Kentucky Early Learner’s Oral Health Survey
November 1, 2024
Our Mission
Advancements in patient care, education, research, and community engagement, for the benefit of Kentuckians and beyond, are made possible by our college’s scientifically oriented, technically capable, and culturally sensitive oral health team.
Acknowledgements
This survey was funded by the Kentucky Department for Public Health.
PROJECT TEAM
Jennifer Harrison, MPH, RDH
Julie Watts McKee, DMD
Lindsey James, MPH
Luciana Shaddox, DDS, MS, Ph.D.
Pam Stein, DMD, MPH
Reuben Adatorwovor, Ph.D.
Ronald Singer, DDS
Courtney Brown, MSW
replace with reflow
Cynthia Beebout
Dana Satterly
Malini Kiradoku
EXECUTIVE SUMMARY
SPECIAL CONTRIBUTIONS
Kadee Whaley
Jessie Bryant
Bri Patino
REGIONAL TEAMS
EASTERN
Brooke Jones, Rhonda Collins, Alexis Dotson, Regina Estep, Kimberly Harris, Tabitha Hughes KNOBS
Susan Caschera, Christeen Johnson, Rebecca Ray LOUISVILLE
Laura Blanton, Sharon Fagan MIDWESTERN
Dianna Ransdell, Heather Capps, Lisa Mellinger
NORTH CENTRAL
Casey Howard, Kimberly Breeding, Mary Jones, Holly O’Daniel, Natalie Sublett NORTHERN
Linda Poynter, Gwen Abbott, Lisa Gammon, Heather Henry, Debra Poe
SOUTH CENTRAL
Gina Miller, Crystal Constant, Melissa Keith WESTERN
Sara Womack, Brenda Law, Mandy Sizemore, Leah Smothers
Foreword
The oral health of young children is essential to health equity as it not only sets the trajectory for oral health across the lifespan, but also influences an individual’s overall health and development.
Baby teeth are important indicators of what adult teeth will look like. They help children eat and speak naturally. They also aid in proper formation of the jaw and forming the path for the eruption of permanent teeth.
The American Association of Pediatric Dentists recommend that children see a pediatric dentist and get established when the first tooth appears (between 6 months and a year) or no later than their first birthday and continue to every 6 months with preventative care. However, most children start going to the dentist too late and it usually is due to complaints of pain (associated with decay).
Although dental decay is a preventable disease it remains the most common chronic childhood disease, approximately four times more prevalent than childhood asthma. If left untreated, dental decay can lead to pain, infection and can even lead to serious life-threatening events. Research shows that dental pain negatively impacts academic achievement and school attendance.
Poor oral health in early childhood can lead to the need for more invasive and costly dental services in the future and early dental experiences shape lifelong attitudes, values and beliefs regarding oral health. Thus, early preventive dental care is fundamental to childhood health and well-being, allowing children to play, learn and grow into healthy adults free of tooth pain.
Introduction
The 2023 Kentucky Early Learner’s Oral Health Survey is the first time in over 20 years that data has been collected on the dental decay rates of pre-school aged children in Kentucky. The survey aimed to evaluate the prevalence of dental decay and treatment needs among Kentucky children ages 2-5 and to identify what populations are most at risk for dental decay. Public health data, such as the information collected from the Early Learner’s Oral Health Survey, plays a critical role in developing policies, programs and services that effectively improve oral health outcomes for people in Kentucky.
From January through October of 2023, 6660 children ages 2-5 were screened in 106 of Kentucky’s 120 counties that were categorized into 8 geographic regions. Local dental hygienists were recruited as screeners and coordinators for each region. They were calibrated to screen for dental decay (caries) during a formal training event in December 2022.
Figure 1. Early Learners Survey Regions
TREATED DECAY
Treated decay is determined by the presence of any type of filling, including a preventive resin restoration, crown, temporary filling, or a tooth that is missing because it was extracted as the result of tooth decay.
UNTREATED DECAY
The presence of a cavity in which the screener can readily observe breakdown of the enamel surface. The guidelines for this survey do not include white spot lesions or stained pit/fissures as untreated decay. In other words, only cavitated lesions are considered to be untreated decay.
EARLY TREATMENT NEEDS
CARIES EXPERIENCE
This indicator was calculated as the presence of treated, untreated or both treated and untreated decay.
Caries without accompanying signs or symptoms, or individuals with other oral health problems requiring care before their next routine dental visit. Recommended to see a dentist within several weeks.
URGENT TREATMENT NEEDS
Signs or symptoms that include pain, infection or swelling. Recommended to see a dentist as soon as possible.
