Running head: LITERATURE REIVEW OF BARRIERS TO CARE 1

A Literature Review of Barriers to Care for

Low Socioeconomic Children

Amanda Mitchell

Siena Heights University

September 25, 2016

LITERATURE REVIEW OF BARRIERS TO CARE 2

A Literature Review of Barriers to Care

In recent years there has been a lack of access to dental care for children in the United

States, highlighted especially for those with a low socioeconomic status. There are many barriers

to care in place that offer considerable difficulty in obtaining even preventative care; these

include but are not limited to financial barriers, the education level of parents, availability of

funds and utilization of those funds, and the lack of knowledge about the link between dental

care and systemic disease incidence. This literature review will attempt to describe these barriers

to care, explain how they relate to socioeconomic status, and offer possible solutions in

eliminating such barriers.

Outline

This review will include qualitative and quantitative research completed on the barriers to

care for children with a low socioeconomic status published between the years 2010-2015. It will

focus on the following research questions:

What are the financial barriers to care for children with low socioeconomic

status?
What effect does a parents education level have on the dental health of their

child/children?
What kind of care and funding are available and are they being utilized?
What link does dental health have to systemic disease incidence and how does

this affect children in their lifetime?

What are the possible solutions in eliminating these barriers?

Literature Review

Financial Barriers
LITERATURE REVIEW OF BARRIERS TO CARE 3

Cost. As with all other industries, dental care costs continue to rise at such a rate that

members of the low socioeconomic status cannot keep pace. Many of these individuals cannot

fund their own dental care and rely on the government to provide such funding for preventative,

maintenance, and emergency procedures. When compared with affluent children, evidence

shows that children with low socioeconomic status are twice as likely to experience toothaches

indicating a barrier to care and a need for funding in this area (Nathe, 2012). The introduction of

measures such as the Patient Protection and Affordable Care Act and the Childrens Health

Insurance Program (CHIP) have targeted the rising costs of dental care but have done little to

deter the impact of cost on the parents of children with low socioeconomic status. Although there

are many possible solutions to the rising costs of dental care laid out in the Affordable Care Act,

they have yet to be put in place and utilized fully (Sparer, 2011).

Reimbursement. Although it is federally required that Medicaid guarantee

comprehensive coverage and care to eligible children, the rate of reimbursement is not universal.

While providers experience multiple setbacks in accepting Medicaid benefits, reimbursement

proves to be one of the most discouraging factors when deciding whether or not to participate as

a Medicaid provider (Nasseh & Vujici, 2015). According to a report conducted by the Pew

Center on the States, Medicaid is only reimbursing dental services at rate of 60.5% of the median

retail cost of dental services. The low reimbursement rate alone offers a substantial reason for

providers to withhold from participating in Medicaid since it does not cover overhead

operational costs for most offices. With such setbacks in place, this barrier to care for low

socioeconomic children cannot be eliminated (Miller & Shaefer 2011).

Comprehensive care. Due to the lack of importance consumers place on oral health, the

basic coverage offered is often less comprehensive when dental benefits are considered. Dental
LITERATURE REVIEW OF BARRIERS TO CARE 4

coverage is almost always offered separately from medical and vision benefits and sometimes is

not offered at all. Since there is a lack of value held in oral health, no group has risen to the

occasion of standing up for individuals who suffer from poor oral health as a result of lack of

dental coverage for the most basic services. If one agency, political affiliate, or community leader

stood up for the dental benefits necessary to reduce the number of barriers to care, the children

with low socioeconomic status in the United States would benefit greatly (Behrens & Lear,

2011).

Education Level of Parents

Correlation. In a 2012 study conducted in Washington state, researchers attempted to

draw a parallel between a low income mothers education level and the dental health of her child

or children. During the study the researchers ascertained whether or not the mothers themselves

had sufficient dental care and came to the conclusion that in most cases the mothers dental

health was much worse than that of the child. This outcome heavily supports the rationale to

eliminate barriers to dental care and provide education to members of low socioeconomic status

(Grembowski, Milgrom, & Spiekerman, 2012).

