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Abstract Background Studies on rural–urban differences in dental care have primarily focused on differences in utilization rates and preventive dental services. Little is known about rural–urban differences in the use of wider range of dental procedures. This study examined patterns of preventive, restorative, endodontic, and extraction procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI). Methods We analyzed DDWI enrollment and claims data for children aged 0-18 years from 2002 to 2008. We modified and used a rural and urban classification based on ZIP codes developed by the Wisconsin Area Health Education Center (AHEC). We categorized the ZIP codes into 6 AHEC categories (3 rural and 3 urban). Descriptive and multivariable analysis using generalized linear mixed models (GLMM) were used to examine the patterns of dental procedures provided to children. Tukey-Kramer adjustment was used to control for multiple comparisons. Results Approximately, 50%, 67% and 68 % of enrollees in inner-city Milwaukee, Rural 1 (less than 2500 people), and suburban-Milwaukee had at least one annual dental visit, respectively. Children in inner city-Milwaukee had the lowest utilization rates for all procedures examined, except for endodontic procedures. Compared to children from inner-city Milwaukee, children in other locations had significantly more preventive procedures. Children in Rural 1-ZIP codes had more restorative, endodontic and extraction procedures, compared to children from all other regions. Conclusions We found significant geographic variation in dental procedures received by children enrolled in DDWI.

Introduction: Strong evidence supports use of dental sealants to prevent tooth decay, and professional guidelines recommend use in children with elevated caries risk. However, not all children indicated for sealants receive this preventive intervention, even when they use routine dental care., Objective: The aim of this study was to explore the extent to which dentists' use of sealants varied in pediatric patients with elevated caries risk., Methods: Claims and enrollment data from a private dental program were used to identify a cohort of 6- to 17-y-olds with elevated caries risk ( N = 27,677) and general dentists ( N = 818) who provided services to the children. Children were identified as having elevated caries risk based on history of restorative treatment over a 5-y period (2010-2014). The 2 outcomes of interest were whether a dentist provided any sealants to children with elevated risk and, if so, the extent to which these were used during a 2-y observation period (2013-2014). A 2-stage hurdle model was used for multivariable analysis to identify dentist characteristics associated with sealant use., Results: Over the observation period, 13.3% ( n = 109) of dentists did not provide any sealants to their elevated risk patients from the study cohort. Logistic regression found that female dentists were significantly more likely to have used sealants (odds ratio = 2.27); dentist age and practice in an isolated small rural town were negatively associated with any sealant use. However, among dentists who did place sealants ( n = 709), female dentists, older dentists, dentists in solo practice, and those working full-time were significantly more likely to provide sealants to a child. Overall, substantial variation in practitioners' use of sealants was observed., Conclusion: This is the first study to explore provider-level variation in sealant use, representing a critical step in future efforts to increase routine use of sealants by dentists and eliminate oral health disparities., Knowledge Transfer Statement: Findings from this study can be used to design targeted policy and behavioral interventions to increase sealant use by general dentists. This study provides foundational evidence for future research that explores motivation and barriers to routine use of preventive dental interventions by clinicians.

Purpose: Little is known about the prevalence of multiple jobholding practices among dental hygienists or the factors contributing to these employment patterns. The purpose of this exploratory study was to examine predictors of multiple jobholding practices among dental hygienists in the state of Iowa. Methods: A mailed paper survey was sent to all licensed dental hygienists (n=2080) in Iowa in May 2018. The dependent variable was whether hygienists worked more than one job in dental hygiene. Key independent variables included individual, family, and practice-related factors. Descriptive, bivariate, and binary logistic regression analyses were completed. Results: A total of 1215 dental hygienists participated in the survey, for a response rate of 58%. Among respondents, 12.2% worked more than one job overall, with 10.7% working 2 jobs and 1.5% working three or more. Respondents who had at least a bachelor's degree, did not have children in the household, were not married, had worked more years at their primary job, and worked more hours per week, were more likely to hold multiple jobs after adjusting for other factors. Conclusions: Consistent with national estimates, there was a high multiple jobholding rate among dental hygienists in Iowa. Multiple individual, family, and practice characteristics were found to be related to multiple jobholding, with the strongest predictors being the hygienist's highest level of education and the number of hours worked at the primary job., (Copyright © 2021 The American Dental Hygienists’ Association.)

Background: In Iowa from 2014 to 2017, there were 2 separate public dental benefit programs for Medicaid-enrolled adults: one for the Medicaid expansion population called the Dental Wellness Plan (DWP), and one for the traditional, non-expansion adult Medicaid population. The programs differed with respect to reimbursement, administration, and benefit structure. This study explored differences in patterns and predictors of dentist participation in the two programs., Methods: Authors sent a survey to all private practice dentists in Iowa (n = 1301) 2 years after DWP implementation. Descriptive, bivariate, and logistic regression analyses were used to examine patterns and predictors of dentist participation in Medicaid and DWP., Results: Overall rates of dentists' acceptance of new Medicaid and DWP patients were 45 and 43%, respectively. However, Medicaid participants were much more likely than DWP participants to place limits on patient acceptance. Adjusting for other factors, practice busyness was the only significant predictor of DWP participation, and practice location was the only significant predictor of Medicaid participation. Dentists who were not busy enough were more than twice as likely to participate in DWP compared to others, and dentists in rural areas were almost twice as likely to participate in Medicaid compared to dentists in urban areas., Conclusions: Dentist participation in Medicaid is an ongoing concern for states aiming to ensure access to dental care for low-income populations. We found distinct participation patterns and predictors between a traditional Medicaid dental program and the DWP, suggesting different motivations for participation between the two programs.

Background: In this study, the authors used observational data from 2014 to evaluate the association between the number of general dentists and several community characteristics., Methods: The authors collected community-level characteristics from secondary sources for all 947 Iowa incorporated communities to study their relationships with the mean number of general dentists per 1,000 population per square mile (population density), the dependent variable. The authors used zero-inflated negative binomial models to examine the association between the dependent and predictor variables., Results: Only 22.8% of communities had a dentist. Urban, young, well-educated, fluoridated communities with at least 1 elementary school had the highest estimated mean concentration of dentists. Isolated communities with older, less educated adults and lacking fluoridation and an elementary school had the fewest dentists., Conclusions: Although population is an important determinant for where a dentist practices, other variables such as urbanization, demographic characteristics, fluoridation status, and presence of at least 1 elementary school are also predictors of the number of dentists in a community., Practical Implications: These findings provide dental students and young practitioners useful information by highlighting community characteristics that are associated with office locations., (Copyright © 2018 American Dental Association. Published by Elsevier Inc. All rights reserved.)

