Oral health care access barriers for low-income residents in Westside, Jersey City

Improving Access to Oral Health Care in Westside, Jersey City

Why oral health care for low-income residents of Westside in Jersey City is an important topic

The timely provision of oral health care is an important part of keeping people healthy. Oral health constitutes an important part of general health. For instance, the U.S. Surgeon General's report on oral health emphasizes that oral health represents an essential element of health that must be included in the provision of other health care services (Ravaghi & Quinonez, 2013). According to these researchers, though, "Despite this, there are differences in provision of general and oral health care in many developed countries" including the United States (Ravaghi & Quinonez, 2013, p. 467). This assertion is based on an analysis of 3,413 men and women aged 18-79 (men=1,601; women=1,812) using the oral health indicator of the total number of decayed and missing teeth. Based on their analysis, Ravaghi and Quinonez (2013) identified significant income-related disparities in oral and general health.

Likewise, the Academy of General Dentistry reports that, "The health of your mouth mirrors the condition of your body as a whole. For example, when your mouth is healthy, chances are your overall health is good, too. On the other hand, if you have poor oral health, you may have other health problems" (The importance of oral health, 2015, para. 2). A growing body of research confirms the association between poor oral health and other conditions including stroke, heart disease, diabetes, leukemia, oral cancer, pancreatic cancer and kidney disease (The importance of oral health, 2015). Moreover, women who suffer from poor oral health conditions such as gum disease are at higher risk of delivering pre-term, low birth-weight babies (The importance of oral health, 2015). While residents in many other American communities have experienced improvements in their oral health care services, low-income residents in any community are faced with severe constraints to their access to these services (Petersen, 2007)..

Consequently, the low-income residents of Westside, Jersey City, are confronted with a number of constraints in their access to oral health care services, including a lack of available dental resources and an inability to pay for these services when they are available. In addition, providing oral health care to the elderly and cognitively impaired residents of Westside represents an especially challenging enterprise. For instance, using a non-randomized convenience sample of 100 nursing home residents who lacked organized access to oral health care services, Matear and Barbaro (2008) conducted a series of structured interviews with 40 family members using questions designed to explore the importance and priorities of dental services for institutionalized elderly.

Based on their findings, Matear and Barbaro (2008) conclude that, "The provision of dental services to elderly populations is a complicated area" (p. 29). Although many elderly residents may suffer from age-related conditions that adversely affect their cognitive abilities, whenever residents are cognitively impaired, providing oral health care becomes far more difficult. In this regard, Matear and Barbaro add that, "When clients are cognitively impaired, a new set of variables are introduced as care can be influenced by designated family members, caregivers or administrators, who are responsible for the oral health care of the client and may influence the types of treatment the client will receive" (p. 30). Taken together, it is clear that improving access to oral health care represents a timely and valuable enterprise for the residents of West Side, Jersey City. To this end, this systematic review of the peer-reviewed literature was guided by the research question set forth below.

Research question

This study was guided by the following research question: "How do low-income residents of Westside in Jersey City currently get access to oral health care?"

Literature Review

Importance of Oral Health Care for Low-Income Westside Residents

Disparities in access to affordable oral health care services can have an enormous impact on low-income consumers in terms of their general health as well as their general appearance (Dolgin, 2013). The situation is far different for those who are able to afford these services, though. For instance, Dolgin (2013) advises that, "For people with financial resources, dental care in the United States provides not only for patients' health needs, but also, often, for their aesthetic yearnings" (p. 1421). Although there are significant health care issues related to good oral health, there are also some stigmatization issues that can adversely affect people who lack good oral health in terms of their ability to secure gainful employment or to successfully develop and maintain interpersonal relationships (Dolgin, 2013). In this regard, Dolgin emphasizes that, "A person's dental condition can signal poverty and low socioeconomic status. For those without teeth or with visibly mangled teeth, social and economic opportunities can be significantly limited" (2013, p. 1422). Conversely, good oral health and teeth can also connote affluence (Dolgin, 2013). These findings suggest that the low-income residents of Westside also experience obstacles to their access to adequate oral health care services.

