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The association between predisposing, enabling and need factors and oral health care utilization among U.S. working age adults

BMC Oral Health volume 25, Article number: 501 (2025) Cite this article

Abstract

Background

Irregular dental visits due to cost-related delays contribute to poor oral health outcomes, dental needs, and emergency service utilization across the life course. The study investigated how predisposing, enabling, and needs factors are associated with cost-related delays in oral health care and postponed dental visits.

Methods

Using secondary data from the 2022 National Health Interview Survey for United States (U.S.) adults aged 18–64 years, the study conducted descriptive, bivariate, and multivariate data analyses. Separate multivariable logistic regressions were used to model cost-related delayed oral health care and postponed dental visits (no dental visit in the past 12 months) as a function of predisposing, enabling, and need factors (n = 17,513). Predictor variables included race, education, smoking status, age, gender and employment status (Predisposing factors), family income as a percentage of the Federal Poverty Level (FPL) and Health Service Deficit (HSD) variables (no health insurance, no usual medical primary care provider, > 12 months of last medical exam and delayed medical care due to cost) (Enabling factors), difficulty engaging in social activities and the presence of > 1 comorbidity (Need factors).

Results

The prevalence of cost-related delayed oral health care was 20.2%, and that of postponed dental visits was 36.4%. Strong predictors for cost-related delayed oral health care emerged from predisposing factors (smoking OR = 1.47, 95% CI, 1.33, 1.62), enabling factors (no health insurance OR = 2.96, 95% CI, 2.56, 3.42), and need factors (difficulty engaging in social activity OR = 1.59, 95% CI, 1.34, 1.88) at p < 0.001. Enabling factors were the strongest predictors of postponed dental visits. The odds decreased with higher family income [> 400% FPL vs. < 100% FPL (OR, 0.50; 95% CI, 0.43, 0.58)], whereas the odds increased by 68%, 64%, 130%, and 57% for persons with no health insurance, no usual primary care provider, > 12 months of last medical exam, and delayed medical care due to cost, respectively.

Conclusions

Individual factors, including smoking, lack of health insurance, and difficulty engaging in social activity, were independently associated with cost-related delayed oral health care, and the strong links between postponed dental visits and HSDs provide a clear opportunity for advocating for medical and dental integration for patient-centered care.

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Background

The Healthy People 2030 objectives for oral health underscore the importance of increasing public engagement with the oral health system [1]. Despite this emphasis, challenges persist in accessing oral health care that is safe, quality, and affordable for many individuals [2, 3]. In the U.S., access to oral health care is often determined by income, insurance status, race, and ethnicity, and it extends beyond service availability to include their utilization [4]. As early as the first year of life, at least one annual dental visit is essential for maintaining optimal oral health for both individuals with partial and complete dentition [5]. The literature suggests that regular visits are linked to oral health outcomes, oral health-related quality of life, and a decrease in oral and craniofacial needs and serve as a key determinant of oral health across the life course [5, 6].

According to the World Health Organization’s oral health status report on high-income countries, disparities in the distribution of oral health services create a disadvantage for individuals in low socioeconomic groups [7]. Globally, disparities in access to oral care and service utilization persist across age, gender, socioeconomic factors (education, income, and occupation), urban-rural differences, ethnicities, and race, manifesting across various stages of life [3, 7,8,9].

Procrastination in dental visits poses a significant public health challenge, primarily driven by the financial barriers associated with oral health care costs [10]. These delays contribute to missed opportunities for the early detection of dental conditions, including caries and oral cancers, leading to a loss in preventive approaches for oral diseases. Furthermore, delayed dental visits correlate with infrequent overall dental attendance, impacting oral health and overall quality of life [10]. Notably, COVID-19 impacted the timeliness of oral health care. Kranz et al. 2021 [11] reported that 46.7% of U.S. adults delayed oral health care or dental visits due to the pandemic. The study reported delays for dental check-ups (74.7%), dental problems (12.4%), and scheduled treatment (10.5%). Additionally, the authors revealed that living in urban areas was associated with increased odds of delayed oral health care, likely because there were more cases of COVID-19 in urban areas than in rural areas [11].

