Dental Care Utilization and Service Needs Among American Indian/Alaska Native/Native Hawaiian Elders: 2008 to 2017

Abstract

Objective: This study describes trends in self-reported dental care utilization and services needed among American Indian/Alaska Native/Native Hawaiian (AI/AN/NH) elders 2008 to 2017, including demographic and socioeconomic variability. Method: Researchers utilized data from the Survey of Elders administered by the National Resource Center on Native American Aging, representing all regions of the United States and 262 tribes. Data were analyzed comparing means over time and between/within groups. Results: Between April 2008 and March 2017, there was a statistically significant (p < .001) increase in the proportion of older adults who visited a dentist and an increase in need for treatment. A smaller proportion of older adults reported need for treatment among those who were privately insured, high income, had no tobacco use, were employed, and had visited a dental professional in the last year. Discussion: These findings highlight current dental needs among tribal elders while also identifying elders at greater risk of poor oral health.

Keywords

American Indian Native American oral health dental care

Introduction

Health care policy and federal funding agencies have most recently promoted a health care system focused on preventing and managing chronic diseases and providing holistic care with attention paid to overall patient health. However, lacking from the conversation around chronic diseases is the need to prevent and treat dental caries and gum disease, and the role of poor oral health on the incidence of chronic disease, especially among the older adults (Centers for Disease Control and Prevention [CDC], 2016). In addition, dental care is largely omitted from the traditional primary care model, with the inaccurate perception that health of the mouth is separate from overall personal health (CDC, 2016; Chou, Cantor, Zakher, Mitchell, & Pappas, 2014; Clark, Slayton, & Section on Oral Health, 2014).

The oral health status of a population is largely predictive of the general health and well-being of the said group (Griffin, Jones, Brunson, Griffin, & Bailey, 2012; Quandt et al., 2009; Watando et al., 2004; Yoneyama et al., 2002). Dental pain may reduce quality of life and affect activities of daily living, while poor oral health has also been associated with low self-esteem (Starr & Hall, 2010). Dental pain and the need for other dental treatment also affect interpersonal interactions and speech (Smith & Sheiham, 1979).

For the older adults, it is especially important to address oral health concerns. Although the above is true for all populations, scholars now also concur that there is direct correlation between poor oral health and several chronic conditions that are common among individuals aged 65 years and older. Low utilization and inadequate access to annual dental care is correlated with several chronic diseases, including hypertension (Singh, 2016), stroke (Joshipura, Hung, Rimm, Willett, & Ascherio, 2003), and diabetes (Demmer, Jacobs, & Desvarieux, 2008). Yoneyama et al. reported in 2002 that, among nursing home residents, pneumonia and death from pneumonia decreased significantly among those who had assistance with oral care from a trained caregiver.

Tooth decay, dental caries, periodontal disease, or complete tooth loss may also lead to poor nutrition and oral dysfunction (Burr & Lee, 2013). To accommodate any tooth loss or pain, an older adult may alter what he or she eats, avoiding hard-to-chew items, including meats, fruits, and vegetables (Daly, Elsner, Allen, & Burke, 2003). This subsequently lowers the quality of his or her diet and overall health. Conversely, good oral health behavior among nursing home residents (regular brushing and preventive dental exams) is correlated with fewer respiratory infections, improved cognitive function among nursing home residents, decreased risk of death from pneumonia (Pace & McCullough, 2010; Sjogren, Nilsson, Forsell, Johansson, & Hoogstraate, 2008), and reduces risk of cardiovascular disease (de Oliveira, Watt, & Hamer, 2010).

There is consensus in the literature on the need for regular oral health examinations, preventive dental care, and good oral hygiene among the older adults; however, individuals ages 65 and older are the least likely age cohort to visit a dental health care professional annually (CDC, 2017; Dye et al., 2007; National Center for Health Statistics [NCHS], 2016). During 2015, only 62.7% of those aged 65 years and older had visited a dentist in the past year compared with 84.7% of individuals ages 2 to 17 and 64% of those aged 16 to 64 years (NCHS, 2016). Although less than two thirds of older adults visited a dental professional, a large majority (87.9%) had visited a general physician (NCHS, 2016). These older adults are clearly accessing health services, but they are not utilizing dental care at the same rate as primary care. There is a need to identify who within this age cohort requires additional oral health literacy, and which individuals are not accessing dental care.

