significantly less likely than those without a disability to have a dental visit.

Conclusions:

Access to preventive dental care was limited among people with disabilities. Further assistance, including providing dental insurance coverage, is needed to increase access to dental care among people with disabilities, especially those with mobility, self-care, and independent living disabilities.

More than 73 million or 28.7% of adults in the United States live with disabilities. ¹ Disability refers to any condition of physical and/or mental impairment that makes it difficult for the person to do certain activities and interact with the surrounding world. ² Dental care is one of the most cited unmet needs for people with disabilities,^3,4 which accounts for the poor oral health status in this population.^{4 -7}

Oral health is fundamental for overall health and well-being. ⁸ Previous studies on dental care of people with disabilities have mostly examined access to dental services (ie, whether people had a dental visit) and found that people with disabilities were less likely than people without disabilities to visit a dentist.^{9 -13} To our knowledge, no research has investigated dental use patterns (ie, dental visits for preventive care vs treatment), which can also reflect oral health status. Moreover, little is known about whether access to dental services varies by type of disabilities. Our study addressed these knowledge gaps.

Extending from prior studies,^{9 -13} we aimed to (1) compare access to preventive dental care between adults with and without disabilities and (2) examine whether visits for dental treatment and preventive care varied by type of disability. The study findings could be useful for health care providers and policy makers as they strive to improve the overall health of people with disabilities. Our findings could assist public health programs to develop or improve dental health interventions, accessibility, and outreach, which could be used to reduce disparities in access to dental care for people with disabilities.

Methods

Data

We obtained data from the 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey (NHANES). NHANES is a stratified multistage probability sample of the civilian noninstitutionalized population in the United States. NHANES includes interviews and physical examinations. Interviews include questions on sociodemographic characteristics, disability, and health service use, including dental care. ¹⁴ For our analyses, we mainly used data from the NHANES Oral Health Module and the Disability Module. The final analytic sample included 11 288 adult respondents aged ≥20 years (5719 in 2015-2016 NHANES and 5569 in 2017-2018 NHANES). We did not use the more recent 2019-2020 NHANES data because of changes in survey design as a result of the COVID-19 pandemic. Because our data are in the public domain, the East Carolina University Institutional Review Board determined that this study was exempt from review.

Outcome Variables

Among the NHANES respondents, we assessed 2 outcomes: having a dental visit in the past year (yes/no) and having a preventive dental visit (yes/no). NHANES respondents were asked, “About how long has it been since you last visited a dentist?” We classified respondents as having a dentist visit (yes) in the past year if they answered “6 months or less” or “more than 6 months, but not more than 1 year.” We classified respondents as not having a dental visit (no) in the past year if they answered “more than 1 year, but not more than 2 years ago,” “more than 2 years, but not more than 3 years ago,” “more than 3 years, but not more than 5 years ago,” “more than 5 years ago,” or “never.”

Respondents were also asked, “What was the main reason you last visited the dentist?” We dichotomized the responses. We classified respondents as having a preventive dental visit if they answered “went in on their own for check-up, examination, or cleaning” or “was called in by the dentist for check-up, examination, or cleaning.” We classified respondents as having a dental visit if they answered “something was wrong, bothering, or hurting,” “went for treatment of a condition that dentist discovered at earlier check-up or examination,” or “other.”

Independent Variables

The NHANES Disability Module asked participants whether they had the following 6 disabilities:

• Hearing: deaf or serious difficulty hearing

• Vision: blind or serious difficulty seeing even when wearing glasses

• Cognition: serious difficulty concentrating, remembering, or making decisions

• Mobility: serious difficulty walking or climbing stairs

• Self-care: difficulty dressing or bathing

• Independent living: difficulty doing errands alone, such as visiting a doctor’s office or shopping

In this analysis, we measured the disability variable in 3 ways: presence of any disability (1 or none), type of disability among the 6 answers (all dichotomous: yes or none; ie, without any disability), and number of disabilities.

