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Abstract

OBJECTIVES: To examine the relationship between time since the most recent dental exam and diagnosis of head and neck cancer. MATERIALS AND METHODS: This study analyzed data from the 2019 and 2020 National Health Interview Survey, which is a nationally representative sample of non-institutionalized adults in the United States. These two years of data yielded a total sample of 7924 adults. Analyses were conducted using a chi-square test and multiple logistic regression. The primary independent variable was time since last dental exam and the outcome was diagnosis of head and neck cancer. RESULTS: After adjusting for sociodemographic and health covariates, those who had not seen a dentist within 10 years had a 2.1 times significantly higher odds for diagnosis of head and neck cancer compared to those who had seen a dentist within 1 year (adjusted odds ratio: 2.09, 95% confidence interval: 1.16–3.75, p < .05). CONCLUSION: There was a significant association between time since last dental exam and diagnosis of head and neck cancer. Dental professionals can help reduce morbidity and mortality associated with head and neck cancer by promoting primary dental preventative care, performing biopsies of suspicious lesions, and facilitating referrals to head and neck specialists.
Association between dental exams and diagnosis of head and neck cancer
Nadia Alexandra Debick
a
, Roger Wong
b
,
*
a
Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
b
Department of Public Health and Preventive Medicine, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
ARTICLE INFO
Keywords:
Cancer
Dental care
Head
Neck
Prevention
ABSTRACT
Objectives: To examine the relationship between time since the most recent dental exam and diagnosis of head and
neck cancer.
Materials and methods: This study analyzed data from the 2019 and 2020 National Health Interview Survey, which
is a nationally representative sample of non-institutionalized adults in the United States. These two years of data
yielded a total sample of 7924 adults. Analyses were conducted using a chi-square test and multiple logistic
regression. The primary independent variable was time since last dental exam and the outcome was diagnosis of
head and neck cancer.
Results: After adjusting for sociodemographic and health covariates, those who had not seen a dentist within 10
years had a 2.1 times signicantly higher odds for diagnosis of head and neck cancer compared to those who had
seen a dentist within 1 year (adjusted odds ratio: 2.09, 95% condence interval: 1.163.75, p <.05).
Conclusion: There was a signicant association between time since last dental exam and diagnosis of head and
neck cancer. Dental professionals can help reduce morbidity and mortality associated with head and neck cancer
by promoting primary dental preventative care, performing biopsies of suspicious lesions, and facilitating referrals
to head and neck specialists.
1. Introduction
Head and neck cancers comprise roughly four percent of new cancer
diagnoses annually in the U.S., and include cancers of the lip oral cavity,
pharynx, larynx, ethmoid and maxillary sinuses and salivary glands [1].
The National Cancer Institute estimates that there will be 54,000 new
cases of oral and pharyngeal cancers diagnosed in the U.S. in 2022, with
an additional 12,470 diagnoses of laryngeal cancer [2,3]. Risk factors for
the development of head and neck cancer include male sex, tobacco use,
alcohol use, and infection with high-risk genotypes of human papilloma
virus (HPV), particularly HPV-16 [49]. Another risk factor identied by
the literature is poor dental hygiene [58]. Poor dental hygiene includes
lack of teeth brushing, lack of regular dental care, and improper care of
oral devices such as dentures [48,1015]. Poor dental hygiene increases
the risk for development of head and neck cancers through both in-
ammatory and microbial mechanisms [10,16]. Patients may develop
chronic periodontitis with bacterium such as P. gingivalis, which has been
posited to lead to pro-carcinogenic changes via alterations in cell cycling
and gene expression [1618].
Cancers of the head and neck may initially be asymptomatic, or
present with signs including hoarseness, dysphagia, leukoplakia, or
lymphadenopathy, depending on the primary site of the cancer [19].
Given the nature of head and neck cancers, patients may have sub-clinical
disease for extensive periods prior to diagnosis. During this time, dele-
terious genetic and epigenetic alterations contribute to cancer
progression.
