摘要：Objectives. We evaluated the relationship between having an intellectual or developmental disability (IDD) and the timing of the first dental visit for children who were newly enrolled in Medicaid in Iowa. Methods. We identified children aged 3 to 8 years with and without IDD who were newly enrolled in the Iowa Medicaid program in 2005 (N = 5391). We gathered data on presence of IDD, health status, age at baseline, gender, length of Medicaid enrollment, medical care visits, household Medicaid enrollment, urbanization, residence in a federally designated Health Professional Shortage Area (HPSA), and time of first dental visit through 2007. Results. About 32% of children had a first dental visit within 6 months of enrollment; this proportion increased to 49%, 64%, and 74% by years 1, 2, and 3, respectively. In the unadjusted models, there was no significant difference between children with and without IDD in time to first dental visit ( P = .22). After adjusting for model covariates, however, children with IDD were 31% more likely to have a delayed first dental visit ( P = .04). Conclusions. Newly Medicaid-enrolled children aged 3 to 8 years with IDD in Iowa were significantly more likely to have a later first dental visit. Future interventions should focus on ensuring timely access to first dental visits for all Medicaid-enrolled children, with an emphasis on those with IDD. The Institute of Medicine's 2001 publication Crossing the Quality Chasm stresses that receiving health care services at the appropriate time is an important measure of health care quality. 1 Although this report does not explicitly discuss dental care, it is widely accepted that the timing of dental visits is important in preventing the onset and progression of dental caries, the most common chronic childhood disease in the United States. 2 , 3 Ensuring that children have earlier first dental visits—ideally by age 12 months, as recommended by the American Academy of Pediatric Dentistry 4 —optimizes the benefits associated with the establishment of a dental home, including the provision of caries risk assessments, 5 anticipatory guidance, 6 – 9 oral hygiene instruction, 10 , 11 dietary counseling, 12 , 13 and health education. 14 , 15 Earlier first dental visits also allow dentists to provide children at increased risk for caries with appropriate preventive dental care, such as pit and fissure sealants and topical fluoride treatments. 16 – 20 Previous research suggests that children with an intellectual or developmental disability (IDD) are at increased risk for dental caries. For instance, many children with IDD take prescription medications that result in xerostomia and reduced salivary buffering capacity. 21 In addition, children with IDD often have behavioral comorbidities that make it difficult for caregivers to provide regular oral hygiene. 22 From a provider perspective, dentists may be less willing to see children with IDD if they have inadequate training 23 , 24 or offices that are ill-equipped to treat patients with IDD. 25 Also, some dentists resist seeing children enrolled in public health insurance programs, such as Medicaid, because of insufficient reimbursement, 26 , 27 additional administrative burdens, 28 and patient behaviors such as frequent late cancellations or no-shows. 29 It is reasonable to believe that these factors would combine to create access problems for children with IDD, but published studies have so far failed to identify significant differences in children's dental utilization on the basis of whether they have IDD. In a study based on data from the 1997 National Health Interview Survey, Schultz et al. reported that for children aged 2 to 17 years, those with a developmental disability were just as likely as those without a developmental disability to have seen a dentist in the previous 6 months (53% and 51%, respectively). 30 A 2001 study reported that 82.5% of caregivers of children in the Iowa Supplemental Security Income program had no problems finding dental care for their child. 31 In a more recent study, Chi et al. found no significant difference in the likelihood of preventive dental care utilization for Medicaid-enrolled children with and without IDD ( P = .14) after adjusting for model covariates. 32 Collectively, these findings suggest that children with IDD do not have worse access to dental services than do those with IDD. However, these studies have 3 major limitations: (1) the lack of adjustment for overall health status, which assumes homogeneity in access to dental care for all children 30 – 32 ; (2) a cross-sectional measure of utilization during a single calendar year, which fails to account for utilization over longer time periods 30 – 32 ; and (3) no control group. 31 No published study to date has investigated the relationship between IDD status and access to first dental visits for Medicaid-enrolled children while accounting for these limitations. We used survival analytic techniques 33 to compare the time to first dental visit for newly Medicaid-enrolled children with and without IDD and to identify the factors related to earlier first dental visit after enrollment in Medicaid. On the basis of the premise that Medicaid-enrolled children with IDD face more barriers to dental care access than children without IDD, we hypothesized that children with IDD would have a later first dental visit than would children without IDD. This research was a continuation of efforts to identify potential explanations for why publicly insured children have difficulties accessing dental care, and we intended our findings to form the basis for future clinical interventions and policies aimed at reducing pediatric oral health disparities for the most vulnerable child subgroup: those who have an IDD.