We classified respondents as having any disability if they answered yes to at least 1 of the 6 questions on type of disability and as not having any disability if they answered no to all 6 questions. We classified type of disability among respondents from a yes answer to the 6 disability questions. We recoded this variable so that the reference group included those without the disability. For number of disabilities, we summed responses to the 6 types of disabilities (range, 0-6 disabilities). We combined disability 5 (self-care) and 6 (independent living) into 1 category because of the low number of responses and coded number of disabilities as 0, 1, 2, 3, 4, and 5.

Covariates

For covariates, we collected the following sociodemographic variables from NHANES:

• Age: grouped as aged 20 to 44, 45 to 64, and ≥65 years

• Sex: male, female

• Race and ethnicity: Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, and other

• Marital status: married or living with a partner versus not married

• Education level: less than high school, high school, some college, and college and higher

• Family income level: ≤130% federal poverty level (FPL), 131% to 349% FPL, and ≥350% FPL; assessed as ratio of total family income to the US poverty level (Poverty Index Ratio)

• Health insurance coverage: yes/no

Statistical Analysis

First, we calculated descriptive statistics of characteristics among respondents according to the 2 outcome variables: having a dental visit and having a preventive dental visit. Next, we conducted multiple logistic regression models to assess the association between disability status (any disability) and the 2 outcome variables. Third, we assessed associations between each of the 6 types of disabilities and the total number of disabilities and the 2 outcome variables. We used Stata version 14.0 (StataCorp, LLC) for analyses, which allowed us to account for the complex survey design of NHANES and generate the weighted percentages. We set significance at P ≤ .05.

Results

Among respondents, 3367 of 11 276 (25.3%) reported a disability. Mobility was the most prevalent disability type (12.3%), followed by cognition (9.9%), independent living (7.6%), hearing (8.0%), vision (5.0%), and self-care (4.5%) (weighted percentages). More than 12% had ≥2 disabilities (Table 1).

Table 1.

Characteristics of adult survey respondents who had dental treatment and preventive dental visits, 2015-2016 and 2017-2018 National Health and Nutrition Examination Surveys, United States ^a

	Sample size		Dental visit		Preventive dental visit
Variable	Unweighted no.	Weighted %	Weighted %	P value b	Weighted %	P value b
Independent variable
Any disability				<.001		<.001
No	7909	74.7	60.5		68.0
Yes	3367	25.3	53.5		49.1
Hearing disability				.97		<.001
No	10 216	92.0	58.8		64.4
Yes	1068	8.0	58.8		48.7
Vision disability				.002		<.001
No	10 533	95.0	59.3		64.1
Yes	751	5.0	48.6		45.6
Cognition disability				<.001		<.001
No	10 017	90.1	59.9		64.9
Yes	1261	9.9	48.3		47.0
Mobility disability				<.001		<.001
No	9446	87.7	59.8		65.9
Yes	1837	12.3	51.1		43.7
Self-care disability				<.001		<.001
No	10 579	95.5	59.3		64.2
Yes	708	4.5	47.0		41.7
Independent living disability				<.001		<.001
No	10 217	92.4	59.6		64.6
Yes	1062	7.6	48.9		45.6
No. of disabilities c				<.001		<.001
0	7921	74.8	60.5		67.9
1	1627	13.3	57.7		54.7
2	818	5.8	49.1		46.1
3	463	3.2	53.5		38.5
4	295	1.9	45.0		39.9
5	164	1.0	41.0		42.9
Covariate
Age group, y				<.001		<.001
20-44	4522	44.3	53.1		67.5
45-64	3888	35.4	61.5		60.6
≥65	2878	20.3	66.4		58.3
Sex				<.001		.002
Female	5839	51.9	62.9		65.1
Male	5449	48.1	54.2		61.1
Race and ethnicity				<.001		<.001
Hispanic	3015	15.5	48.4		57.6
Non-Hispanic Asian	1501	5.9	62.9		70.5
Non-Hispanic Black	2496	11.4	49.9		54.0
Non-Hispanic White	3798	63.1	62.7		65.9
Other d	478	4.1	55.0		56.8
Married				<.001		.001
No	4586	37.1	52.7		59.8
Yes	6693	62.9	62.3		65.2
Education level				<.001		<.001
<High school	2481	12.9	39.3		42.3
High school	2561	24.0	49.2		52.7
Some college	3470	31.6	57.4		63.4
≥College	2758	31.5	75.3		79.0
Family income level				<.001		<.001
≤130% FPL	3004	20.6	40.6		44.8
131%-349% FPL	3991	36.3	51.1		57.3
≥350 FPL	2865	43.1	74.5		78.2
Health insurance				.001		<.001
No	1818	13.5	29.6		50.9
Yes	9442	86.5	63.3		65.0

