Oral Health Status of Immigrant and Refugee Children in North America: A Scoping Review

Dental caries is a major children’s oral health concern in Canada: among 6–19-year-olds, the prevalence is approximately 60% and the mean number of affected teeth is 2.5.^1,2 Children suffering from pain caused by dental problems are more likely to perform poorly at school, as they may be inattentive or miss classes.³ They may be more prone to functional and cognitive problems (e.g., speech impairment, learning and eating problems)⁴ or psychological issues arising from poor self-image in a social setting.³ In particular, disadvantaged children, such as most refugee and immigrant (“newcomer”) children, appear to be at higher risk for dental diseases.⁵ This has implications for countries, such as Canada, where immigrants represent 20.6% (6 775 800) of the total population and immigrant children under 14 years of age represent 19.2% of the recent immigrant population.⁶

Dental diseases are among the most costly diseases to treat in Canada, as they affect the general economy through lost work and lost school days.⁷ Such diseases are disproportionately concentrated among newcomer children.⁶ This might be a result of untreated oral diseases in their home country as well as various barriers to appropriate oral health they face when they arrive in a new country.⁸ Cutbacks in public dental funding have imposed more financial pressures on low-income families, especially those with no or limited dental insurance.⁹ Inadequate access to care for newcomer populations is common, as many are challenged by barriers of culture and language, along with a lack of financial resources.⁶

Promoting the oral health status of newcomer children in North America requires timely knowledge about the underlying factors affecting their access to oral health care. Updated information would assist us in identifying the issues and in developing effective health promotion strategies to address these problems. This scoping review of selected studies on newcomer children in the United States and Canada specifically addresses the following research questions:

• What is the oral health status of children of newcomers?
• What are potential barriers to their use of dental services?
• What interventions have been developed and implemented to improve their oral health?

Methods

Search Methods Used to Identify Studies

Our preliminary search revealed a systematic review that evaluated cultural competencies in oral health research on immigrant children, worldwide.¹⁰ Although the scope of that review was different from ours, it included overall research on the oral health of newcomers from 1995 until 2008. From the pool of papers reviewed in that study, we selected the relevant North American studies and adapted the search strategy to find more recently published research from 2007 to September 2014 in the following databases: Ovid MEDLINE (in-process and non-indexed citations); Embase, Web of Science and Scopus. The search terms (Appendix 1) were initially established using MEDLINE and modified while exploring other databases. We imposed no language or publication restriction. In addition, we searched references in retrieved articles to identify studies not captured by our primary search strategy.

Inclusion Criteria

We included any cross-sectional, cohort, intervention, case control or qualitative/mixed-methods study. Reviews, clinical case studies, case reports, letters and editorials were excluded in terms of evidence-based recommendations, although they were used to identify relevant references. The study population had to be children (ages 0–18 years) of newcomers living in North America.

To allow us to assess the oral health status of newcomer children, their use of dental services, the effects of various barriers to optimal oral health and effective health promotion activities to reduce these barriers, studies had to report on the following specific outcome measures:

• Oral health status measured by caries prevalence and relevant indices, such as decayed/missing/filled teeth/surface scores (in primary and/or permanent dentition), gingivitis and periodontitis
• Oral health behaviour, either protective (such as regular dental visits, adequate oral hygiene practices, use of toothpastes with fluoride) or harming (such as diets rich in sugar, use of nursing bottles)
• Oral health environment that either promotes the child’s oral health status or places it at higher risk, including availability of dental services, publicly funded dental programs, community dental care programs, geographic or language isolation or harmful health beliefs

Data Collection and Analysis

Search results were exported to EndNote (Version X7, Thomson Reuters, Philadelphia, PA) and duplicates were removed. Selection of relevant papers was carried out in 2 stages and both stages were performed independently by 2 reviewers (MR, A Abdelaziz). In the first stage, both reviewers read the titles and the abstracts to select potentially relevant papers according to the inclusion criteria. Disagreements were resolved through discussion and consensus with the other review author (A Azarpazhooh). In the second stage, the full texts of the included articles were evaluated. The PRISMA 2009 checklist was used to assess the availability of required and relevant items.¹¹ We used the retrieved information in the form of a scoping review; no critical appraisal of individual studies was done.

Results

Search Results

From an initial total of 3223 articles from databases and 58 from Riggs et al.,¹⁰ several stages of screening reduced the number that met our criteria to 32 studies published between 1996 and 2014^3-5,8,12-39 (Fig. 1). Six studies were conducted in Canada (3 in Edmonton,^12,13,35 1 in Vancouver,¹⁹ 1 in Montréal [with a comparison to Talca, Chile]³⁰ and 1 in Toronto³⁷) and 26 in the United States (7 in California,^{8,18,21,23,25,26,34} 5 in Massachusetts,^4,5,14,16,33 3 in New York,^15,28,36 2 in North Carolina^27,31 and 1 each in Washington,¹⁷ Virginia,³¹ Georgia,³² Main,²⁰ Vermont³ and Utah²²).