This assertion is supported by findings from a study by Modifi, Rozier and King (2002) that noted obtaining adequate oral health care services for low-income residents can be especially challenging due to inadequate family resources. limited choices in providers and inadequate transportation (Mofidi, Rozier & King, 2002). Moreover, many low-income residents report being treated disrespectfully and even discriminated against by health care providers, further discouraging their attempts to attain services (Mofidi et al., 2002). Using criterion-purposive sampling, Mofidi et al. (2002) recruited 77 caregiver participants for 11 focus groups conducted in North Carolina.

Based on their analysis of these qualitative data, Modifi et al. determined that many focus group caregivers had been discouraged from obtaining dental services for their children who were insured by Medicaid. The researchers also provide rationale in support of their selection of research methodologies citing a dearth of previous studies using empirical observations from focus groups. Based on their content analysis of these focus groups, Mofidi and his associates concluded that negative experiences, including inordinately lengthy wait times and discriminatory behavior on the part of providers, were major barriers to dental care system access.

In fact, the expectation of poor oral health among many low-income residents has been identified as one of the barriers to access to adequate oral health care services, thereby making poor outcomes self-fulfilling and further limited access to the low-income residents of Westside. For example, a study by Kelly, Binkley, Neace and Gale (2005) conducted eight focus groups with a random sample of 76 participants to evaluate psychosocial, cultural and structural barriers to access to oral health care services for children from low-income families.

This study drew on Medicaid utilization records to identify Medicaid-enrolled children of white and African-American caregivers in Jefferson County, Kentucky to recruit participants for the focus groups. The analytical method was a stratified random sampling of participants with a qualitative analysis of the focus group transcripts. The results identified expectations of poor oral health, discriminatory behaviors on the part of providers as well as problems locating providers who accepted Medicaid as being major barriers to access for low-income consumers (Kelly et al., 2005).

The results of a study by Taylor and Marino (2014) emphasize that the combination of a scarcity of dental professionals together with the pressing need for timely and effective oral health care services has resulted in growing calls for improved access in general and for low-income consumers and their children in particular. For instance, Taylor and Marino report that, "dental caries is the silent epidemic" and "in children, dental caries are the most prevalent chronic disease" (2014, p. 5). Similarly, Sams, Rozier, Wilder and Quinonez (2013) cite dental caries among preschool-aged children as a national public health threat. The objectives of this study were to identify the number of state Medicaid programs that had implemented the provision of support preventive dental services by allied health practitioners, the perceived attributes of this alternative providers and barriers to implementation (Sams et al. 2013). These researchers employed a 2008 cross-section survey of Medicaid dental program managers to identify the respective organizational stage of implementation based on the Transtheoretical Model of Behavior Change together with a 3-year follow-up. An assessment of the perceptions of the influence of 18 initiative attributes concerning the adopted decision based on Roger's diffusion of innovations theory was incorporated with descriptive analyses of stage and date of adoption. In addition, barriers and attributes were evaluated according to their adoption stage using variance analyses. The results of this study showed by 42 states had adopted a policy by 2011, but just nine states had incorporated a comprehensive set of preventive services with the most frequently adopted method being fluoride varnish. The level of adoption was found to be influenced by the perceived simplicity of the initiative as well its congruence with other Medicaid programs. Although the types of barriers to constrain access to oral health care services vary from jurisdiction to jurisdiction, the most commonly encountered barrier is administrative in nature in the 15 studies analyzed (Sams et al., 2013), suggesting that many low-income residents of Westside experience bureaucratic delays in obtaining oral health care services. A cross-sectional analysis by Sams et al. of Medicaid dental programs found that just nine states had adopted a comprehensive set of oral health preventive policies with administrative barriers being cited as the most common constraint. itiatives to support preventive dental services provision by nondental health care professionals, their perceived attributes, and implementation barriers. Based on these findings, Sams et al. concluded that there has been an increase in state Medicaid policies to reimburse nondental providers for preventive dental services, but that interventions are still required in order to assure oral health services delivery at the practice level.