Abbreviation: FPL, federal poverty level.

^aRespondents were asked, “What was the main reason you last visited the dentist?” Respondents were classified as having a preventive dental visit if they answered “went in on their own for check-up, examination, or cleaning” or “was called in by the dentist for check-up, examination, or cleaning” within the past year. Respondents were classified as having a dental visit if they answered “something was wrong, bothering, or hurting,” “went for treatment of a condition that dentist discovered at earlier check-up or examination,” or “other” within the past year. Weighted percentages were calculated by using survey procedures. Data source: Centers for Disease Control and Prevention. ¹⁴

^bWald χ² test, with P ≤ .05 considered significant.

^cBecause of the low number of responses for having 6 disabilities, the category of 5 disabilities included those with 6 disabilities.

^dOther includes multiracial groups.

For both outcome variables, a significantly larger proportion of female respondents, respondents who were married, respondents with higher education and income levels, and respondents with health insurance coverage (vs their counterparts) had a dental visit and preventive dental visit (all P < .001). In addition, a significantly larger proportion of older adults (aged ≥65 y) than younger adults (aged 20-44 y) had a dental visit (P < .001), and a significantly larger proportion of younger adults (aged 20-44 y) than older adults (aged ≥65 y) had a preventive dental visit (P < .001). A significantly larger proportion of non-Hispanic Asian respondents than those of other racial and ethnic groups had a dental visit and preventive dental visit (all P < .001) (Table 1).

Logistic Regression Model

In the dental visit logistic regression model, we found no significant differences in having a dental visit between respondents with and without disabilities (P = .39) (Table 2). Respondents aged 45 to 64 years (adjusted odds ratio [AOR] = 1.22; 95% CI, 1.06-1.42; P = .01) and ≥65 years (AOR = 1.60; 95% CI, 1.32-1.95; P < .001) were significantly more likely than respondents aged 20 to 44 years to have a dental visit. Female respondents, those who were married, those with at least some college, those with income levels ≥350% FPL, and those with health insurance were significantly more likely than their counterparts to have a dental visit (all P < .001).

Table 2.

Results of logistic regression models of having a dental or preventive dental visit, 2015-2016 and 2017-2018 National Health and Nutrition Examination Surveys, United States ^a

	Dental visit model		Preventive dental visit model
Variable	AOR (95% CI)	P value b	AOR (95% CI)	P value b
Disability		.39		<.001
Any disability c	0.93 (0.78-1.11)		0.67 (0.59-0.77)
No disability	1 [Reference]		1 [Reference]
Age group, y
20-44	1 [Reference]		1 [Reference]
45-64	1.22 (1.06-1.41)	.01	0.66 (0.53-0.83)	<.001
≥65	1.60 (1.32-1.95)	<.001	0.66 (0.54-0.80)	<.001
Sex		<.001		<.001
Female	1.50 (1.32-1.70)		1.30 (1.15-1.48)
Male	1 [Reference]		1 [Reference]
Race and ethnicity
Hispanic	1.13 (0.92-1.38)	.24	1.07 (0.88-1.31)	.46
Non-Hispanic Asian	1.03 (0.81-1.32)	.79	1.15 (0.93-1.41)	.19
Non-Hispanic Black	0.92 (0.78-1.10)	.37	0.77 (0.66-0.90)	<.001
Non-Hispanic White	1 [Reference]		1 [Reference]
Other d	1.06 (0.74-1.52)	.74	0.86 (0.66-1.13)	.27
Marital status		<.001		.57
Married	1.25 (1.08-1.45)		0.96 (0.82-1.11)
Not married	1 [Reference]		1 [Reference]
Education level
<High school	1 [Reference]		1 [Reference]
High school	1.23 (1.07-1.42)	.01	1.26 (1.09-1.46)	<.001
Some college	1.49 (1.28-1.74)	<.001	1.62 (1.37-1.91)	<.001
≥College	2.37 (1.93-2.91)	<.001	2.55 (2.03-3.19)	<.001
Family income level
≤130% FPL	1 [Reference]		1 [Reference]
131%-349% FPL	1.20 (1.03-1.39)	.02	1.44 (1.22-1.70)	<.001
≥350% FPL	2.49 (2.10-2.94)	<.001	3.07 (2.52-3.76)	<.001
Health insurance		<.001		.06
Yes	2.55 (2.15-3.01)		1.23 (0.99-1.51)
No	1 [Reference]		1 [Reference]