The United States may have made some progress, achieving an overall figure of 17.8% for individuals experiencing delays or being unable to obtain essential dental services due to costs, from a base of 20.2% in 2019 [1]. Nevertheless, without coverage, the cost-related burden of dental visits rests on the individual, and even among those with coverage, cost remains a challenge in access to care for adults under 65 years [12]. The target is unmet for adults aged 18–64 in the U.S [1]. In 2020, individuals aged 18–44 years and 45–64 years reported 24.1% and 24.7%, respectively [1]. Individuals living below 100% and between 100% and 199% of the federal poverty line were less likely to make dental visits than those in higher income brackets [13]. Moreover, Lutfiyaa and colleagues reported that health service deficits, including lack of health insurance, not having a regular health care provider, delaying medical care due to cost, and not making a routine medical visit in one year, were associated with increased odds of not making regular dental visits [14]. These proxy measures of access to care and utilization are directly related to preventive healthcare access and uptake, and the relationship with dental visits highlights healthcare fragmentation and the medical-dental divide [3, 15, 16].

Reported cases of cost-related delayed care are decreasing among the dependent age groups [1]. Attention should be redirected towards the working adult age group, which has yet to meet oral health targets. Although, in recent times, adults retain most of their natural dentition, some working-age adults continue to experience similar rates of dental cavities, gum infections, and oral cancers as those reported about 20 years ago [17]. Addressing this requires policies implemented to enhance regular access to professional oral health care for working-age adults, ensuring routine access to preventive and prompt treatment to promote improved oral health outcomes [17]. An understanding of the individual and social factors would be essential. This insight will guide the planning and implementation of effective interventions. In the current study, we aimed to analyze the role of predisposing (e.g., education, employment), enabling (e.g., income, health service deficits), and need factors (e.g., functional limitations, comorbidities) in shaping cost-related delays in oral health care and postponed dental visits, independent of the impact of the COVID-19 pandemic. Grounded in Andersen’s health service utilization framework [18], this study seeks to inform policy strategies that address the individual and social factors that affect oral health while promoting equitable access to oral health care in the U.S.

Methods

Design

The target population for this cross-sectional study included adults aged 18–64 years from all 50 states in the U.S. living in households or noninstitutional group quarters. These data were drawn from the 2022 National Health Interview Survey (NHIS), managed by the National Center for Health Statistics, which collects health information about the noninstitutionalized population in the U.S., retrieved from the Integrated Public Use Microdata Series (IPUMS) website [19]. The NHIS is the longest ongoing household survey and is recognized as a gold standard for access to healthcare data. Sampling methodologies for the NHIS have been previously described elsewhere [20]. The final sample was obtained after a listwise deletion in the Stata software. Cases were dropped from the analysis when there was a missing value in at least one of the variables. Thus, an initial sample of 27, 515 was reduced to a final sample of 17, 513.

Dependent variables

The dependent variables were “cost-related delayed oral health care” and “postponed dental visit.” Cost-related delayed oral health care implies the lack of uptake of oral health care promptly due to cost [21]. At the same time, we have annotated postponed dental visits that were put off for other reasons besides cost in this study. Responses to the following question determined cost-related delayed oral health care: “During the past 12 months, have you delayed getting oral health care because of the cost?”. The variable name, “delaydt” from the IPUMS website had six possible responses (not in universe (niu), no, yes, unknown, /refused, unknown-not ascertained, unknown-don’t know) and these were recoded to generate a dichotomous variable with these options; “no” or “yes”, coded as 0 and 1 respectively. We thus excluded < 2% of the responses in the new variable now referred to as “cost-related delayed oral health care.” The second outcome variable postponed dental visits represented as “Dentint” was obtained from the IPUMS website and was defined as the interval between dental visits via the interview question which asked, “when the respondent had last seen someone for oral health care” This text considered dentists, orthodontists, oral surgeons, other dental specialists, and dental hygienists as providers of oral health care. The respondents selected from the following 11 options: niu, never, within the past 12 months, 1 year to < 2 years, 2 years to < 3 years, 3 years to < 5 years, 5 to 9 years, 10 + years, unknown-refused, unknown-not ascertained, unknown-don’t know. Next, we generated a dichotomous variable with the following options: yes, visit within last year, and no (postponed dental visits), coded as 0 and 1, respectively. With the new variable referred to as postponed dental visits, we excluded approximately 2% of nonvalid responses.

