Predictors of Early Dental Care Recommendation: Insights from Demographic and Behavioral Factors

ABSTRACT

Aim:

Early dental care is essential for preventing oral diseases and establishing positive health behaviors, particularly among vulnerable populations. However, limited data exist on the factors influencing early dental care recommendations among U.S. adults. This study investigated whether demographic and behavioral predictors (e.g., frequency of dental visits) and diabetic status were associated with early dental care recommendations using data from the National Health and Nutrition Examination Survey (NHANES) from March 2017 to March 2020, prior to the pandemic.

Materials and Methods:

A cross-sectional analysis of 3766 adults from the NHANES was conducted. Rao–Scott chi-square tests assessed bivariate associations between predictors (demographics, socioeconomic status, dental behavior, and diabetes status) and outcomes (poor self-reported oral health and early dental care recommendations). Weighted logistic regression models were constructed in three stages to examine the associations of predictors with receiving early dental care recommendations. Odds ratio (OR) and 95% confidence intervals (CIs) were estimated.

Results:

Males were more likely than females to receive early dental care recommendations (OR: 1.26, 95% CI: 1.02–1.58). Black race (OR: 1.61, 95% CI: 1.27–2.04), lower income (OR: 1.90, 95% CI: 1.43–2.52), and lower education (OR: 1.56, 95% CI: 1.19–2.05) were factors significantly associated with increased likelihood of receiving such recommendations. Individuals who had not visited a dentist in over a year were over four times more likely to be advised to seek dental care early (OR: 4.53, 95% CI: 3.54–5.79). Diabetes status was not significantly associated with dental visit recommendations (P > 0.05).

Conclusion:

Early dental care recommendations are strongly influenced by socioeconomic and behavioral factors. Surprisingly, the diabetes status was not linked to early visit recommendations, despite its known connection to oral health issues. These findings highlight the need for targeted public health strategies that address oral health disparities and improve dental access for underserved populations.

INTRODUCTION

Oral health is integral to general well-being, influencing nutrition, speech, self-esteem, and quality of life. Despite advances in dental care, significant disparities persist in the United States, particularly among low-income, uninsured, and minority populations who experience higher rates of untreated dental conditions and limited access to preventive services.[1] According to the Centers for Disease Control and Prevention (CDC), oral diseases account for over $124 billion in annual dental care expenditures and contribute to millions of lost work and school hours due to emergency visits and unplanned care.[2]

Early dental care is essential for preventing caries, periodontal disease, and other oral pathologies by facilitating timely diagnosis and intervention. However, access to preventive care is not uniform, with social determinants such as income, education, and racial or ethnic background influencing care utilization and the likelihood of receiving professional recommendations. Evidence suggests that dentist recommendations play a critical role in encouraging timely visits, yet the predictors of such recommendations have been underexplored at the national level.[3,4]

Chronic systemic conditions, particularly diabetes mellitus, further complicate oral health outcomes. Diabetes significantly increases the risk of periodontal disease—by approximately two- to three-fold—and also heightens the susceptibility to other oral issues such as dental caries, xerostomia, candidal infections, and impaired wound healing.[5] Diabetes is known to increase susceptibility to periodontal disease, delayed wound healing, and other oral complications through bidirectional inflammatory mechanisms. Chronic hyperglycemia triggers exaggerated and prolonged inflammatory responses, impaired immune cell function, oxidative stress, advanced glycation end-product deposition, and disruptions to wound-healing processes—all of which contribute to worsened periodontal outcomes and delayed healing.[6,7] Moreover, the relationship between diabetes and periodontal disease is bidirectional: uncontrolled diabetes promotes periodontal disease, while severe periodontitis can worsen glycemic control and elevate risks of macrovascular and renal complications.[8,9] While clinical guidelines recommend regular dental checkups for individuals with diabetes, it is unclear whether healthcare providers consistently advise this population to seek early dental care. Individuals with diabetes are advised to have dental visits every 6 months (or more frequently as needed) to allow for professional monitoring, early detection, and timely intervention.[10,11,12] However, there is limited data on how consistently medical providers actually advise patients in practice to follow through on such dental referrals.