Abbreviations: AOR, adjusted odds ratio; FPL, federal poverty level.

^aRespondents were asked, “What was the main reason you last visited the dentist?” Respondents were classified as having a preventive dental visit if they answered “went in on their own for check-up, examination, or cleaning” or “was called in by the dentist for check-up, examination, or cleaning” within the past year. Respondents were classified as having a dental visit if they answered “something was wrong, bothering, or hurting,” “went for treatment of a condition that dentist discovered at earlier check-up or examination,” or “other” within the past year. Data source: Centers for Disease Control and Prevention. ¹⁴

^bWald χ² test, with P ≤ .05 considered significant.

^cThe National Health and Nutrition Examination Surveys asked participants whether they had serious difficulty in conducting any of the following 6 activities: hearing, seeing, mobility, self-care, cognition, or independent living; participants who answered yes to any of these activities were classified as disabled.

^dOther includes multiracial groups.

In the preventive dental visit logistic regression model, respondents with disabilities were significantly less likely than those without a disability to have a preventive dental visit (AOR = 0.67; 95% CI, 0.59-0.77; P < .001) (Table 2). Respondents aged 45 to 64 years (AOR = 0.66; 95% CI, 0.53-0.83; P < .001) and ≥65 years (AOR = 0.66; 95% CI, 0.54-0.80; P < .001) were less likely than those aged 20 to 44 years to have a preventive dental visit. Non-Hispanic Black respondents were significantly less likely than non-Hispanic White respondents to have a preventive dental visit (AOR = 0.77; 95% CI, 0.66-0.90; P < .001). Respondents with at least some college, family income ≥ 350% FPL, and health insurance were more likely than their counterparts to have a preventive dental visit (all P < .001).

In the dental visit logistic regression model by type of disability, mobility (AOR = 0.77; 95% CI, 0.63-0.94; P = .01), self-care (AOR = 0.66; 95% CI, 0.52-0.86; P < .001), and independent living (AOR = 0.75; 95% CI, 0.61-0.93; P = .01) were all significantly associated with decreased odds of having a dental visit (Table 3). In addition, respondents with ≥4 disabilities were significantly less likely than those without any disability to have a dental visit.

Table 3.

Results of logistic regression models of having a dental or preventive dental visit, by type and number of disabilities, 2015-2016 and 2017-2018 National Health and Nutrition Examination Surveys, United States ^a

	Dental visit model b		Preventive dental visit model b
Disability type	AOR (95% CI)	P value c	AOR (95% CI)	P value c
Hearing	1.00 (0.78-1.29)	.99	0.62 (0.50-0.77)	<.001
Vision	0.86 (0.64-1.14)	.28	0.73 (0.54-1.00)	.05
Cognition	0.83 (0.67-1.03)	.09	0.64 (0.54-0.77)	<.001
Mobility	0.77 (0.63-0.94)	.01	0.58 (0.47-0.72)	<.001
Self-care	0.66 (0.52-0.86)	<.001	0.57 (0.42-0.78)	<.001
Independent living	0.75 (0.61-0.93)	.01	0.62 (0.48-0.79)	<.001
No. of disabilities d
1	1.05 (0.85-1.30)	.63	0.77 (0.65-0.92)	.01
2	0.81 (0.64-1.03)	.08	0.59 (0.48-0.74)	<.001
3	0.98 (0.72-1.33)	.89	0.54 (0.34-0.86)	.01
4	0.66 (0.45-0.98)	.04	0.54 (0.34-0.85)	.01
5	0.56 (0.34-0.95)	.03	0.66 (0.44-0.98)	.04

Abbreviation: AOR, adjusted odds ratio.

