摘要：Objectives. We used objective oral health screening and survey data to explore individual-, psychosocial-, and community-level predictors of oral health status in a statewide population of adults. Methods. We examined oral health status in a sample of 1453 adult Wisconsin residents who participated in the Survey of the Health of Wisconsin Oral Health Screening project, conducted with the Wisconsin Department of Health Services during 2010. Results. We found significant disparities in oral health status across all individual-, psychosocial-, and community-level predictors. More than 15% of participants had untreated cavities, and 20% did not receive needed oral health care. Individuals who self-reported unmet need for dental care were 4 times as likely to have untreated cavities as were those who did not report such a need, after controlling for sociodemographic and behavioral factors. Conclusions. Our results suggested that costs were a primary predictor of access to care and poor oral health status. The results underscored the role that primary care, in conjunction with dental health care providers, could play in promoting oral health care, particularly in reducing barriers (e.g., the costs associated with unmet dental care) and promoting preventive health behaviors (e.g., teeth brushing). Oral health is an essential and integral component of overall health, yet unmet health care needs and poor oral health are pervasive. Poor oral health care is associated with increased use of medical services, increased risk for several chronic conditions (including heart disease and diabetes), 1,2 as well as reduced quality of life and employment opportunities. 3,4 There is growing momentum both nationally and internationally for increased understanding and use of a more holistic social-ecological perspective to understanding and addressing oral health disparities. 5 With the implementation of the Affordable Care Act and the potential for increased access to care among adults, there is a unique and novel opportunity to improve equity in oral health care and outcomes. Spurred by a 2001 surgeon general’s report in which poor oral health was described as a “Silent Epidemic” sweeping the nation, the Institute of Medicine convened experts to develop a vision for improved oral health care into the future. A 2011 Institute of Medicine report suggested that oral health care should be integrated into an overall model of health care delivery, with an emphasis on the primary care setting. 6 National recommendations suggested that addressing oral health disparities would require a more fundamental shift toward viewing oral health as a medical issue. Improving access to primary care that includes education and training on the importance of oral health care during medical visits might be a solution to improving oral health equity. 7,8 Elucidating the true magnitude of oral health disparities and unmet needs, including the complex network of population-level predictors, is often limited. A 2010 report by the World Health Organization identified several research gaps, including understanding the social determinants and modifiable risk factors for poor oral health. 5 Although many risk factors are well-established (age, gender, race/ethnicity, and access to care), 9–13 others, such as psychosocial determinants and behaviors, are not as well understood. Few, if any, population-based studies have included objective oral health screenings. Oral health screenings of children have been the national benchmark for tracking disparities among children for quite some time, but no analogous nationwide program exists for adults. The Association for State and Territorial Dental Directors (ASTDD) has developed tools, such as the Basic Screening Survey (BSS) protocol, for use in adults. However, access to representative population-based studies of adults is not often feasible or cost effective for most state-based programs. Consequently, most prevalence estimates of unmet oral health needs are based on self-reported, telephone-based surveys that do not include data on predictors, such as tooth brushing, psychosocial factors, and community-level data. With national shifts in overall health insurance coverage, baseline data and information are needed to support evaluation of the impact of this “natural experiment” on oral health disparities. 6,8 Changes in baseline estimates of oral health disparities and predictors could be followed over time for program evaluation and to guide policy efforts to achieve oral health equity at a time when significant changes to access to primary care are happening. Despite these urgent calls, to date, most oral health surveillance among adult populations rely on subjective survey data, and the true magnitude of poor oral health and multilevel view of determinants at a community level are lacking. We aimed to address these gaps using data gathered as a result of a unique partnership that was established between the state of Wisconsin Department of Health Services (DHS) Oral Health Program and the University of Wisconsin Survey of the Health of Wisconsin (SHOW). The partnership facilitated integration of an objective oral health screening using the BSS protocol into an existing population-based examination survey. Our goals were to identify who was at greatest risk for poor oral health in Wisconsin and to examine how social-ecological and individual factors, such as health behaviors and mental health, focusing on some of the often overlooked social determinants, predict adverse oral health outcomes (i.e., cavities) or unmet oral health care needs. Furthermore, with pending changes in access to primary care, we sought to explicitly examine the role that access to oral health care has on oral health status and health equity among a representative sample of Wisconsin adults.
