~esource. m#: 4608 65 JANUARY-FEBRUARY 1998

JOURNAL OF DENTISTRY FOR CHILDREN

Carlos Nurko, DDS, MSLuis J\ponte-Merced, DMD, PhD, MPH

Edwin L. Bradley, PhDLiesl Fox, MS

.

..

he 1990 census estimated that there were 20.8 mil-lion persons of Hispanic ancestry in the United States}Currently, Hispanics are the second largest minority inthe United States. By the year 2000,11.5 million Hispanicchildren will represent the largest population of minor-ity children.2 Contributing to this population growth isthe youthfulness and fertility rate among Hispanics.3Despite !:he increasing number of Hispanics in the UnitedStates, the data currently available provide only a weakfoundation for understanding the general health of His-panics and, in particular, their oral health.~ Recent stud-ies of the oral health status of Mexican-American -migrants have documented a significantly high preva':lence of dental caries and unmet restorative treatmentneeds in the children of !:hese families}o.llDr. Nurko was a resident in Pcdiatric Dentistry at the~niversity ofAlabama at Bim1lnghaml and now is a fellow at thet:rniversity ofTexas Health Science Center at San Antonio. Dr. Aponte-Me~ed is ( ,,'an Associate Professor, Departments of Pediatric Dentistry and Inter- '.national Public Health; Dr. Bradley is Professor and Director of theGraduate Program, Department of Biostatistics; and Ms. Liesl Fox isa graduate student, Department of Biostatistics. University of Ala-bama at Binnlngham. School of Dentistry and School of Public Health;The authors thank the National Center for Health Statistics for itshelp and cooperation in providing the dental data tape fromHHANES. 1982-1984. Results of analysis and conclusions are solelythose of the authors and not necessarily those of the National Centerfor Health Statistics. The authors thank Paula Kretzschmar. staff. chil-dren and parents from the Blount County Migrant Program for theircooperation ana-Dr. Julia Austin for her editorial assistance.

The first national. estimates on a variety of health in-dicators for the Hispanic and non-Hispanic populationwere derived from the National Health Interview Sur-vey (NHIS).12 Regarding illness and utilization of healthservices, the NHIS found that among the Hispanics, thepercentage of four-to-sixteen-year-old Mexican-Ameri-cans never receiving dental care was three times that ofwhite persons and twice that of other Hispanic persons.Mexican-Americans with annual family incomes of$10,000 or more were 1.5 times more likely to have vis-ited a dentist than were Mexican-Americans with in-comes below $10,000.12

A second survey, the Hispanic Health and NutritionExamination Survey (HHANES) was conducted by theNational Center for Health Statistics (NCHS) between1982 and 1984, with the goal to produce estimates of thethree major Hisparu,c subgroups (Mexican-Americans,

, Puerto Ricans, and Cuban-Americans), which accountedfor approximately 76 percent of the Hispanic originpopulation in the United States in 1980}3

Ismail et al found that a relatively small percentage ofthe Mexican-American children who were examined inHHANES were highly susceptible to dental caries.14Children from low-income families had a substantiallyhigher incidence of decayed teeth and a lower percent-age of restored teeth j:han children from the high-incomefamilies. I

66 ]A1'1lUARY-FEBRUARY 199/\,

JOURNAL OF DENTISTRY FOR CHILDREN

possible discomforts, risks, and confidentiality of thestudy, as well as possible benefits, were explained fullyto the parents, and their infonned consent was obtainedbefore the study was begun. A questionnaire targeted atobtaining information concerning demographics anddental care W21S given verbally to all the parents and re-corded by Spalnish-speaking ESL staff or by the princi-pal investigator, The study had been approved by theInstitutional Review Board for Human Use of the Uni-versity of Alabama at Birmingham.