This study explores how travel distance and other transportation barriers are associated with dental utilization in a Medicaid expansion population. We analyzed data from the Iowa Dental Wellness Plan (DWP), which provides comprehensive dental benefits for low-income adults aged 19 to 64 y as part of Iowa's Medicaid expansion. Transportation and geographical characteristics were evaluated as enabling factors within the framework of Andersen's behavioral model of health services use. In March 2015, a random sample of DWP members ( n = 4,800) was surveyed; adjusted survey response rate was 30% ( n = 1,258).The questionnaire was based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Dental Plan Survey and assessed need for dental care, use of dental services and transportation to visits, and self-perceived oral health status. Respondent and dentist addresses were geocoded and used to calculate distance to the nearest DWP general dentist. A logistic regression model predicting utilization of dental care was developed using variables representing each domain of the behavioral model. Most respondents (57%) reported a dental visit since enrolling. Overall, 11% of respondents reported unmet dental need due to transportation problems. Median distance to the nearest general dentist was 1.5 miles. In the adjusted model, travel distance was not significantly associated with the likelihood of dental utilization. However, other transportation-related issues were significantly associated with utilization, including concern about cost of transportation and driver/passenger status. As concern about transportation cost increased, likelihood of having a dental visit decreased. Targeted approaches to assisting low-income populations with transportation barriers should be considered in designing policies and interventions to improve access to dental care. Knowledge Transfer Statement: The results of this study can be used by policy makers and public health planners when designing programs and interventions to improve access to dental care. Consideration of transportation availability and costs could improve utilization of routine dental care, especially among low-income populations.

The objective of the study was to assess the effects of medical well baby visits in promoting earlier first dental visits. We analyzed Iowa Medicaid claims data (2000-2013). The sample included 4 cohorts of children born in 2000, 2003, 2007, or 2010 and enrolled in Medicaid from birth ( N = 38,211). Children were followed for 3 y. The independent variables were cohort year and medical well baby visit frequency during 3 time periods (birth to age 10 mo, ages 11-19 mo, ages 20-36 mo). We used survival analyses to estimate first dental visit rates. First dental visit rates improved significantly from 2000 to 2013, with children in latter cohorts having significantly earlier first dental visits. Children with more medical well baby visits before age 11 mo had significantly delayed first dental visit rates than children with fewer medical well baby visits. The opposite was observed for children with more medical well baby visits between ages 11 to 19 mo and ages 20 to 36 mo. First dental visit rates for Medicaid-enrolled children have improved, but there continues to be a need for early interventions to improve age 1 dental visits and other preventive oral health behaviors. Knowledge Transfer Statement: The results of this study can be used by policy makers when developing strategies to improve access to dental care for young children in Medicaid. With consideration to promoting earlier preventive dental visits for publicly insured children, this study could lead to early interventions and improved health outcomes., Competing Interests: The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

Objective: To examine the effects of distance to dentists and dentist supply on dental services use among children with Medicaid coverage in Iowa., Data Source: Iowa Medicaid claims for enrolled children between 2000 and 2009., Study Design: The study sample included 41,554 children (providing 158,942 child-year observations) who were born in Iowa between 2000 and 2006 and enrolled from birth in the Iowa Medicaid program. Children were followed through 2009. We used logistic regression to simultaneously examine the effects of distance (miles to nearest dentist) and county-level dentist supply on a broad range of dental services controlling for key confounders. Additional models only used within-child variation over time to remove unobservable time-invariant confounders., Principal Findings: Distance was related to lower utilization of comprehensive dental exams (2 percent lower odds per 1 mile increase in distance), an effect that also held in models using within-child variation only. Dentist supply was positively related to comprehensive exams and other preventive services and negatively related to major dental treatments; however, these associations became smaller and insignificant when examining within-child changes except for other preventive services., Conclusions: Longer distance to dentists is a barrier for use of comprehensive dental exams, conditional on dentist supply., (© Health Research and Educational Trust.)

Objectives: Using administrative data from Iowa Medicaid and a large private dental insurer, we compared distance to the nearest primary care dentist for children ages 6-15 in 2012. Additionally, we examined rates of provider bypass in both populations as an indicator of spatial accessibility to dental care., Methods: We calculated measures of travel burden, including distance to the nearest primary care dentist and distance to current primary care dentist. Distance outcomes and rates of bypass, traveling beyond the nearest dentist for care, were compared by insurance type., Results: We found that Medicaid-enrolled children lived farther from the nearest dentist and farther from their current dentist than privately insured children. However, rates of bypass were higher among the privately insured population. These results were consistent among urban and rural residents; additionally, both rural populations demonstrated greater travel distances than urban dwellers., Conclusions: Travel burden was greater among Medicaid-enrolled children. Lower rates of bypass, in conjunction with lower rates of dental utilization in this population, may indicate a distance threshold beyond which dental care becomes unattainable., (© 2016 American Association of Public Health Dentistry.)

Some U.S. states have more difficulty than others in recruiting or retaining dentists. Part of the problem is that often dental students are not aware of opportunities across geographic regions of either their home state or the state where they were educated. With student input, the University of Iowa College of Dentistry and Dental Clinics designed and launched an interactive website that provides basic demographic, economic, and other meaningful information to help dental students locate potential practice locations and identify current employment opportunities in Iowa. Although this website is not a recruitment or retention panacea, it provides an easy method for dental students to explore all or parts of the state as they go about making one of the most important decisions of their careers. The website also provides a showcase for current practitioners and communities to demonstrate what they have to offer as practice opportunities.