Oral health status and utilization of care is not generalizable across aged populations. American Indians, Alaska Natives, and Native Hawaiians (AI/AN/NH) report worse oral health and lower dental visits rates than the general U.S. population of all ages (Phipps & Ricks, 2016; Wu, Liang, Plassman, Remle, & Luo, 2012). Most AI/AN/NH older adults received dental care primarily to relieve pain as opposed to visiting the dentist for preventive care or an annual exam (Jones, Niendorff, & Broderick, 2000). In 2015, the Indian Health Services (IHS) conducted an oral health survey among AI/AN dental patients served by tribal clinics and IHS (Phipps & Ricks, 2016). The survey was limited to only those who were currently seeking dental treatment at an IHS facility. The survey found that, compared with the general U.S. older adult population, AI/AN older adults suffered disproportionally from untreated dental caries (dental decay/cavities), were more likely to have severe periodontal disease, were more likely to be missing teeth, and were more likely to report poor oral health, oral pain, and avoidance of food due to oral problems. Although providing a valuable baseline and comparisons between AI/AN elders’ oral health conditions between 1999 and 2015, this study only reported the dental health of those who had visited a dentist at IHS and/or those who sought treatment at an IHS/tribal facility. In addition, the report did not identify subgroups of AI/AN older adults who may be at an increased risk of poor oral health. Several studies cite the lack of significant AI/AN/NH elder participation in research on oral health care status and call for further research in an effort to draw generalizable conclusions and/or make meaningful comparisons (Jones et al., 2000; Kim, Bryant, Goins, Worley, & Chiriboga, 2012; Quandt et al., 2009). Our study is a response to this call for research.

This study is the largest known survey of dental care utilization and oral health status among AI/AN/NH older adults. The aims of this research included the following: (a) identify dental visit rates for AI/AN/NH older adults between 2008 and 2017, (b) identify the prevalence of oral health conditions and self-reported dental treatment need among AI/AN/NH older adults between 2008 and 2017, (c) measure the current (2017) relationship between various demographic and behavior variables (age, income, education, insurance coverage, smoking status, employment status, and residence) and dental visit rates among AI/AN/NH older adults, and (d) measure the current (2017) influence of demographics and behavior variables on oral health conditions and self-reported dental treatment need.

This study sought to describe dental care utilization between 2008 and 2017 while also identifying AI/AN/NH older adults currently (2017) in greatest need of dental intervention. Results from this research have the capacity to inform IHS, oral health policy, community/tribal interventions, and dental providers serving tribal populations. In addition, the findings will illustrate the need to develop policies and programs for specific subpopulations of AI/AN/NH older adults, those who self-report greater need for dental treatment, and who are not utilizing or do not have access to dental services.

Method

The National Resource Center on Native American Aging (NRCNAA) conducts the national Survey of Elders (ages 55+) every 3 years. Funded by the Administration for Community Living on Aging, under the U.S. Department of Health and Human Services, The NRCNAA first administered the survey in 2001 (Cycle 1) and just completed Cycle 6 (2017). Data represent all regions of the United States and 262 tribes. The full survey originated to identify the self-reported health and social needs of tribes, villages, and homesteads nationally (National Resource Center on Native American Aging [NRCNAA], 2018). Self-reported measures in the Survey of Elders include general health status; activities of daily living; vision, hearing, and dental care screenings; health care access; tobacco and alcohol usage; weight and nutrition; social support/housing; demographics; and social functioning.

Our university’s institution review board approved the survey, proposed analyses, and research method. We also secured tribal resolutions from the Official Tribal Council of each participating tribe. We utilize the results of these surveys to inform tribes, share data with the Administration for Community Living on Aging, to assist tribes in identifying grants to address needs evident in the data, and to publish work drawing attention to the social, physical, and mental health needs of our AI/AN/NH older adults.

We at the NRCNAA research team utilize data from the Survey of Elders to publish articles on a variety of AI/AN/NH older adult needs. As such, the following discussion addressing the basic survey methodology, inclusion criteria, and categorical variables may appear in other publications utilizing NRCNAA data (Adamsen, Schroeder, LeMire, & Carter, 2018). Similarly, the demographic breakdown for each cycle as presented in the results is consistent with other publications. However, the analyses for this study are specific to oral health needs and dental visits among AI/AN/NH older adults and are not addressed in previous publications. More information regarding the NRCNAA or the Survey of Elders may be found at https://www.nrcnaa.org/needs-assessment.

Participants

The Title VI Nutrition and Caregiving Grant program director within each participating tribe distributed the survey among their tribal older adults. To be eligible for the Title VI Nutrition and Caregiving grant, a federally recognized tribe must represent a minimum of 50 NA older adults (ages 60 or older). More information on Title VI grants is available through the Administration for Community Living (U.S. Department of Health and Human Services, Administration for Community Living, 2018).

Survey participants included AI/AN/NH older adults with tribal affiliation (living on or off of the reservation) ages 55 and older. Participants were American Indian (AI), Alaska Native (AN), Native Hawaiian (NH), a descendant, or “other” self-identified ethnicity. In the most recent cycle (April 2014-March 2017), 80.5% of older adults identified as AI, 7.5% were AN, and 1.4% were NH.

In Cycle 4 (April 2008-March 2011), 18,089 participants represented 234 federally and state recognized tribes from all regions of the United States; the survey had a 61% response rate (18,089/29,719 AI/AN/NH older adults). Cycle 5 (April 2011-March 2014) included 17,049 AI/AN/NH older adults affiliated with 262 tribes, a 65% response rate (17,049/26,206 AI/AN/NH). Cycle 6 had a 65.6% response rate (18,134/27,639 AI/AN/NH) and included representation from 267 (of 567) federally and state-recognized tribes.