A demograp~ic questionnaire requested the follow-ing informatioln: complete name, age (birth date), gen-der, places of birth, parents' place of birth, parents' levelsof education, Ifather's occupation, number of childrenin the family, total family income in the last twelvemonths, and the ability of the child and parents to speakEnglish. InforInation was also obtained regarding thechild's oral he!alth and dental history. The questions,place of birth, I;~nguage spoken, total family income, anddental histor:y, were matched with those used inHHANES,I:1

All children had a routine dental examination, con-sisting of a viSiual, tactile examination, using a dentalmirror, sickle-shaped explorer, a portable chair, and anartificial light. No radiographs were taken. The dentalexamination was performed by a single examiner pre-viously standaJrdized, using the NIH diagnostic criteriaand the Simplified Oral Hygiene Index (OHIS).27,za Theoral examination included the following items:

0 Dental Caries Evaluation by decayed and filledprimary teeth and surfaces (dft and dfs) and Per-manent Decayed Missing and Filled Teeth and Sur-faces (DMFT and DMFS);

0 Oral Hygiene Evaluation (OHlS).

Reports of caries prevalence in migrant children ofvarying ethnic backgrounds in the United States hav

~demonstrated disturbing tr~nds.I;-2u The Mexican-

American migrant population experiences a high per-

centage of decayed teeth, a low level of restorative care,and poor oral hygiene.1u.ll.2l.n Studies have compared thedental health of migrant children (Mexican-American,Hispanic, African Americans, and Native American)with that of national studies and that of urban school-children.15.17-19 In these it was noted that migrant chilldren had a lo\v prevalence of dental restorations and ahigh rate of dental caries. None has compared the den-tal health of Mexican-American migrant workers' chil-dren to HHANES, which was one of the purposes ofthis investigation.

According to the National Agricultural Workers Sur-vey (NAWS) data, there are an estimated 2.5 million farmworkers hired in the United States?3 The farm workersare predominantly male (82 percent), Hispanic (94 per-cent), born in Mexico (80 percent), and married \vith anaverage of approximately two children (52 percent).24

These migrant workers tend to be socioeconomicallydisadvantaged, as reflected in their low education, lan-guage problems, low income, and high unemploymentrates, compared with the United States population as awhole.25 Their average annual income is $5,500 for afamily of 5.3 members?6 These and other factors ofMexican-Americans have given rise to a series of barri-ers to obtaining health services.

In recent years, Mexican-American migrant workershave been coming to central and northern Alabama inever-increasing numbers. Data on the dental health ofMexican-American migrant workers' children in thestate of Alabama, however, are not available.

The purposes of this study were to investigate theprevalence of dental caries, to investigate the overall oralhealth in a population sample of Mexican-Americanmigrant workers' children, and to assess their dentalhealth care. The study also compared the results withMexican-American children from the SouthwesternHHANES, conducted by the NCHS between 1982 and1984.

Data analysis

The data were collected and entered into a database,using a customized Oral Health Software Package.29 Thisfile was used tlo perform statistical analyses using theSAS Statistical ~)oftware Packag~.JO The data were sum-marized by generating descriptive statistics for the se-lected factors for the population sample by age-groupand gender. The level of statistical significance was setat p < .05. The data were analyzed using the Chi-squaretest for the demographic variables and the ANaYA testwith the Fisher's Protected Least Sigriificant Differencetest for the dent,al examination results. The results of thisstudy werecomLpared with the results of 3,241 Mexican-American children, three through sixteen years of age,from the HHArIJES survey of 1982-84.

METHODS AND MATERIALS

One hundred and thirty Mexican-American children,ages three to sixteen from the Blount County MigrantProgram, Alabama, who were enrolled in the cqurse,"English as a Second Language" (ESL), in the summerof 1995, were involved in this study. The procedures,

67 NURKO. APONTE-MERC":ED. BRADLEY. FOX

DENTAL CARE FUR MEX!C:AN-,\MERICAN CHILDREN

RESULTST.."I" 1 q Percentage "t tli.,rihution by place uC hinh Rnd language.poken by children in the AJ.Lllmo-M;\.\1C stUdy. h...ing visited th"dcntis, bot"". .lnd Og'J ot lirst,i,it.---'- .~J/l.Cft "t bi~!h lanK'lnge spoken

_M"X;CtI l;SA SI!/lni.h English

Demographics

Ilad vi.it"d the denti.,

400';'-600/0-1000;,

fi4~/."36%"100"1.

34%"66%-100'r.

57%.43'~.iolio/.

The population was distributed in the Alabama Mexi-can-American migrant children (Alabama-MAMC)study as follows: 67/130 (51.5 percent) were males and63/130 (48.5 percent) were females. The mean age was8.25 (range 3-16).