Objectives: Private practice dentists are the major source of care for the dental safety net; however, the proportion of dentists who participate in state Medicaid programs is low, often due to poor perceptions of the program's administration and patient population. Using a discrete choice experiment and a series of hypothetical scenarios, this study evaluated trade-offs dentists make when deciding to accept Medicaid patients., Methods: An online choice-based conjoint survey was sent to 272 general dentists in Iowa. Hypothetical scenarios presented factors at systematically varied levels. The primary determination was whether dentists would accept a new Medicaid patient in each scenario. Using an ecological model of behavior, determining factors were selected from the categories of policy, administration, community, and patient population to estimate dentists' relative preferences., Results: 62 percent of general dentists responded to the survey. The probability of accepting a new Medicaid patient was highest (81 percent) when reimbursement rates were 85 percent of the dentist's fees, patients never missed appointments, claims were approved on first submission, and no other practices in the area accepted Medicaid. Although dentists preferred higher reimbursement rates, 56 percent would still accept a new Medicaid patient when reimbursement decreased to 55 percent if they were told that the patient would never miss appointments and claims would be approved on initial submission., Conclusions: This study revealed trade-offs that dentists make when deciding to participate in Medicaid. Findings indicate that states can potentially improve Medicaid participation without changing reimbursement rates by making improvements in claims processing and care coordination to reduce missed appointments., (© 2015 American Association of Public Health Dentistry.)

Objectives: To identify the factors associated with paediatric emergency department (ED) visits and parental perceptions of the avoidability of their child's ED visit., Design: Cross-sectional study by performing secondary analysis of 2010-2011 Iowa Child and Family Household Health Survey data., Setting: State-wide representative population-based sample of families with at least one child in the state of Iowa in the USA., Patients/participants: Among the eligible households, 2386 families completed the survey, yielding a cooperation rate of 80%., Exposure/intervention: Presence of a medical home., Main Outcome Measures: Child visiting an ED in the past year; parents believing that ED care could have been provided in a primary-care setting., Results: Among children who needed medical care in the past year, 26% visited an ED. Younger children, non-Hispanic black children, non-Hispanic others, children whose parents were not married, children who were from food-insecure households and had poorer health status were more likely to visit an ED. Having a medical home was not associated with ED visits (OR=0.80, 95% CI 0.61 to 1.04), even after stratifying by the child's health status. About 69% of parents who took their child to an ED agreed that ED care could have been provided in a primary-care setting. Parents of children with public insurance, those who were not referred to the ED and those who could not get routine care appointments were more likely to report a primary-care preventable ED visit., Conclusions: The majority of parents believed that paediatric ED visits could be avoided if adequate primary-care alternatives were available. Expanding access to primary care could lead to a reduction in avoidable ED visits by children., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Dental emergency department (ED) visits are increasing nationally, but EDs provide only palliative care. The authors examine time to subsequent dentist visit within 6 months after the ED visit, as well as the effect of having a dentist visit in the prior year., Methods: Using 2010-2012 Iowa Medicaid claims data, the authors identified adults with an index dental ED visit. The authors examined the claims data for a subsequent dentist visit within the next 6 months. The authors used Kaplan-Meier curves and log-rank tests for bivariate analyses. The authors included a dentist visit in the year before the index ED visit, subsequent ED visits, and sociodemographic characteristics in a Cox multivariable regression model., Results: A total of 2,430 adults enrolled in Medicaid satisfied the study inclusion criteria. Within 6 months, 52.4% had a subsequent dentist visit, 12.0% lost Medicaid eligibility, and 35.6% did not have subsequent dentist visit. Bivariate and multivariable analyses revealed that nonwhites, those without a dentist visit in the prior year, and those with subsequent ED visits had a significantly lower rate of subsequent dentist visits., Conclusions: Almost one-half of adults with a dental ED visit did not visit a dentist in the next 6 months. Adults who did not visit a dentist in the past year and those with repeated ED visits may be living with unresolved dental problems that can affect their quality of life., Practical Implications: Adults without a dentist visit in the past year and those who visit ED repeatedly can be targeted by ED diversion programs because they are at higher risk of not receiving follow-up dental care., (Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the availability of general dentists who treat very young children with private insurance in the context of recommendations for age one dental visit., Methods: Administrative data from Delta Dental of Iowa were analyzed to identify general dentists providing care to children younger than 18 years old in 2005 and 2012. Characteristics of dentists providing care to children younger than two years old were compared, examining changes over time. Geographical distribution of dentists who treated children younger than two years old was examined., Results: The proportion of dentists treating children younger than two years old increased from six percent in 2005 to 18 percent in 2012. Younger dentists, females, graduates of The University of Iowa College of Dentistry, and those in metropolitan locations were significantly more likely to treat children younger than two years old. Fifty-one of 99 counties lacked any dentists who had provided care to privately insured children younger than two years old., Conclusions: The proportion of dentists in Iowa treating privately insured children younger than two years old has increased since 2005. However, relatively few general dentists provided care to very young children when compared to previous survey-based figures. Geographic distribution of providers supports the hypothesis that provider availability may pose a barrier to early dental visits.

Objective: Examine the current capacity of Iowa's public dental safety net and organizational readiness for implementation of the Affordable Care Act (ACA)., Methods: We surveyed Iowa Community Health Center (CHC) dental clinics for factors related to clinic capacity and organizational readiness for ACA-related change., Results: With 14 clinics (93%) responding, clinics had means of 13,064 patient visits and 23% broken appointments in 2012. Seventy percent of clinics reported high confidence in their ability to respond to changes associated with health care reform. However, over 60% agreed that current circumstances limited their ability to respond to these challenges., Conclusions: CHC dental clinics in Iowa understand ACA-related changes regarding their patient population, but are limited in their ability make needed changes in response to increased demand. This may affect the clinics' transition into an environment with increased demand for dental services as a result of Medicaid expansion in Iowa.

Early preventive dental visits are vital to the oral health of children. Yet many children, especially preschool-age children enrolled in Medicaid, do not receive early visits. This study attempts to uncover factors that can be used to encourage parents to seek preventive dental care for preschool-age children enrolled in Medicaid. The extended parallel process model was used as a theoretical framework for this research. This model suggests that people will act if the perceived threat (severity and susceptibility) is high enough and if efficacy levels (self-efficacy and response efficacy) are likewise high. Following Witte's method of categorizing people's perceptions and emotions into one of four categories based on levels of threat and efficacy, this article describes four groups (high threat/high efficacy, high threat/low efficacy, low threat/high efficacy, and low threat/low efficacy) of parents and how they compare to each other. Using logistic regression to model if a child had a preventive visit, results indicate that parents with low threat/high efficacy and parents with high threat/high efficacy had approximately 2.5 times the odds of having a child with a preventive oral health visit compared to parents with low threat/low efficacy, when controlling for perceived oral health status, health literacy, and child's age. The importance of efficacy needs to be incorporated in interventions aimed at increasing preventive dental visits for young children., (© 2015 Society for Public Health Education.)