Not surprisingly, in households where money is already tight, there may be little or nothing left for oral health care services for any member of the family, despite the need for these services for younger people in particular (Gross-Panico & Freeman, 2012). A study by Gross-Panico and Freeman (2012) identified dental caries among young people from low-income homes as being the result of a lack of sufficient resources to pay for oral health care service. This study used the results of 34 self-report surveys (English=21; Spanish=13) of parents/guardians of young people aged 0-18 years receiving preventive dental services from an affiliated practice dental clinic in Chandler, Arizona.

The data was analyzed using the Friedman's, Kendall's W and Wilcoxon Signed Ranks Tests to provide descriptive statistics and non-parametric findings. The results of the Gross-Panico and Freedman (2012) study indicate that although transportation and geographic proximity to services represented major constraints to access, the main barrier was the cost of oral health care services for low-income populations. Based on these findings, Gross-Panico and Freeman (2012) concluded that, "Funding efforts, reimbursement mechanisms and legislative policies should support this dental care delivery model to provide care to underserved children, adults and seniors throughout the U.S." (p. 306).

Likewise, Taylor and Marino emphasize that, "More than half of 5-year-olds from low income families have early childhood caries [ECC] with a high rate of preschool children being untreated" (2014, p. 6). This finding suggests that even when oral health care services are available, low-income residents may not be able to access them due to the other constraints described further below.

Left untreated, ECC can result in a wide range of other health problems, including problems with chewing, insufficient nutritional intake, oral pain, and in some cases, a failure to thrive (Taylor & Marino, 2014). In addition, there are other impairments that can be caused by poor oral health that have specific implications for younger people. For example, Taylor and Marino caution that, "Dental decay and tooth loss can also lead to speech-language development issues, poor self-esteem, declining school performance and costly emergency medical services and dental restorations" (2014, p. 6). These are important issues because the findings that emerged from a study by Brickhouse, Rozier and Slade (2008) indicate that, "Untreated tooth decay continues to be a significant problem for children with public insurance coverage" (p. 877). Using a retrospective cohort design, Brickhouse et al. (2008) evaluated untreated dental caries levels for 79,731 children and found that among those enrolled in public insurance programs, nearly one-third (30%) had dental caries. These findings were based on a calibrated oral screening of kindergarten children dental health outcomes obtained during the 2000-2001 school year together with data concerning eligibility and claims for children enrolled in Medicaid and State Children's Health Insurance Program (SCHIPs) who were eligible for dental services during the period from 1999 to 2000.

A series of logistic regression models were developed in order to analyze children's extent and likelihood of experiencing untreated dental caries based on enrollment in Medicaid and SCHIP programs. Irrespective of the program used, enrolled children experienced better oral health care outcomes compared to those who were not. Based on their statistical analysis, Brickhouse et al. found that children enrolled in Medicaid or SCHIP were 1.7 times more likely to experience untreated dental caries compared to children who were not enrolled in one of these programs. Based on the results of a two-part regression model, these researchers concluded that untreated tooth decay remains a serious issue for children from low-income families that rely on public insurance coverage. For low-income residents of Westside, then, access to oral health care services may be constrained by their existing public health insurance coverage.

Even though a majority of oral diseases are controllable or outright preventable, oral health care for low-income residents of communities such as Westside remains largely unmet (Taylor & Marino, 2014). These issues assume even greater importance and urgency when the long-term costs of untreated dental diseases are taken into account. As Taylor and Marino point out, "Early oral health intervention and preventative services can set the stage for healthy dentition and oral health habits. Yet, profound disparities exist in the level of dental services obtained by children, especially for children of low socioeconomic status" (2014, p. 6). In some cases, even when young children finally receive oral health care services, the damage has already been done. As Taylor and Marino conclude, "Of particular concern is the low rate of early detection and preventative care for children three years and younger. Unfortunately, preventative and curative dental care for children often occurs after damage to teeth has taken place" (2014, p. 7). These findings underscore the need for improving access to oral health care services for low-income residents in Westside as a cost-preventative measure.

