The Behavioral Risk Factor Surveillance System (BRFSS) is a health-related telephone survey conducted in all 50 states, the District of Columbia, and several US territories. Adults aged 18 years and older in households with telephones are contacted via random-digit dialing, and interviewers use a computer-assisted, telephone-interviewing system to conduct the survey. North Carolina has participated in the BRFSS since 1987. In 2011, a new weighting methodology—raking, or iterative proportional fitting—was implemented, along with the addition of cell phone interviews, in order to reduce the bias in BRFSS estimates and improve the generalizability of the results to the statewide population. Due to these changes, BRFSS results from 2011 and later are not comparable with earlier years [1].
In even-numbered years, the core BRFSS questionnaire contains a module on Oral Health (see Figure 1). These Oral Health survey questions are asked biannually, and no changes are made to questions between survey years.
BRFSS Oral Health Module Questions
Dental Visits
The BRFSS Oral Health module begins with a question regarding dental visits. Results for North Carolina are presented as the calculated variable “Adults with a Dentist or Dental Clinic Visit within the Past Year for Any Reason” in Table 1. In 2016, 63.6% of adults visited a dentist or dental clinic within the past year for any reason, which is not statistically different from the 2012 and 2014 results. Variation among selected sociodemographic groups does exist. In 2016, for those with less than a high school education, only 34.8% visited a dentist or dental clinic within the past year, while 82.2% of college graduates had a visit in the past year. A similar trend is seen in household income, where 40.2% of adults in a household with less than $15,000 annual income had a visit within the past year, and 83.2% of adults in a household with $75,000 or higher annual income had a visit within the past year.
Trends in Adults with a Dentist or Dental Clinic Visit Within the Past Year for Any Reason by Sociodemographic Groups in North Carolina, 2012–2016
Continuing to look at the 2016 survey results, another category with significant differences is those identified with a disability. Of adults with a disability, 53.3% had a visit within the past year, while 66.1% of adults without a disability had a visit within the past year. Veterans had a higher visit percentage, with 71.7% of veterans having a visit within the past year, while 62.5% of non-veterans had a visit within the past year.
Meanwhile, the most recent national data on adults with a visit to a dentist or dental clinic within the past year for any reason is for 2014, when the median response for all states, DC, and territories was 65.3%, with a range from 54% in Guam to 74.9% in Connecticut [2].
Teeth Removed
The second BRFSS Oral Health module question results for North Carolina are presented in Table 2 as “Adults That Have Not Had Any Permanent Teeth Extracted.” No statistical difference exists among the 2016 result of 52.4% of adults who did not have permanent teeth extracted because of tooth decay or gum disease in comparison to results from 2012 and 2014.
Trends in Adults That Have Not Had Any Permanent Teeth Extracted by Sociodemographic Groups in North Carolina, 2012–2016
The most striking variation in percentages of adults who have not had permanent teeth removed is the breakdown by age group. In 2016, 78.5% of adults in North Carolina aged 18–34 years old have not had permanent teeth removed, while only 19.0% of adults 75 years old and older have not had permanent teeth removed. Statistically significant differences are also observed in education level and household income, with increasing percentages of adults with no permanent teeth removed with increased education level as well as with increased household income.
Regarding veteran status, 45.6% of veterans have had no permanent teeth removed, while 53.3% of non-veterans have not had permanent teeth removed. An examination of the veteran population shows that a third of the survey respondents who are veterans are 65 years old or older, while in the non-veteran response group only 17.5% are 65 years old or older. Another statistically significant difference exists based on disability status, with 28.8% of adults with a disability having had no permanent teeth removed. Of those without a disability, 56.3% have not had permanent teeth removed.
Nationally, the median response for all states, DC, and territories in 2014 showed that 56.4% of adults had not had permanent teeth removed for tooth decay or gum disease. The range for percent of adults with no permanent teeth removed was from 39% in Puerto Rico to 66.8% in Utah [2].
Limitations
The BRFSS is self-reported data, and respondents may not accurately recall their last dental visit. As it is a telephone survey, adults in households without a telephone are not included. Finally, the survey data are cross-sectional and cannot be used to determine causality.
Conclusion
The BRFSS provides state-level data on oral health status that can be examined for various sociodemographic groups. While the overall trends have not changed significantly from 2012 to 2016, sub-populations are identified with poorer oral health outcomes that can be targeted through specific programs and outreach efforts.
Acknowledgments
The State Center for Health Statistics receives support from the Centers for Disease Control and Prevention to conduct the BRFSS.
Potential conflicts of interest. E.E.H. has no relevant conflicts of interest.
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