^aRespondents were asked, “What was the main reason you last visited the dentist?” Respondents were classified as having a preventive dental visit if they answered “went in on their own for check-up, examination, or cleaning” or “was called in by the dentist for check-up, examination, or cleaning” within the past year. Respondents were classified as having a dental visit if they answered “something was wrong, bothering, or hurting,” “went for treatment of a condition that dentist discovered at earlier check-up or examination,” or “other” within the past year. Data source: Centers for Disease Control and Prevention. ¹⁴

^bFor both models, the reference group was those without disabilities. Both models included covariates of age, sex, race and ethnicity, marital status, education, income, and health insurance.

^cWald χ² test, with P ≤ .05 considered significant.

^dBecause of the low number of responses for having 6 disabilities, the category of 5 disabilities included those with 6 disabilities.

In the preventive dental visit logistic regression model by type of disability, all disability types were significantly associated with decreased odds of having a preventive dental visit (all P ≤ .05) (Table 3). In addition, having more disabilities was associated with decreased odds of having a preventive dental visit. Overall, we noted an additive effect—as the number of disabilities increased, the odds of having dental visits and preventive dental visits decreased (P = .04 to <.001).

When we stratified respondents into groups aged 20 to 64 years versus ≥65 years, having any disability (as the independent variable) did not have a significant effect in the dental visit model but had a significant effect in the preventive dental visit model (similar to that shown in Table 2). Briefly, for the dental visit outcome, the AOR for the any disability variable was 0.95 (95% CI, 0.76-1.19) in the model for those aged 20 to 64 years and 0.83 (95% CI, 0.63-1.10) in the model for those aged ≥65 years. For the preventive dental visit outcome, the AOR for the any disability variable was 0.68 (95% CI, 0.57-0.81; P = .03) and 0.69 (95% CI, 0.50-0.90; P = .04) for the 2 age groups, respectively.

Discussion

In this study, we aimed to assess disparities in dental use pattern (eg, preventive dental care vs dental treatment) between adults with and without disabilities and whether disparities varied by type of disability and number of disabilities. In our analyses of the combined 2015-2016 and 2017-2018 NHANES data, we found that among adults who had a dental visit in the past year, adults with disabilities were less likely than those without disabilities to have a preventive dental visit. Our results also showed that, overall, disability status was not significantly associated with having a dental visit; however, some types of disability (ie, mobility, self-care, and independent living) were significant barriers for having a dental visit.

To our knowledge, this study is the first to report disparities in dental use patterns among adults with disabilities. Our results indicate that adults with disabilities were more likely to see a dentist for dental treatment than for preventive care, with results consistent among the 6 types of disabilities. All 6 types of disabilities were associated with decreased odds of having a preventive dental care visit. These findings suggest that, for adults with disabilities, a dental visit may be necessitated by an existing dental problem. Adults who have had a dental visit may be unaware of the need for dental care up to a point when they must go to see a dentist. Delaying or not seeking care can expose adults with disabilities to oral health issues. Some may end up going to a hospital emergency department for treatment, which is costly and largely ineffective because definitive treatment requires care in a dental setting. Nevertheless, a growing body of evidence indicates that poor oral health may contribute to other diseases, such as diabetes, ¹⁵ cardiovascular disease, ¹⁶ and dementia.^{17 -19} Patterns of care that are characterized by preventive services and recall visits for oral health maintenance suggest that such health behavior is likely to result in better long-term oral health than episodic, disease-driven patterns of care. ²⁰ Oral health education and oral care should be further promoted in adults with disabilities and their caregivers.