MoSt of the children and parents were born in Mexico(children 72 percent, fathers 84 percent, and mothers 79percent). The mean number of children in each familywas 3.6 (502.0). Ability to speak English and theeduca-tionallevels of parents and children, in general, werelimited. Only 42 percent of the children, 40 percent ofthe fathers, and 9 percent of the mothers spoke English.The percentage of mothers who had an educational levelabove elementary school, was 30 percent, and the per-centage above high school was 8 percent. Thc fatherswith education above elementary school were 25 per-cent, and those above high school were 2 percent. Mostof the families (60 percent) had an average annual in-come of less than $10,000.

Dental history

Spanish and were younger than four years, and 19 per-cent who were older than four years at their first dentalvisit.

There was an association between the total family in-come and the ages of the children on their first visit tothe dentist (p < 0.0001), and the frequency of visits tothe dentist every year (p < 0.05). Only 5 percent of thechildren from families with incomes of less than $10,000in the last twel ve months; and 13 percent of the childrenfrom families with incomes of more than $10,000, butless than $19,999, had been to the dentist before fouryears of age. Of the children from families with incomesof less than $10,000 ill the last twelve months, 2S per-cent saw the dentist twice a year, compared to 56 per":cent of the children from families with incomes of morethan $10,000, but less than $19,999.

There was an association between dental insuranceand place of birth (p < 0.0001). Of the children born inthe United States, 44 perct:nt had some type o{dentalinsurance, compared with 18 perc~nt of the children whowere born in Mexico.

Dental examination

Ot'\ly 46 percent of the children had ever seen a dentistbefore: 7 percent before they were four years of age, and24 percent visited the dentist in the last twelve months.The percentage of children covered by some type of den-tal insurance was 24 percent. Most of the children (72percent) brushed their teeth and used toothpaste, butonly 10 percent flossed.

A significant relationship was found between havingvisited the dentist and the child's place of birth and thelanguage spoken (p < 0.05) (Table 1). Of the childrenborn in the United States, 64 percent had been to thedentist compared with 40 percent of the children bornin Mexico. Of the children who spoke English, 57 per-cent had been to the dentist, compared to 34 percent ofthe children who only spoke Spanish.

The age of the child at the first visit to the dentist hadan association with the place of birth (p < 0.001) andlanguage spoken (p < 0.05) (Table 1). Only 1 percent ofthe children born in Mexico had been to the dentist whenthey were younger than four years, compared to 25 per-cent of the children born in the United States. Of thechildren who spoke English, 4 percent had been to thedentist when they were younger than four years old,and 47 percent when they were older than four years,compared with 11 percent of the children who spoke

The results of the dental examination are shown in Tables2,3, and 4. In the primary dentition the decayed compo-nent was the highest and the most prevalent of both; dft(88 percent), with a mean of 3.6 (SO 3.7), and dfs (80percent), with a mean of 6.5 (507.6). The posterior teethhad 76 percent of the total dft and 78 percent of the totaldfs. The dishibution of pitted and smooth decayed andfilled surfaces was 37 percent in pitted surfaces and 63percent in smooth surfaces.

Similar to the primary dentition, in the pennanentdentition the Decayed component was more prevalentthan the Filled component; the Missing component was

68 JANUARY-FEBRUARY 1,998

JOURNAL OF DENTISTRY FOR CHILDREN

There was a significant difference in the two studies(p < 0.001) (Table 6) regarding the percentage of thepopulation that had visited the dentist. In the Alabama-MAMC, 46 peocent of the population had previouslyseen a dentist, compared to 62 percent of the HHANESpopulation. Thel:e was a significant difference in the twostudies (p < 0.001) (Table 6) regarding the age at thefirst visit to the dentist. In the Alabama-MAMC sample,7 percent of the c:hildren had their first visit to the den-tist when they vl'ere four years or younger, comparedwith 15 percent in the HHANES population. There wasa significant dif£erence in the frequency of visits to thedentist in the last: twelve months between the two stud-ies (p < 0.001) (Table 6). In the Alabama-MAMC, 24 per-cent of the population had been to the dentist in the lasttwelve months, compared with 53 percent in theHHANES population. There was a statistical differencein the percentage of children who had some type of den-tal insurance (p < 0.001). Only 24 percent of the chil-dren in the Alabama-MAMC sample had dentalinsurance compclred with 38 percent of the HHANESpopulation.

not present in this study. The Decayed component was94 percent of the total OMFT with a mean of 2.2 (SO2.37), and 94 percent of the total OMFS with a mean of3.0 (SO 3.5). The posterior teeth had 92 percent of thetotal OMFT and 94 percent of the total OMFS. The dis-tribution of pitted and smooth Decayed Missing andFilled surfaces was 56 percent in pitted surfaces and 44percent in smooth surfaces.