Independent variables

The selection of independent variables from the NHIS dataset was guided by the Anderson and Newman framework of health service utilization and previous research on dental service utilization [14, 22, 23].

Organized into three categories: predisposing factors, which refer to preexisting characteristics that influence an individual’s likelihood of utilizing oral health services; enabling factors, which either facilitate or hinder access to these services; and need factors, which encompass both perceived needs and those determined by an individual’s health status [24, 25]. Predisposing factors measured in this study were demographic characteristics such as age, gender (reference: males), education (less than high school (reference), high school or GED, college, bachelor’s or higher degree), and employment status; enabling factors include family income (<100% Federal Poverty level (reference), 100–199% Federal Poverty Level, 200–399% Federal Poverty Level, > 400% Federal Poverty Level). This variable represents the family income as a percentage of the U.S. Census Bureau’s poverty threshold for the same year. It is based on the individual’s income and does not account for tax [19, 26]. We placed health service deficits variables in this category because they influence health service utilization as described by Luftiyya M. N. and colleagues., 2011 [16], St Hill CA and colleagues, 2017 [27] and Luftiyya M. N. and colleagues., 2019 [14]. The variables were lack of health insurance coverage, no usual medical primary care provider, > 12 months last doctor visit, and delayed medical visit due to cost. Notably, the health insurance variable was a composite variable developed by IPUMS [19], which comprises the following categories: private insurance, military coverage, Medicaid, Medicare, health insurance Programs, state-sponsored plans, and other plans aside from Medicare. The need factors included functional limitations such as difficulty engaging in social activities, difficulty running errands, limitations in the type and amount of work, and the presence of one or more diagnosed comorbidities: asthma, arthritis, cancer, chronic heart disease (CHD), elevated cholesterol, dementia, depression, diabetes, heart attack, hypertension, chronic obstructive pulmonary disease, or stroke. Each of these twelve conditions was initially recoded as present or absent before developing a composite variable measuring the absence or presence of one or more conditions. See Fig. 1 for the organization of variables.

Covariates

The covariates were self-reported health status (excellent, very good, good, fair, poor), marital status, nativity status (describes the place of birth as either foreign-born or born in the U.S.), and region of residency (Northeast, Northcentral/Midwest, South, West).

Fig. 1
figure 1

Conceptual framework adapted from the Andersen Framework for health service utilization

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Analysis

For descriptive analyses, frequencies and percentages were used to summarize categorical data, whereas means and standard deviations were used to summarize continuous data. Chi-square tests were used to test associations between the dependent and independent variables. Bivariate and multivariate analyses were conducted. Separate multivariable logistic regression models regressed cost-related delayed oral health care and postponed dental visits in the last 12 months on the predisposing, enabling, and need factors. The models were adjusted for all listed covariates. Notably, one of the health service variables, delayed medical visits due to cost, was excluded from the model for cost-related delayed oral health care to avoid multicollinearity. Odds ratios (OR) for the independent variables were estimated and reported. We were mindful of the Table 1 fallacy [28], thus it is noteworthy that after adjusting for all the covariates, the remaining effects represented the direct effects, and the total effect included both direct and indirect pathways. Analyses were conducted via Stata version 18.0 (Stata Corp, College Station, TX). Sampling weights were applied throughout the analyses to obtain point estimates because data from the NHIS were collected through complex, multistage sampling, stratification, clustering, and oversampling of some population sub-groups [20]. All results were considered statistically significant at p-values less than 0.05.

Table 1 Association between predisposing, enabling and need factors and postponed dental visits and cost-related delayed oral health care
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Results

Descriptive analysis results

Our analytic sample (after listwise deletion) included 17,513 participants, representing an estimated target population of 184,146,405 Americans aged 18–64 years. The mean age was 40.9 years (95% CI, 40.6, 41.2), and the gender distribution was balanced (males: 49.4%). An examination of the prevalence cost-related delayed dental care and postponed dental visits revealed that 20.2% (95% CI, 19.4, 21.0) had delayed dental treatment due to cost, and 36.4% (95% CI, 35.4, 37.3) had not visited the dentist in the last 12 months. Regarding health service deficits (HSDs), 12% of the participants lacked health insurance, 13% did not have a usual primary care provider, 8% delayed medical care due to cost, and 20% had not visited for routine medical check-ups in the last 12 months (Table 2).