Disparities in dental visits between people with and without disabilities have been previously assessed.^{9 -13} In this analysis, we assessed disparities in dental visits among adults with disabilities by using data from NHANES. We did not find significant differences in dental visits after controlling for sociodemographic characteristics. Although not directly comparable because of different measurement or definition of disability status, our findings were similar to analysis of data from the Medical Expenditures Panel Survey, in which access to dental visits among adults with intellectual and other disabilities was not significantly different from adults without disabilities. ¹³ In another analysis of data from the National Health Interview Survey, adults with an intellectual, acquired, or developmental disability were >2.44 times less likely than adults without disabilities to have a dental visit. ¹²

One interesting finding of our study was that certain types of disability—mobility, self-care, and independent living—were significantly associated with decreased odds of having a dental visit, which was not shown with hearing, vision, and cognition disabilities. These findings suggest that adults with a mobility disability and/or a diminished capacity for independence had greater barriers to accessing dental care than adults with hearing, vision, and cognition disabilities. Adults with hearing, vision, and cognitive challenges may have support to help them in visiting a dentist or seeking dental care. This support could include a regular caregiver. Reasons to account for these findings are not known. Future research is needed to investigate barriers to dental services for people with different disabilities.

Overall, we found that non-Hispanic Black adults were less likely than adults from other racial and ethnic groups to have a preventive dental visit; adults with higher income (vs lower income) and higher education levels (vs lower education levels) were more likely to have a dental visit and a preventive dental visit. Our findings are consistent with prior findings on the use of dental services.^{21 -24} Our results also showed that, when compared with young adults aged 20 to 44 years, adults aged ≥65 years were more likely to have dental visits but less likely to have preventive dental visits. In contrast, younger adults (aged 20-44 y) were less likely to have dental visits but more likely to have preventive dental visits than those aged ≥65 years. One possible explanation is that young adults are more prone to seek preventive care than older adults (aged ≥65 y). Older adults may place less importance on preventive care than young adults but still need treatment for dental problems. Previous studies showed similar results, in which working-age adults used less dental care than adults aged ≥65 years.^25,26

Dental insurance is essential to accessing dental care. However, in most US states, Medicaid stops covering dental benefits for people aged >21 years. ²⁷ In addition, even in states where Medicaid provides adult dental benefits, the participation rate of dentists in Medicaid is low. ²⁸ Thus, many adults with disabilities have no access to affordable dental care. To eliminate dental care disparities for adults with disabilities, Medicaid programs must provide dental coverage along with case management services for adults with disabilities.

Other social determinants of health, such as built and social environments, can be barriers to dental care, ²⁹ including lack of transportation, lack of dental professionals who participate in Medicaid, and discrimination against people with disabilities. ³⁰ Barriers may also exist at dental offices, such as the presence of dentists without sufficient education and training, limited behavior tolerance of dental professionals to patients with disabilities, and limited accessibility for wheelchairs. ³¹ Policy changes at the federal, state, and community levels, as well as adoption of best practices by dental providers, could improve care for adults with disabilities. ³⁰ Moreover, oral health education and support measures for good oral hygiene are needed for people with disabilities and their caregivers to raise awareness of the importance of oral health as an essential component of general health and quality of life. Instructions and use of aids for toothbrushing and flossing are needed, especially for people with dexterity difficulties. ³²

Limitations

Our study had some limitations. First, the data used for our study were cross-sectional. Thus, causality between disability and use of dental services could not be inferred. Second, our disability estimates were likely to be underestimates because NHANES is not administered to adults who are institutionalized (eg, nursing home residents), who might have higher disability prevalence and face additional barriers to dental care than noninstitutionalized populations. Third, NHANES data were self-reported and might be subject to self-reporting biases, including recall bias and social desirability bias.

Conclusions

We found that adults with disabilities were less likely than those without disabilities to have preventive dental visits. Lack of dental care can compound the management of other chronic conditions, such as diabetes, ¹⁵ and result in adverse health outcomes. Further assistance, including providing dental insurance coverage, is needed to help this population access dental care.