The National Health and Nutrition Examination Survey (NHANES) offers a unique opportunity to evaluate population-level oral health indicators and healthcare behaviors. While NHANES data have been widely analyzed to assess dental care utilization, few studies have focused on professional recommendations for early dental visits as an outcome. Understanding the demographic, socioeconomic, and behavioral factors that influence these recommendations is critical to designing targeted interventions aimed at reducing disparities and improving oral health equity.

The present study aims to (1) assess whether early dental care recommendations are associated with diabetes status and recent dental visit patterns and (2) identify key demographic and socioeconomic predictors of early dental care recommendations among U.S. adults, using nationally representative NHANES data collected between 2017 and 2020, prior to the COVID-19 pandemic.

MATERIALS AND METHODS

Multiple datasets were extracted from the NHANES 2017 through 2020 COVID pre-pandemic data. The NHANES used a stratified multistage probability sampling to obtain well-representative samples from all civilian non-institutionalized people from the 50 states of the United States and the District of Columbia. This study used publicly available, de-identified data from the NHANES 2017–March 2020 pre-pandemic cycle. There was an exemption from the Institutional Review Board for the present study due to secondary data analysis using publicly accessed database. Five datasets from four NHANES modules—demographics, examination, questionnaire, and laboratory—were combined for this study. Individuals aged 20 years or older who completed all of these modules were included in the analysis. The oral health examination was performed by licensed dentists at the mobile examination center, and each participant received an overall recommendation for dental care. Recommendations for oral care, as the primary outcome, were classified into two categories (1) need to see a dentist earlier and (2) continue regular care. Self-reported oral health was categorized into good and poor. There are three categories of last dental visit (1) less than 6 months; (2) within 1 year; (3) more than 1 year.

Type 1 and type 2 diabetes were not distinguished in the NHANES. However, the present study excluded participants who were diagnosed with diabetes at age <25 years and were being treated with insulin.[13] A diabetic was defined as any participant who had at least 1 of 2 conditions: (1) fasting plasma glucose at least 126 mg/dL or (2) diagnosed with diabetes by a doctor or other healthcare professional. Non-diabetic individuals had none of the abovementioned two conditions.

Demographic variables used in the analysis of this study include age (20–39, 40–59, and 60+ years), gender (male and female), and race/ethnicity White, African American, Hispanic, and other races. Additionally, socioeconomic status (SES) variables included poverty level (PL) and education. The PL is defined as family poverty-to -income ratio (PIR), and it is a ratio of family income to the federal PL (FPL) considering the family number and location, which had three categories: poor (PL < 100%FPL), near-poor (100 FPL ≤ PL < 300FPL) and non-poor (PL ≥ 300%FPL). Education included three categories by education years: <12 years of education, 12 years (equivalent to high school diploma), and >12 years.

STATISTICAL ANALYSIS

Frequency, weighted frequencies, and weighted relative frequencies were used to describe the population. The distribution of all explanatory variables stratified by oral health status, recommendation for dental care, and diabetic status was assessed. Bivariate relationships between each explanatory variable and three outcomes were assessed by applying the Rao–Scott χ² test. The prevalence of poor oral health and recommendation for early dental care by diabetic status were compared within each category of exploratory variables. The bivariate association between demographic variables and socioeconomic factors was investigated with Rao–Scott χ² test before the modeling construction. A series of weighted logistic regression models were built to investigate the determinates of recommendation for early dental care. Model 1 only contained demographics including gender, age, and race/ethnicity. Model 2 additionally adjusted for poverty and education levels. The third model additionally adjusted for the diabetic status and the last dental visit. Odds ratios (ORs)and 95% confidence interval (CI) were constructed. C-statistics, equivalent to areas under receiver operating characteristic curves, were used to evaluate the goodness-of-fit of logistic regression models. Generally, a C value >0.7 indicates a good model. All statistical analyses were conducted using the Statistical Analysis System (SAS, version 9.4, Cary NC). A P value < 0.05 was considered denoting statistical significance.