Dentists thereby might help to prevent head and neck cancer at
routine dental visits through opportunistic examinations to detect cancer
and through the provision of dental care and optimization of oral hy-
giene. This may be particularly impactful in the context of the COVID-19
pandemic, as many patients, especially those in rural or otherwise un-
derserved areas, have been unable to access dental care [20]. Nationally
representative studies indicate that greater than 20% of people reported
delaying dental care in response to the COVID-19 pandemic, when
queried in May and June of 2020. A signicant proportion of those who
delayed care reported doing so despite the presence of pain or a dental
complaint [21]. The goal of this study is to examine the association be-
tween time since the most recent dental exam and the diagnosis of head
and neck cancer.
* Corresponding author. 2263 Weiskotten Hall, 766 Irving Avenue, Syracuse, NY, 13210, USA.
E-mail address: WongRo@upstate.edu (R. Wong).
Contents lists available at ScienceDirect
Oral Oncology Reports
journal homepage: www.journals.elsevier.com/oral-oncology-reports
https://doi.org/10.1016/j.oor.2022.100006
Received 25 September 2022; Received in revised form 26 October 2022; Accepted 27 October 2022
2772-9060/©2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Oral Oncology Reports 3-4 (2022) 100006
2. Participants and methods
2.1. Study design
Data from the 2019 and 2020 National Health Interview Survey
(NHIS) were analyzed, with a total sample size of 7924 respondents.
NHIS includes survey data collected from non-institutionalized adults
aged 18 years and older in the United States. Data from the most recent
two survey years were combined due to a low response rate in 2020
during the onset of the COVID-19 pandemic. The 2019 interviews were
conducted in person, while the 2020 interviews were conducted via
phone due to concerns related to the COVID-19 pandemic. The 2021
NHIS data did not include the key independent variable of interest, and
was therefore not included in analyses. Ethical considerations for this
study were approved by SUNY Upstate Institutional Review Board for the
Protection of Human Subjects (#1875885-1).
2.2. Variables
The dependent variable for this study was the presence or absence of a
diagnosis of head and neck cancer. NHIS denes head and neck cancers
as those of the larynx, trachea, pharynx, mouth, tongue, or lip.
The primary independent variable for this study was the time since
the respondent last had a dental exam. Responses were placed into four
categories: within 1 year, between 1 and 3 years, between 3 and 10 years,
or 10 years or longer.
Several key covariates were included for analysis. Age in years was
included as a continuous variable, and of note, those 85 years and older
were top coded into one category to protect respondent identity. Cate-
gorical covariates included medical insurance status, separate dental
insurance, sex, history of conventional cigarette smoking, history of e-
cigarette smoking, income group, and race and ethnicity. Respondents
with medical insurance reported having private, Medicaid or public in-
surance, or another form of insurance. Respondents were also asked if
they had separate insurance for dental costs or not. Each of the smoking
covariates were included as binary variables (ever smoked or never
smoked). Income was measured as annual household income in ve
categories: less than or equal to $34,999; $35,000 to $49,999; $50,000 to
$74,999; $75,000 to $99,999; or greater than or equal to $100,000. Race
and ethnicity was included as categories of Non-Hispanic White, Non-
Hispanic Black, Non-Hispanic Asian, Hispanic, and other. The other
category included those who identied as non-Hispanic American Indian
or Alaskan Native with or without another group, and Other Single and
Multiple Races. For all covariates, any unknown or refused responses
were coded as missing.
2.3. Statistics
To examine the bivariate relationship between time since last dental
exam and diagnosis of head and neck cancer, a chi-square test was con-
ducted. A multiple logistic regression model was then developed to
examine the association between time since last dental exam and diag-
nosis of head and neck cancer, after adjusting for all covariates. The
average variance ination factor (VIF) was 1.09, indicating that there is
no harmful multicollinearity. All statistical analyses were conducted
using SPSS 27.0 with two-tailed tests at a 0.05 signicance level.
3. Results
Approximately 1.4% (n ¼107) of the sample reported a diagnosis of
head and neck cancer, which included both HPV positive and negative
subtypes (Table 1). Of these respondents, 30 reported a cancer of the
oropharynx, tongue or lip, 8 reported a cancer of the larynx or trachea,
and 69 reported a cancer of the pharynx. Most of the respondents
(69.6%) reported having a dental exam within 1 year, whereas only 7.7%
of respondents reported not having seen a dentist within 10 years. Nearly
all respondents (96.0%) reported having a medical doctor visit within 1
year, while only 0.3% of respondents reported not having seen a doctor
within 10 years. The mean age of respondents in the sample was 67.8
years with a standard deviation of 13.1 years. Within the sample, 58.3%
of respondents identied as female. Most of the sample (97.4%) had
some form of medical insurance. Roughly one in three respondents
(32.0%) reported having separate dental insurance. Almost half the
sample (48%) had a history of conventional cigarette use while far fewer
had a history of e-cigarette use (8.8%). Income groups were bimodally
distributed, with 30.5% earning less than $34,999 and 25.8% earning
more than $100,000 annually. The most represented racial and ethnic
group was non-Hispanic White, which comprised 86.6% of the sample.