TheOHIS for the Alabama-MAMC study was 1.4 (SO0.7) and was distributed as follows: The Debris Indexwas 0.7 (SO 0.4), and the Calculus Index was 0.7 (SO0.4).

Comparison of demographics and dentalconditions

Correlation of demographic information with the den-tal conditions for the Alabama- MAMC study was per-formed with the ANOV A with Fisher's Protected LeastSignificant Difference test. Significant statistical differ-ence was found between the Place of Birth and DentalCaries in the variables as follows: Primary decayed andfilled teeth (p < 0.05), Permanent Decayed Teeth (p <0.0001), Pent\anent Decayed Missing and Filled Teeth(p < 0.0001), Pennanent Decayed Surfaces (p < 0.001)and Pennanellt Decayed Missing and Filled Surfaces (p< 0.001). A higher rate of decay was present in the chil-dren who were born in Mexico; the children born in theUnited States had a higher rate of decay only in the vari-able of primary decayed and filled teeth. AImostall thechildren who were born in Mexico (99 percent) had adecayed or filled surface compared with 88 percent ofthe children who were born in the United States (p =0.008).

Comparison of ,dental caries between theAlabama-MAMC and HHANES

Comparison of demographics and dental healthbetween the Alabama-MAMC and HHANES

Several questions were matched with those utilized inHHANES, and comparisons were made between thetwo studies, using the Chi-square test. Significant statis-tical difference between the two studies was found inrelation to the place of birth (p < 0.001) (Table 5). TheHHANES population was born predominantly in theUnited States (83 percent), while the Alabama-MAMCsample (72 percent) was born predominantly in Mexico.A significant difference in the distribution of incomebetween the two studies was found (p < 0.001) <Table5). In the Alabama MAMC sample, 60 percent of thepopulation had an income of less than $10,000 comparedwith 31 percent of theHHANES population.

The Alabama-M)I,.MC and HHANES were analyzed forstatistical differences in relation to dental caries. Allpailwise comparisons were tested with the ANDV A test,using the Fisher' 5: Protected Least Significant Differencetest. The results of the primary, permanent decayed filledteeth and surfac:es, the anterior and posterior (dfs,DMFS), and the smooth and pitted (dfs, DMFS) for thestudies are shown in the Tables 2, 3 and, 4.

There were significant statistical differences betweenthe Alabama-MAMC stud y HHANES in relation tQ de-cayed teeth, the total dft, decayed surfaces, and the totaldfs (p < 0.0001). In the Alabama-MAMC study, the de-cayed componenlt was higher and more prevalent thanthe filled compOJr\ent, compared with HHANES (seeTable 2 for mean c:lifferences between the groups).

The distriblltion of the dft in the anterior and poste-rior teeth and the distribution of dfs in smooth and pit-ted surfaces hadl a significant statistical differencebetween the Alabama-MAMC and HHANES (p < 0.05)(see Table 3 for m.ean differences betw~en the groups).

There was a significant statistical difference betweenthe Alabama-MAMC and HHANES in relation to theDecayed teeth, the total Decayed Missing and FilledTeeth, the Decayed Surfaces, and the total DecayedMissing and Fill~:i Surfaces DMFS (p < 0.0001). In the

69 NURKO. APONTE.MERCED. BRADLEY. FOX

DENTAL CARE FOR MEXICAN-AMERICAN CHILDREN

Table 4 0 rer..~nl4ge distribution of primarJ and permanent

decayed alld filled, IInterior ann pooterior an smooth and pilled

,u~ce. in each .~. -

I:!~: 2.2"0.1"2.3.2.9"0.3"3.2*

2.40.82.53.51.2

3.8

0.5-0.9-1A-0.7-1.5-2.3-

1.32.02.52.03.7~.5

Sig;;-ificaM(p < .05) diffe~II"e ~Mell Alabam.;:MAMC ~and HHANES sd1dy.

+HHANES wa. the only group who presented a Mi.sing com~nent. This was 1.6% "f the DMrf (mean of 0.02 :!: 0.2), and 4% of thelotal DMFS (mcan of 0.1 :: 0.8).