RESULTS

Table 1 presents data on various explanatory variables related to dental health, encompassing gender, age, race, family income level, education, frequency of dental visits, self-reported oral health, doctor recommendations for dental care, and whether individuals received dental treatment in the past year. Among the 3766 respondents, roughly equal proportions of males (48.41%) and females (51.59%) participated. Age distribution shows that 20–39-year-olds constitute 36.53%, 40–59-year-olds 34.46%, and those aged 60 and over 29.01%. In terms of race, Whites comprise the largest group at 63.15%, followed by Hispanics (15.5%), Blacks (11.12%), and other races (10.22%). Family income distribution indicates that rich individuals represent the highest proportion (46.99%), followed by near-poor (31.3%) and poor (21.71%) individuals. Regarding education, the majority have more than 12 years of education, (62.88%), followed by 12 years (26.4%) equivalent to high school diploma, and less than 12 years (10.72%). Dental visit frequency shows that 43.66% of individuals have had dental visits within the last 6 months, 41.56% of individuals have not visited a dentist in over 1 year, and 14.78% have had visits between 6 months and 1 year. Self-reported oral health indicates 73.01% reporting good oral health and 26.99% reporting poor oral health. Doctor recommendations lean toward routine care (61.67%) compared to immediate attention (38.33%).

Table 1.

Characteristics of the study population

Explanatory variables	Frequency	Weighted frequency	Weighted percent (%)
Overall	3766	100,287,428
Gender
Female	1939	51,735,970	51.59
Male	1827	48,551,457	48.41
Age (years)
20–39	1134	36,631,995	36.53
40–59	1250	34,559,996	34.46
60 and over	1382	29,095,437	29.01
Race
White	1295	63,331,682	63.15
Black	977	11,155,528	11.12
Hispanic	831	15,547,482	15.5
Other race	663	10,252,736	10.22
Family PIR
Poor	1100	21,773,210	21.71
Near-poor	1420	31,387,835	31.3
Non-poor	1246	47,126,383	46.99
Education
<12 years	704	10,746,145	10.72
12 years	564	26,474,501	26.4
>12 years	1789	63,066,781	62.88
Dental visit
<6 month	1413	43,782,435	43.66
6 month–1 year	564	14,819,728	14.78
>1 year	1789	41,685,266	41.56
Self-reported oral health
Good	2484	73,221,277	73.01
Poor	1282	27,066,151	26.99
Doctor recommendation
Early dental care	1748	38,436,435	38.33
Routine	2018	61,850,993	61.67

Table 2 presents associations between various explanatory variables and indicators of poor oral health, seeking dental care as early as possible, and diabetes prevalence, along with corresponding P value from Rao–Scott chi-square tests. There is a significant association between gender and seeking early dental care (P = 0.002), with a higher percentage of males (42.09%) than females (34.79%) seeking immediate dental attention. Age is significantly associated with all three variables: poor oral health (P = 0.01), seeking early dental care (P = 0.0105), and diabetes prevalence (P < 0.0001). Older age groups tend to have lower percentages of poor oral health and seeking early dental care, but higher diabetes prevalence. Race also shows significant associations with all outcome variables, with disparities evident among racial groups. Both family income level and educational level exhibit substantial associations with poor oral health, seeking early dental care, and diabetes prevalence, with P < 0.0001. Dental visit frequency is significantly associated with poor oral health (P < 0.0001) and seeking early dental care (P < 0.0001), with diabetes prevalence on the borderline.

Table 2.

Prevalence of poor oral health and early dental care and diabetes by exploratory variables

Explanatory variables	Poor oral health (%)	P value	Early dental care (%)	P value	Diabetes (%)	P value
Gender		0.0816		0.002		0.0454
Female	25.25		34.79		14.24
Male	28.84		42.09		17.47
Age (years)		0.01		0.0105		<0.0001
20–39	26.21		39.33		4.66
40–59	30.95		41.73		15.01
60 and over	23.25		33.01		30.77
Race		<0.0001		<0.0001		0.0009
White	22.46		33.18		13.97
Black	38.61		54.08		17.51
Hispanic	37.17		48.81		19.7
Other race	26.86		37.07		19.34
Family PIR		<0.0001		<0.0001		<0.0001
Poor	41.79		51.89		17.21
Near-poor	35.03		53.66		20.36
Non-poor	14.8		26.72		12.11
Education		<0.0001		<0.0001		<0.0001
<12 years	50.65		54.49		25.99
12 years	36		49.55		18.61
>12 years	19.17		30.86		12.89
Dental visit		<0.0001		<0.0001		0.0494
<6 month	16.15		20.09		15.28
6 month–1 year	26.56		34.73		12.17
>1 year	38.52		58.75		17.64