Methodology
Sample Size & Sampling Methods
Multi-sampling methods were used in various stages for this project. First, Probability Proportion to Size, with replacement, was used to determine facilities. Simple Random Sampling and Convenience Sampling were used in the second stage of selecting children. Convenience sampling was utilized in all regions when local teams were struggling to reach the target sample size. For example, convenience sampling was used in the Western region because some facilities would not allow project screeners to conduct screenings at their sites. For this reason, we utilized data that had already been collected through a UKCD outreach program. Other regions utilized convenience sampling when local screeners had a connection to a vacation bible school or other screening site in their community.
The Cabinet for Health and Family Services, Division of Childcare (DOC) was engaged and the DOC Active Provider Directory, which includes all daycares and Head Start programs in Kentucky, was utilized in determining the 2-to-5-year-old population in each region. A sample size tool was used to calculate the needed sample size for each region.
Sample Characteristics
Table 1. Regional target sample size and actual sample size
Figure 2. Number and Percent of Screens By Facility Type
*Other Facilities included kindergartens, elementary schools, church preschools/churches, a dental hygiene school clinic and home school children.
Table 2. Self-Identified Race
Data Collection Methods
CALIBRATION & TRAINING
Dental hygienists from each region were recruited as local screeners and then calibrated to screen for treated and untreated decay as well as urgency of treatment needs during a training in December 2022. Each local screener was provided with a tablet that had the REDCap mobile app preloaded with the project survey. The REDCap mobile app allows screeners to collect data without an internet connection and upload data to the project database at a later date/time once an internet connection can be established. Project tablets also continued a direct link to the REDCap survey that could be used when the screeners had access to a reliable and consistent internet connection. Each screener was also provided with screening materials, PPE and paper copies of the survey to use if they had any technical issues. Screeners were trained on data collection with REDCap at the December 2022 event.
PASSIVE CONSENT PROCESS
Parents of 2-5 year-olds at daycares and Head Start programs that agreed to hold screening events were given passive consent letters prior to the scheduled screening dates. Parents were instructed to sign and return the form if they did not want their child to be screened.
SCREENING PROCEDURES
Screeners collected location and demographic data on each child as provided by the screening facility. Then they conducted their screening and entered results for each child regarding the presence of treated and/or untreated decay, urgency of treatment need for untreated decay (i.e. none, early and urgent) as well as any additional notes regarding the child’s oral health status.
A letter with the child’s screening results was given to the child’s parent/guardian by the screening facility. The letter contained information on the child’s oral health status, indication of any treatment needs, referral information for local dentists and contact information for regional coordinators so that parents could reach out with questions and requests for assistance connecting to local dental services (See Appendix A: Screening Results Letter
Statistical Methods
Non-parametric methods were employed to evaluate the prevalence of tooth decay. More specifically, Mantel-Haenszel statistics were utilized to compare the rate (proportions) of decay for three different categories —treated, untreated and caries experience—among the children screened for this survey. A multiple logistic regression model was used to evaluate the comparative strength across factors found to be associated with increased rates of all categories of tooth decay. The list below contains statistical models utilized during the project.
NON-PARAMETRIC METHODS
• Wilcoxon signed-rank test (assess the distributions of the outcomes)
COMPARE CARIES RATES
• Contingency tables (Chi-square tests)
• Mantel-Haenszel statistics (test of association)
• Cochran-Mantel-Haenszel Test (adjusting for covariates)
• Cochran-Armitage Trend Test
EXACT/INVERSE PROBABILITY WEIGHTING METHODS
• Small sample techniques
• Inverse Probability Weighting (correct for bias due to non-random sampling)
REGRESSION MODEL
• Simple logistic regression (binary outcomes)
• Multivariate logistic regression (adjusting for risk factors)
Findings
Key Findings
Key Finding #1
Kentucky children have rates for caries experience and untreated decay that are considerably higher than the national average (See Figure 3). In the most recent national survey, children living at or below 100% of the federal poverty level have the highest rates of decay among 2-5-year-olds in the U.S. Despite coming from diverse socioeconomic backgrounds, the Kentucky children screened have rates of decay that are slightly higher than children living at or below 100% of the federal poverty level nationwide. The overall dental health of Kentucky children reflects a state of dental poverty.
Key Finding #2
Age was the most significant factor linked to caries experience and the second most significant factor related to untreated decay, suggesting that the risk of tooth decay only increases over time. Thus, prevention and early intervention strategies for young children are essential to improve oral health in Kentucky's youth.
Key Finding #3
Untreated tooth decay is strongly correlated to various demographic, geographic, and social factors, underscoring their influence on access to dental care. Rural location, Hispanic/Latino ethnicity, residence in the Eastern or South Central regions, and facility types that primarily serve children from lower socio-economic backgrounds (e.g., Head Start, School-Based Head Start, and Other facilities) were significantly associated with higher rates of untreated decay.
Our analysis highlights how multiple factors can intersect and contribute to elevated rates of untreated decay among marginalized groups, likely exacerbating existing oral health disparities. For example, untreated decay was significantly associated with children from Louisville ZIP codes with the highest poverty levels, which also have the highest percentages of Black/African American residents. Rural children screened in Head Start facilities also had significantly higher untreated decay rates compared to their urban counterparts.