The lack of timely and efficacious oral health care services for low-income families was also the subject of a study by Larsen and Larsen (2009) who report that far too many children from these families lack access to oral health care services today. According to Larsen and Larsen (2009), "Tooth decay is the most common chronic childhood disease in the United States. Every year, children lose an estimated 52 million school hours due to dental-related problems" (p. 117). Based on their analysis of visit and billing data from CAS, a privately operated social welfare agency based in New York City, during the period July 2004 to June 2005, Larsen and Larsen determined that young people from low-income families are at far more risk of developing untreated cavities compared to their more affluent counterparts, and a significant percentage of children from low-income families start their academic careers without having been treated by a dentist at any time in their lives (Larsen & Larsen, 2009). Moreover, large numbers of children in the United States still lack dental insurance coverage (Larsen & Larsen 2009). These findings highlight the lack of access that exists for low-income residents in Westside.

While children from low-income families tend to receive far less oral health care services by the time they start school than their more affluent counterparts, there are other factors involved besides money that can restrict this access as well. For example, Larsen and Larsen found that, "The low utilization of dental services and missed appointments by [low-income] families involve many issues including difficulty of transportation, prolonged waiting time at the office, uncertainty about reason for visit, unwanted absences from school, and dental fear" (2009, p. 117). These findings make it clear that the low-income residents of Westside are confronted with many of the same constraints as their more affluent counterparts, but these are all intensified due to an overarching lack of resources.

Other clinicians cite the high prevalence of illicit drug use in low-income communities and the problems this can cause for their oral health. For instance, Shekarchizadeh and Khami (2013) report that, "Oral health problems, among the most prevalent comorbidities related to addiction, require more attention by both clinicians and policy-makers" (p. 929). When oral health care services are made available to addicted individuals, though, it is possible to facilitate their recovery from their addictions, reduce stigmatization and improve their general health in the process (Shekarchizadeh & Khami, 2013). For substance abusing low-income residents of Westside, these findings indicate that they may not be accessing oral health care services at all.

Although the constraints to the provision of oral health care services for this segment of the population differ from community to community, there are some common constraints that have been identified, including the following:

Difficulty in accessing addicts as a target population,

Lack of appropriate settings,

Lack of valid assessment protocols for conducting oral health studies, and,

Poor collaboration between dental and general health care sectors serving addicts process (Shekarchizadeh & Khami, 2013, p. 930).

All of these constraints can prevent clinicians from providing optimal oral health care services, but there are other factors involved as well that must be taken into account with addicted individuals. For example, many health care insurance programs do not include an oral health services component and many clinicians are unaware of or uninterested in the novel problems that are involved in the provision of oral health care services to addicted populations (Shekarchizadeh & Khami, 2013). As Shekarchizadeh and Khami (2013) conclude, "Regardless of these barriers, oral health care at various levels including education, prevention, and treatment should be integrated into general care services for addicts" (p. 931). These are especially poignant issues for communities such as Westside which has been experiencing a rapid increase in the number of drug users in general and heroin users in particular in recent years (Barna, 2014).

It is also important to note that enormous disparities can exist between access to oral health care services in one community while a neighboring community enjoys exemplary oral health care services. For instance, Peterson (2007) points out that, "At present, the distribution and severity of oral diseases vary in different parts of the world and within the same country or region" (p. 3). Irrespective of the geographical setting, though, dental caries remains a significant public health concern throughout the United States, affecting a majority of all schoolchildren and the overwhelming majority of adults (Peterson, 2007). Besides addicts, the elderly and the cognitively impaired, clinicians are also faced with severe challenges in treating adults who use tobacco products. Although the situation is far more drastic in developing nations, residents in the United States are not immune from these problems. As Peterson emphasizes, "Severe periodontitis, which may result in tooth loss, is found in most populations. In industrialized countries, studies show that tobacco use is a major risk factor for adult periodontal disease" (p. 4). Because the condition is preventable, these findings also underscore the need for civic leaders in Westside to recognize the public health threat represented by inadequate access to oral health care services for this segment of their population.

Indeed, the low-income residents of Westside are experiencing many of the same constraints to accessing oral health care services as their Third World counterparts. For instance, Petersen (2007) notes that, "Despite great improvements in the oral health status of populations across the world, problems still persist. This is particularly so among underprivileged groups in both developed and developing communities" (p. 5). As noted above, a wide array of oral diseases and conditions can adversely affect an individual's general health, but low-income residents of many American communities remain on the fringe of accessible and affordable oral health care services today. In this regard, Petersen confirms that, "People in deprived communities, certain ethnic minorities, homebound or disabled individuals and older people are not sufficiently covered by oral health care" (p. 5). These findings confirm that access to oral health care services for low-income residents in Westside is confounded by a variety of causes.