A chi-square test was conducted to assess for an association between
dental care and diagnosis of head and neck cancer (Table 2). This sta-
tistical test showed a signicant association between time since last
dental exam and diagnosis of head and neck cancer [
χ
2
(3) ¼23.14, p <
.001]. As the time since last dental exam increased, the proportion of
Table 1
Sample characteristics.
Frequency Percent
Diagnosis of Head and Neck Cancer
Yes 107 1.4
No 7817 98.6
Last Dental Exam
Within 1 Year 5476 69.6
Between 1 and 3 Years 1101 14.0
Between 3 and 10 Years 682 8.7
Beyond 10 Years 608 7.7
Last Doctor Visit
Within 1 Year 7574 96.0
Between 1 and 3 Years 244 3.1
Between 3 and 10 Years 53 0.7
Beyond 10 Years 21 0.3
Age (mean, SD) 67.8 13.1
Medical Insurance Status
Insured 7714 97.4
Not Insured 206 2.6
Separate Dental Insurance
Yes 2526 32.0
No 5367 68.0
Sex
Female 4619 58.3
Male 3305 41.7
History of Conventional Cigarette Smoking
Ever 3729 48.0
Never 4040 52.0
History of E-cigarette Smoking
Ever 681 8.8
Never 7093 91.2
Income Group (in U.S. dollars)
34,999 2420 30.5
35,000 to 49,999 1120 14.1
50,000 to 74,999 1388 17.5
75,000 to 99,999 952 12.0
100,000 2044 25.8
Race and Ethnicity
White, Non-Hispanic 6860 86.6
Black, Non-Hispanic 440 5.6
Asian, Non-Hispanic 92 1.2
Hispanic 384 4.8
Other 148 1.9
Table 2
Chi-square analysis of time since last dental exam and diagnosis of head and neck
cancer.
Time Since Last Dental
Exam
No
Diagnosis
Diagnosis
χ
2
df p-
value
Within 1 Year 5420 (69.8) 56 (52.8)
Between 1 and 3 Years 1082 (13.9) 19 (17.9)
Between 3 and 10 Years 671 (8.6) 11 (10.4) 23.14 3 <.001
Greater than 10 Years 588 (7.6) 20 (18.9)
N.A. Debick, R. Wong Oral Oncology Reports 3-4 (2022) 100006
2
head and neck cancer diagnoses trended upward, particularly among
those who had not seen a dentist in 10 years or greater.
A multiple logistic regression was used to assess the relationship be-
tween time since the most recent dental exam and diagnosis of head and
neck cancer, after adjusting for several sociodemographic and health
covariates (Table 3). The model was statistically signicant [
χ
2
(20) ¼
111.79, p <.001] and there was excellent model t as the model
correctly predicted 98.7% of head and neck cancer cases. After adjusting
for sociodemographic and health covariates, those who had not seen a
dentist in the past 10 years had a 2.1 times signicantly higher odds of
having a diagnosis of head and neck cancer when compared to their
counterparts who had seen a dentist within 1 year (adjusted odds ratio
[aOR]: 2.09, 95% condence interval [CI]: 1.163.75, p <.05).
Our regression model identied other variables signicantly associ-
ated with head and neck cancer. Those who had not seen a medical
doctor within 10 years had a 7.3 times signicantly higher odds of
reporting a diagnosis of head and neck cancer when compared to their
counterparts who had seen a medical doctor within 1 year (aOR: 7.34,
95% CI: 1.5434.56, p <.05). Those who identied as male had a 4.6
times signicantly higher odds of having a diagnosis of head and neck
cancer when compared to females (aOR: 4.60, 95% CI: 2.867.42, p <
.05). Those who had never smoked conventional cigarettes were 58%
signicantly less likely to have a diagnosis of head and neck cancer when
compared to those who had ever smoked conventional cigarettes (aOR:
0.42, 95% CI: 0.260.68, p <.05). Those who reported having separate
dental insurance were 51% signicantly less likely to have a diagnosis of
head and neck cancer when compared to their counterparts who reported
not having separate dental insurance (aOR: 0.49, 95% CI: 0.290.85, p <
.05). All other covariates were not signicantly associated with diagnosis
of head and neck cancer.