We applied a prestudy calculation to determine the required size of the simple random sample for each participating tribe independently. The tribes own the data that are generated from the survey, and as a result, we apply independent random sample sizes for each tribe as opposed to an aggregate sample size among all participating communities. This decision also allows our research team to provide survey results to each tribe with data that are generalizable and representative of the respective AI/AN/NH older adult population.

Measures

The Survey of Elders collects a variety of self-reported measures related to individuals’ behavior, perceived health status, emotional and spiritual health, and demographics. Under this funding, the NRCNAA staff work to build tribal capacity in research. Among each participating tribe, individuals from within the tribe are trained to administer the survey to the tribal older adults, reading the questions and marking the older adults’ responses. These individuals are not paid directly by the NRCNAA. Instead, many are employed by Title VI programs. These individuals assist the older adults in understanding the questions and collecting the measures for research. Older adults are allowed to skip questions they are not comfortable answering. The survey itself is a paper-based Scantron form (Scantron Corporation) that is scanned in-house by NRCNAA team members.

For our study, the independent variables included the following: age categorically (55-64, 65-74, 75), categorical income (US$15,000, US$15,000-US$49,999, US$50,000+), education (less than Grade 12, high school diploma only, education beyond high school), employment (employed, unemployed), insurance coverage (Medicare, Medicaid, private, veteran affairs, tribal, none, other), smokeless tobacco use (chew, no chew), smoking status (daily, ceremonial/recreationally, no), and residence (on the reservation, off of the reservation). Having visited a dental professional in the last year (yes, no) was used as an independent variable to determine if dental visits were correlated with better perceived oral health. However, dental visits were also assessed as a dependent variable to determine if dental visits were more or less common among various socioeconomic, demographic, and behavior categories. See Table 1 for further description of the variables and how the questions appeared in the survey.

Table 1.

Survey Questions, Response Categories, and Coding.

Survey question	Response categories as they appear in the survey	Variables used for analysis and (original codes)
A. Age	Open response (ratio)	55-64 years, 65-74, 75+
B. What is your personal annual income?	Categorical, single response: □ Under US$5,000 (1) □ US$20,000-US$24,999 (6) □ US$5,000-US$6,999 (2) □ US$25,000-US$34,999 (7) □ US$7,000-US$9,999 (3) □ US$35,000-US$ 49,999 (8) □ US$10,000-US$14,999 (4) □ US$50,000 or more (9) □ US$15,000-US$19,999 (5)	<US$15,000 (1-4), US$15,000-US$49,999 (5-8), US$50,000 (9)
C. Have you been employed full or part-time during the past 12 months?	□ Full-time (1) □ Part-time (2) □ No (3)	Employed (1-2); Unemployed (3)
D. What is the highest grade or year of school you completed?	□ Never attended or kindergarten only (0) □ Elementary 1□ 2□ 3□ 4□ 5□ 6□ 7□ 8 □ High school 9□ 10□ 11□ 12 □ College/technical school 13□ 14□ 15□ 16 □ Graduate/professional school 17	Less than Grade 12 (1-11), High school diploma only (12), Education beyond high school (13-17)
E. Do you reside on/in a reservation, trust land, Alaska village, or Hawaiian homestead?	□ Yes (1) □ No (0)	Yes (1), No (0)
F. What type of health coverage do you have? (Please mark all that apply)	□ Medicare (1) □ Indian Health Services (5) □ Medicaid (2) □ Alaska Native Health (6) □ Private insurance: □ Indian Health/Tribal (7) □ Health/Medical (3) □ Veteran’s Administration (8) □ Private insurance: □ Other (9) Long-term care (4) □ None (10)	Medicare (1), Medicaid (2), Private (3-4), Tribal/Indian Health Services (5-7), VA (8), Other (9), None (10)
G. Do you smoke tobacco now?	□ Yes, everyday (1) □ Yes, some days (e.g., ceremonial, social; 2) □ No (3)	Every day (1), ceremonial/recreation (2), No (3)
H. Do you use chewing tobacco or snuff?	□ Yes (1) □ No (0)	Yes (1), No (0)
I. Please mark all that apply to your nutritional health.	Survey includes 10 statements (mark all that apply). One statement utilized for analysis: I have tooth or mouth problems that make it hard for me to eat. □ Yes (1) □ No (0)	Yes (1), No (0)
J. Have you seen a dentist or dental hygienist in the past year?	□ Yes (1) □ No (0)	Yes (1); No (0)
K. What type of dental care do you need? (Mark all that apply)	Code for each variable: 1 = box checked, 0 = box not checked □ Teeth filled or replaced □ Teeth pulled □ Gum treatment □ Relief from pain □ Denture work (new dentures) □ Work to improve appearances (for example □ braces or bonding) □ Other □ None	Teeth filled or replaced, teeth pulled, gum treatment, denture work (new dentures), relief from pain, work to improve appearances (for examples braces or bonding), other, none

Dependent variables included self-reported need for various dental services. The survey asks an older adult to identify type of dental care needed now and allows respondents to select all that apply. Response options include the following: teeth filled or replaced (fillings, crowns, and/or bridges), teeth pulled, gum treatment, denture work (new dentures), relief from pain, work to improve appearance, other, and none. An additional dependent variable includes presence of tooth/mouth problems that make it hard to eat; this is tracked under a question where older adults mark all statements that apply to their nutritional health.