In response to these needs, many dental practitioners are calling for a multidisciplinary allied health approach for low-income residents. For example, Benzian and Nackstad (2007) note that, "The growing risks to health and oral health need to be tackled by all oral health professionals and their organizations in the most efficient and appropriate way, such as involvement of the dental team in tobacco control, nutritional advice and HIV prevention" (p. 719). One organization that has taken this need to heart has been the World Dental Federation which is comprised of 157 dental associations in 136 countries representing more than 900,000 dental health care providers around the world (Benzian & Nackstad, 2007). Together with the World Health Organization (WHO), the World Dental Federation has been in the vanguard in promoting increased access to oral health care services for low-income consumers (Benzian & Nackstad, 2007). Some of the recent recommendations published by the World Dental Federation has special implications for low-income residents of communities such as Westside, including the following:

The dental workforce and the misdistribution of oral health personnel in the world, both between and within countries, needs to be continuously monitored with regard to dentists, dental educators and allied personnel.

Develop internationally accepted standards of care, workforce planning and integration in primary health-care systems to eliminate illegal oral care which is a major concern in many countries, as it puts patients at high risk.

Migration of both oral health professionals and patients will increase, posing difficult challenges to national health authorities and professional organizations, requiring international coordination and dissemination of best practices.

Making oral health care and preventive services available, accessible and affordable remains a major challenge. Further development of integrative approaches in general health programs and primary health care is needed to improve access and to reduce inequalities (Benzian & Nackstad, 2007, p. 720).

These recommendations will require close and ongoing collaboration between WHO, the World Dental Federation, allied health and dental practitioners in the United States, but it remains unclear whether this level of collaboration can be achieved given the dearth of practitioners in low-income communities (Benzian & Nackstad, 2007). These recommendations are also highly congruent with the results of a study by Ravaghi and Quinonez (2013) who found, "There were income-related inequalities for oral health outcomes with the disease concentrated more among the poor. Inequalities in oral health were greater than inequalities in general health" (p. 466). These findings make it clear that there are some resources available to facilitate access to oral health care services for low-income consumers, including those residing in Westside.

Although these findings are not surprising, they do underscore the need for better access to oral health care services by low-income residents in Westside, especially given the current state of oral health care under controlling federal legislation. In this regard, a study by Cubanski and Boccuti (2015) notes that, "Gaps remain in Medicare's coverage and accessibility for low- to moderate-income older adults. Because traditional Medicare does not cover dental services, some beneficiaries may not be able to afford them, which may adversely affect their overall health" (p. 26).

As emphasized in the introduction, the failure to receive timely and efficacious oral health services can result in a wide array of adverse clinical outcomes, and these issues apply to the young as well as the elderly in low-income communities. For instance, Cubanski and Boccuti also point out that, "Oral health care is closely correlated with health and well-being, and lacking adequate or appropriate oral health care can exacerbate health problems or create new ones" (2015, p. 27). The existing coverage gaps for oral health care services and the inability to afford Medicaid coverage combine to create sometimes insurmountable constraints to access that many low-income consumers (Cubanski & Boccuti, 2015).

It is important to note, though, that Medicaid coverage varies from state to state, and the type of Medicaid program that is in place can have significant implications for access to oral health care services (Coughlin, Long & Yu-Chu, 2005). Using an analysis of a representative sample of more than 100,000 children and nonelderly adults from the 1999 and 2002 National Survey of America's Families (NSAF) in 13 states (i.e., thirteen states (Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin), Coughlin and her associates (2005) identified significant disparities between the level of oral health care services among the states. Although the study did not use a random sampling method, the authors point out that these 13 states account for a majority of Medicaid enrollees and are representative of demographics nationwide (Coughlin et al., 2005).