Table 3 0 Mean (:!: S.D.) of decayed and filled primftry andpermanent lurfa...es ~ ~ of ,~th surra~ it. ead. oludy.

Alabanl1&-MA.\iC HHANES+n-130 n-3,241---

Table 6 0 Pcrcentage distribution uf the Alahama.MAMC studychildren and th~ Mexican-American children from SouthwlOStemHllA."iES (1982-84/ hnv;ng visit..d the dcntist before, ag" at fint visi..

,and ~ving vi,ited t le_uc:nti!lt in the IR,t twelve ~onth.,

+HH.\.'IESwa. Ihe unIT group that presented a Mi..ing componenl(ID.liO 0.1 :: 0.8).

'Sigllificant (p < .05) difference between Alabamli-~IAMC .oldyand H~ES study.

DISCUSSION

The results of this study revealed that the Mexican-American migrant workers in this study have a lowerrate of dental services, a disproportionate prevalence ofdecayed teeth, and an urgent need for dental treatmentcompared with the l\.1exican-American children fromHHANES. The demographic findings of this study sup-port the information from ~AWS showing that most ofthe general population of farm workers are born inMexico, ~nd most of them had just recently immigratedfrom Mexico. The popula tion of children examined wasevenly distributed; children older than twelve years ofage, however, comprised only 10 percent of the popula-tion, reflecting that many children of these ages wereworking in the summer months and not enrolled in the

Alabama-MAMC, the Decayed component was higherand more prevalent and the Filled component was lessprevalent compared with HHANES (see Table 2 formean differences between the groups),

The distribution of the DMFS in the posterior teethand smooth surfaces had a significant statistical differ-ence between the Alabama-MAMC and HHANES (p <0.05) (see Table 3 for mean differences between thegroups).

Oral hygiene

There was a statistical difference in the OHI betweenthe Alabama-MAMC and HHANES sample (p <0.0001). The Alabama-MAMC had an OHI of 1.4 whileHHANES had an OHI of 0.9.

!~ ~III

Table 5 0 Per"entage distribution by placc oc birth and tutMI familyincomc in the last tWel~e m"nth. oC the A]ahama-MA.\1C study andth~ Mexican-Alnerican children from Suuthw..tf!m HHAN~ (1982-84).

70 jANUARY.FEBRUARY lUg!'.

JOURNAL OF DENTISTRY FOR CHILDREN

school program, because the family's yearly incomemust be earned by all family members. Low income,lack of edLlcation, and limited knowlet.ige of the Englishlanguage were constantly found. The average annualincome was below the poverty level. The shortages ofbilingual and bicultural staff in Alabama, compared withthe Southwest or other areas with a higher density ofbilingual population, is a factor that could inhibit thispopulation from accessing the health-care deliverysystem.

The results obtained from the questionnaire providecvidence that there is a general lack of dental care, den-tal insurance, dental prevcntion, and dental education,when compared with the HHANES population. Theassocia tion between the place of birth and language spo-ken with having dental insurance and having visitedthe dentist before agrees with the findings by Ismail et althat children who were born in Mexico and spoke andwrote only Spanish with a low acculturation status hadsought significantly less dental care and were less likelyto be covered by dental insurance than those who wereborn in United States or spoke English.4 In this study,almost half of the children had never been to the dentistand only a fourth had dental insurance.

Areas of dental health knowledge that were particu-larly lacking included the role of fluorides and dentalfloss, and the relation between sweets in the diet andcaries (47 percent of the children ate snacks, and not al-lowing toddlers to sleep with a bottle was reported only0.8 percent as a second best way of preventing caries).The use of sealants was not mentioned by the parents,and 01UY 7 percent of the population in this study hadsealants. The results of primary and permanent decayed,filled teeth, and surfaces of this and previous shtdies oforal health that have identified Hispanics or Mexican-American migrant workers show a disproportionateprevalence of decayed teeth and a prevalent need ofliental treatment, because of the almost nonexistenth.eatment of these teeth. The percentage of caries-freechildren in this study was 4.6 percent.