Analysis

Descriptive statistics and crosstabulations examined the demographic and socioeconomic differences in both proportion of individuals who had visited a dental professional and needed dental treatment. Chi-square tests or t tests (p < .05) as well as an ANOVA (p < .05) were conducted to evaluate demographic/socioeconomic group differences in dental care utilization and service needs. SPSS version 23.0 (Armonk, NY) was utilized for all data analyses.

Results

The demographic makeup of survey participants presented little variability over time (Cycles 4, 5, and 6). See Table 2. As an example, during Cycles 4, 5, and 6, respectively, 68.3%, 62.2%, and 66.0% identified as unemployed. Most recently (Cycle 6), 33.5% of the participating AI/AN/NH older adults were ages 55 to 64, 35.2% were ages 65 to 74 and 23.3% were ages 75 or older. A majority of older adults either reported an annual income of less than US$15,000 (41.3%) or between US$15,000 and US$49,999 (38.2%). More than half of the older adults (64.2%) were covered by Tribal Insurance while 43.2% indicated Medicare coverage and 23.3% were covered under Medicaid. Respondents can report more than one form of health insurance. Only 1.8% indicated they had no health coverage. Most older adults (71.4%) indicated they did not use smoking tobacco; 89.9% did not chew tobacco. See Table 2 for all sample demographics in Cycles 4, 5, and 6.

Table 2.

Respondent Demographic and Socioeconomic Variables Cycles 4, 5, and 6.

	Cycle 4 (18,089)		Cycle 5 (17,049)		Cycle 6 (18,134)
	n	%	n	%	n	%
Age
55-64	6,375	35.2%	6,190	36.3%	6,080	33.5%
65-74	6,329	35.0%	5,762	33.8%	6,386	35.2%
75+	4,125	22.8%	3,934	23.1%	4,217	23.3%
Income
<US$15,000	8,921	49.3%	8,066	47.3%	7,489	41.3%
US$15,000-US$49,999	5,943	32.9%	5,739	33.7%	6,928	38.2%
US$50,000+	884	5.6%	1,104	6.5%	1,396	7.7%
Employment
Employed	5,077	31.7%	4,649	27.3%	5,353	29.5%
Unemployed	10,956	68.3%	10,603	62.2%	11,966	66.0%
Education
Less than Grade 12	5,453	30.1%	4,700	27.6%	4,108	22.7%
High school diploma only	5,895	32.6%	5,494	32.2%	6,264	34.5%
Education beyond high school	6,043	33.4%	6,386	37.5%	7,195	39.7%
Chew tobacco
Yes	467	2.6%	336	2.0%	488	2.7%
No	14,930	82.5%	14,554	85.4%	16,306	89.9%
Smoking tobacco
Every day	3,083	17.0%	2,941	17.3%	3,004	16.6%
Ceremonial/recreation	1,004	5.6%	974	5.7%	1,255	6.9%
No	12,994	71.8%	12,163	71.3%	12,952	71.4%
Insurance coverage (mark all that apply)
Medicare	8,284	45.8%	9,325	54.7%	10,296	43.2%
Medicaid	3,676	20.3%	3,473	20.4%	4,227	23.3%
Private	3,939	21.8%	3,678	21.6%	4,134	22.8%
VA	1,115	6.2%	971	5.7%	1,210	6.7%
Tribal (Indian Health Services)	12,058	66.7%	11,341	66.5%	11,638	64.2%
None	N/A	N/A	N/A	N/A	329	1.8%
Other	892	4.9%	844	5.0%	743	4.1%
Residence
Resides on reservation	11,541	63.8%	10,699	62.8%	11,131	61.4%
Off of reservation	4,998	27.6%	5,128	30.1%	6,341	35.0%

Note. Reporting raw percentages of total sample; demographic nonrespondents included in denominator, percentages will not equal 100%. VA = Veterans Affairs.

Aim 1: Dental Visit Rates Between Cycles 4, 5, and 6

Between Cycle 4 (April 2008-March 2011) and Cycle 6 (April 2014-March 2017), there was a gradual, statistically significant (p < .001) increase in utilization of dental services among AI/AN/NH older adults. Among respondents in Cycle 4, 49.1% indicated that they had visited a dentist or dental hygienist in the past year; by Cycle 6, the rate increased to 56.7% of the older adult AI/AN/NH population. See Figure 1.

Aim 2: Prevalence of Dental Treatment Need and Oral Health Conditions Between Cycles 4, 5, and 6

There was a significant decrease (p < .001) in the proportion of elders indicating no current need for dental care between Cycles 4 (35.8%) and 6 (33.6%). See Figure 1 above. The proportion of older adults reporting a need for dental services consistently decreased during the three survey cycles for only one service: the need for denture work or new dentures (p < .001). See Figure 1. Dental services that older adults consistently indicated an increased need for during Cycles 4, 5, and 6 included gum treatment (p < .001) and other services (p < .001). There was significant variation (p < .001) but no consistent trend in either direction across the three cycles for the perceived need for teeth to be pulled, teeth requiring a filling or replacement, relief from pain, work to improve appearance, and reporting that the older adult experienced tooth or mouth problems that made it hard for him or her to eat. See Figure 1.