Spatial accessibility of dental care is mediated by dentist workforce availability and travel costs. In this study, we generated dental service areas through small area analysis of Medicaid administrative data and claims. Service areas were then used to assess dimensions of spatial accessibility, including dentist-to-population ratios, and examine relationships in geographic variation of routine dental care among Medicaid-enrolled children. Our findings indicate significant geographic differences in accessibility for Hispanic children compared to other children, even after controlling for individual and service area characteristics., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Dental coverage for adults is an elective benefit under Medicaid. As a result of budget constraints, California Medicaid eliminated its comprehensive adult dental coverage in July 2009. We examined the impact of this policy change on emergency department (ED) visits by Medicaid-enrolled adults for dental problems in the period 2006-11. We found that the policy change led to a significant and immediate increase in dental ED use, amounting to more than 1,800 additional dental ED visits per year. Young adults, members of racial/ethnic minority groups, and urban residents were disproportionately affected by the policy change. Average yearly costs associated with dental ED visits increased by 68 percent. The California experience provides evidence that eliminating Medicaid adult dental benefits shifts dental care to costly EDs that do not provide definitive dental care. The population affected by the Medicaid adult dental coverage policy is increasing as many states expand their Medicaid programs under the ACA. Hence, such evidence is critical to inform decisions regarding adult dental coverage for existing Medicaid enrollees and expansion populations., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: The authors investigated the role of private practitioners in the dental safety net, including the provision of care for Medicaid enrollees and attitudinal factors that affect participation., Methods: In 2013, the authors sent a mixed-mode survey to all general dentists in Iowa assessing their current Medicaid participation and factors affecting participation, including attitudinal statements about altruism, the Medicaid program, and the government's role in providing access to dental care., Results: Fifty-six percent of responding dentists accepted new Medicaid-enrolled patients; dentists living in nonmetropolitan areas were significantly more likely to accept Medicaid than were those in metropolitan areas. Results from a logistic regression model demonstrated that participating dentists scored significantly higher in altruistic attitudes and perceived problems with Medicaid as less important., Conclusions: Dentists who accepted Medicaid-enrolled patients had significantly more positive attitudes about Medicaid administration and altruistic attitudes in general. Investigators in future studies should examine how these attitudes are shaped by educational and professional experiences., Practical Implications: Dentists' perceptions about Medicaid potentially are modifiable by changing program policies in ways to improve access for vulnerable populations, including new Medicaid enrollees., (Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Objectives: The study assessed the time until first dental caries for young children seen at five Federally Qualified Health Centers (FQHC) in Iowa and the relationship with the frequency and gaps (in months) of dental episodes, the number of topical fluoride treatments, and the number of dentists caring for the subject., Methods: Forty children were randomly selected at each FQHC (n = 200). All children were continuously enrolled in the Medicaid program and had their first dental visit prior to age 6. Dental chart findings, claims data for the child and family, and birth certificate information were merged into one dataset. Dental visits were followed for a minimum of 36 months, including dental visits external to the FQHCs. Using time until first caries as the dependent variable, the data were subject to left, interval, and right censoring and were analyzed via Weibull regression., Results: Slightly more than half of the 200 children experienced caries. Regression analysis indicated that the hazard of first dental caries increased by approximately 2% with each additional month that transpired between preventive recall examinations. In addition, children with older siblings who had a dental visit at the same center during the previous year prior to the subject's first visit were more likely to have a longer time until first dental caries., Conclusions: Timing of dental care episodes was associated with caries experience in young children from low income families. Dental professionals should focus on regularity of dental care to prevent or delay caries experience in young children., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Existing research about the influence of educational debt on students' decision to enter general practice immediately after graduation is conflicting. Other potential factors that could affect this decision include the influence of a spouse or other family member, the importance of a mentoring dentist, and how students perceive the burden of their debt. The goal of this study was to examine the importance of debt on career decision-making while also considering the role of other influences., Methods: Responses to a self-completed questionnaire of all final (fourth) year students at the University of Iowa College of Dentistry from 2007 through 2010 were analyzed to identify the importance of educational debt and the influence of spouses, other family members, and mentoring dentists in the decision to enter private general practice immediately after graduation. Statistical analysis included bivariate tests (t-tests and Chi-square tests) and multivariable logistic regression., Results: 58.9% of respondents (N = 156) planned to immediately enter private practice after dental school. Bivariate analyses revealed women to be more likely to enter private practice than their male counterparts (69.0% vs. 51.8%, p = .006). Students planning to enter practice immediately did not differ significantly from those with other career plans on the basis of marital status or having a family member in dentistry. Anticipated educational debt of at least $100,000 was positively associated with plans to enter private practice immediately after graduation. Self-reported importance of educational debt was not associated with career plans. However, the influence of a spouse, other family members, and family dentists were also positively associated with the decision to enter private practice. These factors all maintained significance in the final multivariable model (p < 0.05); however, educational debt of at least $100,000 was the strongest predictor of plans to enter private practice (OR = 2.34; p = 0.023)., Conclusions: Since the 1970s, increasing numbers of dentists in the U.S. have pursued specialty training after dental school. However, rising educational debts may counter this trend as increasing numbers of dentists choose to immediately pursue general dentistry at graduation. This project has demonstrated the significant influence of educational debt, beyond other external influences.

The Institute of Medicine and the Commission on Dental Accreditation (CODA) have recommended that dental schools incorporate community-based dental education (CBDE) programs into their curricula. The expectation is that CBDE participation will help dental students gain the skills and motivation to treat vulnerable populations after graduation. The purpose of this study was to determine whether dentists' involvement with charitable dental care is associated with participation in CBDE as dental students. A questionnaire was mailed to private practice Iowa dentists (N=1,312); the response rate was 41.2 percent (n=541). Logistic regression analyses, controlling for age, gender, number of hours worked per week, graduation year, and alma mater, were conducted. A majority of the respondents provided charitable care: 85 percent in their offices, and 70 percent in the community. Seventy-nine percent had participated in CBDE as dental students. Respondents who reported being very satisfied/satisfied with their charitable care experiences were more likely to provide charitable care in their offices and the community than respondents who were not satisfied with their experiences. Respondents who participated in CBDE as dental students were more likely to provide charitable care in the community than respondents who did not participate in CBDE. The type of sites where dentists completed their CBDE experiences was associated with where they provide charitable care. This study suggests that participation in CBDE may be associated with dental students' providing charitable dental care after graduation.