The Coughlin et al. (2005) study restricted its analysis to adults aged 19-64 years reporting the same type of Medicaid or private insurance coverage. The Medicaid analysis sample produced a total national sample of 7,493 Medicaid beneficiaries and the samples from the 13 states ranged from 795 in Massachusetts to 236 in Texas. Based on their findings, Coughlin et al. concluded that, "Medicaid beneficiaries' access matches that of the low-income privately insured for most of the ambulatory outcomes examined but is worse for dental services and prescription drugs" (2005, p. 1073).

This point is also made in a study by Krisberg (2014) who report, "Even though millions of Americans are joining the ranks of the insured and gaining access to affordable health care, access to oral health care is still expected to lag, especially among adults" (p. 2). Pursuant to recent changes in state and federal health laws, pediatric dental coverage has assumed even more importance but coverage varies from state to state and in many cases, significant gaps still exist in coverage for young people (Krisberg 2014). In this regard, Krisberg (2014) points out that, "Each state exchange is different, with some offering a mix of integrated and stand-alone plans and others offering only one or the other" (p. 2). There are some other constraints to access for oral health care services that adversely affect low-income families in disproportionate ways compared to their more affluent counterparts. As Krisberg concludes, "Even for kids who are covered by Medicaid, their parents may not be in a position to take time off work and go to a Medicaid provider. Being able to provide those services in school and to all kids is still a high priority" (2014, p. 2). These are especially salient issues for low-income residents who must balance an already tight budget with the exigencies of daily life in a metropolitan setting.

Although the importance of timely and efficacious oral health care services for children, adolescents and adults is well documented, the situation for adults in general and older adults in particular is even more severe because the American population is aging rapidly, and many analysts argue that existing disparities in access to oral health care services for the elderly will become even more pronounced in the years to come. What is especially disturbing about these trends is the fact that the need for good oral health in the elderly has been well documented for nearly a century now (Tosiello, 2010). For instance, Tosiello (2010) reports that, "When Eugene Lyman Fisk, the founder of the Life Extension Institute, examined 'supposedly healthy' individuals for life insurance purposes in the 1920s, he found that the greatest number of physical examination abnormalities were in the oral cavity" (p. 69). The current gaps in Medicaid coverage for oral health care services combined with limited incomes following retirement mean that growing numbers of low-income elderly will suffer even greater limitations to their access to these services in the future. In this regard, Tosiello concludes that, "Given the continued prevalence of oral health needs, the ever-aging population, and the lack of access to dental care due to the structure of health care financing, a 'perfect storm' of health disparity for the elderly is brewing" (p. 70).

The situation is also dire for many children from low-income families in the United States. One specific provision of Medicaid that attempts to address these disparities is the Medicaid program Early and Periodic Screening Diagnosis and Treatment (EPSDT) that provides for dental care together with the provision of other health care services that are subsumed under the umbrella definition of "medical assistance" (Mandell & Machefsky, 2008). Based on their analysis of special education records from the Philadelphia School District and Medicaid data for children 6 to 18 years of age for 2002, Mandell and Machefsky (2008) concluded that although the mission of Medicaid has been aligned with the goals of the Individuals with Disabilities Education Act (IDEA), many young people, especially those with developmental disabilities, still experience constraints in their access to oral health care services (Mandell & Machefsky, 2008).

Because children from low-income families are at greater risk of experiencing developmental disabilities, this issue creates yet another barrier to access to the level of oral health care services these young people need for a healthy life (Smith & Ruiz, 2009). The working hypothesis of this study was that by using a nationally representative data set (with age-adjusted findings), it would be possible to contribute to the existing body of knowledge concerning the impact of disabilities on access to dental care. The study's guiding research questions were: (a) is there a difference in reported inability to see a physician due to cost between women with and without disabilities and between women and men with disabilities; and, (b) do disability and gender predict a reported reduction in ability to see a physician services due to cost? (p. 4).

Based on their analysis of the Behavioral Risk Factor Surveillance System (BRFSS), developed by the Centers for Disease Control and Prevention that provides the results of state-based, random-digit dialed telephone surveys monitoring various risk factors, health behaviors, and health status indicators for non-institutionalized adults aged 18 years and older in the U.S., Smith and Ruiz identified cost as a major barrier to access to oral health care services for low-income consumers. These findings indicate that many low-income residents in the United States continue to lack access to adequate oral health care services.