Although 56.7% of AI/AN/NH older adults reported having visited a dental professional in the past year during Cycle 6, we found significant variability among age, income, and employment categories (p < .05). A larger proportion of the older adult population ages 75 or older had not visited a dental professional in the past year; 50.7% had no dental visit compared with 42.2% of those ages 65 to 74 (p < .001). See Table 3.

Table 3.

Dental Care Utilization in the Past Year Among AI/AN/NH Older Adults by Demographic Variables, Cycle 6.

	N (Denominator)	Dental visit% (n)	No dental visit% (n)
Age
55-64	5,906	59.9% (3,540)	40.1% (2,366)
65-74	6,181	57.8% (3,572)	42.2% (2,609)
75+	4,054	49.3% (1,999)	50.7% (2,055)
Income
<US$15,000	6,673	48.3% (3,226)	51.7% (3,447)
US$15,000-US$49,999	6,381	61.0% (3,890)	39.0% (2,491)
US$50,000+	1,269	77.1% (979)	22.9% (290)
Employment
Employed	4,798	52.6% (3,080)	47.4% (1,718)
Unemployed	10,864	64.2% (5,715)	35.8% (5,149)
Education
Less than Grade 12	3,673	43.1% (1,584)	56.9% (2,089)
High school diploma only	5,657	55.6% (3,143)	44.4% (2,514)
Education beyond high school	6,522	64.9% (4,231)	35.1% (2,291)
Chew tobacco
Yes	449	47.4% (213)	52.6% (236)
No	14,882	56.6% (8,420)	43.4% (6,462)
Smoking tobacco
Every day	2,710	47.0% (1,275)	53.0% (1,435)
Ceremonial/recreation	1,114	55.1% (614)	44.9% (500)
No	11,880	58.8% (6,984)	41.2% (4,896)
Insurance coverage
Medicare	9,450	55.7% (5,267)	44.3% (4,183)
Medicaid	3,887	50.3% (1,954)	49.7% (1,933)
Private	3,812	68.2% (2,598)	31.8% (1,214)
VA	1,115	52.7% (588)	47.3% (527)
Tribal (Indian Health Services)	10,687	57.5% (6,140)	42.5% (4,547)
None	286	42.7% (122)	57.3% (164)
Other	667	60.6% (404)	39.4% (263)
Residence
Resides on reservation	10,005	53.7% (5,373)	46.3% (4,632)
Off of reservation	5,769	61.6% (3,555)	38.4% (2,214)

Note. The variability between groups was statistically significant at p < .05 for all variables. Reporting valid percentages; omits nonrespondents. AI = American Indian; AN = Alaska Native; NH = Native Hawaiian; VA = Veterans Affairs.

Although only 48.3% of older adults with an income of US$15,000 or less saw a dental professional in the past year, 77.1% of those with an income of US$50,000 or greater reported a dental visit (p < .001). Similarly, those who had some education beyond high school had visited a dental professional (64.9%) in higher proportion than those who had not graduated high school (43.1%, p < .001). Elders who reported chewing tobacco, using tobacco daily, or using tobacco recreationally/ceremonially presented as having not visited a dental provider in higher proportion (p < .001) than those who did not chew nor smoke tobacco. See Table 3 above. A higher proportion of AI/AN/NH older adults (p < .001) living off of the reservation (61.6%) had visited a dental provider during Cycle 6 compared with those living on the reservation (53.7%). Individuals who reported private insurance (68.2%) and those covered by tribal or IHS (57.5%) reported a higher percentage of their population utilizing dental services than those covered by Medicare (55.7%), Veterans Affairs (52.7%), Medicaid (50.3%), or no insurance (42.7%). See Table 3.

Aim 4: Current (Cycle 6) Relationship Between Demographic and Behavior Variables and Perceived Dental Treatment Need and Oral Health Conditions

Those who had visited a dental professional in the past year were significantly more likely than those who had not to report a need for teeth to be filled/replaced (p < .001), teeth to be pulled (p< .01), treatment for relief from pain (p < .01), and other (p < .001). Those who had not visited a dental professional in the past year were more likely to report needing denture work/new denture and were more likely to report tooth or mouth problems that were making it hard for them to eat. See Figure 2.

A higher proportion of older adults who were higher income (34.6%) indicated a need to have teeth filled or replaced compared with middle- (27.2%) and lower income (21.9%) elders (p < .001). See Figure 3. The opposite trend occurred among those indicating a need for teeth to be pulled, with lower income presenting in higher proportion (13%) than middle- (10.3%) and higher income (7.8%) older adults (p < .001). Among the seven forms of medical coverage, those covered by either private insurance (29.3%) or other (30.5%) were more likely to indicate need for teeth to be filled or replaced compared with other payer types including Tribal/IHS (26.2%), uninsured (25.9%), VA (23.7%), Medicare (22.5%), and Medicaid (20.5%). See Figure 3. Tooth extraction was a more common need among older adults who were uninsured (24.1%) or covered by Medicaid (13.1%) compared with those with other insurance (12.3%), VA (11.6%), Tribal/IHS (11.3%), Medicare (10.4%), or private (8.5%). See Figure 3.

