Document Type


Date of Degree

Summer 2012

Degree Name

PhD (Doctor of Philosophy)

Degree In

Oral Science

First Advisor

Kuthy, Raymond A

First Committee Member

Damiano, Peter

Second Committee Member

Hanley, Paul

Third Committee Member

Jones, Michael

Fourth Committee Member

McQuistan, Michelle

Fifth Committee Member

Momany, Elizabeth


Significant efforts have been undertaken in medicine to identify hospital and primary care service areas (eg, the Dartmouth Atlas of Health Care) using patient origin information. Similar research in dentistry is nonexistent. The goal of this dissertation was to develop and refine methods of defining dentist service areas (DSAs) using dental insurance claims. These service areas were then used as spatial units of analysis in studies that examined relationships between utilization of oral health services, dentist workforce supply, and service area characteristics.

Enrollment and claims data were obtained from the Iowa Medicaid program for children and adolescents ages 3-18 years during calendar years 2008 through 2010. The first study described rates of treatment by orthodontists in children ages 6-18 years. Orthodontic DSAs were identified by small area analysis in order to examine regional variability in utilization. The overall rate of utilization was approximately 3%; 19 DSAs were delineated. Interestingly, children living in small towns and rural areas were significantly more likely to have received orthodontic services than those living in metropolitan and micropolitan areas.

The second study identified 113 DSAs using claims submitted by primary care dentists (ie, general and pediatric dentists). Characteristics of these primary care DSAs were then compared with counties. Localization of care was used as a measure of how well each region approximated a dental market area. Approximately 59% of care received by Medicaid-enrolled children took place within their assigned service area versus 52% of care within their county of residence.

Hierarchical logistic regression was used in the final study to examine the influence of spatial accessibility and the importance of place on the receipt of preventive dental visits among Medicaid-enrolled children. Children living in urban areas were more likely to have received a visit than those living in more rural areas. Spatial accessibility assessed using measures of dentist workforce supply and travel cost did not appear to be a major barrier to care in this population.

More studies are needed to explore the importance of spatial accessibility and other geographic barriers on access to oral health services. The methods used in this dissertation to identify service areas can be applied to other populations and offer an appropriate method for examining revealed patient preferences for oral health care.


Dental, Market areas, Medicaid, Orthodontics, Primary care, Small area analysis


xi, 220 pages


Includes bibliographical references (pages 210-220).


Copyright 2012 Susan C. McKernan