Perceived barriers. Many factors contribute to a parents ability to seek dental care for

their children. Parents with a low socioeconomic status have showed significantly lower

initiative in seeking healthcare information and that initiative is lowered further by lack of

education. Adding to this barrier is the fact that many parents with a lower education level also

perceive barriers to care even when they do not exist. Research indicates that in perceived

barriers, parents are standing in the way of getting care for their children more than the

accompanying factors. Many mothers who sought care for other ailments from a public health

clinic were directed to a dental provider who accepted coverage that they already had and did not
LITERATURE REVIEW OF BARRIERS TO CARE 5

know about. By promoting the public health clinics for children with low socioeconomic status,

the perceived barrier of no care being available can be destroyed (DiMarco, Lundington, &

Menke 2010).

Members of the low socioeconomic status have consistently displayed a lower level of

education that leads to less initiative in information seeking as far as the health of their children

is concerned. As the level of education decreases, the research shows more perception of barriers

to care that do not actually exist. Their confidence in seeking and comprehending the information

lowers significantly with a high school diploma or less; parents with a college education showed

significantly higher comprehension outcomes where health care related information was

involved. Furthermore, parents with a high school diploma or less also demonstrated less trust in

government health agencies which is where more of the care for Medicaid recipients takes place.

These barriers are perceived to be bigger than they are and cannot be eliminated until the parents

of children in low socioeconomic status are educated about the care that is available to their

children (Allen, Richardson, Vallone, & Xiao, 2012).

Another large factor in whether or not a mother seeks care for her child/children is

whether or not she herself fears dental treatment. Often times this fear is based in an ignorance

about what goes on during a dental appointment and this undermines importance of dental care

in relation to the childs oral and overall health. Without proper education, parents cannot be

expected to overcome their fears and seek dental care (DiMarco, Ludington, & Menke 2010).

Level of education. Members of the low socioeconomic status traditionally have a lower

level of education that heavily influences their healthcare knowledge; this has a dramatic effect

on health information seeking and is directly related to the dental health of the children who

utilize Medicaid benefits. The evidence from an article in the Journal of Health Care for the Poor
LITERATURE REVIEW OF BARRIERS TO CARE 6

and Underserved concluded that parents with a high school diploma or less displayed less

confidence and less initiative in seeking healthcare information for their children. The lack of

education demonstrated in the low socioeconomic strata is a concerning factor when considering

barriers to care (Allen, Richardson, Vallone, & Xiao 2012).

According to Carol, Guarnizo-Herreno, and Wehby (2012), the education level of a

parent can also have a direct effect on the ability to identify dental problems that their children

may be experiencing. This in turn will affect whether or not the parent seeks care and can lead to

dental ailments becoming worse over time. Education level also affects the nutritional decisions

of the household and this can lead to high sugar consumption and malnutrition, both maladies

which affect the childrens teeth and oral health. Finally, education level has shown to be related

to whether or not the parent in a low socioeconomic household enforces oral health routines at

home. Without proper nutrition, a standard oral care routine, and education about why these are

important, children in low socioeconomic households are at a strong disadvantage where oral

health is concerned.

Availability and Utilization

Medicaid. Medicaid is defined as the federal program that distributes funds to states for

health care services provided to certain groups including aged, blind, and disabled people; those

with low incomes; and certain members of families with dependent children (Nathe, 2011, p.

