Sociopolitical Policies That Reduce Disparities in Children's Oral Health

Project: Research project


The disparity between rich and poor in children’s tooth decay doubled in the past two decades at the same time that dental care utilization increased among low income children. Dental care does not eliminate income disparities because it does not target upstream risk factors that disproportionately affect low income groups.
The solution requires population-based interventions that preferentially benefit children at highest risk. Our approach is guided by a multilevel conceptual framework. Investigators from social- and oral epidemiology, health economics, political science, and nutrition will partner with community representatives from the Pew Charitable Trust, the Association of State and Territorial Dental Directors and a local Community Advisory Board of influential community stakeholders. At the crux of the project is the idea that state-to-state variation in policy adoption acts as a natural experiment. The overall objective is to identify cost-effective state policies that influence community, behavioral, nutritional and biological determinants of oral health disparities and identify community action to support sustainable reduction in disparities. Dental caries is the primary disease of interest. Secondary outcomes are serum cotinine and oral human papilloma virus (HPV) infection as surrogate markers of early risk of periodontitis and oral cancer. Times series data will be collected on policy adoption for 50 states and the District of Columbia for all years available. Policy activities prioritize six intervention themes: community water fluoridation; restricted soda consumption; tobacco control; HPV vaccine promotion; children’s dental insurance coverage; and poverty minimization.
In phase one (years 1-2) we will compile a time-series state policy database on: cigarette excise tax; sugar-sweetened beverage (SSB) tax; HPV vaccine promotion, minimum wage, earned income tax credit, health plans with pediatric dental coverage and community water fluoridation (community level). The database will be enriched with time-series factors that mediate policy effects across multiple levels of influence. State policy (level 1) influences communities (level 2, e.g. per capita sales of cigarettes and SSB). Effects flow to behavior (level 3, e.g. plain water intake, SSB intake, smoking), nutrition (e.g. daily total energy, total nutrient intake); and become embedded in biology (level 4, e.g. serum cotinine). The database will be merged into the 1988-2014 National Health and Nutrition Examination Survey (NHANES) cycles using restricted access geocodes.
Phase two (years 3-4) activities examine the relationship between state policy, intermediate variables and the individual-level outcomes measured in children aged 2 to 21 years in 1988-2014 NHANES. Aims 1 and 2 will quantify the effects of fluoridated water and soda consumption on disparities in dental caries. Aims 3 and 4 will quantify effects of tobacco regulation on disparities in serum cotinine and oral HPV infection, respectively.
This fundamental cause approach to eliminating disparities is very different for an individually oriented risk-factor approach. Unlike racial disparities, poverty and its pathways are modifiable and change is sustainable.
Effective start/end date9/18/158/31/17


  • NIH National Institute of Dental and Craniofacial Research (NIDCR)


Oral Health
Papillomavirus Vaccines
Dental Care
Nutrition Surveys
Dental Caries
Virus Diseases
Tobacco Products
Dental Insurance
Geographic Mapping
Income Tax