Objectives: To describe rates of Medicaid-funded services provided by orthodontists in Iowa to children and adolescents, identify factors associated with utilization, and describe geographic barriers to care., Methods: We analyzed enrollment and claims data from the Iowa Medicaid program for a 3-year period, January 2008 through December 2010. Descriptive, bivariate, and multivariable logistic regression analyses were performed with utilization of orthodontic services as the main outcome variable. Service areas were identified by small area analysis in order to examine regional variability in utilization., Results: The overall rate of orthodontic utilization was 3.1 percent. Medicaid enrollees living in small towns and rural areas were more likely to utilize orthodontic services than those living in urban areas. Children who had an oral evaluation by a primary care provider in the year prior to the study period were more likely to receive orthodontic services. Service areas with lower population density and greater mean travel distance to participating orthodontists had higher utilization rates than smaller, more densely populated areas., Conclusions: Rural residency and increased travel distances do not appear to act as barriers to orthodontic care for this population. The wide variability of utilization rates seen across service areas may be related to workforce supply in the form of orthodontists who accept Medicaid-insured patients. Referrals to orthodontists from primary care dentists may improve access to specialty care for Medicaid enrollees., (© 2013 American Association of Public Health Dentistry.)

Background: Well baby visits (WBVs) are a cornerstone of early childhood health, but few studies have examined the correlates of WBVs for socioeconomically vulnerable infants. The study objective was to identify factors related to the number of WBVs received by Medicaid-enrolled infants in the first three years of life and to present a preliminary explanatory model., Methods: We analyzed Iowa Medicaid claims files and birth certificate data for infants born in calendar year 2000 (N = 6,085). The outcome measure was the number of well baby visits (WBVs) received by Medicaid-enrolled infants between age 1 and 41 months (range: 0 to 10). An ecological health model and existing literature were used to evaluate 12 observed factors as potential WBV correlates. We ran multiple variable linear regression models with robust standard errors (α = 0.05)., Results: There were a number of infant, maternal, and health system factors associated with the number of WBVs received by Medicaid-enrolled infants. Infants whose mothers had a greater number of prenatal healthcare visits (ß = 0.24 to 0.28; P = .001) or were married (ß = 0.20; P = .002) received more WBVs. Having a chronic health condition (ß = 0.51; P < .0001) and enrollment in a case management program (ß = 0.48; P < .0001) were also positively associated with WBVs. Eligibility for Medicaid through the Supplemental Security Income Program (ß = -0.70; P = .001), increased maternal age (ß = -0.27 to -0.35; P = .004), higher levels of maternal education (ß = -0.18; P = .005), maternal smoking (ß = -0.13; P = .018), and enrollment in a health maintenance organization plan (ß = -1.15; P < .0001) were negatively associated with WBVs. There was a significant interaction between enrollment in a health maintenance organization plan and enrollment in a Medicaid case management program (P = .015). Maternal race, maternal alcohol use during pregnancy, and rurality were not significantly related to the number of WBVs., Conclusions: Multiple infant, maternal, and health system variables were related to the number of WBVs received by Medicaid-enrolled infants. Additional research is needed to develop strategies to optimize access to WBVs for Medicaid-enrolled infants at risk for poor use of preventive medical care services.

Objectives: To study the factors associated with young children who had their first dental visit (FDV) at a Federally Qualified Health Center (FQHC) and returned within 12 months for a second dental episode., Methods: Two hundred Medicaid-enrolled children who were less than 6 years old were randomly selected from five Iowa FQHCs. Dental utilization was followed for 36 months using dental charts and Medicaid medical and dental claims data, regardless of provider. Child's birth certificate data were also used as covariates. Multivariable logistic regression, using backward elimination, was used to identify variables that were associated with whether a child returned for a dental recall visit within 1 year of the initial dental episode., Results: About 56% of the children returned for dental care within 1 year of their initial episode. The number of children in the household had a positive impact on children returning for a second dental episode. However, an increase in the frequency of medical well-child visits at the FQHC prior to the FDV had a negative influence. Unadjusted analysis demonstrated that children with dental caries at the FDV were less likely to return within 12 months; however, this variable failed to make the final regression model. Moreover, age at FDV did not make a difference in regard to returning for a second episode within 12 months., Conclusions: The experience gained from having other Medicaid-enrolled children in the household appears to be important for younger children entering into continuous and comprehensive dental care., (© 2013 American Association of Public Health Dentistry.)

Purpose: To examine whether there is a difference in the likelihood that a general dentist practices in a rural location based on individual characteristics, including dental school attended, birth state, practice arrangement, sex, and age., Methods: All private practice, general dentists in Iowa were included in this study. Data were extracted from the year 2010 version of the Iowa Dentist Tracking System, which monitors practice patterns of active dentists. Rurality of primary office location, categorized using Rural-Urban Commuting Area codes, served as the outcome variable. Chi-square tests and multivariable logistic regression were used to explain associations between rural practice location and dentist characteristics., Findings: Fifteen percent of the state's population resided in isolated small rural towns, but only 8% of general dentists practiced here. Approximately 17% of dentists in isolated small rural towns were age 40 or younger, compared to 32% of dentists in urban areas. Among male dentists, those who were born in Iowa (P = .002) were older (P = .020), and graduated from dental schools other than the University of Iowa (P = .009) were more likely to practice in rural areas than were their counterparts. Conversely, among female dentists, solo practice (P = .016) was the only variable significantly associated with rural practice location., Conclusions: The dentist workforce in rural areas of Iowa is dominated by older males who were born in Iowa. As this generation retires and increasing numbers of women enter the profession, state policy makers and planners will need to monitor changing trends in the rural workforce., (© 2013 National Rural Health Association.)

Objective: To study the association of having minor children and contribution to household income on weekly work hours of Iowa female dentists., Methods: A 28-question survey was mailed to all active Iowa dentists. This study represents female dentists who responded to the survey (n = 192; response rate = 63 percent). The dependent variable was whether dentists currently worked full- or part-time (≥ 32 versus <32 hours/week). The associations of having minor children and the percent women contributed toward their household income were then analyzed using stepwise logistic regression, controlling for covariates (alpha = 0.05)., Results: Of the respondents, 14.6 percent worked part-time. Females who had no minor children (40.1 percent) were 3.1 times as likely to work full-time (P = 0.0353), and those who contributed >60 percent to household income (57.8 percent) were 3.0 times as likely to work full-time (P = 0.0129). The final regression model indicated that those who contributed >60 percent to household income (P = 0.0096) and had no leave of absence longer than 45 consecutive days within the prior 2 years (P = 0.0483) were more likely to work full-time compared with their counterparts., Conclusion: Iowa female dentists who provided more than 60 percent to household income and had not taken a leave of absence during the past 2 years were more likely to work full-time. The inclusion of leave of absence as a predictor variable negates any additional influence of the presence or absence of minor children in the regression model, indicating that these variables are highly correlated for this population., (© 2013 American Association of Public Health Dentistry.)