4. Discussion
We analyzed the association between time since last dental exam and
diagnosis of head and neck cancer. In our analysis of the 2019 and 2020
NHIS data, those who had not seen a dentist in 10 years or greater were
signicantly more likely to report a diagnosis of head and neck cancer
when compared to their counterparts who had seen a dentist within 1
year. These ndings are consistent with prior literature that implicates
poor dental hygiene, including infrequent dental exams, in the patho-
genesis of head and neck cancers. Routine dental care and optimal dental
hygiene thereby may reduce the risk for development of head and neck
cancers [10]. Consistent with the literature, other covariates included in
our analysis that were signicantly associated with diagnosis of head and
neck cancer included time since last visit with medical doctor, male sex,
and history of conventional cigarette smoking [4,8].
Dentists can help to prevent cancers of the head and neck through
routine care and detect cancers of the head and neck both through direct
visualization and palpation of regional lymph nodes. By reducing the
incidence of periodontitis, dental providers can prevent head and neck
cancers associated with this pathophysiology [17,22,23]. Research sug-
gests that patients may not seek medical care for cancers of the head and
neck until overt symptoms develop [24]. However, lower stage or less
functionally limiting cancers may be detected during routine dental care
[24]. Logically, patients who undergo non-symptom based examinations
in the setting of a dental practice are diagnosed with cancers of the head
and neck at earlier stages than their counterparts who sought care once
symptoms developed [25]. For patients with access to dental care, early
identication and expedited treatment planning will allow clinicians to
offer prompt surgical interventions. These data demonstrate why access
to, and utilization of dental care should be considered when assessing
risk for diagnosis of head and neck cancers.
From a public health perspective, these ndings are concerning for
adults who are uninsured or underinsured and for those who reside in
dental underserved areas. For those on Medicaid, there are substantial
gaps in dental coverage due to state discretion in providing dental
benets and outright lack of Medicaid expansion. Expansion of coverage
and strengthening of benets could potentially help to alleviate this
disparity [2629]. For example, expanded states such as Colorado saw
substantial increases in dental coverage and the amount of patients with
Medicaid seeking dental care through federally qualied health centers
[30,31]. However, since there is signicant overlap between those at
high risk for development of head and neck cancer and those who do not
regularly see a dentist, increased efforts to reach this population must
continue to be made [32]. In line with other healthcare services, dis-
parities in access to dental care exist on the basis of geographic and
sociodemographic conditions. Those who live in dental underserved
areas as dened by the Health Resources and Services Administration
face geographic barriers to accessing care. These concerns are further
compounded by sociodemographic factors such as income and education
levels [33,34].
Due to the cross-sectional nature of the NHIS data, a causal rela-
tionship between dental exam and head and neck cancer could not be
explored. In addition, the dependent variable of head and neck cancer
diagnosis was self-reported. Therefore, the psychometric properties of
this variable are not available. Correspondingly, data on the stage at
diagnosis was not collected, which may elucidate the role of dental care
in early detection of cancers of the head and neck. Finally, there is an
absence of some potential confounding variables in the data that could be
adjusted for in future research, which include alcohol use and HPV
vaccination status.