Table 2 Sociodemographic characteristics of study participants
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Bivariate analysis results

Table 1 shows that all the HSD variables were significantly associated with cost-related delayed oral health care and postponed dental visits (p < 0.001). Similarly, family income less than 100% FPL, having less than a high school degree, unemployment, and difficulty in engaging in social activities were associated with dental visits greater than 12 months (postponed dental visits) and cost-related delayed oral health care (p < 0.001).

Multivariate logistic regression of postponed dental visits, predisposing, enabling, and need factors

Strong predictors for postponed dental visits emerged from predisposing, enabling, and need factors. The odds of postponed dental visits among individuals with a college degree or bachelor’s degree or higher were lower by 33% and 54%, respectively (OR = 0.67, 95% CI, 0.57, 0.79, & 0.46, 95% CI, 0.39, 0.55) compared with those less than a high school degree. Compared with nonsmokers and females, smokers and males had 1.26 times and 1.25 times greater odds of postponed oral health care, respectively (95% C1, 1.16, 1.38; 95% CI, 1.14, 1.36). The higher odds were among the enabling factors. All the HSDs strongly predicted foregone oral health care. Individuals who had not undergone a medical exam in the last 12 months had 2.30 times greater odds of foregoing oral health care than those who had (OR = 2.30, 95% CI, 2.06, 2.56). Additionally, a lack of health insurance, no usual primary care provider, or delayed medical care due to cost increased the likelihood of foregoing care by 68%, 64% and 57%, respectively (OR = 1.68, 95%C. I, 1.46, 1.94; OR = 1.64, 95% CI, 1.44, 1.86 & OR = 1.57, 95% CI, 1.35, 1.81). Earning 200–399% of the FPL and > 400% of the FPL resulted in 27% and 50% lower odds for postponed dental visits, respectively (OR = 0.73, 95% C.I, 0.63, 0.85, & OR = 0.50, 95% CI, 0.43, 0.58). Additionally, individuals with one or more comorbidities had 1.11 times greater odds of receiving postponed dental visits care than those without comorbidities (95% CI, 1.01, 1.22). (Table 3).

Table 3 Multivariate logistic regression of postponed dental visits, predisposing, enabling and need factors
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Multivariate logistic regression of cost-related delayed oral health care and predisposing, enabling, and need factors

Predisposing, enabling, and need factors strongly predicted cost-related delays in oral health care. Compared with nonsmokers, smokers had 47% greater odds of postponed dental visits (OR = 1.47, 95% CI, 1.33, 1.62), whereas males had a 30% lower chance of having cost-related delayed oral health care than females did (OR = 0.70, 95% CI, 0.63, 0.78). Similarly, all the health service deficit variables strongly predicted cost-related delayed oral health care. Individuals without health insurance had 2.96 times higher odds of experiencing cost-related delays in oral health care compared to those with insurance (95% CI, 2.56–3.42). Similarly, having no usual medical primary care provider and failing to have a medical exam within 12 months resulted in 31% and 15% higher odds for cost-related delayed oral health care, respectively (OR = 1.31, 95% CI, 1.11, 1.54, & OR = 1.15, 95% CI, 1.02, 1.31). A household income of > 400% FPL produced 57% lower odds for cost-related delayed oral health care (OR = 0.43, 95% CI, 0.36, 0.51). The variable difficulty in engaging in social activities was the strongest predictor among the need factors for cost-related delayed oral health care, with an odds ratio of 1.59 (95% CI, 1.34, 1.88). In contrast, individuals with one or more comorbidities had 33% greater odds for cost-related delayed oral health care (OR = 1.33, 95% CI, 1.18, 1.50). (Table 4).