Purpose: The purpose of this study was to estimate age at first dental visit (FDV) and identify variables predicting earlier visits for Medicaid-enrolled children at Iowa Federally Qualified Health Centers (FQHC)., Methods: Statewide Medicaid claims data were used to draw a random sample of children who received their FDV prior to six years old at a FQHC, were Medicaid-enrolled within the first two months of life, and remained continuously enrolled over the study period. Forty children from each of five FQHCs had their dental charts abstracted and merged with other Medicaid records and birth certificate data. The logarithmic age at FDV was regressed against several predictor variables., Results: Mean and median ages for FDV were 25.6 and 23 months old, respectively. When controlling for other variables, there were differences in FDV age according to: mother's marital status (P=.04); whether the child had any medical well-child visits (MCVs) at a FQHC prior to the FDV (P<.001); and which FQHC the child visited. Only approximately 28 percent of these children, however, had any MCV at the FQHC., Conclusions: Medicaid-enrolled children who visited Federally Qualified Health Centers for their first dental visit were seen at an earlier age than previously recorded for such health centers (mean=four years old). Children who also received any medical well-child visits at FQHCs were more likely to have earlier FDVs.

Objectives: We examined the relationship between preventive well baby visits (WBVs) and the timing of first dental examinations for young Medicaid-enrolled children., Methods: The study focused on children born in 2000 and enrolled continuously in the Iowa Medicaid Program from birth to age 41 months (n = 6322). The main predictor variables were number and timing of WBVs. The outcome variable was timing of first dental examination. We used survival analysis to evaluate these relationships., Results: Children with more WBVs between ages 1 and 2 years and ages 2 and 3 years were 2.96 and 1.25 times as likely, respectively, to have earlier first dental examinations as children with fewer WBVs. The number of WBVs before age 1 year and the timing of the WBVs were not significantly related to the outcome., Conclusions: The number of WBVs from ages 1 to 3 years was significantly related to earlier first dental examinations, whereas the number of WBVs before age 1 year and the timing of WBVs were not. Future interventions and policies should actively promote first dental examinations by age 12 months at WBVs that take place during the first year of life.

Background: Studies on the barriers to preventive dental care for preschool-aged children in Medicaid often focus on whether parents understand the importance of preventive dental care. Fewer studies have examined the perceptions and experiences of parents once their child begins utilizing dental care. This qualitative study of parents who are using preventive dental care for their preschool-aged, Medicaid enrolled children uses parental perceptions and experiences to help us understand the barriers to preventive dental care., Methods: This qualitative study focused on 41 parents who participated in focus groups designed to uncover barriers and facilitators to preventive dental care use for young children in Medicaid., Results: Parents of preschool-aged children enrolled in Medicaid face a number of barriers when trying to utilize preventive dental care, even when the parents are experienced with accessing care for their young children. These barriers can be broadly categorized into system-level barriers and provider-level barriers. System-level barriers are related to the low number of dentists who accept Medicaid and/or young children. Provider-level barriers are centered on dentist behavior or clinic environment., Conclusion: Families of preschool-aged children in Medicaid continue to encounter barriers to preventive care even after the child initially utilizes care, which suggests that access to dental care is an ongoing problem for young Medicaid-enrolled children. Interventions that address system-level and provider-level barriers to care can help to ensure continual access to preventive dental care through childhood for Medicaid-enrolled children.

Background: The authors conducted a study in which they explored the geographical distributions of primary care dentists, physicians and pharmacists to determine if a spatial pattern existed between provider types across cities in Iowa., Methods: The authors analyzed practice locations of primary care providers, including dentists, pharmacists and physicians, at the city and county levels in Iowa for 2000 and 2010. They categorized cities on the basis of types of primary care providers in each city and compared population characteristics., Results: Among cities with primary care providers of any type, the most common scenario was for all three provider types to be found together. Several cities that had at least one physician and pharmacist but no dentist in 2000 gained one by 2010., Conclusions: There appears to be a heterarchy of primary care providers in Iowa cities, with pharmacists more prevalent than physicians and dentists., Clinical Implications: Communities with at least one physician and pharmacist but no dentist may be able to offer new or relocating dentists a competitive opportunity for practice.

The purpose of this study was to determine dental utilization and type of dental services for Medicaid-enrolled adults who had been identified as having intellectual and developmental disabilities (IDD). Using Iowa claims data, the authors identified adults who met any of five IDD criteria for inclusion during calendar year 2005. Service utilization rates, including use of preventive dental, routine restorative, and complex restorative services, were determined. Approximately 60% of adults with IDD had at least one dental visit in 2005. Among adults with at least one dental visit, 83% received a preventive service, 31% a routine restorative service, and 16% a complex dental service. Those age 65 and older had fewer preventive dental services than other age groups. In Iowa, dental utilization for adults 22-64 years of age with IDD was reasonably high (64%) in 2005, but individuals over age 65 had lower utilization (45%)., (©2010 Special Care Dentistry Association and Wiley Periodicals, Inc.)

Objectives: To compare preventive dental utilization for children with intellectual and/or developmental disability (IDD) and those without IDD and to identify factors associated with dental utilization., Methods: We analyzed Iowa Medicaid dental claims submitted during calendar year (CY) 2005 for a cohort of children ages 3-17 who were eligible for Medicaid for at least 11 months in CY 2005 (n = 107,605). A protocol for identifying IDD children was developed by a group of dentists and physicians with clinical experience in treating children with disabilities. Utilization rates were compared for the two groups. Crude and covariate-adjusted odds ratios were estimated using conditional logistic regression modeling., Results: A significantly higher proportion of non-IDD children received preventive care than those identified as IDD (48.6 percent versus 46.1 percent; P < 0.001). However, the final model revealed no statistically significant difference between the two groups. Factors such as older age, not residing in a dental Health Professional Shortage Area, interaction with the medical system, and family characteristics increased one's likelihood of receiving preventive dental care., Conclusion: Although IDD children face additional barriers to receiving dental care and may be at greater risk for dental disease, they utilize preventive dental services at the same rate as non-IDD children. Clinical and policy efforts should focus on ensuring that all Medicaid-enrolled children receive need-appropriate levels of preventive dental care.