P value was obtained from Rao-Scott χ² test

Table 3 shows the percentages of individuals reporting poor oral health and those seeking dental care as early as possible, stratified by diabetes status and various explanatory variables. Across gender, females generally exhibit higher percentages of poor oral health compared to males in both diabetes and non-diabetes groups. However, when it comes to seeking early dental care, the prevalence of men and women was higher in the diabetes group compared to the non-diabetes group, with females consistently having higher percentages than males. Regarding age, individuals aged 20–39 have the highest percentages of poor oral health and seeking early dental care in both diabetes and non-diabetes groups. Among racial groups, Blacks and Hispanics tend to have higher percentages of poor oral health and lower percentages of seeking early dental care compared to Whites and Other races. Family income level also demonstrates disparities, with individuals categorized as poor having the highest percentages of poor oral health and seeking early dental care, followed by near-poor and non-poor categories. Education level shows a similar trend, with individuals with less than 12 years of education having the highest percentages of poor oral health and seeking early dental care. Finally, the time of the last dental visit indicates that individuals who have not seen a dental visit over 1 year tend to have higher percentages of poor oral health and higher percentages of needing early dental care, regardless of the diabetes status.

Table 3.

Prevalence of poor oral health and early dental care stratified by diabetes

Explanatory variables (n)	Poor oral health (%)		Early dental care (%)
	Diabetes	Non-diabetes	Diabetes	Non-diabetes
Gender
Female	39.11	22.95	45.81	32.96
Male	28.83	28.84	43.37	41.82
Age (years)
20–39	45.51	25.28	55.6	38.53
40–59	43.96	28.66	51.48	40.01
60 and over	25.34	22.31	38.34	30.65
Race
White	26.73	21.77	38.06	32.39
Black	48.57	36.5	54.21	54.05
Hispanic	44.51	35.37	56.86	46.83
Other race	32.77	25.45	44.6	35.26
Family PIR
Poor	52.2	39.62	56.98	50.83
Near-poor	34.98	35.04	51.71	44.97
Non-poor	19.88	14.1	28.24	26.51
Education
<12 years	47.35	51.81	55.27	54.22
12 years	41.1	34.83	52.11	48.97
>12 years	24.35	18.41	36.19	30.07
Last dental visit
<6 month	26.94	14.2	24.7	19.26
6 month–1 year	39.27	24.8	53.49	32.13
>1 year	38.29	38.57	60.3	58.42

The recommendation probabilities for seeking dental care as soon as possible are modeled across various factors in three different models [Table 4]. We investigated the interactions in model building. The two-way interaction of these demographic variables is not significant. P value for interactions between gender and age, gender and race, and race and age are 0.95, 0.18 and 0.63, respectively (data are not shown in the table). In Model 1, age, gender and race are considered. Model 2 includes the same variables as Model 1 but adds family income level and education level. Model 3 encompasses all variables from Model 2 and incorporates dental visit frequency and diabetes status.

Table 4.

Odds ratios (ORs) and their 95% confidence interval (CI) of exploratory variables from weighted logistic regression models

Probability = early dental care	Model 1	Model 2	Model 3
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Gender
Female (reference)
Male	1.39 (1.14, 1.69)*	1.43 (1.16, 1.76)**	1.27 (1.03, 1.58)*
Age (years)
20–39 (reference)
40–59	1.14 (0.89, 1.45)	1.16 (0.90,1.50)	1.28 (0.98,1.66)
60 and over	0.83 (0.65, 1.06)	0.78 (0.60, 0.99)*	0.88 (0.66,1.16)
Race
White (reference)
Black	2.39 (1.93, 2.96)***	1.86 (1.48, 2.32)***	1.61 (1.27, 2.04)***
Hispanic	1.87 (1.49, 2.34)***	1.31 (1.03, 1.66)*	1.23 (0.95, 1.58)
Other race	1.18 (0.90, 1.54)	1.06 (0.80, 1.40)	1.01 (0.76, 1.35)
Family PIR
Non-poor (reference)
Near-poor		1.95 (1.52, 2.50)***	1.56 (1.20, 2.03)**
Poor		2.22 (1.68, 2.92)***	1.90 (1.43, 2.52)***
Education
>12 years (reference)
12 years		1.82 (1.39, 2.37)***	1.56 (1.19, 2.05)***
<12 years		1.77 (1.38, 2.29)***	1.1 (1.14, 1.99)***
Dental visit
<6 month (reference)
6 month–1 year			1.39 (1.19, 2.63)***
>1 year			4.53 (3.54, 5.79)***
Diabetes
No (reference)
Yes			1.26 (0.91, 1.60)
C-statistics	0.549	0.681	0.734