Despite these limitations, most studies evaluating the relationship
between dental care and diagnosis of head and neck cancers are con-
ducted as single-center, case-control studies. Use of NHIS data also
Table 3
Multiple logistic regression exploring the association between last dental exam
and diagnosis of head and neck cancer.
aOR 95% CI p-value
Last Dental Exam
Within 1 Year Reference Reference Reference
Between 1 and 3 Years 1.44 0.83, 2.51 .20
Between 3 and 10 Years 1.16 0.58, 2.31 .61
Beyond 10 Years 2.09 1.16, 3.75 .014
Last Doctor Visit
Within 1 Year Reference Reference Reference
Between 1 and 3 Years 1.70 0.66, 4.36 .27
Between 3 and 10 Years 2.63 0.56, 12.28 .22
Beyond 10 Years 7.34 1.55, 34.74 .012
Age in Years 0.99 0.97, 1.01 .27
Medical Insurance Status
Insured Reference Reference Reference
Not Insured 0.37 0.08, 1.70 .27
Separate Dental Insurance
No Reference Reference Reference
Yes 0.49 0.29, 0.85 .011
Sex
Female Reference Reference Reference
Male 4.6 0 2.86, 7.42 <.001
History of Conventional Cigarette Smoking
Yes Reference Reference Reference
No 0.42 0.26, 0.68 <.001
History of E-cigarette Smoking
Yes Reference Reference Reference
No 0.71 0.39, 1.27 .24
Income Group (in U.S. dollars)
34,999 Reference Reference Reference
35,000 to 49,999 0.99 0.54, 1.82 .96
50,000 to 74,999 0.81 0.42, 1.55 .52
75,000 to 99,999 1.21 0.62, 2.37 .57
100,000 1.12 0.61, 2.05 .71
Race and Ethnicity
White, Non-Hispanic Reference Reference Reference
Black, Non-Hispanic 0.52 0.16, 1.66 .27
Asian, Non-Hispanic 1.05 0.14, 8.09 .96
Hispanic 1.13 0.45, 2.90 .79
Other 1.71 0.79, 3.68 .17
N.A. Debick, R. Wong Oral Oncology Reports 3-4 (2022) 100006
3
allowed for analysis of covariates that are not typically included in
electronic medical records, such as income and history of e-cigarette use.
5. Conclusion
Our ndings demonstrate the important role of dental examination in
both prevention and treatment of head and neck cancers. Dental pro-
viders may help to facilitate the diagnosis and treatment of cancers of the
head and neck. Given the consistency of these ndings with prior
research, further investigation into the role of dental disease in the
pathophysiology of head and neck cancer is warranted.
Sources of funding
None.
Author contributions
Nadia Alexandra Debick: Conceptualization, Formal Analysis, Writing
and Editing; Roger Wong: Formal Analysis, Methodology, Writing and
Editing.
Declaration of competing interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
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Oral and esophageal squamous cell carcinomas harbor a diverse microbiome that differs compositionally from precancerous and healthy tissues. Though causality is yet to be definitively established, emerging trends implicate periodontal pathogens such as Porphyromonas gingivalis as associated with the cancerous state. Moreover, infection with P. gingivalis correlates with a poor prognosis, and P. gingivalis is oncopathogenic in animal models. Mechanistically, properties of P. gingivalis that have been established in vitro and could promote tumor development include induction of a dysbiotic inflammatory microenvironment, inhibition of apoptosis, increased cell proliferation, enhanced angiogenesis, activation of epithelial‐to‐mesenchymal transition, and production of carcinogenic metabolites. The microbial community context is also relevant to oncopathogenicity, and consortia of P. gingivalis and Fusobacterium nucleatum are synergistically pathogenic in oral cancer models in vivo. In contrast, oral streptococci, such as Streptococcus gordonii, can antagonize protumorigenic epithelial cell phenotypes induced by P. gingivalis, indicating functionally specialized roles for bacteria in oncogenic communities. Consistent with the notion of the bacterial community constituting the etiologic unit, metatranscriptomic data indicate that functional, rather than compositional, properties of the tumor‐associated communities have more relevance to cancer development. A consistent association of P. gingivalis with oral and orodigestive carcinoma could have diagnostic potential for early detection of these conditions that have a high incidence and low survival rates.
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Poor oral hygiene is an established risk factor of head and neck cancer (HNC); however, its role in the survival of HNC patients is unclear. This study evaluated the association between oral hygiene habits, including regular dental visits, frequency of tooth brushing, and use of dental floss, and the overall survival (OS) of HNC patients using interview data collected from 740 HNC patients. In addition, the interactions between oral hygiene and the polymorphisms of TLR2 and TLR4 on the OS of HNC patients were assessed. The analysis indicated that poor oral hygiene was significantly associated with poorer OS of HNC patients (hazard ratio (HR) = 1.38, 95% confidence interval (CI): 1.03‐1.86). This association was modified by a single nucleotide polymorphism, rs11536889, of TLR4. A significant association between poor oral hygiene and worse survival of HNC was observed among those with the CG or CC genotype (HR = 2.32, 95% CI: 1.41‐3.82) but not among those with the GG genotype (HR = 0.95, 95% CI: 0.65‐1.40). Our results suggested that poor oral hygiene is not only a risk factor but may also be a prognostic factor of HNC.