Table 4 Multivariable logistic regression of cost-related delayed oral health care, predisposing, enabling and need factors
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Discussion

This study extends evidence on disparities in oral health care in the U.S. We utilized a nationally representative dataset to demonstrate the association between predisposing characteristics, enabling and need factors, and dental service utilization using an adapted version of Anderson and Newman’s framework of health service utilization. Our findings show that HSDs, family income, educational level, and smoking were important determinants of postponed dental visits. In addition, HSDs, family income, smoking, gender, difficulty engaging in social activities, and the presence of one or more comorbidities were also important determinants of cost-related delayed oral health care. In our study, predisposing and enabling factors emerged as relatively more important predictors for postponed dental visits than need factors, whereas predisposing, enabling, and need factors emerged as strong predictors for cost-related delayed oral health care. Based on our findings, determining the relative importance of predisposing, enabling, or need factors as determinants of cost-related delayed oral health care is ultimately a judgment call. However, in line with previous research, we confirmed that these factors are strongly associated with dental service utilization [25, 29,30,31,32,33].

We report a prevalence of 36.4% for postponed dental visits, which is similar to that reported by the Centers for Disease Control and Prevention (34.5%) [13]. Our estimate for cost-related delayed oral health care (20.2%) was similar to the overall national population estimate (18.9%) but much lower than the estimate (24%) for the target age group of this study at the pre-COVID-19 pandemic. This decrease may reflect the continued decline observed in previous trend analyses, especially between 2019 and 2020 [1]. While it is laudable that the results suggest some progress, the figures are short of the Healthy People 2030 targets for postponed dental visits and cost-related delayed oral health care [1, 34].

Our bivariate analyses revealed that HSDs were significantly associated with oral health care in our study, similar to the findings of Lutfiyya et al. 20 [14]. This association underscores the broader impacts of poor access to oral health care that contributes to poor oral health outcomes and reinforces previous research that links health service availability to oral health care utilization [3]. Other prior studies have emphasized the connections between oral health, quality of life, general health, and access to health services [15, 35,36,37,38,39]. However, the separation of the dental and medical delivery of services- due to distinct training, reimbursement, and practices- has contributed to the disparities in access to oral care. These circumstances affect how individuals perceive the importance of oral health in relation to their general health. Furthermore, reimbursement issues deter providers from offering dental services, and patients cannot receive coordinated care because of this fragmentation [3]. Although it was not a primary aim, an interesting finding that emerged from our analysis was that participants with no usual place of primary care provider or no physician visit for medical examination in a year had 64% and 130% increased odds of foregoing oral health care, respectively. This strong association indicates an opportunity to reevaluate the need for the integrated delivery of medical and dental services to promote more holistic health. Evidence from the literature suggests that medical and dental integration improves efficiency in health care delivery and leads to decreased disparities in access to oral care and an improved overall health outcome [6, 40,41,42]. Federally Qualified Health Centers (FQHCs) are good places to integrate dental and medical care [43, 44]. These centers were created as safety net programs to provide comprehensive primary care to the underserved, uninsured, and low-income earners [45, 46]. From 2012 to 2021, the provision of oral health services in these centers increased from 76.3 to 81.1% [47]. Despite this progress, many states continue to fall behind in the proportion of patients receiving oral health care at FQHCs [47]. Therefore, there is an urgent need for increased federal funding for these centers, stronger efforts to integrate dental benefits for adults on Medicaid, and improved recruitment and retention of the dental workforce to enhance the delivery of oral health services [3, 47].

Access to oral health care is recognized as a social justice issue [2, 3], and our findings on cost related delayed oral health care and foregone oral health care further highlight this reality. The association between these social and individual factors such as education level, household income, and race, demonstrate increased odds of cost-related delays and a likelihood of unmet oral health needs.