The purpose of this study was to compare the perceived change in comfort level and future willingness of senior dental students toward treating 12 different groups of traditionally underserved populations. Written surveys of senior dental students were conducted prior to and after completing extramural clinical rotations. A Likert-type scale was used to assess student comfort, whereas future willingness to treat these populations was dichotomous. Over a 13-year period (1992-2004), 560 students completed both surveys. There was an improvement in students' comfort level for 7 of 12 groups after the community-based assignments, yet there were no differences among population groups based on students' gender or assignments. There were positive changes for future willingness to treat patients who were mentally compromised, homeless, and non-English speaking, while there was a negative change for treating patients who were frail and elderly and those who were HIV+ or had AIDS. Students with improved comfort levels were more apt to be willing to treat patients who were frail elderly, medically complex, mentally compromised, and non-English speaking in the future. While student comfort in treating several groups improved after completion of the community-based experiences, there were mixed results for future willingness to treat underserved populations., (©2010 Special Care Dentistry Association and Wiley Periodicals, Inc.)

Objective: The purpose of this study was to identify which underserved populations are being treated by dentists after participation in community-based clinical rotations as dental students and to determine which predictor variables are associated with dentists' treatment of these populations., Methods: A 25-item written survey was developed and mailed to University of Iowa College of Dentistry alumni (1992-2002; N = 745) to assess what percentage of their current total patient population was composed of each of the twelve identified populations. Separate statistical analyses (descriptive, bivariate, and generalized logistic regression) were performed for each underserved population., Results: Three-hundred seventy-two dentists responded for an adjusted response rate of 50 percent. Respondents were most likely to treat "other ethnic groups" and low income populations. In contrast, 70 percent or more of all respondents said they never treat the homebound, homeless, and incarcerated. Additionally, over 40 percent of respondents said they never treat HIV+/AIDS patients and Medicaid patients. Logistic regression models showed that comfort in treating a population, treating more than seven populations, and having the total percentage of underserved populations treated within a practice total more than 50 percent were the most frequently associated (P < 0.05) and strongest predictors of treating the listed underserved populations., Conclusions: Although respondents reported treating most populations, community leaders and dentists should identify at-risk populations and develop protocols to help ensure that these populations are able to obtain, at a minimum, emergency care. Additionally, dental schools should develop educational curricula to help increase students' comfort in treating underserved populations.

Background: State dental boards maintain minimal demographic and practice characteristics about licensed dentists. The authors describe the creation and monitoring of an enhanced surveillance system concerning Iowa's dentists., Methods: The Iowa Dentist Tracking System (IDTS) was used to collect demographic, educational, practice arrangement, office location and work hour data for all active Iowa dentists beginning in 1997. IDTS staff members add newly licensed dentists to the system as practice locations become available. They also contact each dental office semiannually by telephone to update this information. The IDTS Advisory Committee meets annually to review these data and monitor trends., Results: The Iowa dentist workforce was relatively stable from 1997 through 2007; however, a large number of dentists are expected to retire during the next decade, which could create a shortage of providers, especially in rural areas. Although the percentage of male and female dentists who practice part time (< 32 hours per week) decreased between 1997 and 2007, young female dentists are more likely than young male dentists to practice part time., Conclusions: IDTS is a workforce tracking model that can be used to understand trends at the community, regional and state levels. An aging dentist workforce in Iowa could put a strain on the public's ability to access dental care, especially in rural counties., Practice Implications: In the development of workforce policy, workforce tracking systems such as IDTS provide additional information in considering the number of dentists, location, accessibility and potential productivity of a workforce.

The purpose of this project was to determine new dentists' comfort levels in treating traditionally underserved populations after participating in two consecutive five-week community-based clinical experiences while in dental school. A written survey was mailed to all known University of Iowa alumni (1992-2002; N=745). Respondents were asked to rank their comfort levels in treating twelve underserved populations on a five-point Likert type scale (5=no problem; 1=will not). Bivariate and logistic regression model analyses were performed to examine associations (p<0.05) among comfort and six predictor variables. Alumni (n=372) were most comfortable treating other ethnic, low-income, non-English-speaking, and HIV+/AIDS populations and least comfortable treating incarcerated and homebound populations. The following variables were significantly associated with comfort: 1) perception that the community experiences had great/much value; 2) practice located in larger communities; 3) non-solo practitioners; and 4) dentist's gender. As more dental schools utilize community-based clinical experiences to increase students' exposure to underserved populations, it is important that these experiences provide exposure to a variety of populations. Additionally, dental schools should continuously monitor the short- and long-term value of these programs for their students and recent graduates.

Objectives: Dental sealants, by their ability to prevent caries and maintain teeth in better health, have some inherent utility to individuals, programs, or society. This study assessed the 4-year incremental cost utility of sealing first permanent molars of 6-year-old Iowa Medicaid enrollees from a societal perspective and identified the group of teeth or children in whom sealants are most cost effective., Methods: Dental services for first permanent molars were assessed using claims and encounter data for a group of continuously enrolled Medicaid enrollees who turned 6 between 1996 and 1999. Previously published utilities were used to weight the different health states. The weighted sum of outcomes [Quality-Adjusted Tooth-Years (QATYs)] was the measure of effectiveness. Costs and QATYs were discounted to the time of the child's sixth birthday., Results: For all first molars, the cost of treatment associated with sealed teeth was higher but the utility was also slightly higher over the 4-year period. The relative incremental cost per 0.19 QATY ratio [changing the health state from a restored tooth (utility= 0.81) to a nonrestored tooth (utility = 1)] by sealing the molar ranged from $36.7 to $83.5 per 0.19 QATY. The incremental cost/QATY ratio was lower for sealing lower utilizers and for mandibular versus maxillary molars., Conclusions: Sealants improved overall utility of first permanent molars after 4 years. The 4-year cost/QATY ratio of sealing the first permanent molar varied by arch and type of utilizers. Sealing first permanent molars in lower dental utilizers is the most cost-effective approach for prioritizing limited resources.