88). While dental benefits covered under Medicaid vary from state to state, every state is

required to cover a minimum of basic dental coverage for children. States decide the budget for

coverage based on the usage data collected from the providers to determine the level of coverage

and distribution to the recipients. Although this benefit is available to members of low

socioeconomic status, barriers to care related to cost are still prevalent (Nathe, 2012).
LITERATURE REVIEW OF BARRIERS TO CARE 7

According to Nathe (2011), when considering where to allocate funds, states use the fee-

for-service or capitation system. Fee-for-service is described as the fee scale developed for all

services provided by the dental provider and a payment is then developed for the service(s)

rendered, while capitation is described as when a dental provider contracts with a program to

provide all or most dental services to the programs subscribers in return for payment on a per

capita basis (p. 78). In general, capitation is used as an umbrella of funds to cover preventative

costs of dentistry while fee-for-service coverage is utilized for more costly treatments. Where

Medicaid is concerned, most states will limit dental coverage to children in order to cover more

services per child. Although this care is available, it is not always utilized fully and still stands as

a barrier to care.

Although the Medicaid benefits cover full dental services for children, the utilization rate

is still low among eligible children. As of 2010, only 30-40% of eligible children in the United

States were utilizing their benefits. This disparity in care can be linked to shortage of providers,

geographic location of offices, and availability of dental benefits by state. This barrier to care is

significant to children and needs to be considered when providing care to those with low

socioeconomic status (DiMarco, Ludington, & Menke 2010).

Shortage of providers. According to Behrens and Lear (2011), the current supply of

dental providers is unable to keep pace with the level of care necessary for the underserved

population in the United States and is expected to reduce in capacity over the coming years. Cost

of professional education, impact of cost on operating offices, and lengthy paperwork procedures

all contribute to the shortage of providers who are willing to accept Medicaid.

The shortage of providers being experienced has become more prevalent in recent years

leaving millions of children without access to care; this shortage has been shown to have a
LITERATURE REVIEW OF BARRIERS TO CARE 8

substantial impact on the underserved population as compared to the affluent population due to

income, availability of Medicaid benefits, and the geographic location of the community in need

of more care. These disparities represent a large barrier to care for the members of the low

socioeconomic status and these needs must be met before the barrier can be eliminated

(Isringhausen, VanderWielen, & Vanderbilt, 2014).

Conversely, a study conducted by the Health Policy Institute for the American Dental

Association suggests that there is no shortage in providers in the United States; the authors went

on to predict that by the year 2033 there would be a steady increase in providers when compared

to the population. Ultimately the research suggests that while the numbers demonstrate no

shortage in supply of providers, the adequacy of the workforce and changing needs of the

population may alter the outcomes of the study. Furthermore, the model utilized in this study was

operated under ideal circumstances rather than allowing for potential alternative outcomes.

Although this research states that as of now there is no shortage of dentists expected, the

alternate possibilities in outcomes of the study continue to suggest a need for more providers in

order to eliminate barriers to care for the underserved population (Munson & Vujicic 2014).

Distribution and location. In addition to a shortage of providers, the members of the low

socioeconomic status are also experiencing a misdistribution of providers; most dental practices

are located in affluent areas, discouraging those without means to visit these practices (Behrens

& Lear, 2011). The location of offices also makes it difficult to obtain appointments and even

when the appointment is made it is difficult to keep since it is made so far in advance (DiMarco,

Ludington, & Menke, 2010). The declining dentist-to-population ratio also contributes to the

distribution of dental providers; although the general population does not experience the shortage
LITERATURE REVIEW OF BARRIERS TO CARE 9

as heavily as the individuals with low socioeconomic status, the shortage is still in full effect

(Biordi et al, 2015).

According to Isringhausen, VanderWielen, and Vanderbilt (2014), the number of dentists

needed to cover the current shortage for the total population would be 6,600 dentists. Their study

points out that the low socioeconomic population, Medicaid recipients, and those living in rural

communities suffer from this misdistribution of providers more than any other population.

Without some sort of dramatic change in the way the providers are distributed, this barrier to care

cannot be addressed.