As evident in Table 4, older adults who were lower income were more likely than middle and higher income elders (p < .05) to self-report needing dental care for relief from pain (4.7%) and to report tooth or mouth problems that make it hard for them to eat (13.1%). Other independent variables associated with a significantly higher proportion of the population reporting a need for relief from pain included unemployed (4.2%), Medicaid enrollees (5.7%), and those covered by tribal (IHS) insurance (4.2%). See Table 4. Similarly, subpopulations reporting a higher proportion of older adults with tooth or mouth problems making it difficult to eat (p < .05) included lower income elders (13.1%) compared with middle- and high income, unemployed (11%) compared with employed, less than Grade 12 education (9.4%) compared with those with a high school diploma or education beyond Grade 12, daily smokers (14%) measured against those who do not smoke or only recreationally, and uninsured (16.6%) and Medicaid enrollees (12.4%) compared with all other insurance types.

Table 4.

AI/AN/NH Older Adults’ Perceived Dental Treatment Need by Demographic Categories, Cycle 6.

	N (denominator)	Need relief from pain	Tooth/mouth problems making it hard to eat	No self-reported need for dental service of any kind
Income
<US$15,000	6,905	4.7%* (326)	13.1%* (905)	32.2%* (2,224)
US$15,000-US$49,999	6,548	3.4%* (220)	7.9%* (518)	35.7%* (2,339)
US$50,000+	1,292	2.3%* (30)	4.5%* (58)	37.0%* (478)
Employment
Employed	4,927	3.2%* (160)	6.9%* (338)	33.3%* (1,640)
Unemployed	11,202	4.2%* (471)	11.0%* (1,234)	35.2%* (3,938)
Education
Less than Grade 12	3,813	4.4% (169)	12.2%* (466)	34.0%* (1,296)
High school diploma only	5,838	3.7% (215)	8.5%* (498)	36.4%* (2,125)
Ed. beyond high school	6,713	3.7% (251)	9.4%* (629)	32.5%* (2,180)
Chew
Chew	453	2.6% (12)	9.3% (42)	30.5%* (138)
No	15,128	4.0% (598)	9.9% (1,493)	35.1%* (5,303)
Smoking tobacco
Every day	2,758	4.3% (119)	14.0%* (385)	31.7%* (874)
Ceremonial/recreation	1,134	4.3% (49)	11.4%* (129)	31.7%* (359)
No	12,061	4.3% (463)	8.8%* (1,057)	35.8%* (4,322)
Insurance coverage
Medicare	9,619	3.9% (374)	10.4%* (997)	35.1%* (3,378)
Medicaid	3,946	5.7%* (224)	12.4%* (491)	35.1% (1,308)
Private	3,855	2.5%* (98)	6.2%* (239)	38.7%* (1,493)
VA	1,133	4.1% (46)	10.3% (117)	34.5% (391)
Tribal (Indian Health Services)	10,852	4.2%* (459)	10.1%* (1,096)	33.8% (3,664)
None	290	5.9% (17)	16.6%* (48)	32.4% (94)
Other	676	3.3% (22)	10.8% (73)	34.0% (230)

Note. Reporting valid percentages; omits nonrespondents. AI = American Indian; AN = Alaska Native; NH = Native Hawaiian; VA = Veterans Affairs.

The variability between groups was statistically significant at p < .05.

Also evident in Table 4, a larger proportion of higher income older adults (37%) reported no need for dental services of any kind compared with middle- (35.7%) and lower income (32.2%) older adults (p < .05). Those who did not chew tobacco and those who did not use smoking tobacco were more likely than their peers to report no need for any dental services (p < .05). Privately insured older adults were more likely to report no need for treatment (38.7%) than their peers covered by any other insurance type (p < .05). See Table 4.

Discussion

Increase in Dental Care Utilization and Need for Dental Treatment Between 2008 and 2017

Between survey Cycles 4 (April 2008) and 6 (March 2017), we found a statistically significant increase in the percentage of AI/AN/NH older adults who had visited a dental professional in the past 12 months. This increase mirrors national longitudinal prevalence in dental visits for all races ages 65 and older (NCHS, 2016). However, the current rate of dental visits for AI/AN/NH older adults (56.7%) is still lower than the general (all races) U.S. population ages 65 and older (62.7%; NCHS, 2016). Low dental visit rates may be the result of low utilization, poor access to care, lower oral health literacy among this population (Jamieson, Divaris, Parker, & Lee, 2013), historical trauma regarding dental care, and/or issues of dental care access and funding as it relates to IHS (Artiga, Arguello, & Duckett, 2013; Indian Health Services [IHS], 2015). There is opportunity to provide education among tribal older adults on the importance of good oral health, but programs focused on oral health literacy and increased utilization of preventive dental care must ensure that there is trusted, affordable, and timely access to dental services for those they educate.

