Racial and ethnic inequities in children’s oral health persist from coast to coast, according to data published by 22 states and analyzed by The Pew Charitable Trusts. The prevalence of treated and untreated tooth decay among American Indian, Alaska Native, Native Hawaiian, Hispanic, and Black third-graders is considerably higher—and the use of dental sealants to prevent decay tends to be lower—than in their White classmates.
Many children lack access to regular, quality dental care, especially if they rely on public insurance or live in areas with a shortage of dentists. For example, according to data reported by the Centers for Medicare and Medicaid Services, about half of the children enrolled in Medicaid did not see a dentist in 2019.
The analysis also found that many states do not consistently collect or report important children’s oral health indicators by race and ethnicity, which undermines the states’ ability to measure progress in advancing health equity.
Pew has long advocated for states to improve children’s oral health by authorizing dental therapists to provide routine preventive and restorative care in underserved communities and allowing dental hygienists to administer dental sealants in schools and other community settings.
This analysis is based on results from each state’s most recent Basic Screening Survey (BSS), a standardized surveillance tool that the Association of State and Territorial Dental Directors developed to help states collect oral health data. It presents data on three indicators: untreated decay, caries experience (treated and untreated decay), and dental sealants.
States use different categories and terminology for racial and ethnic populations. For example, some categorize American Indian and Alaska Native populations together, others segment American Indians, and Hawaii reports on Native Hawaiians. To present the data as clearly as possible in the following section (“Results by race and ethnicity”), Pew uses Black, Hispanic, and White across all states, and groups the topline data for American Indian, Alaska Native, and Native Hawaiians together. This approach is imperfect, but the map reflects the distinct categories and terminology that each state uses.
Results by race and ethnicity
American Indian, Alaska Native, Native Hawaiian. Six states have reported data on American Indian, Alaska Native, and Native Hawaiian third-graders at least once since 2010. Compared with their White classmates, these children were up to 4.6 times more likely to have untreated decay and up to 7.7 times more likely to have experienced caries.
White children were up to 2.5 times more likely to have sealants than American Indian and Alaska Native children in three states, and 1.5 times more likely than Native Hawaiian children. In the other two states, American Indian and Alaska Native children were 1.5 times more likely to have dental sealants than White children.
Black. Fifteen states have reported data for these indicators for Black third-graders at least once since 2010. These children were up to 2.6 times more likely to have untreated decay and up to 2.3 times more likely to have experienced caries than White classmates. In one state, the prevalence of untreated decay was lower for Black children than their White peers and, in two others, Black children had similar or lower prevalence of caries, when compared to White children.
In 13 of 14 states, White children were up to 2.1 times more likely to have dental sealants than Black children. In one, Black third-graders were 1.2 times more likely to have dental sealants than White children.
Hispanic. Sixteen states have reported oral health data for Hispanic third-graders since 2010. In 11 of them, Hispanic children were up to 1.5 times more likely to have untreated decay than White students. In the other five, Hispanic third-graders were less likely to have untreated decay than White third-graders. Across 15 states, Hispanic children were up to 3.5 times as likely to have experienced caries. In one state, the prevalence of both untreated decay and caries was similar or lower for Hispanic third-graders compared with White third-graders.
In seven out of 15 states that reported dental sealant data for Hispanic children, White children were up to 2.1 times more likely to have sealants than Hispanic children. In the other eight states, Hispanic third-graders were equally likely or up to 1.3 times more likely to have dental sealants than White children.
Gaps in data
Most states are not reporting children’s dental health by race or ethnicity in a consistent, comparable, and timely way. Consequently, Pew limited this analysis to the 22 states that published BSS survey results online for some combination of White, Black, Hispanic, American Indian, Alaska Native, and Native Hawaiian third-graders at least once since 2010. Even among this cohort, most states’ data is at least four years old.
Of the 28 states not included in the analysis, nine had recent data segmented by race and ethnicity but with different grades combined; six segmented data by race and ethnicity but have not published data since 2010; seven had recent data but did not segment it by race or ethnicity; four did not make their reports available online; and two have never administered the BSS.