Figure 3. Kentucky
Compared to National Data
The 2023 Kentucky Early Learners Survey found rates for caries experience and untreated decay that are considerably higher than the national average. In fact, Kentucky rates are comparable to the group at highest risk for dental decay in the U.S.—children living at or below 100% of the Federal Poverty Level.
Figure 4. Caries Experience by Region
Figure 5. Untreated Decay by Region
Out of 1,433 Children with Untreated Decay
No Treatment Needs (n=78) Early Treatment Needs (n=1,135)
Urgent Treatment Needs (n=220)
What FACTORS are the strongest predictors of decay?
A multiple logistic regression model was used to evaluate the comparative strength across all of the covariates—region, age, facility type, and urban or rural dwelling—that were significant factors for increased risk of caries experience, untreated decay and treated decay.
Increased age emerged as the most important risk factor, followed by Eastern and South Central region, rural location, and finally facilty type (i.e., Head Start, School-Based Head Start and Other) for both caries experience and treated decay. However, the importance of factors was different for untreated decay. The most significant risk factor for untreated decay was being located in the Eastern and South Central regions, followed by increased age, facilty type and rural location.
Additional Findings
REGION is significantly associated with all types of decay even after adjusting for other important factors such as facility type and age. South Central and Eastern regions have significantly higher prevalence rates for caries experience, untreated and treated decay compared to the other regions.
INCREASED AGE is significantly associated with higher prevalence of all three decay categories even after adjusting for region and rural vs. urban location.
BLACK/AFRICAN AMERICAN RACE is significantly associated with higher prevalence of caries experience in the Louisville region, with higher prevalence of untreated decay in the South Central region and higher prevalence of treated decay in the Northern region.
HISPANIC/LATINO ETHNICITY is significantly associated with higher prevalence of caries experience and untreated decay, but not treated decay. This suggests that access to care may contribute to this oral health disparity.
FACILITY TYPE such as Head Start, School Based Head Start and other facility types are significantly associated with higher prevalence of all decay categories compared to private facilities, even after adjusting for age and rural vs. urban location. This is consistent with previous surveys that identified poverty as a key risk factor, as Head Start programs provide care for children with lower socio-economic status than most private daycares.
RURAL LOCATION is significantly associated with higher rates of all three decay categories and seems to amplify other associations. For example, increased age is more strongly associated with all types of decay in rural locations. Head Start and other facility types are also more strongly associated with higher rates of decay in rural locations.
ZIP CODES in Louisville classified as having high poverty rates showed a significantly higher prevalence of any caries experience and untreated caries compared to children screened in zip codes not classified as having high poverty. The high poverty zip codes also have the highest percentages of Black residents. There was no significant difference in prevalence of treated caries between the sets of zip codes. This suggests an issue with access to care.
Recommendations
On November 1, 2024, the results of the Kentucky Early Learner’s Oral Health Survey were presented to stakeholders (e.g., dentists, dental hygienists, oral health researchers, oral health coalition members, public health department representatives, health center representatives, etc.) from across the commonwealth. The following recommendations come directly from stakeholder input that was gathered during group discussions after the presentation of findings.
Recommendation #1: Expand Early Childhood
Programs Incorporate children ages 2-5 into oral health initiatives to address critical needs early. This includes expanding preventive services, sealant and fluoride programs, minimally invasive treatments, and embedding dental screenings into pediatric visits.
Recommendation #2: Address Disparities in
Access to Care Focus on removing barriers to care in rural and low-income areas through supports such as community health workers and transportation programs. Incentivize provider participation in Medicaid and reduce administrative strain for Medicaid dentists.
Recommendation #3: Improve Data Collection
Establish regular oral health surveillance and create a standardized statewide data collection system. Collect information on health outcomes, access to and utilization of care, and workforce. This will enable targeted resource allocation and policy advocacy. Invest in training and tools for data collection to ensure accurate and consistent data integration with broader public health systems.
Recommendation #4: Promote Collaboration and Advocacy Unite stakeholders, including policymakers, educators, parents and healthcare providers, to integrate oral health into broader public health initiatives and service delivery systems. Build educational resources for parents and multidisciplinary professionals to promote oral health in diverse settings. Advocate for policies that address systemic barriers and support workforce development to meet care needs across Kentucky.
Recommendation #5: Strengthen Kentucky’s Oral Health Workforce
Build a robust oral health workforce by expanding the roles, duties and practice settings of public health dental hygienists (PHRDHs), implement mid-level practitioner programs, and address barriers to provider participation in Medicaid. Offer loan repayment and training incentives to attract professionals to underserved areas, ensuring equitable and sustainable care delivery models.
Appendix A
Data collection for this project was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.