Respondents in the most recent survey Cycle 6 reported the highest percentage of dental visits since 2008 but also reported a significantly higher need for dental care than years prior. Only 33.6% of those surveyed in Cycle 6 indicated that they had “no current need for dental care” compared with 36.3% the cycle prior 5. Although a small decline, it was statistically significant and in contrast to the pattern of dental visits. With the increase in dental visit rates between 2008 and 2017, we did not see a consistent decrease overtime for the perceived need for gum treatment, other treatment need, need for teeth to be filled or replaced, need for care to treat pain, or need for work to improve appearance. Only one dental service need declined between all three survey cycles and that was the need for denture work or new dentures. It may be that this is the only service that consistently declined overtime as AI/AN/NH older adults mirror national trends in which the overall rate of edentulism (no teeth) is declining (NCHS, 2016). Future survey cycles may consider including a measure of edentulism or number of functioning teeth to determine if AI/AN/NH older adults are remaining dentate at the same rate as other races. Currently, the increase in dental visit rates has only had a significant impact on need for dentures.

Regardless of the increase in dental visits, it is clear that efforts are needed to increase the dental workforce, improve dental care access, and provide oral health literacy in an effort to improve utilization of preventive dental services as opposed to primarily reactive care. These efforts are more imperative among some subpopulations of AI/AN/NH older adults than others.

Current (Cycle 6) Dental Care Utilization and Treatment Need Among AI/AN/NH Older Adults

Our data indicate AI/AN/NH older adults report worse dental visit rates than the general U.S. older adult population. However, much like the general population, there is variability among tribal older adults. AI/AN/NH older adults who had less than a high school diploma, chewed tobacco, reported smoking daily, lived on the reservation, and had an annual individual income of less than US$15,000 reported a significantly lower dental visit rate than their peers. A lower income, lower educational attainment, and use of tobacco products have been cited in the literature as variables correlated to lower dental care utilization and poorer oral health status across populations and age cohorts (CDC, 2017; Mai et al., 2013). However, our research also illustrated the lack of dental care utilization among AI/AN/NH older adults living on and off of the reservation; only 53.7% of those living on the reservation saw a dental provider compared with 61.6% of those who lived off of the reservation. Given that those on the reservation likely utilize IHS for dental care, and there is both dental provider and dental care funding shortages among IHS facilities, it may be that those on the reservation cannot gain access to care as readily as those who are living off of tribal land (Phipps & Ricks, 2016). Future research should explore if this variability in dental visits is the result of dental care access for AI/AN/NH older adults on and off of the reservation or if there is variability in oral health literacy and dental care perceptions between the two groups. In addition, our future research agenda includes exploring correlated predictors and applying factor analysis to determine which, if any, of the aforementioned sociodemographic variables may be a greater predictor of oral health need and dental visit rates.

A greater proportion of those with higher income than those with middle- or lower income reported the need for teeth to be filled or replaced; however, the opposite trend occurred for the need to have teeth pulled, with lower income older adults reporting a higher proportion of need than their peers. Much like the earlier argument, it can be surmised that those with a higher income had a higher rate of dental visits, and the need for a filling was an appropriate course of treatment, while those with lower income and lower dental visit rates perceived a need for their teeth to be pulled, unaware of other treatment options. An additional consideration is the cost of care for tooth extraction compared with a dental filling. Lower income older adults may elect tooth extraction because it is more affordable. Tooth extraction also does not require future monitoring of said tooth nor is there the potential for further treatment need.

With the overall rate of edentulism (no teeth) declining among the general U.S. population (NCHS, 2016), it is important to consider interventions for AI/AN/NH older adult populations who more readily identify the need for teeth to be pulled. Both prevention and early treatment of dental pain can reduce the rate of edentulism and the need for teeth to be pulled among AI/AN/NH older adults. Oral health education can influence older adults’ perceptions of dental care, helping them to find value in preventive visits, encouraging regular exams and not reactive care, and illustrating treatment options for dental pain outside of tooth extraction.

Older adults who were higher income, who did not use chew tobacco, did not use smoking tobacco, and those privately insured had a larger percentage of individuals indicate no need for dental care when compared with their peers . Conversely, a larger percentage of elders who were lower income, chewed tobacco, used smoking tobacco daily, and were without insurance or covered by Medicare needed care.

The most recent IHS data brief discussed results of an oral health survey among AI/AN adult dental patients in 2015 (Phipps & Ricks, 2016). Although the results were limited to describing the oral health among only those AI/ANs who had sought dental treatment, they found similar dental inequities. AI/AN adults suffered from untreated dental caries at twice the rate of the general U.S. population and any racial/ethnic group (Phipps & Ricks, 2016). AI/ANs reported more missing teeth, a greater rate of periodontal disease, dental pain, and untreated decay. Our research, in conjunction with the work by IHS, illustrates the need for health system reform to address the dental care needs among AI/AN/NH older adults, with special attention paid to those older adults who are lower income, without insurance, use tobacco products, and have less than a high school diploma. The IHS report illustrates the outcome of this inadequate access and utilization of dental services among this population, yet calls for the same action.