Preventative Care and Systemic Disease

Dental caries. Dental caries, more commonly known as cavities, has been named the

silent epidemic in the United States in a report from the Surgeon General. A staggering 80% of

tooth decay occurs in low-income families and points out a significant connection to the many

barriers to care experienced by this population (DiMarco, Ludington, & Menke 2010). It has

been suggested that along with other factors, dental disease including caries has a significant

impact on the quality of life experienced by members of the low socioeconomic status (Kleber,

Olmsted, Rublee, & Zurkawski, 2013). The importance of eliminating these barriers to care is

highlighted yet again by Nathe (2012) who states that dental caries continues to be one of the

most common chronic diseases of childhood (p. 4). In the destruction of the barriers faced by

children with a low socioeconomic status, a widespread, chronic disease can be prevented and

eliminated the in United States (Nathe, 2011).

Compounding health problems. When considering life-long health problems for

children, oral health as a child has a large impact on oral health as an adult (Gremowski,

Milgrom, & Spiekerman, 2012). As aforementioned, dental caries is considered to be one of the
LITERATURE REVIEW OF BARRIERS TO CARE 10

most common chronic diseases of childhood and must be taken seriously as a disease since the

oral health of a child affects the overall health of a child. The lack of knowledge about dental

health and its relation to overall health can lead to pain stemming from the absence of

preventative dental care for children (Nathe, 2012). Furthermore, children with a low

socioeconomic status are at a higher risk for oral disease that can lead to long term overall poor

health that compounds over their lifetime (Miller & Shaefer, 2011).

As childrens dental needs are neglected the chance to intercept chronic diseases early on

disappears. Many systemic diseases such as diabetes, HIV/AIDS, heart disease and other

inflammatory diseases can be detected early in life with regular dental screenings that these

children are missing out on (DiMarco, Ludington, & Menke, 2010). Preventative dental care has

to be received in a timely manner in order to prevent issues later in life with hospital visits,

dental costs, and improved overall care (Kenney, Klein, Marton, Pelletier, & Talbert, 2011).

According to Alfano, Fulmer, Shelley, Stradtlander, and Strauss (2012), research has shown that

chronic diseases other than dental caries are being recognized and appreciated by dental

providers; this shows potential in finding even more reasons to break down the remaining

barriers to dental care for those in the low socioeconomic status.

Possible Solutions

Lowering costs. In order to remedy the rising costs of healthcare and combat the many

problems that arise with Medicaid coverage, it has been suggested that federal laws be put in

place rather than letting states determine funding for dental needs. The expansion of care in the

Childrens Health Insurance Program and the Affordable Care Act have been instrumental in

attacking barriers at their core but have yet to show significant decreases in the barriers to care

for children with a low socioeconomic status. In order to improve these processes, it has been
LITERATURE REVIEW OF BARRIERS TO CARE 11

suggested that small improvements would make large differences in the underserved population

(Behrens & Lear 2011). It has also been suggested that raising reimbursement rates would lower

the overall cost of dental care for children with low socioeconomic status. With the current

reimbursement rate being too low to cover overhead operational costs for most providers, a

reimbursement rate increase could be implemented to incentivize more providers to accept

Medicaid benefits (Miller & Shaefer, 2011).

According to Nathe (2011), Medicaid is often operated under private insurance

companies. By removing Medicaid from private insurance agencies and placing it under federal

regulations, uniform care can be obtained rather than being delegated state by state. As of now,

states have the option to provide straight Medicaid plans, separate CHIP, or Childrens Health

Insurance Program plans, or a combination of the two. If the funds all came from the same place

and were uniformly applied to children, the question to whether or not a child qualifies for care

would be erased.

Diagnostic codes. In order to implement a more regulated federal system for payments,

dental offices must begin using diagnostic codes, or codes that describe what a patient is

diagnosed with, rather than just procedural codes, or what treatment was performed. The

diagnoses codes allow providers and insurance companies to track procedures and treatments and

in turn allocate funds for such services. With the use of procedural codes only, providers are not

tracking the prevalence of dental maladies and funds cannot be allocated properly (Behrens &

Lear, 2011).