^*P < 0.05,

^**P < 0.01,

^***P < 0.001

For gender, females consistently exhibit lower odds of the need to seek early dental care compared to males across all models, with statistically significant differences in Models 1 and 2. Among age categories, individuals aged 60 and over generally have lower odds of the need of seeking early dental care compared to those aged 20–39, especially evident in Model 2, where it is statistically significant. Regarding race, Black individuals consistently have higher odds of the need of seeking early dental care compared to Whites across all models, with statistically significant differences. Hispanics also show higher odds in Model 1, but the effect diminishes in subsequent models. Family income level demonstrates that near-poor and poor individuals have higher odds of the need of seeking early dental care compared to non-poor individuals, with significant differences in all models. Similarly, individuals with 12 years or less of education exhibit a higher need of seeking early dental care compared to those with over 12 years of education, with statistically significant differences in all models. The dental visit frequency significantly affects the need for seeking early dental care, with individuals last visiting a dentist more than a year ago showing substantially higher need compared to those last visiting within 6 months. Finally, notably, the presence of diabetes does not significantly affect the need of seeking early dental care.

DISCUSSION

This study assesses the self-reported oral health of participants and recommendations by dentists to seek early dental care, categorized by diabetic status, among adults in the U.S. Women (34.79%) are generally less likely to receive recommendations for early dental care from dentists compared to men (42.09%), with P = 0.002. There may be a lower risk perception among providers when assessing female patients, especially in the absence of overt symptoms. In terms of sociocultural expectations, there is often a perception that women are more attentive to their health and more likely to seek care on their own, potentially leading providers to prioritize men for preventive recommendations. Gender differences in dental care utilization and provider interaction can be influenced by provider expectations, patient communication styles, and societal norms regarding gender and health behavior.[14]

It is noteworthy that participants aged 60 years or older were less likely to be recommended for early dental care in Model 2, with an OR of 0.78 (95% CI: 0.60–0.99); however, this association lost statistical significance in Model 3 after further adjustment. Similarly, Hispanic individuals were significantly more likely than White individuals to receive early dental care recommendations, with an OR of 1.31 (95% CI: 1.03–1.66). These marginal associations may reflect limited statistical power, potentially due to smaller sample sizes within specific subgroups.

Previous studies have documented a higher prevalence of mucosal disorders in individuals with diabetes mellitus compared to nondiabetic individuals, with more than 90% of diabetic patients experiencing a type of oral complication.[15] A systematic review by González-Serrano et al.[16] noted a higher prevalence of oral mucosal disorders in type 2 diabetes patients (45%–88%) compared to nondiabetic groups (38.3%–45%) and in type 1 diabetic individuals (44.7%) compared to the nondiabetic population (25%).[17,18] Considering the effect of periodontal disease on diabetes and the potential benefits of good oral health practices to minimize the risk of periodontal disease, it is essential for diabetes patients to be motivated to engage in good oral hygiene behaviors and offered risk assessment and dental referrals as a part of routine diabetes care.[16]

The burden of oral diseases is higher among people with lower SES in the United States, and these disparities also extend to oral healthcare services. A study among US adults found that those with lower income and educational levels visited the dentist less frequently than those with a higher income and academic level.[19] The result of our study was consistent with that of a study from 2018, which reported that 60% of US adult diabetics reported at least one dental visit in the past year, with higher compliance among diabetic females.[20] Another study on dental visits among US adults with diabetes reported disparity in dental visits among racial or ethnic groups and socioeconomic groups, which is consistent with results from our research which reported lower percentages of seeking early dental care among blacks and Hispanics compared to whites and other races.[21] Although our study showed that diabetic patients categorized as poor, that is, with a low family income level and with less than 12 years of education reported higher percentages of seeking early dental care, many studies have consistently reported disparities in seeking dental care across race/ethnicity, poverty status, and education categories.[22]