Our results demonstrate dental caries rates five timesgreater than in the HHANES population. The greateststatement of dental need in this study is evidenced inthe permanent dentition, where the Decayed componentaccounted for 94 percent of the total DMFf and DMFS.The decayed component of the dfs or dft was abovc 80percent, indicating that three of four decayed teeth areuntreated. The caries rate in the primary dentition inthis study is comparable to published national data onHead Start low-income children ages three to five inwhom the decayed teeth frequently exceeded 60 per-

cent?'The filled teeth component in tl1is stud y was only12 percent of the dft and 6 percent of the DMFT, reflect-ing the lack of dental treah1\ent provided to these chil-dren. In HHANES, half of the teeth had been treated.An interesting finding was that the total primary de-cayed and filled teeth of the children born in the UnitedStates in this study was statistically higher than the chil-dren born in Mexico, a mean of 5.4 of dft compared with3.7. A possible expla11ation for this is the change in dietto one with more carbohydrates in the form of refinedsugars, a characteristic of diets in industrialized coun-tries. In the permanent dentition the decayed teeth weredouble and the decayed surfaces almost tripled in thechildren born in Mexico compared with the childrenborn in the United States. The distribution of the cariesin smooth and pitted surfaces in the primary dentitionreflects a higher concentration of caries in the smoothsurfaces. In this study, three of five surfaces of the de-cayed surfaces are found in the smooth surfaces, whencompared with half in HHANES. This indicates a pos-sible increased frequency of carbohydrates and sugar inthe diet and a lack of fluoride exposure.

The children in the HHANES population reside in theSouthwest where naturally fluoridated water is widelyavailable. In this study we were not able to detern\inethe exposure of these children to the benefits of fluo-ride, because this population is mobile. One of four de-cayed or filled primary surfaces in this study was foundin the anterior teeth, compared with one of six inHHANES, suggesting a tendency for Early ChildhoodCaries in these childl:en, as reported by Weinstein et al}Z

Another interesting finding was the distribution ofpitted and smooth surfaces in this study compared withthe HHANES population. Fifty-five percent of the de-cayed and filled surfaces were concentrated in the pit-.ted surfaces while HHANES reported almost 80 percent.This strongly suggests that the children in this studywould be helped by a sealant program, as was observedby Ismail et al in the HHANES population.4 The needfor the provision of restorative services for these chil-dren, however, should also be emphasized. The OHISin this study was double of what was reported byHHANES. Even though periodontal disease was notevaluated in this study, the calculus index was almosthalf of the total OHI. This'shows a predisposition laterin life to periodontal disease. This also supports theHHANES finding that 77 percent of the children suf-fered from gingivitis.'4

Children's dental caries is unevenly distributed, witha small percentage of children demonstrating the ma-jority of carious tooth surfaces}'.:\1 The popular state-

71 NURKO. APONTE-MERCED. BRADLEY. FOX

DENTAL CARE rOR MEXIC,7I.N-AMERICAN c.:HILDREN

ment that half of United States school children havenever experienced tooth decay grew out of the 1986-87national survey of the oral health of school children bythe NIDR, in which the dental disease in the primarydentition was ignored, failing profoundly to reflect theextremity and severity of this highly prevalent condi-tion of childhood." The National Health Promotion andDisease Prevention Objectives of "Healthy People 2000"published by the NIH pointed out the need for assur-ance that primary and" secondary prevention servicesfor oral health are reaching all segments of the popula-tion and that infonnation on health status and risk fac-tors has been placed as a high priority need for all lifestages and particularly for specific race, ethnic, and so-cioeconomic groups.34 Also populations lacking dentalinsurance have been placed as high-priority researchneeds to describe their characteristics. The findings, par-ticularly among children with low education and low-income status parents, point toward the urgent need forimproved policy to target educational and preventionprograms for those at greatest disease risk and treatmentneed. These findings should be continually presentedto community and business leaders and funding agen-cies, so that they will recognize that dental caries hasnot been relegated to the status of an occasional disease,especially for minority children, like the Mexican-Ameri-can migrant workers' children.

REFERENCES,

r:1::1;:

1~,

!(.

,i';.

CONCLUSIONS+

,~

'{"

!!Of;

D Dental caries is a major problem for migrant chil-dren, and the unmet dental caries need remains aproblem to be addressed.

0 Aggressive preventive and restorative services re-main a priority with migrant children.

D A topical fluoride supplementation program is rec-ommended due to the high caries experience.