Our findings are consistent with the literature, which underscores the impact of these factors on worsening disparities in access to oral health care [3]. Adopting the Anderson framework in our study analyzes the interplay of the individual, social, and environmental factors intersecting to influence equity in access to oral health care [3, 24, 48]. We note predisposing factors such as smoking are associated with 47% and 27% increased odds of cost-related delayed oral health care and postponed dental visits, respectively. While smoking is a known risk factor and a common risk factor for oral diseases and other non-communicable diseases, its association with access to oral care was also previously reported in the Lutfiyaa study [14]. Additionally, compared to females, males had greater odds of postponed dental visits and cost-related delayed oral health care. These findings are quite consistent with the literature that men are more exposed to tobacco intake, have poorer attitudes towards dental visits, and invariably have worse oral health outcomes, making them a focus for planning targeted interventions [49, 50]. Using the Andersen framework [24, 25], we also highlighted a notable association between a need factor and cost-related delayed oral health care. We report that the difficulty in participating in social activities was associated with 59% increased odds of cost-related delayed oral health care. The difficulty in engaging in social activities may limit the potential for social integration and lead to cost-related delays in oral health care [32]. Although not analyzed in this study, the difficulty could have been mediated by poor health literacy and low self-esteem, as reported by Walther and colleagues [51]. Social ties play an important role in population health, and social support may cover indirect expenses such as providing transportation to health centers [25, 52]. Additionally, social activities may foster social ties, which enhance the personal control needed to make healthy choices. Building these ties could be a short- or long-term investment for the oral health of populations [51, 52].

Implications

The findings of this study have population health and policy implications; cost-related delayed oral health care and postponed dental visits are still public health problems that should be addressed. To reduce reliance on emergency services, which ultimately increases the healthcare economic burden [53], greater focus should be placed on addressing the substantial proportion of adult Americans who delay dental visits due to cost and postponed dental visits. Given that all the health service deficit variables, including health status and the presence of > 1 comorbidity, had increased odds of postponed dental visits and cost-related delayed oral health care, and evidence has already suggested that oral diseases are risk factors for systemic conditions [54,55,56], this study provides a further basis for patient-centered care which includes oral health care. Additionally, these findings highlight the need for oral health service delivery to be framed by adopting a whole-population approach that addresses individual and social factors common to other medical conditions [57].

Limitations

Our study is not without limitations. This study did not account for desirable measures such as attitudes, values, social norms and culture, cognitive aspects, motivation, and the intention to utilize dental services. However, we have focused on enabling factors, including HSDs, which may shape human agency and create an oral health advantage [58]. Further inquiry combining qualitative and quantitative approaches that explore broader determinants of delays in oral health care at a granular level and highlight the connections with neighborhood deprivation may be warranted. As a cross-sectional survey, we can only establish an association, not causality, in our findings. The information gathered in this study was in the context of an imminent recovery from disruptions in preventive and curative health service utilization following the COVID-19 pandemic, which impacted access to care and dental service utilization [59,60,61]. However, we selected a period in which most in-person health care visits returned, 2022, to highlight the prevailing issues around access to oral health care. Additionally, the large nationally representative NHIS reinforces the widespread usability of the results.

Conclusion

While family income, the level of education, and health service deficits are essential predictors of cost-related delayed oral health care and postponed dental visits, other predictors, such as difficulty engaging in social activities, should be considered. Without these social interactions, there may not be sufficient motivation to prioritize dental visits; thus, reminders and encouragement about dental health that support networks may have provided could be missed. Given the associations with individual and social factors, we recommend that oral health service delivery adopt a whole-population approach that addresses the predisposing, enabling, and need factors traditionally associated with chronic diseases. Furthermore, the strong association between health service deficits and postponed dental visits is a clear opportunity for advocating medical and dental integration, ensuring the delivery of comprehensive and patient-centered care.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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  1. John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, USA

    McKing I. Amedari, Mauda Monger & Benjamin H. Walker

  2. Meselson Center at RAND Corporation, Arlington, VA, USA

    Adejare Jay Atanda

  3. Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria

    Ifeoma K. Amedari

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MIA, BHW, IKA contributed to the conception of this article. MIA, BHW, AA, MM were involved in the manuscript writing and revision. MIA, AA, BHW were responsible for the data analysis and interpretation. All authors read and approved the final manuscript.

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Amedari, M.I., Atanda, A.J., Amedari, I.K. et al. The association between predisposing, enabling and need factors and oral health care utilization among U.S. working age adults. BMC Oral Health 25, 501 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12903-025-05821-w

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BMC Oral Health

ISSN: 1472-6831

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