Multilevel model to estimate county-level untreated dental caries among US children aged 6-9Â years using the National Health and Nutrition Examination Survey

Because conducting population-based oral health screening is resource intensive, oral health data at small-area levels (e.g., county-level) are not commonly available. We applied the multilevel logistic regression and poststratification method to estimate county-level prevalence of untreated dental caries among children aged 6-9 years in the United States using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 linked with various area-level data at census tract, county and state levels. We validated model-based national estimates against direct estimates from NHANES. We also compared model-based estimates with direct estimates from select State Oral Health Surveys (SOHS) at state and county levels. The model with individual-level covariates only and the model with individual-, census tract- and county-level covariates explained 7.2% and 96.3% respectively of overall county-level variation in untreated caries. Model-based county-level prevalence estimates ranged from 4.9% to 65.2% with median of 22.1%. The model-based national estimate (19.9%) matched the NHANES direct estimate (19.8%). We found significantly positive correlations between model-based estimates for 8-year-olds and direct estimates from the third-grade State Oral Health Surveys (SOHS) at state level for 34 states (Pearson coefficient: 0.54, P = 0.001) and SOHS estimates at county level for 53 New York counties (Pearson coefficient: 0.38, P = 0.006). This methodology could be a useful tool to characterize county-level disparities in untreated dental caries among children aged 6-9 years and complement oral health surveillance to inform public health programs especially when local-level data are not available although the lack of external validation due to data unavailability should be acknowledged.