States should use the BSS or other standardized public health surveillance tools to generate the data that public health agencies need to identify inequities in oral health, design interventions to close the gaps, and track progress. Without this information, millions of children will continue to suffer disproportionately from poor oral health into adulthood because of where they are born, live, go to school, and work.
Persistent oral health inequities
Racial and ethnic inequities in oral health are a long-standing problem in the United States.
In 2020, Pew conducted an analysis of data from the Centers for Disease Control and Prevention comparing oral health among White, Black, Mexican American, and higher- and lower-income children and adolescents between 1999-2004 and 2011-2016. Although there were substantial oral health gains overall, relative gaps by race and income widened over that time period for some indicators. For example, untreated decay decreased for all children aged two to five in the surveys, but relative differences increased by race and income because Black, Mexican American, and lower-income children started with much higher prevalence of disease than White and higher-income children.
Several years earlier, Pew shared similarly troubling statistics showing that populations of color are more likely to experience tooth decay and loss and less likely to be able to visit a dentist and receive preventive treatments than White populations. In 2014, for example, more than 40% of preschool-aged American Indian and Alaska Native children had untreated decay, compared with about 20% of Black and Hispanic children and 11% of White children.
These inequities are, in part, the consequence of an inadequate dental delivery system. Access to dental care is limited for the millions of children—disproportionately children of color—who rely on Medicaid and the Children’s Health Insurance Program. Fewer than a third of U.S. dental practices treated any patients on public insurance in 2020. Black and Hispanic dentists are more likely than White dentists to treat Medicaid beneficiaries, but they are underrepresented in the profession.
Geography also contributes to inequity: More than 64 million people in the United States—including millions of children—live in areas with dentist shortages. Children are further denied care when their parents cannot access transportation or take time off from work.
When people do not have regular access to dentists, many seek care in emergency rooms. Children enrolled in Medicaid account for most pediatric dental visits to the ER, about 70% in 2017. These facilities can provide short-term relief for symptoms (e.g., by administering pain medication and antibiotics), but they do not treat underlying dental conditions.
Expanding access to dental care
Similar to physician assistants in medicine, dental therapists are members of the dental team who can perform preventive and routine restorative procedures once limited to dentists, such as filling cavities, placing temporary crowns, and extracting badly diseased or loose teeth. In the 13 states where they are authorized to practice, these professionals expand access to care, prevent disease, and enhance quality of life, especially for underserved and vulnerable populations, including racial and ethnic minorities, Americans in federally designated shortage areas, rural residents, and people on public insurance. Lawmakers in the remaining states and territories can expand access to care by authorizing these providers.
Policymakers can also remove state-level barriers that prevent or limit dental hygienists from administering dental sealants in community settings, including schools. School-based sealant programs are a highly efficient, convenient, and cost-effective way to provide preventive care to children whose parents have inflexible work schedules, lack insurance, or otherwise cannot afford dental care.
This analysis examines prevalence of untreated decay, caries experience, and dental sealants among White, Black, Hispanic, American Indian, Alaska Native, and Native Hawaiian third-graders. It is based on the states’ most recent publicly available results of the Basic Screening Survey since 2010. Pew selected third-graders because they are the most consistently reported age cohort across states. To maintain consistency in the data, we excluded states that combined children from multiple grades. We set 2010 as the cut-off date to balance the need to include as many states as possible against the need for timely data. These criteria led to 22 states being included in the analysis.
The Association of State and Territorial Dental Directors advises that, while BSS data should not be used to “test research hypotheses,” they can be used for “the identification of populations at high risk.” Pew’s analysis of the data provides a historical snapshot and is not intended to indicate trends. Because it includes only 22 states, it is not representative of and should not be generalized to the United States. In addition, given the variability in the years of the data, this analysis should not be used to compare the performance of states relative to each other.
Allison Corr is an officer with The Pew Charitable Trusts’ dental campaign and Josh Wenderoff is an officer with Pew’s health programs. Maureen Bowers with Pew’s research review and support team led the data collection for this analysis.