According to Anderson’s behavioral model of health service use, including dental healthcare services, there are many factors that impact the use of dental care services.[23] In this study, age, race, family income level, and educational level were significantly associated with the participants self-reporting poor oral health, consistent with findings from a previous study on self-reported general health and oral health among adults in the United States.[24] A study examined the dental service utilization among older adults with selected chronic diseases and found consistently lower dental service utilization among diabetes patients.[25] Previous studies have shown that U.S. adults aged 30 or older with diabetes engage in poorer preventive oral health care, have lower attendance at dental visits, use preventive dental services less, practice interproximal cleaning less frequently, and have a lower prevalence of dental visits for any purpose within the past 12 months compared to those without diabetes (57%–66% with diabetes vs 65%–72% without diabetes).[26,27] However, our study did not report any significant relationship between diabetes status and the need to seek early dental care. The possible reasons may include (1) healthcare providers do not consider diabetes status when making dental recommendations, which may reflect a gap in integrated care rather than a true lack of association; (2) individuals with diabetes may already be engaged in routine dental care; (3) individuals with diabetes may have better oral hygiene behavior than others.

An important insight emerging from our findings is the potential gap in interprofessional coordination between medical and dental providers, particularly in the context of chronic conditions such as diabetes. Although diabetes patients are at an increased risk for oral health complications and should ideally receive routine dental referrals, the present study found no strong association between diabetes status and early dental care recommendations. This may reflect a lack of integrated communication and referral systems between healthcare disciplines. The disconnect suggests that despite clinical guidelines advocating collaborative care, patients may not be routinely referred to dental services during medical visits. Strengthening interprofessional collaboration—through shared electronic health records, co-located services, or interdisciplinary training—could improve early identification and referral for dental care, especially among high-risk populations.

The individuals who have not had dental care over 1 year are more likely to receive the recommendation for an early visit. There are several plausible explanations. First, patients who have been absent from dental care for extended periods are often perceived as having a higher risk for oral disease, particularly if they present with visible symptoms or deterioration when they finally return. Second, the recency of dental visits often correlates with perceived oral health status. Patients who visit regularly and show no signs of active disease might not be advised to return early, while those returning after a long absence might trigger a more cautious, preventive recommendation from providers—despite having less consistent past behavior. This result agrees with that of the previous study by Macek et al. which showed that individuals with longer intervals since their last dental visit should be recommended for subsequent care sooner.[28]

For most people, a dental checkup every 6 months is common and widely recommended.[28] However, many individuals face significant barriers to maintaining regular dental care. Many individuals have limited or no dental insurance coverage. Traditional health insurance programs like Medicare typically do not include dental benefits, and those on Medicaid often face additional challenges as dental coverage varies by state and is frequently limited to emergency services.[29] Access to dental care is further restricted in rural or underserved urban areas, where there may be a shortage of providers who accept Medicaid or serve low-income patients. Additional barriers such as dental fear or anxiety, unstable housing, and language differences can also contribute to lapses in regular dental care.

The relationship between diabetes and periodontal inflammation indicates the importance of routine preventive dental care (e.g., dental prophylaxis or cleaning and supportive periodontal therapy) to prevent the complications of both diseases. The CDC recommends that diabetic patients visit a dentist at least once every 6 months, and more frequent dental visits are recommended for those with periodontal disease.[30]

This study used self-reported oral health data that may be affected by reporting bias as individuals may under- or overestimate their oral health status. There is also the potential for residual confounding in observational analyses as unmeasured or inadequately measured variables—such as health literacy, diet, or comorbid conditions—can influence both dental care utilization and oral health outcomes.