Literacy campaigns. In order to address the level of education of the parents of children

with low socioeconomic status, it has been suggested that a national oral health literacy

campaign be implemented. This campaign would be directed at parents whose children qualify
LITERATURE REVIEW OF BARRIERS TO CARE 12

for Medicaid benefits and would include information on the importance of optimal oral health

(Behrens & Lear, 2011). Similarly, health promotion classes could also alleviate the barrier of

lack of education for parents and offer information tailored to the beliefs of the families at

highest risk. These classes would include information about receiving dental care prior to

seeking an appointment to attempt to alleviate some of the fears associated with visiting the

dental office (DiMarco, Ludington, & Menke, 2010).

The use of preventative care among children with Medicaid benefits relies strongly on the

attitudes of their parents toward dental care and the importance of prevention rather than

treatment. Current no-show rates for appointments made for children with Medicaid further

indicates a lack of knowledge about the importance of preventative care; the absence of dental

pain therefore results in the parent believing that there is no need for dental care. This trend of

not keeping an appointment lends to the lack of providers willing to accept Medicaid and ties

two prominent barriers in together. In order to eliminate this barrier and relieve the providers

from high no-show rates, a prenatal and postpartum education program has been suggested to

educate mothers earlier and highlight prevention rather than pain relief where dental

appointments are concerned. This suggestion would eliminate the need for costly dental

procedures as well as pain experienced by children at a young age due to dental disease (Gold &

Rahbari, 2015).

Increase provider pool. In order to combat the shortage and misdistribution of dental

providers for the underserved population, it has been suggested that the addition of a mid-level

provider be considered. There has been much opposition of this mid-level dental therapist

displayed by the American Dental Association and similar affiliations citing reasons such as the

possibility of inadequate levels of care and inferior service; however, multiple studies have
LITERATURE REVIEW OF BARRIERS TO CARE 13

shown that the addition of a mid-level provider, or dental therapist, would remedy the shortage

situation without decreasing the quality of care received. Dental therapists are directed

specifically at treating the underserved population that is already lacking care rather than as a

competitive entity for a dentist. This in itself lends to the necessity of a mid-level provider and

suggests that a significant barrier to care has the possibility of being eliminated (Friedman &

Mathu-Luju, 2014).

These mid-level practitioners would not have the same job descriptions as a dentist,

rather they would perform only an expanded version of what a registered dental hygienist does as

of now. Depending on the laws, the dental therapist would be under direct or indirect supervision

of a dentist further pointing out the necessity of the dentist to remain in practice as they are. The

dental therapist would perform procedures such as basic preventative and restorative treatment

with the intent to deliver dental care to the underserved population, especially children (Miller &

Shaefer, 2011).

Dental hygienists and assistants also pose a significant possibility in decreasing the

barriers to care when their scope of practice is considered. Many laws prohibit these dental

providers from conducting care that they are able to do but are not legally allowed to practice. It

has been recommended by other dental providers that the current scope of practice laws be

standardized across the United States rather than be determined on a state-by-state basis in order

to eliminate any confusion as to what the provider is legally able to do. Since most dental offices

in the United States are located in communities with a majority of private-pay patients, the

expansion of the role of the dental hygienist and assistant would remove the limitations on

geographic location and allow hygienists and assistants to work where the underserved

population is located (Behrens & Lear, 2011).

LITERATURE REVIEW OF BARRIERS TO CARE 14

As the dentist-to-population ratio continues to decline and presents a large barrier to care

for those with low socioeconomic status, the addition of only one kind of mid-level provider may

not be enough to meet the already present demands of the underserved population. It has been

suggested that cross-training other health care providers, such as nurse practitioners and

dieticians, would improve access to care especially for children. These types of providers are

readily available at medical and WIC offices that low-income parents take their children to on a

regular basis and can provide the most basic preventative dental measures such as fluoride

application and oral health education with little to no interruption in their schedule. This solution

provides mothers who are waiting for appointments with necessary information on oral health

and where to obtain care. With proper utilization, this solution could remedy the declining

provider ratio (Biordi et al., 2015).