D A need for dental public health programs of ser-vice and education for these families to make thispopulation aware and to translate the need of den-tal treatment to demand for dental treatment isstrongly supported by this study.

D The association between higher decayed valuesand place of birth and language spoken requiresspecial efforts in order to understand this popula-tion and to devise ways to ease the transition andintegration into the American health care system.

D The generalized lack of dental insurance, whichplaces these children in a more difficult situation toreceive dental treatment, points toward the urgentneed for an improved policy in relation to this issue.

1. United States Bureau of Census: Current Popul~tion Reports,SeriL'S P-20, No 449. The Hispanic Population in the Unit~d Stilte,;.Washington D.C.: Government Printing Office, March 1990.

2. Waldman, H.B: Hi!'panic children; An increa!iin~ reality in pedi-atric dental practice. J Dent Child..59:221-224, May-Junc 1992.

3. Coalition of Sp~nish Speaking He~lth and Human Service Olga-niZiltion: DeliverinK Preventive H~alth Care to Hi!;panics. AManual for I"roviders. Washington, D.C., 1988.

4. Ismail, Al. and Szpunzar, S.M.: Oral health status of Mexican-Amcricilns with low and high acculturation statu!;. FindinK!; fnlmsouthwestern HHANES, 19B2-19!i4.J of Public Health Dent,50:24-31, Wintcr 1990.

5. Novello, A.C.; Wise, P.H.; Klcinm,m, D. V.: Hisptlni<: health: tim~for data, time for action. JAMA, 265:248-252, January 1991.

6. Furinu, A. and Mun()!i, E.: Health statu!; among Hispanics: Majorthemes and new priorities. JAMA, 265:255-257, January 1991.

7. Cinzberg. E.: Access to health care for Hisp~nics. JAMA, 265:238-241, January 1991.

8. Newman,J.F.: Forty years of national public hcalth data, contin-ued value? J Pllblic Health Dent, 50:323-329, Fall 1990.

9. US Departrn~nt of H~alth and Human Services: Health status ofminorities and low income groups, 3rd edition. Washington D.C.:USC(wemmentPrintingOffice,1991.

10. Call, R.L.; Entwistl~, 5.; Swan~m, T.L.: Dental caries in perma-nent teeth in children of migrant farm workers. Am J Pub Health,77:1002-1003, AUbF\Jl!;t 1987.

11. DiAngclis, A.J.; Katz, R. V.; Jensen, M.E. et al: Dental n~!; in chil-dren of Mexican Americ~n migrant workers. J School Health,51:395-399, August 1981.

12. Health Indicators for Hisp'lnic, Black and WhitcAmericans. Datafrom the Nanon~1 Health Survey Series 10, no. 148. Hyattsville,MD: National Ccntcr for Health Statistics, September 1984.

13. l"lan and Operation of the Hispanic Health and Nutrition Exami-nanlm Survey 1982-1984: US Department of Health and HumanServices. Program and Collection Procedures Scries I, Nu 19.f Iyattsville, MD: National Center for Health St~tistics, Sept~m-ber 1985.

14. Ismail, A..L.; 51-art, B.A.; Brunelle, J.A.: I"revalence of dental c'lricsand periooontal di!'ea!'e in Mexican-Am~rican children ~g~d 5to17 years: results fronl Southwestern HHANES 1982-1984. Am JPublic H~alth,77:967-970, August 1987.

15. Bachand, R.C.; Gangarosa, L.P.; Bragassa, C: A !;tudy of dentalneeds, DMF, def and tooth eruption in migrant Negro children. JD~nt Child, 38:399-403, November-Dec~mber 1971.

16. Avery, K. T.: Dcnt..,1 hcalth of migrant agricultural work~r1;. J OcropMed,16:606-608, September 1974.

17. Cipes, M.H. and C.~staldi, C.R.: Dental health of children ofmigrant farm workea~ in Hartford Connel:tiL"Ut. J Conn Stat~ Ot!ntAssoc, 56:59-62, May 1982.

18. Ragno, J. and Ca!;taldi, C.R.: Dental health in a I;n)UP of migrantchildren in Connecticut. J Conn State Dent Assoc, 56:15-21, Janu-ary 1982.

19. Kuday, M.; Roscnstein, D.l.; Nana Lop~z, C.M.: Dental decay ratesamong children of migrant workers in Yakima, W A. l"ublic HealthReports,105:530-533, ~ptember-October 1990.