The Current (Cycle 6) Impact of Dental Visits on Perceived Need for Dental Treatment

Research concurs that dental visits are imperative for well-managed oral hygiene and good overall health. Typically, oral health and general health outcomes research indicates that those who have had at least one dental visit have better overall health and oral hygiene (e.g., Giannobile et al., 2013). However, our data indicated a significantly higher percentage of older adults who identified various dental care needs actually had visited a dentist in the past year. More specifically, among those who indicated a need for teeth to be filled or replaced, 67.8% had visited a dental provider compared with only 32.2% who had not. We found similar variability among those indicating a need for teeth to be pulled (53.5% had visited the dentist, 46.5% had not) and need for dental care to relieve pain (61.5% compared with 38.5%). Although it would appear that our results are in contrast to the literature and dental care needs were more prevalent among those who had visited a dental provider, those who had not visited a dentist were significantly more likely than those who had to report tooth or mouth problems that made it hard to eat and the need for dentures or denture work.

Together, these results illustrate how imperative dental visits are for oral health literacy and knowledge of dental treatment. We argue that these findings do not indicate that those who had not visited a dentist had better oral health, but instead, illustrate how important a dental visit is for AI/AN/NH older adults to recognize their need for treatment. After having visited a dental provider, AI/AN older adults may be more aware of treatments options. Having had no dental visit, older adults are unaware of treatment options, which may explain the higher percentage of those with mouth problems and need for dentures reporting no dental visit. Also of concern among this population is the 38.5% who indicated a need for dental care to relieve pain that had had no dental visit in the past 12 months. Earlier research identified that AI/AN/NH older adults more commonly wait for dental pain before visiting a dental provider (Jones et al., 2000); these results also indicate that many older adults are living with dental pain and not utilizing any dental services. Increasing both access and utilization of dental care will not only improve the physical health of the mouth and quality of life for AI/AN/NH older adults, but it may also increase their understanding of proper oral hygiene and available treatment options

Limitations

The NRCNAA data set includes more than 18,000 AI/AN older adults in Cycle 6 alone, making it one of the only health assessments for AI/AN/NH older adults that tracks social and health perceptions longitudinally and with a large representative sample. However, there are limitations. One limitation of the research is self-reported health conditions. Perceived need for dental treatment is not analogous with a clinical diagnosis. However, our results report lower need for treatment and experienced pain overall than did the data brief provided by IHS, indicating that at most, this limitation leads to underreporting the significant dental need among older adults. When discussing the older adult population as a collective, older adults were defined as those ages 55 and older as opposed to the more common definition of 65 years of age and older. As a result of the lower average life expectancy for AI/AN/NH older adults, this decision was made in an effort to address the dental health of those recognized as “older adults” within the tribal population. However, we did also present and discuss age categorically. When looking at AI/AN/NH older adults ages 55 to 64, they reported a higher rate of dental visits and better oral health than other age cohorts, meaning this limitation again would run the risk of underreporting dental need. There is also no tracking of individual participants, meaning we are not comparing the same set of individuals between cycles. Instead, there is the influence of new AI/AN/NH older adults who age into the study each cycle and data are influenced by older adults who age out or no longer participate.

Although we discuss rates of edentulism for the general U.S. population, ages 65 and older, the Survey of Elders does not identify if the older adults are edentulous nor does it track the number of functional teeth for each participant, both of which are common variables tracked in other health surveys. This does not negatively affect the results of our research, but knowing this information would benefit future discussion of AI/AN/NH older adults’ oral health status.

The variable regarding employment was restricted to two categorical responses: employed and unemployed. This did not allow us to explore the variation between voluntary retirement, unemployed (and seeking employment), employed, and other employment categories that may very likely be correlated with dental care utilization rates. Future survey cycles (beginning with Cycle 7) will have the capacity to explore additional employment categories. Finally, those who work with tribal populations will recognize the limitation of discussing AIs, ANs, and NHs as a collective population. AIs, ANs, and NHs have diverse life experiences, histories, traditions, and health behaviors. We ran analyses without differentiating among these populations because of cell size.

Despite the limitations of this research, it is clear that there is a need to address the oral health status, literacy, and access to and utilization of care for AI/AN/NH older adults. Healthy People 2020 has set a goal to reduce untreated dental decay among individuals 65 to 74 years of age and 75+ years of age to 15.4% and 34.1%, respectively (Healthy People 2020, 2018). Recognizing that AI/AN/NH older adults are self-reporting greater rates of decay (need for teeth to be filled/replaced) than all-race populations can assist in the allocation of resources and population health priorities. Treating dental caries and increased dental visits among AI/AN/NH older adults may also help reach the Healthy People 2020 goal for proportion of people ages 65-74 who are edentulous (21.6% goal; Healthy People 2020, 2018). As health policy, federal funding, and community- and tribal-based programs seek to improve tribal oral health, this research can assist in creating targeted interventions for those in greatest need. Recognizing oral health inequities present among low-income, uninsured, and unemployed older adults as well as among those with less than a high school education and living on the reservation may also point to the need for community interventions that address poverty as a significant contributor to overall older adult health. Our research, much like that which has come before, clearly indicates a need to address social determinants of health in concert with issues of access and utilization.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project is funded by the Administration of Community Living, under grant number 90OI0008-03-00.

ORCID iD

Shawnda Schroeder

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