The purpose of this study was to analyze students' perceptions of comfort and anticipated willingness to treat selected special needs and traditionally underserved populations immediately upon completion of community-based clinical assignments. The sample consisted of University of Iowa senior dental students who completed a questionnaire that asked, in part, about student comfort with and future willingness to treat twelve vulnerable population groups. With student comfort and future willingness to treat each group as dependent variables, logistic models were developed to determine whether there were significant associations between dependent variables and gender, graduation year, and students' prior experience with these groups. Regression models indicate students' prior experience is most often associated with comfort in treating the associated population group. Likewise, experience and comfort add different dimensions to perceived future willingness to treat almost all of the twelve groups. Student gender, graduation year from dental school, and community assignments influence only a few of these targeted population groups. This study provides empirical evidence concerning students' perceptions about comfort with various vulnerable populations after completing their extramural rotations. Students were more comfortable treating certain population groups as well as more willing to consider including these groups in their future practices.

Objective: To assist clinical decision making for an individual patient or on a community level, this study was done to determine the differences in costs and effectiveness of large amalgams and crowns over 5 and 10 years when catastrophic subsequent treatment (root canal therapy or extraction) was the outcome., Methods: Administrative data for patients seen at the University of Iowa, College of Dentistry for 1735 large amalgam and crown restorations in 1987 or 1988 were used. Annual costs and effectiveness values were calculated. Costs of initial treatment (large amalgam or crown), and future treatments were determined, averaged and discounted. The effectiveness measure was defined as the number of years a tooth remained in a state free of catastrophic subsequent treatment. Years free of catastrophic treatment were averaged, and discounted. The years free of catastrophic treatment accounted for individuals who dropped out or withdrew from the study., Results: Teeth with crowns had higher effectiveness values at a much higher cost than teeth restored with large amalgams. The cost of an addition year free of catastrophic treatment for crowns was 1088.41 dollars at 5 years and 500.10 dollars at 10 years. Teeth in women had more favorable cost-effectiveness ratios than those in men, and teeth in the maxillary arch had more favorable cost-effectiveness ratios than teeth in the mandibular arch., Conclusions: Neither the large amalgam or crown restoration had both the lowest cost and the highest effectiveness. The higher incremental cost-effectiveness ratio for crowns should be considered when making treatment decisions between large amalgam and crown restorations.

The purpose of this study was to assess the status of cross-cultural education in U.S. dental schools and to identify characteristics associated with having a formal cross-cultural curriculum. An eighteen-item survey, which included questions about curricular format, teaching and evaluation methods, time, and course content, was sent to all U.S. dental schools. Comparisons were made using whether or not institutions had formal cross-cultural curricula. Forty-five of fifty-six schools responded. Twenty-nine schools reported having formal cross-cultural curricula in a separate course and/or integrated with other courses with specific goals and objectives. Schools that have formal cross-cultural curricula had higher scores on depth of curricula and spent more time than schools that reported having informal curricula (p=0.03). Competing curricular time and lack of faculty expertise were the most frequently cited impeding factors for inclusion of cross-cultural issues (87.8 percent and 68.3 percent, respectively), while diverse patient population and leadership commitment were the most frequently cited facilitating factors (92.5 percent and 67.5 percent, respectively). There is wide variation among dental schools regarding how they teach these issues and how students are evaluated. Dental schools lack guidance about how to best incorporate this curricular content.

Background: Little is known about general dentists' referral patterns. The authors explored the practice, dentist and patient characteristics associated with general dentists' likelihood of referring children aged 3 to 5 years to pediatric dentists., Methods: The authors sent all Iowa general dentists (N = 1,089) a 25-item questionnaire regarding the referral of children in their practices. The authors merged the resulting information with an existing database (Iowa Dentist Tracking System) to create the dataset. A total of 65.4 percent of the dentists (712) participated., Results: Logistic regression analysis demonstrated that an increase in the percentage of children in the practice decreased the likelihood of the dentist's referring the children (odds ratio [OR] = 0.93, 95 percent confidence interval [CI] = 0.90 to 0.96). Practices with more than 5 percent of patients with public insurance were more likely to refer children (OR = 1.96, 95 percent CI = 1.26 to 3.06), as were dentists with additional training beyond dental school (OR = 1.69, 95 percent CI = 1.06 to 2.69)., Conclusion: These data indicate that both practice and dentist characteristics are associated with the likelihood of making referals; however, there needs to be further study on general dentists' referral decisions., Practice Implications: As the characteristics of the dental work force evolve, there is a need to study referral patterns and the influence they have on work force policy, patient accessibility and educational curriculum.

This study analyzed senior dental students' perceptions prior to extramural rotations for comfort and future willingness to treat patients with special needs and other vulnerable groups. The sample included 690 University of Iowa senior dental students who graduated from 1992 through 2004. These students completed a questionnaire concerning twelve vulnerable population groups. Logistic regression models were performed, using student comfort and future willingness to treat each group as the dependent variable. There was a wide percentage of range of comfort with these groups, yet there was no individual group that more than 60 percent of these students were willing to treat in their future practices. Generally, prior experience with the group had a positive impact on comfort level. When gender was included in the regression models, male students were more likely to express comfort. In all instances except one, experience had a positive influence on perceived future willingness to treat the associated group. However, younger graduates had a greater willingness to treat. When controlling for other variables within the future willingness to treat models, comfort was statistically significant only for HIV+/AIDS and non-English speaking groups. This study provides insight about comfort with and perceived future willingness to treat special needs and other vulnerable patient groups.

Ethics education in dentistry is a requirement for accreditation. Despite universal adoption of ethics courses, there is ongoing discussion about the appropriate content of these courses and about methods to engage students. Faculty who teach ethics must select a limited set of topics from the broad fields of professional ethics, bioethics, and the humanities. The purpose of this article is to describe the ethical issues reported by fourth-year dental students during community-based extramural clinical experiences. Senior dental students (n=123) wrote essays describing an ethical issue they encountered during one of two extramural rotations. Ethical issues were categorized and coded by consensus between two faculty authors. Students most often reported perceived dilemmas related to patients' limited resources (25 percent), conflict between professionals (19 percent), clinic policy or procedures (15 percent), and decision making by patients' surrogates (13 percent). One student (<1 percent) reported encountering no ethical issues. Students' perceptions of ethical issues in clinical practice offer faculty a foundation for designing a dental ethics curriculum that is practical and immediately relevant to the experience of a dental student. Students' reports may also yield a method for systematic assessment of students' abilities to apply classroom ethics instruction to clinical practice.