To further encourage providers to work in the low socioeconomic arena and limit the

shortage of providers, it has been suggested that incentives be added for those who choose to

accept Medicaid and locate their offices in less affluent areas to attract the underserved

population. Measures such as loan forgiveness programs can lessen the burden on providers

leaving more financial freedom to treat patients with Medicaid. The implementation of a

community care leader, or an individual in each low socioeconomic area who coordinates

education and utilization efforts in order to eliminate barriers to care has also been suggested to

alleviate some of the concerns faced with Medicaid benefits. The burdens of lengthy paperwork

and bureaucratic demands on those who accept Medicaid would be lessened and the provider

could in turn focus more on the care of the underserved population. With these suggestions, the

barriers to care presently experienced should be lessened or eliminated (Behrens & Lear, 2011).
LITERATURE REVIEW OF BARRIERS TO CARE 15

Location. Behrens and Lear (2011) go on to suggest alternate treatment sites in order to

engage providers and offer care at different geographic locations. School-based oral care services

have been suggested as an alternate site for care; preventative procedures such as fluoride

application and cursory dental screenings could be performed by school nurses at regular checks.

Mobile dental units are also becoming increasingly popular in treatment modules and are ideal in

that they do not require any additional space or supplies for school to contend with. These small

suggestions can make large differences in the care that children with low socioeconomic status

receive.

FHQs. When dealing with the barriers to care faced by low socioeconomic children, the

research suggests that the shortage and misdistribution of providers experienced is one of the

most significant problems faced. An FHQ, or federally qualified health center, is a clinic based

care center that has specific requirements as far as location and patient load are concerned; they

must be located in medically underserved areas or serve a medically underserved population

(p. 5). These sites provide dental care to children with Medicaid and are often located with more

geographic convenience as compared to the more affluent offices. It has been suggested that by

developing a dental residency program at the FHQs, dentists may be more likely to remain in

the public health arena and continue to serve the low socioeconomic population rather than move

into a more affluent location. Furthermore, the FHQ sites have begun to develop relationships

with surrounding dental schools in order to provide care and education for children and their

parents. The research goes on to show a positive correlation to access to care when the

relationship between an FHQ and a dental school is developed; the potential to decrease a

significant barrier to care has presented itself in this study (Isringhausen, VanderWielen, and

Vanderbilt, 2014).
LITERATURE REVIEW OF BARRIERS TO CARE 16

Systemic Health

Prevention. As mentioned previously, children with a low socioeconomic status are most

likely to experience dental disease due to the barriers to care that they face; these problems can

compound over a lifetime and cause serious health problems (Miller & Shaefer, 2011). Research

shows that receipt of preventative dental care for children lessens the likelihood of dental costs

later in life as well as improved overall health for the child (Kenney, Klein, Marton, Pelletier, &

Talbert, 2011). Although most children with Medicaid do not receive their first dental screening

before twelve months of age, they do attend multiple well baby visits that are covered by their

Medicaid benefits. These visits are aimed at the medical health of the child, but many providers

have begun to suggest that the parents seek dental visits during such appointments. This shift in

focus to preventative care has shown to reduce the need for more invasive procedures during

childhood or later in life. Furthermore, the research suggests that a dental screening within the

first twelve months of life during a well baby visit would promote better dental health and

encourage parents to follow up with a dentist regularly. Understanding the relationship between

dental health and overall health is imperative to the importance of overcoming barriers to care

for the underserved children in the United States (Askelson et al, 2013).