Records identified through database search (2007–14) (n = 3221) through Riggs et al.10 (1995–2008) (n = 58) through other sources (n = 2)

 

Duplicates removed (n = 859)

 

Records screened (n = 2422)

 

Records excluded (n = 2315)

 

Full-text articles assessed for eligibility (n = 107)

 

Articles excluded: not done in North America (n = 52) review paper; references checked (n = 2) lacked relevant data on children of refugees or immigrants (n = 21)

 

Articles included in scoping review (n = 32)

Of the included studies, 22 were cross-sectional,^{4,13-18,20,22,24-35,37} 5 were cohort,^5,8,19,38,39 4 were qualitative^12,21,23,36 and 1 was descriptive³ (Table 1) Six of the studies included consultation services (for example group discussions or one-on-one counseling)^{3,8,12,15,19,21} and 1 study included free dental care.⁵

Questionnaires were used to collect data in all of the studies; in 15, they were administered by interviewers.^{5,12-15,17,18,23,28,31,34-37,39} Data collected from dental examinations were used in 12 of the studies.^{4,5,13,14,16,19,25,26,32,33,35,37} External data sources used in the studies included the California Health Interview Survey,¹⁸ the National Survey of America’s Families,²⁴ the Migration Transitions Study,²⁷ the NYC Child Community Health Survey,²⁸ the Medical Expenditure Panel Survey,²⁹ the DeKalb County Board of Health,³² the New Immigrant Survey,³⁸ the California Oral Health Needs Assessment²⁵ and the Survey of Income and Program Participation.³⁹ Of all the studies, 4 reported the use of validated questionnaires.^13,26,27,30

Oral Health Status of Children of Newcomers

Children of newcomer families tend to exhibit poorer oral health compared with their non-newcomer counterparts (Table 2), especially those whose families speak languages other than English at home.^{5,25,26,29,37} For example, in a sample of African newcomer children in Edmonton, 64% had untreated caries (mean decayed/extracted/filled surfaces of primary teeth  = 11.2 ± 12.9, of which mean decayed surface = 6.9 ± 8.5).¹³ When compared with children of Canadian-born parents, children of newcomers presented higher mean decayed/extracted/filled primary teeth scores (3.05 vs. 1.83, p < 0.05) mean decayed/missing/filled permanent teeth scores (0.73 vs. 0.42, p < 0.05).³⁷ Similarly, in the United States, compared with children of US-born parents, children of immigrants had a significantly larger number of carious surfaces (11.5 vs. 9.4, p = 0.01)⁵ and twice the prevalence of early childhood caries (odds ratio 2.06; 95% confidence interval 1.47–2.88).⁴ The situation was even worse among refugee children, who exhibited a greater number of untreated caries (up to about 75%).^{14,16,20,26,32}

Use of Dental Services for Children

A smaller proportion of children of newcomer families have regular dental visits compared with non-newcomers (Table 2).^{4,13,24, 26-28,36-39} Children of non-permanent residents have the lowest utilization rate (only 32% had 1 or more dental visits in a year), followed by children of permanent residents (41%), naturalized parents, i.e., foreign-born with United States citizenship (50%) and US-born parents (> 50%).³⁹ Similar findings were noted in a sample of African newcomer children in Edmonton, Alberta,¹³ and Latino newcomers in North Carolina,²⁷ where over 50% had never had a dental visit. In addition, newcomer children are most likely to visit a dentist for emergencies or when in pain.^{26,28,31,36-38}

It seems that parental education remains a predictor of dental care utilization. A study among Chilean newcomer families in Montréal shows that children of parents with a university education are twice as likely to visit a dentist compared with children of parents without higher education.³⁰

Newcomer families are also less likely than non-newcomers to visit the same dental office.¹⁷ In a group of recent newcomer mothers who had children enrolled in Medicaid, only 38% reported having a regular dental office, 27% had a regular dentist, fewer mothers saw the same dentist at each visit and an even smaller number remained with the same dentist for 1 year or more.¹⁷

Limited English proficiency has also been shown to hinder access to dental care for children of newcomer families.^12,13 In particular, those who speak a non-English language at home are less likely to visit a dentist for preventive or other services and more likely to visit only when their child is in pain.^{12,13,29,31,36,37} Similarly, higher rates of caries have been found among children of newcomer families speaking languages other than English at home.^{5,25,26,29,37}

Barriers to Appropriate Oral Health for Newcomer Children

Risk factors reported to act as barriers to achieving and maintaining adequate oral health for children of newcomers were grouped into 3 levels: child, family and community (Table 2).

