title: Oral Health Disparities and Unmet Dental Needs among Preschool Children in Chelsea, MA: Exploring Mechanisms, Defining Solutions.
abstract: BACKGROUND
  Significant disparities exist in children's receipt of preventive dental care (PDC) in the United States. Many of the children at greatest risk of dental disease do not receive timely PDC; when they do receive dental care, it is often more for relief of dental pain. Chelsea is a low-income, diverse Massachusetts community with high rates of untreated childhood caries. There are various dental resources available in Chelsea, yet many children do not access dental care at levels equivalent to their needs.
  
  
  OBJECTIVE
  Using Chelsea as a case-study, to explore factors contributing to forgone PDC (including the age 1 dental visit) in an in-depth way.
  
  
  METHODS
  We used a qualitative study design that included semi-structured interviews with parents of preschool children residing in Chelsea, and Chelsea-based providers including pediatricians, dentists, a dental hygienist and early childhood care providers. We examined: a) parents' dental attitudes and oral health cultural beliefs; b) parents' and providers' perspectives on facilitators and barriers to PDC, reasons for unmet needs, and proposed solutions to address the problem. We recorded, transcribed and independently coded all interviews. Using rigorous, iterative qualitative data analyses procedures, we identified emergent themes.
  
  
  RESULTS
  Factors perceived to facilitate receipt of PDC included Head-Start oral health policies, strong pediatric primary care/dental linkages, community outreach and advertising, and parents' own oral health experiences. Most parents and providers perceived there to be an adequate number of accessible dental services and resources in Chelsea, including for Medicaid enrollees. However, several barriers impeded children from receiving timely PDC, the most frequently cited being insurance related problems for children and adults. Other barriers included limited dental services for children <2 years, perceived poor quality of some dental practices, lack of emphasis on prevention-based dental care, poor care-coordination, and insufficient culturally-appropriate care. Important family-level barriers included parental oral health literacy, cultural factors, limited English proficiency and competing priorities. Several solutions were proposed to address identified barriers.
  
  
  CONCLUSIONS
  Even in a community with a considerable number of dental resources, various factors may preclude access to these services by preschool-aged children. Opportunities exist to address modifiable factors through strategic oral health policies, community outreach and improved care coordination between physicians, dentists and early childhood care providers.
authors.affiliation: Boston Children's Hospital, Boston, MA, USA ; Harvard Medical School, Boston, MA, USA.
authors.forename: Inyang
authors.initials: I
authors.lastname: Isong
authors.affiliation: Cambridge Health Alliance, Cambridge, MA, USA ; Harvard School of Dental Medicine, Boston, MA, USA.
authors.forename: Laila
authors.initials: L
authors.lastname: Dantas
authors.affiliation: Department of Public Health, Brown University, Providence, RI, USA.
authors.forename: Macda
authors.initials: M
authors.lastname: Gerard
authors.affiliation: Harvard Medical School, Boston, MA, USA ; Center for Child & Adolescent Health Research and Policy, MGHfC, Boston, MA, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Kuhlthau
keywords: Children; Early childhood caries; Oral health; Preventive dental care