20. Avcry, K.T.: The oral health status of migrant and s~a!;(malfarmworkers and their families in Florida. Community Dent OralEpidcmiology, 4:19-21, January 1976.

21. Woolfolk, M.P.; Sgan-Cohen, H.D.; Bagramian, R.A. I!t /1/: ~lf-re-ported health behavior and dental knowledge of a migrant workerpopulation. Community Dcrit Orill Epidcmiology, 13:140-142,June 1985.

22. Woolfolk, M.P.; Hammard, M.; BaKramiam, R.A.: Oral health ofchildren of migrant farm workers in northwest Michigan. J PublicH~alth Dent, 3:101-105, Summer 1984.

72 JANUARY-FEBRUAR.Y ~998

JOURNAL OF DENTISTRY FOR CHILiJ~N

30. SAS/STA:r, Release 6.03 Edition. Copyright 1988 by SAS Insti-tute Inc.

31. Edelstein, B.L. and Douglas, Ch.W.: Dispelling the myth t~t 50percent of US sch()()lchildren have never had a cavity. I'ublicHealth Report.,;, 110:522-530, September-October 1995.

32. Weinstein, P.; Domoto, P.; Wohlcrs, K. et al: Mexican-Americanparents with children at risk for baby bottle tooth decay: Pilotstudy at a migrant farmworkers clinic. J Dent Child, 61:376-386,September-October 1992.

33. Brown, L.]f.; Kaste, L.M.; Selwitz. R.H. etal: Dental caries and seal-ant u.o;age in US children, 1988-1991. J Am Dent Assoc. 127:335-343, March 1996.

34. US Department of Health and Human Services, Public HealthService. Healthy People 2000: National Health Promotion andDisease f'revention Objectives. Dept. of Public Health, 1990;DHHS pl;lblication No. (PHS) 91-50213. pp 350-362.

23. lnvisiblc Children: A I'ortrait of Migrant Education in the UnitedStates. A final report of the National Commission on MigrantEducation. Washington, D.C.: Government Printing Office, 1992.

24. Cavenaugh, D. and Lynch, L: Migrant Child Welfare: A state ofthe fit:ld study of child w~lfare service for migrant children andtheir families who are in stream. home based, or settled out. FinalReport. Washin.i;ton D.C.: Interamerica Research Associates, 1977.

25. Martin, P.: Paper Commissioned by the National Commission onMigrant Education, Washington D.C., 1992.

26. de !..con Siantz, M.I.: The Mexican-American lnigrant farmworkerfamily. Mental health issues. Nursing Clinics of North America,29:65-72, March 1994.

27. Diagnostic Criteria for Coronal Caries. Oral Heal th of the UnitedStates Children. The National Survey of Dental Caries in USSchool Children, 1986-1987. NIH Publication No 89-2247, pp 355-359,1989.

28. Greene, J.C. and Vermillion, J.R.: The simplified oral hygiencindex. J Am Dent Assoc, 68:7-13, August 1964.

29. Butts, J.T.; Mclendon, J.; Aponte-Merced, LA.: Oral HealthExamination and Data Analysis Software Package, Birmingham,AL,l990.

~j

PREDICTORS OF DENTAL CARE U11LIZATION

Although dental decay has been significantly reduced over the past 30 years, dental disease

continues to be a substantial health problem for many low-income and minority Americans.

Low-income and minority Americans experience greater levl~ls of oral disease and are less able

to obtain dental care, less likely to be covered by dental ins\lrance and less likely to seek care

than higher-income and nonminority Americans Several studies examining dental care utilization have oo~n conducted. Most of these stud-

ies focused on children and older people. For instance, Gift and Newman analyzed the 1989

National Health Interview Survey, or NHIS, and reported on the use of dental services for U.S.

children. They reported that 57 pen::ent of black children visited the dentist during the past

year as compared with 72 percent of white children, and 57 pen::ent of Hispanic children vis-

ited the dentist during the past year as compared with 71 ]~n::ent of non-Hispanic children.

Gift and Newman reported that these differences persisted c~ven when controlling for income,

the education level of the responsible adult in insurance.

Manski, R.]. and Magder, L.S.: Demographic and socioeconomicprE!dictors of dental care utilization.

J Amer Dent Assoc, 129":195-200, February 1998.

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