Conclusion

Summary

Children with a low socioeconomic status face many barriers to care when seeking dental

treatment. This literature review has focused on four main research questions and the possible

solutions in breaking down those barriers. Through the research presented in this review, the

different types of barriers and their importance were highlighted; detailed solutions were offered

to remedy the barriers and overcome the unmet needs for children with Medicaid in the United
LITERATURE REVIEW OF BARRIERS TO CARE 17

States. It is imperative that these barriers be broken down or there will continue to be an unmet

need for a large underserved population.

Span of Research

The research pertaining to barriers to care for those in a low socioeconomic status dates

back for decades; for purposes of this literature review, the research was limited to a five-year

span dating from 2010-2015. Some studies regarding the barriers to care experienced are still

ongoing and are expected to reveal more up to date trends regarding the ever changing climate

the low socioeconomic status faces. This ongoing research lends to the lack of up-to-date

information and statistics within recent years.

A Time to Act

The barriers to care highlighted within this literature review are not considered to be new

or recently developed. They have been active for a number of years without much progress in

obtaining ways to overcome the plight of the underserved population. In order to aid this

population, the current legislators, dental providers, and citizens alike must come together and

recognize the lack of dental care to children with low socioeconomic status as an important issue

in the United States and stand together to eliminate these barriers to care. The vision for the

future of preventative dentistry must be focused on the overall population rather than the affluent

members of society. Only then can the barriers to care be overturned and dental caries be

eradicated as the number one chronic disease among children in the United States.
LITERATURE REVIEW OF BARRIERS TO CARE 18

References

Alfano, M. C., Fulmer, T., Shelley, D., Stadtlnder, C. T., & Strauss, S. M. (2012). The role of

dental practices and dental science research in addressing systemic health

conditions. American Journal of Public Health, 102(9), E5-E6. Retrieved from

http://search.proquest.com/docview/1045927008?accountid=28644

Allen, J. A., Richardson, A., Vallone, D., & Xiao, H. (2012). Effects of race/ethnicity and

socioeconomic status on health information-seeking, confidence, and trust. Journal of

Health Care for the Poor and Underserved, 23(4), 1477-93. Retrieved from

http://search.proquest.com/docview/1281823530?accountid=28644

Askelson, N. M., Chi, D., Damiano, P. C., Jones, M. P., Kuthy, R. A., Momany, E. T., & Wehby,

G. L. (2013). Relationship between medical well baby visits and first dental examinations

for young children in Medicaid. American Journal of Public Health, 103(2), 347-354.

Retrieved from http://search.proquest.com/docview/1312687933?accountid=28644

Behrens, D., Lear, J. G. (2011). Strengthening childrens oral health: Views from the field.

Health Affairs, 30(11), 2208-13. Retrieved from

http://search.proquest.com/docview/908419464?accountid=28644

Biordi, D. L., DiMarco, M., Fitzgerald, K., Heitzer, M., Mundy, E., Taylor, E., . . . Thacker, S.,

(2015). Improving access and provision of preventive oral health care for very young,

poor, and low-income children through a new interdisciplinary partnership. American

Journal of Public Health, 105, E23-E29. Retrieved from

http://search.proquest.com/docview/1667326556?accountid=28644
LITERATURE REVIEW OF BARRIERS TO CARE 19

Carol, C., Guarnizo-Herreo, C. C., & Wehby, G. L. (2012). Explaining Racial/Ethnic disparities

in children's dental health: A decomposition analysis. American Journal of Public

Health, 102(5), 859-866. Retrieved from

http://search.proquest.com/docview/1009903823?accountid=28644

DiMarco, M. A., Ludington, S. M. , & Menke, E. M. (2010). Access to and utilization of oral

health care by homeless children/families. Journal of Health Care for the Poor and

Underserved, 21(2), 67-81. Retrieved from

http://search.proquest.com/docview/603850677?accountid=28644

Friedman, J. W., & Mathu-Muju, K. (2014). Dental therapists: Improving access to oral health

care for underserved children. American Journal of Public Health, 104(6), 1005-9.

