摘要：Objectives. We examined regional variation in tooth loss in the United States from 1999 to 2010. Methods. We used 6 waves of the Behavioral Risk Factor Surveillance System and data on county characteristics to describe regional trends in tooth loss and decompose diverging trends into the parts explained by individual and county components. Results. Appalachia and the Mississippi Delta had higher levels of tooth loss than the rest of the country in 1999. From 1999 to 2010, tooth loss declined in the United States. However, Appalachia did not converge toward the US average, and the Mississippi Delta worsened relative to the United States. Socioeconomic status explained the largest portion of differences between regions in 1999, but a smaller portion of the trends. The Mississippi Delta is aging more quickly than the rest of the country, which explains 17% of the disparity in the time trend. Conclusions. The disadvantage in tooth loss is persistent in Appalachia and growing in the Mississippi Delta. The increasing disparity is partly explained by changes in the age structure but is also associated with behavioral and environmental factors. People in Appalachia have worse oral health than other Americans. 1–4 West Virginia, the only state entirely located in Appalachia, has the highest rate of people missing 6 or more teeth (65.6%) and the second highest rate of complete tooth loss (37.8%) for people aged 65 years and older. 5,6 The Mississippi Delta, another economically disadvantaged region, also has poor oral health. Mississippi, which falls mostly in the Mississippi Delta, follows West Virginia with the second highest rate of people missing 6 or more teeth (58.2%) and the fourth highest rate of complete tooth loss (27.3%) among those aged 65 years and older. 5,6 Of the 5 states with the highest rate of people missing 6 or more teeth, 4 fall in the Mississippi Delta or Appalachia. Numerous studies have examined the causes of poor oral health in Appalachia and the Mississippi Delta. Studies have highlighted the importance of both individual attributes and broader elements that affect Appalachian communities. Individual attributes include socioeconomic status (SES), genetics, oral bacteria, tobacco use, knowledge of health behaviors, and dental insurance. 1,2,4,7–9 Broader elements include fluoride in the water supply, cultural importance placed on oral health, presence of coal mining, and number of dentists and dental hygienists per capita. 1,2,4,10,11 Less research has been done on oral health in the Mississippi Delta, although this region also has high rates of tooth loss. Studies that have analyzed this region have highlighted the roles of race, private dental insurance, parental oral health, parental health behaviors, and diet. 12–15 Oral health in the United States has significantly improved in the past 4 decades. The number of decayed, missing, and filled teeth; prevalence of untreated caries; edentulous rate; and rate of periodontal disease have all declined. 16–22 The overall improvement in oral health outcomes in the United States raises the question of whether all areas of the United States are improving equally or whether there are persistent regional disparities in oral health outcomes. Previous reports from the Centers for Disease Control and Prevention have provided raw data on tooth loss in each state, 5,6 but data on regional disparities is lacking. Moreover, without microdata it is impossible to discern whether divergent regional trends are attributable to relatively innocuous differences, such as the age structure of the regions, or driven by more concerning disparities, such as poverty and access to oral health care. To address this gap, we used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine regional variation in the level and improvement in the rate of tooth loss from 1999 to 2010. Our regions of interest, Appalachia and the Mississippi Delta, are defined as groups of counties. We analyzed the association between tooth loss and individual characteristics, individual behavior, and county factors. We tested 3 hypotheses: (1) The Mississippi Delta and Appalachia will have had less improvement in oral health than the rest of the country in the past decade, (2) the age profile of the regions will explain a portion of the regional differences, and (3) individual characteristics, individual behavior, and county characteristics will explain a portion of the regional differences.