There are some signs that a growing number of policymakers have recognized the importance of oral health services for young people in the U.S. in general and the need for these services for children from homeless families in particular (DiMarco, Ludington & Menke, 2010) The research to date confirms that nurse-managed free clinics and shelter-based clinics offer a cost-effective approach to meeting the needs of homeless residents of Westside (DiMarco et al., 2010). Using a convenience sample of 120 homeless families, DiMarco et al. (2010) found that almost half had dental caries with 10 basic variables accounting for the one-third of the barriers to access to oral health care services, with the most prominent being mental health, oral health beliefs and victimization. In addition, a significant percentage (43%) of low-income families able to receive shelter-based oral health care services which were deemed more accessible (DiMarco et al., 2010).

The DiMarco et al. study used 10 independent variables that successfully explained one-third of the access barrier variances, with most influential being (a) mental health (B=-.426), (b) oral health beliefs (B=.243), and (c) victimization (B=.185). Likewise, 10 independent variables also successfully explained nearly one-quarter (24.3%) of the oral health variances, with the most influential being: (a) mother's age (B=.351), (b) number of children at the shelter (B=.337), and (c) race (B=.154) (DiMarco et al., 2010). Finally, the most effective intervention in improving access identified was shelter-based care (DiMarco et al., 2010).

The results of a case study with 60 interviews with low-income adults (n=41) by Wallace and MacEntee (2012) together with 13 interviews with health and social service-providers support the findings by Dimarco et al. (2010) and others concerning the disparities in access to oral health care services. For instance, Wallace and MacEntee (2012) emphasize, "Other responses are needed to address the multiple dimensions of access to dentistry, including community dental clinics sensitive to the special needs of low-income people" (p. 32). Based on the findings that emerged from 60 interviews with low-income consumers who either sought or believed they needed dental care during the previous 2 years indicated that the main barriers to access were cost, fear and a lack of transportation (Wallace & MacEntee, 2012). The study also examined evidence of unmet needs, perceptions of need, as well as three discrete dimensions of access to care (availability, affordability, and acceptability). The study identified a serious disconnect between public oral health needs and private dental practice for low-income consumers based on the main barriers described above (Wallace & MacEntee, 2012). In sum, alternative approaches are needed to address these unmet needs and improve access to oral health care services for low-income consumers (Wallace & MacEntee, 2012).

The results of a study by Dubay and Kenney (2001) found that the special needs of low-income residents include continuity of oral health care services, something that many such individuals currently lack. These researchers cite an alarming paucity of timely and relevant recent studies concerning the extent to which children from low-income families are better served by private insurance or by public programs such as Medicaid. The research to date has relied on outdated data from the 1980s and even this research was marked by several constraints (Dubay & Kenney, 2001).

Therefore, because it remained unclear whether Medicaid-covered children experience worse outcomes compared to privately insured children because they have lower incomes and socioeconomic status or due to problems within Medicaid. Based on their analysis of the data on 12,680 low-income children contained in the 1997 National Survey of America's Families (NSAF) (a household survey that provides information on more than 100,000 children and adults representing the noninstitutionalized civilian population under 65 years of age), Dubay and Kenney found that low-income consumers lack the continuity of oral health care services needed for good dental health.

Likewise, Arias (2008) reports that the results of a study by George Washington University's Rapid Health Policy Response Project underscored the need for oral health care services for the country's most vulnerable populations, including children from low-income families. In this regard, Arias reports that:

As tooth decay and other oral health problems become more prevalent in young children nationwide, increasing Medicaid reimbursements to dentists, adding a mandatory dental health benefit to the State Children's Health Insurance Program and other measures could improve dental care for low-income children. (p. 7)

The Rapid Health Policy Response Project study also found that an alarming number of children from low-income families in the United States already suffered from cavities in their permanent teeth, and far fewer of these children were found to have "good" or "excellent" teeth compared to their more affluent counterparts (Arias, 2008). Once again, these findings lend significant support to the lack of access to oral health care services that are experienced by low-income consumers.