Retrieved from http://search.proquest.com/docview/1538587468?accountid=28644

Gold, J., & Rahbari, M. (2015). Knowledge and behaviors regarding early childhood caries

among low-income women in Florida: A pilot study. Journal of Dental Hygiene, 89(2),

132-138. Retrieved from http://jdh.adha.org/content/89/2/132.full

Grembowski, D., Milgrom, P., & Spiekerman, C. (2012). Social gradients in dental health among

low-income mothers and their young children. Journal of Health Care for the Poor and

Underserved, 23(2), 570-88. Retrieved from

http://search.proquest.com/docview/1013613548?accountid=28644

Isringhausen, K., VanderWielen, L. M., & Vanderbilt, A. A. (2014). Addressing health care

disparities and access to dental care while improving education: Schools of dentistry and

federally qualified health centers. Journal of Health Care for the Poor and
LITERATURE REVIEW OF BARRIERS TO CARE 20

Underserved, 25(2), 670-4. Retrieved from

http://search.proquest.com/docview/1534012175?accountid=28644

Kenney, G. M., Klein, A. E., Marton, J., Pelletier, J. E., & Talbert, J. (2011). The effects of

Medicaid and CHIP policy changes on receipt of preventive care among children. Health

Services Research, 46(1), 298(21). Retrieved from

http://www.galenet.com.ezproxy.sienaheights.edu:2048/servlet/HWRC/hits?

docNum=A250677427&year2=&year1=&index3=KE&index2=AU&index1=TD&tcit=0

_1_0_0_0_0&index=BA&locID=lom_sienahul&rlt=2&text3=&text2=kenney&origSearc

h=true&text1=medicaid+and+chip+policy+changes&op2=AND&op1=AND&t=RK&s=

11&r=d&o=&secondary=false&n=10&day2=&l=d&day1=&month2=&month1=&search

Term=2NTA&c=1&bucket=per

Kleber, L., Olmsted, J. L., Rublee, N., & Zurkawski, E. (2013). Public health dental hygiene: An

option for improved quality of care and quality of life. Journal of Dental Hygiene, 87(5),

299-308. Retrieved from http://jdh.adha.org/content/87/5/299.full

Miller, M., & Shaefer, H. L. (2011). Improving access to oral health care services among

underserved populations in the U.S.: Is there a role for mid-level dental

providers? Journal of Health Care for the Poor and Underserved, 22(3), 740-4. Retrieved

from http://search.proquest.com/docview/903813884?accountid=28644

Munson, B., & Vujicic, M. (2014). Supply of dentists in the United States is likely to grow.

Health Policy Institute Brief. Retrieved from http://www.ada.org/~/media/ADA/Science

%20and%20Research/HPI/Files/HPIBrief_1014_1.ashx
LITERATURE REVIEW OF BARRIERS TO CARE 21

Nathe, C. (2011). Dental public health & research: Contemporary practice for the dental

hygienist. (3rd ed.). Boston, MA: Pearson Education, Inc.

Nathe, C. (2012). Low income populations. RDH, 32(32). Retrieved from

http://search.proquest.com/docview/1037690099?accountid=28644

Nasseh, K., & Vujicic, M. (2015). The impact of Medicaid reform on childrens dental care

utilization in Connecticut, Maryland, and Texas. Health Services Research, 50(4), 1236-

14. Retrieved from

http://www.galenet.com.ezproxy.sienaheights.edu:2048/servlet/HWRC/hits?

r=d&origSearch=false&o=DateDescend&bucket=per&rlt=2&n=10&l=d&basicSearchOp

tion=KE&c=1&tcit=1_1_0_0_0_1&docNum=A426541971&locID=lom_sienahul&secon

dary=false&t=KW&s=1&SU=medicaid+dental+children

Sparer, M. (2011). US health care reform and the future of dentistry. American Journal of Public

Health, 101(10), 1841-4. Retrieved from

http://search.proquest.com/docview/894726440?accountid=28644