Child level (oral hygiene practices): Children of newcomers and foreign-born parents differ from non-newcomers in their oral hygiene practices; tooth brushing or flossing is not carried out regularly (or at all),^14,37,40 nor are these practices valued by the children or their parents.¹²

Family level (parenting practices, oral health perceptions): A higher percentage of foreign-born mothers of 19-month-old infants in Alberta reported the use of nursing bottles compared with Canadian-born mothers (85% vs. 62%).³⁵ More important, foreign-born mothers reported more riskier practices, such as propping of bottles against the child’s mouth, leaving the baby unattended with a bottle and giving a bottle as soon as the child cries. A smaller number of foreign-born mothers reported cleaning their children’s teeth.³⁵

Foreign-born parents may have different views on the significance of preventive oral care compared with native-born parents. For example, about 75% of a sample of African newcomer parents in Edmonton reported that they didn’t need professional dental care for young children.¹³ Similar findings were reported in a sample of Chinese parents of children with extensive caries living in New York; the majority (75%) did not value dental treatment for primary teeth and considered dental examinations as a financial burden.⁴⁰ In another study,²¹ no members of ethnic minority groups (African-American, Chinese, Latino and Filipino) in San Francisco obtained early preventive care for their children because of lack of knowledge about the importance of primary teeth. Such perceptions may be a result of an illness reaction (as opposed to illness prevention) parental approach to oral health.¹²

Community level (dental insurance, dental care provider): Newcomer populations are more likely to be uninsured^{18,22,24,26,34} and more likely to rely only on public health insurance or no insurance at all.²² For example in the United States, the highest proportion of those with no insurance was seen among foreign-born children with non-naturalized parents (52.3%), followed by US-born children with non-naturalized parents (34.37%), US-born children with US naturalized parents (15.34%) and, finally, foreign-born children with naturalized US-citizen parents (12.86%).²⁴ In both insured and uninsured groups, newcomer children are less likely to use dental services compared with non-newcomer children.¹⁸

The dental care provider may present another barrier to newcomer parents seeking treatment for their children. One study²⁶ reported the characteristics of dental care providers that act as a barrier. Most of the children in this study were from a population of poor and newcomer families (43% lived in non-English-speaking households and 10% were born outside the United States) and visited dentists only if the dental office was near their home. Their parents reported that almost 50% of children had to travel 5 or more miles to get dental treatment on their last visit and about 20% of dentists were not fluent in the language spoken by the child.²⁶

Interventions for Newcomer Children

Three studies^3,8,19 explored intervention programs developed to improve the oral health status of newcomer children; 2 of them targeted parents and the other targeted children.

Programs for parents: An educational program among 20 newcomer Latino parents of low socioeconomic status was successful in improving the knowledge of 10 participants; however, only 5 showed an improvement in reported behaviour.⁸ In a health promotion program in Vancouver, British Columbia, designed to educate Vietnamese mothers of preschool children with extensive tooth decay, mothers who had more than 1 counseling session reported significant reductions in the use of a nursing bottle for their children during both sleep time and day time.¹⁹ Children of these mothers also demonstrated a significant reduction in the prevalence of caries compared with other children of similar age at baseline.¹⁹

Programs for children: In a school-based program, dental services provided for newcomer and impoverished children were successful in reducing the need for restorative care in the second year of its implementation. Although in the first year, 52% and 22% of children received preventive and restorative care, respectively, in the second year, the figures were 60% and 11%.²

Discussion

This scoping review aimed to provide a better understanding of the oral health of newcomer children in North America. In the Canadian setting, oral health has traditionally received low priority in public policy discussions and has not been subjected to the tenets of the Canada Health Act, i.e., comprehensive, accessible, portable, universal and publicly funded and administered. As a result, almost all Canadians are burdened with financing their own dental care.⁶ Although various oral health strategies, including increased accessibility and some publicly funded dental services (usually for emergency care) are in place for children from low-income families or those on social assistance,⁴¹ many Canadians still do not have easy or affordable access to dental health services. Successive reductions in public dental funding, especially for disadvantaged populations, has left Canada ranked second to last among Organisation for Economic Co-operation and Development nations in terms of public funding of dental care.⁶

A case in point is the proposed cuts to dental benefits for newcomers to Canada under the Interim Federal Health Program.⁹ The limitations and problems with this program, for both providers and newcomer patients, have been outlined in a report by Amin and colleagues.⁴² A symposium mentioned by these researchers revealed that newcomers to Canada have many pressing concerns, such as housing, employment, education and general health; thus, preventive oral health may not be high on their priority list.⁴² The following discussion of the findings from our review should be considered in this context.