The NHANES does not differentiate between type 1 and type 2 diabetes. To minimize the inclusion of individuals with type 1 diabetes, we excluded participants diagnosed before the age of 25 who were using insulin therapy. This approach aligns with methods used in prior studies to approximate type 2 diabetes populations in NHANES data. For instance, Casagrande et al.[13] utilized similar criteria to distinguish between diabetes types in survey data. Additionally, the cross-sectional design cannot infer causal inferences between sociodemographic characteristics and recommended early dental cares among adults in the United States. Furthermore, this study does not provide insights into the indications for the recommendations of dental visits. There was no information on why dental visits were recommended, whether for preventive care, treatment of existing conditions, or other reasons. In the real world, other variables, such as tobacco use, body mass index, and insurance status, are also important determinants of oral health and may act as confounders. However, they were not included in the final model due to data limitations and the desire to maintain a parsimonious model focused on the most directly relevant and widely available predictors. Future research should consider including these additional factors to further refine the understanding of predictors influencing dental care recommendations.

Using a dentist’s recommendation for an early dental care as a proxy for clinical need is justified on the basis that such recommendations are typically informed by the licensed dentists professional assessment. Dentists make these recommendations based on observed clinical indicators such as the presence of caries, periodontal inflammation, oral lesions, or other signs of deteriorating oral health. The recommendation reflects the clinician’s judgment, which incorporates both objective clinical findings and patient-specific factors (e.g., oral hygiene, medical history, and previous dental care patterns). Therefore, it can serve as a meaningful proxy for elevated clinical need, particularly when triangulated with other self-reported or administrative data.

Policymakers should support actionable strategies, such as promoting integrated medical-dental care and expanding tele-dentistry services, particularly for underserved populations, to improve the oral health status. Integrating oral health into primary care settings can facilitate early detection of dental issues during routine medical visits, encourage interdisciplinary collaboration, and improve continuity of care. Tele-dental service can bridge geographic and socioeconomic gaps by providing remote consultations, preventive guidance, and follow-up care to individuals in rural or low-resource communities who face barriers to in-person visits.

CONCLUSION

This study shows that sociodemographic and behavioral factors strongly influence recommendations for early dental cares among U.S. adults. Individuals from minority groups, lower-income backgrounds, and those with less education were more likely to be advised to return early, especially if they hadn’t visited a dentist in over a year. Surprisingly, diabetes status was not independently linked to early visit recommendations, despite its known connection to oral health issues. These findings highlight the need for equity-focused strategies to improve access and reduce disparities in dental care.

CONFLICTS OF INTEREST

There are no conflicts of interest.

AUTHORS CONTRIBUTIONS

YL: analyzed data and drafted the manuscript. YL: designed the study, assessed the data, conducted data management, and interpreted the results. MO: searched for literature, interpreted the results, and critically revised the manuscript. KW: contributed to the conception and design of the study, interpreted the results, and critically revised the manuscript. All authors were involved in a substantive review of the manuscript. All authors read and approved the manuscript.

ETHICAL POLICY AND INSTITUTION REVIEW BOARD STATEMENT

Not applicable.

PATIENT DECLARATION OF CONSENT

Not applicable.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are openly available in [https://wwwn.cdc.gov/nchs/nhanes/default.aspx] at https://www.cdc.gov/nchs/nhanes/index.html.

Ethical policy and Institutional Review Board statement

The data used in this study are publicly accessible and de-identifed; therefore, this study was exempt from IRB review.

SUPPLEMENTARY MATERIAL

SupplementTable 1.

Interaction terms investigated to build three models

For model 1		For model 2		For model 3
Effect	P value	Effect	P value	Effect	P value
Gender	0.1442	Gender	0.1035	Gender	0.0614
Age	0.1527	Age	0.1616	Age	0.7328
Race	<.0001	Race	0.0077	Race	0.0075
Gender*age	0.959	Family PIR	0.0861	Family PIR	0.0666
Gender*race	0.1775	Education	0.1694	Education	0.0233
Race*age	0.6254	Family PIR*gender	0.8934	Last dental visit	<.0001
		Family PIR*age	0.1982	Diabetes	0.706
		Family PIR*race	0.1907	Last dental visit*gender	0.4187
		Education*gender	0.304	Last dental visit*age	0.7638
		Education*age	0.1806	Last dental visit*race	0.0942
		Education*race	0.243	Last dental visit*Family PIR	0.4214
		Family PIR*education	0.6187	Last dental visit*education	0.5088
				Diabetes*gender	0.2234
				Diabetes*age	0.9523
				Diabetes*race	0.7124
				Diabetes*Family PIR	0.6092
				Diabetes*education	0.3832
				Last dental visit*diabetes	0.6111

Funding Statement

Not applicable.