There are some other constraints to the provision of oral health care services to low-income consumers that are related to gaps in the controlling legislation in the United States as well. For instance, a study by Gibson-Howell and Hicks (2010) found that although dental hygienists are licensed providers of preventive oral health care, preliminary periodontal treatment and oral hygiene education, there remains a lack of standardized nationwide guidance concerning the proper role of dental hygienists in performing oral examinations in dental practices in the United States today. In this regard, Gibson-Howell and Hicks (2010) emphasize that, "Dental practices in the U.S. are not standardized in the role dental hygienists have in conducting clinical examinations of patients or in the scope of dental hygiene services delivered" (p. 1). In support of these assertions, Gibson-Howell and Hicks (2010) cite the fact that there are significant variations in the type of role dental hygienists should fill in American dental practices from state to state, resulting in their limited use in private practices that can also translate into a lack of oral health care services to low-income communities. For example, Gibson-Howell and Hicks conclude that, "In addition to hygienists being limited within private dental practices, they are also limited in providing examinations and dental hygiene care to underserved populations" (p. 2). These findings indicate that large numbers of low-resident residents of Westside are only able to access oral health care services from public providers, and these are already stretched razor-thin.

In response to these constraints, some clinicians are recommending the adoption of a preventive health care model that integrates allied health and dental professionals to replace the existing reactive approach that is commonly used throughout the West (Hamissi & Bakianian, 2010). The purpose of the Hamissi and Bakianian study was to develop new insights concerning the oral hygiene attitude and knowledge among pregnant women. These researchers designed questions to avoid the need for a dental examination. The age groups ranged from 17 to 41 years and SPSS was used for the statistical analysis. The surveys were administered at three different family planning centers.

Based on their analysis of 760 randomly selected pregnant women, Hamissi and Bakianian concluded that, "Health authorities should strengthen the implementation of community- based oral disease prevention and health promotion programs. More importance must be given to oral health care center in family planning centers" (p. 29). These findings also underscore the need for more community-based resources and allied health services to improve access.

In far too many cases, though, health care consumers in general and low-income consumers in particular may lack the information they need to use good oral health care practices and consult professional providers when appropriate even if these resources are available and affordable (Hamissi & Bakianian, 2010). In this regard, Hamissi and Bakianian (2010) emphasize that, "The role of the dentist and hygienist in providing information and motivating patient is important. This can promote oral health status of patients, which is important in general well-being" (p. 28). This guidance has specific implications for younger and older people, as well as pregnant women (Hamissi & Bakianian, 2010) living in Westside today.

The importance of consumer education in promoting better oral health among low-income health care consumers is also cited in a study by Yuen and Wiegand (2008). For instance, based on the findings that emerged from an epidemiologic oral health study in South Carolina involving more than 21,000 kindergarten and third-grade pupils determined that more than half of these children already had a history of caries and nearly one-third suffered from untreated caries on their primary or permanent teeth (Yuen & Wiegand, 2008).

The prevalence of caries was even more pronounced among minority children from low-income families (Yuen & Wiegand, 2008). As Yuen and Wiegand point out:

Besides the traditional limited access to (e.g., because of inadequate provider supply) and utilization of (e.g., because of financial constraints) dental care among low income and minority rural families, inadequate dental health knowledge among children and adolescents has been reported to be associated with a higher prevalence of untreated dental caries. (2008, p. 16)

The study by Yuen and Wiegand (2008) also found that young people who lacked appropriate oral health knowledge were at double the risk of developing caries compared to their counterparts who possessed adequate oral health knowledge. These findings highlight the need for additional education among young people in Westside concerning the need for oral health care services. Although it is fairly intuitive that low-income health care consumers will be at an across-the-board disadvantage in receiving health care services of any type, what remains unclear is the current state of affairs with respect to controlling legislation that specifically addresses these disparities in access.

Summary and Conclusion

Taken together, the results of the systematic review of the juried literature made it clear that the low-income residents of Westside are faced with some formidable challenges in receiving the oral health care services they need to live healthy lives, making the proposed study a timely and valuable enterprise for a number of reasons. Paramount among these reasons is the fact that many of the oral health conditions that low-income consumers suffer from are preventable in highly cost-effective ways, and early interventions can help prevent the need for more expensive dental interventions in the future.