Regardless of their birthplace, many studies have shown that children of newcomers have worse oral health than their non-newcomer counterparts.^5,16,37 Several barriers play a role, such as cost of regular dental care, insufficient dental insurance coverage, language and parental beliefs and practices that put the children at higher risk for dental diseases.^26,36,37 Consequently, newcomers rank lower in terms of use of dental services.¹⁸

The data obtained from the studies included in this review reveal a number of key findings that will familiarize clinicians, researchers and public health policymakers with evidence-based information on the oral health status of newcomer children in both Canada and the United States, although most of the studies were conducted in the United States. This scoping review aimed to map available research, without necessarily ranking individual articles based on design or quality. As many of the studies used questionnaires or interviews to obtain information, this could have introduced recall bias by parents trying to remember details of the child’s oral health and social acceptance bias by parents trying to respond to questions in a way that would please the researcher.

Higher Levels of Caries

Newcomer children have consistently been shown to have higher levels of caries.³³ A more detailed study of these children is needed to identify which group is in the majority: Canadian-born children of newcomer parents, foreign-born children who have been raised in Canada or foreign-born children recently moved to Canada. This is important because, if those born or raised in Canada exhibit more disease, this would reflect the need for prevention and treatment programs that target such children as early as possible (e.g., school-based oral health programs).

Variations in Oral Health Status by Location

Children of newcomers living in different parts of the new country may exhibit different oral health characteristics.^3,4 Hence, a general policy may not be applicable to all newcomer children in all regions. A targeted approach to the delivery of dental services for particular groups may allow the best use of the limited resources.

Language Literacy

Newcomer children are less likely to receive routine or preventive dental care.²⁹ Various reasons have been associated with this, including language and cultural barriers.^{12,13,25,36,37} Language barriers have been consistently associated with less use of dental care²⁹ and issues of communication with health care providers.³⁴ An interesting finding from Noyce and colleagues²⁹ indicates that, among a group of people of the same race/ethnicity, those who speak English at home are more likely to seek dental care. Although it is not possible to separate the impact of the language barrier from other socioeconomic factors, such as parental education, household income and health insurance status, general education programs to improve language literacy (in 1 of the official languages) as well as more specific programs to improve oral health literacy could overcome cultural beliefs and practices that are harmful to the oral health of children and help increase the use of dental services.

To make interventional and educational programs more effective, large public health units and private offices could make use of internal staff resources for interpreting or use a company or organization providing telephone interpretation services,⁴² e.g., Can Talk Canada. However, even when these services are available, public health facilities and private offices may insist that the patient or their parents bring an interpreter along to visits. The availability of more multicultural and multi-language providers may prove beneficial in creating a better understanding of oral health messages.⁴²

Awareness of the Importance of Oral Health

Although dental insurance is an important determinant of the use of dental care services, newcomer children use dental care less, regardless of their insurance status.¹⁸ This may be related to newcomer children relying mainly on publicly funded dental programs, where practitioner reimbursement rates are relatively low.²² In addition, as newcomer children usually come from low-income families, the required co-payments may be a financial burden.

It is essential to realize that less use of dental services may be a result of lack of parental understanding of how preventive services and routine regular dental visits can be effective in improving the oral health of their children. It may also be caused by a lack of understanding or knowledge of health care resources²⁴ or fear or suspicion of government. Therefore, effective educational and supportive programs are important to help raise awareness among immigrant parents and their children of the importance of maintaining good oral health through regular preventive care. However, as mentioned above, newcomers in Canada have to focus on urgent needs related to housing, employment, language barriers, education and acute health care issues; thus, preventive dental care may not be a priority.³⁹

Comprehensive Accessible Dental Care

Newcomer children are at higher risk of dental caries compared with non-newcomer children. They are also more likely to live in poverty or come from low-income households where the cost of dental care is a burden.²⁴ Providing free (or perhaps affordable) accessible and comprehensive dental care may be the most efficient way to eliminate caries in newcomer children who are in urgent need of dental care.⁴² It is important to ensure access to care for this population (and other marginalized populations) through effective oral public health policies.

Conclusion

Children of newcomers are associated with worse oral health outcomes, including lower utilization rates, higher dental status scores and higher prevalence of caries compared with their non-newcomer counterparts. Barriers that play a role include cost of regular dental care, insufficient dental insurance coverage, communicating with dental care providers because of language barriers and parental beliefs and practices that put these children at a higher risk of dental diseases.^18,26,36,37 The increase in disparities between newcomer and non-newcomer children can be reduced through:

• implementation of more effective preschool and school-based oral health programs for young children
• improving newcomer parents’ literacy in the official language(s)
• edu…