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There is increasing evidence for an association between periodontitis/tooth loss and oral, gastrointestinal, and pancreatic cancers. Periodontal disease, which is characterized by chronic inflammation and microbial dysbiosis, is a significant risk factor for orodigestive carcinogenesis. Porphyromonas gingivalis is proposed as a keystone pathogen in chronic periodontitis causing both dysbiosis and discordant immune response. The present review focuses on the growing recognition of a relationship between P. gingivalis and orodigestive cancers. Porphyromonas gingivalis has been recovered in abundance from oral squamous cell carcinoma (OSCC). Recently established tumorigenesis models have indicated a direct relationship between P. gingivalis and carcinogenesis. The bacterium upregulates specific receptors on OSCC cells and keratinocytes, induces epithelial-to-mesenchymal (EMT) transition of normal oral epithelial cells and activates metalloproteinase-9 and interleukin-8 in cultures of the carcinoma cells. In addition, P. gingivalis accelerates cell cycling and suppresses apoptosis in cultures of primary oral epithelial cells. In oral cancer cells, the cell cycle is arrested and there is no effect on apoptosis, but macro autophagy is increased. Porphyromonas gingivalis promotes distant metastasis and chemoresistance to anti-cancer agents and accelerates proliferation of oral tumor cells by affecting gene expression of defensins, by peptidyl-arginine deiminase and noncanonical activation of β-catenin. The pathogen also converts ethanol to the carcinogenic intermediate acetaldehyde. In addition, P. gingivalis can be implicated in precancerous gastric and colon lesions, esophageal squamous cell carcinoma, head and neck (larynx, throat, lip, mouth and salivary glands) carcinoma, and pancreatic cancer. The fact that distant organs can be involved clearly emphasizes that P. gingivalis has systemic tumorigenic effects in addition to the local effects in its native territory, the oral cavity. Although coinfection with other bacteria, viruses, and fungi occurs in periodontitis, P. gingivalis relates to cancer even in absence of periodontitis. Thus, there may be a direct relationship between P. gingivalis and orodigestive cancers.
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Background Head and neck cancer (HNC) is the seventh most common type of cancer in the world and constitute 5% of the entire cancers worldwide. The global burden of HNC accounts for 650,000 new cases and 350,000 deaths worldwide every year and a major proportion of regional malignancies in India. More than 70% of squamous cell carcinoma of the head and neck are estimated to be avoidable by lifestyle changes, particularly by effective reduction of exposure to well-known risk factors such as tobacco smoking and alcohol drinking. Methods A retrospective analysis of 12 years (2001 - 2012) of HNC patients attending RCC, PGIMS Rohtak was done. Total numbers of cancer patients seen were 26,295 and out of these 9,950 patients were of HNCs, which were retrospectively analyzed for their associated risk factors in different HNC subtypes. Most of the patients, i.e. 92.3%, were presented as locally advanced HNC (stages III and IV). Results It has been observed that smoking and alcohol are the strongest independent risk factors responsible for increased risk of HNC and are further having synergetic correlations. Conclusion The present study confirms the principal role of alcohol consumption and smoking in HNC carcinogenesis, as well as the differential associations with HNC subtypes, and a significant, positive, multiplicative interaction with different risk factors.
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Objective: To examine the impact of the Affordable Care Act on dental care use among low-income adults ages 21-64. Methods: Our analysis uses national survey data from the 2010-2016 Gallup Wellbeing-Index. We use a differences-in-differences analysis to assess changes since the end of 2013 in dental care use among low-income adults. We compare changes in states that expanded Medicaid and offer adult Medicaid dental benefits versus changes in other states. Results: Relative to the pre-reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased 3-6 percentage points in 2016. Conclusions: In Medicaid expansion states with adult dental benefits, evidence suggests that low-income adults have greater access to dental care.
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