International Journal of

Environmental Research
and Public Health

Article
Exploring the Intersection between Social
Determinants of Health and Unmet Dental Care
Needs Using Deep Learning
Man Hung 1,2, * , Eric S. Hon 3 , Bianca Ruiz-Negron 2 , Evelyn Lauren 4 , Ryan Moffat 1 ,
Weicong Su 5 , Julie Xu 6 , Jungweon Park 1 , David Prince 1 , Joseph Cheever 1 and
Frank W. Licari 1
1 College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, USA;
[email protected] (R.M.); [email protected] (J.P.); [email protected] (D.P.);
[email protected] (J.C.); [email protected] (F.W.L.)
2 Department of Orthopaedic Surgery Operations, University of Utah, Salt Lake City, UT 84108, USA;
[email protected]
3 Department of Economics, University of Chicago, Chicago, IL 60637, USA; [email protected]
4 Department of Biostatistics, Boston University, Boston, MA 02115, USA; [email protected]
5 Department of Mathematics, University of Utah, Salt Lake City, UT 84112, USA; [email protected]
6 College of Nursing, University of Utah, Salt Lake City, UT 84112, USA; [email protected]
* Correspondence: [email protected]; Tel.: +1-801-878-1270




Received: 6 September 2020; Accepted: 4 October 2020; Published: 6 October 2020


Abstract: The goals of this study were to develop a risk prediction model in unmet dental care
needs and to explore the intersection between social determinants of health and unmet dental care
needs in the United States. Data from the 2016 Medical Expenditure Panel Survey were used for
this study. A chi-squared test was used to examine the difference in social determinants of health
between those with and without unmet dental needs. Machine learning was used to determine
top predictors of unmet dental care needs and to build a risk prediction model to identify those
with unmet dental care needs. Age was the most important predictor of unmet dental care needs.
Other important predictors included income, family size, educational level, unmet medical needs,
and emergency room visit charges. The risk prediction model of unmet dental care needs attained
an accuracy of 82.6%, sensitivity of 77.8%, specificity of 87.4%, precision of 82.9%, and area under
the curve of 0.918. Social determinants of health have a strong relationship with unmet dental care
needs. The application of deep learning in artificial intelligence represents a significant innovation in
dentistry and enables a major advancement in our understanding of unmet dental care needs on an
individual level that has never been done before. This study presents promising findings and the
results are expected to be useful in risk assessment of unmet dental care needs and can guide targeted
intervention in the general population of the United States.

Keywords: unmet dental care need; artificial intelligence; deep learning; data science; machine
learning; social determinants of health; precision dentistry; oral health outcomes

1. Introduction
Oral health plays a key role in the quality of life of an individual. Indeed, it is a gateway to one’s
overall health and well-being [1–3]. Although societal oral health has been steadily improving, unmet
dental care needs do remain. Unmet dental care needs are problematic and are a global public health
concern. Previous research on unmet dental care needs has suggested that age, race, and socioeconomic

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Int. J. Environ. Res. Public Health 2020, 17, 7286 2 of 13

factors are barriers of dental care [4,5]. In particular, social determinants of health are thought to be the
root cause of unmet dental care needs and medical problems [6].
A retrospective study demonstrated that many states did not offer dental coverage for adults with
Medicaid, forcing many people to resort to visiting the emergency departments for dental treatments [7].
In Rhode Island, the number of adults enrolled in the state Medicaid program increased after the
implementation of the Affordable Care Act, yet the number of Medicaid enrollees who received dental
care decreased [8]. It was concluded that this was due to the increasing number of private dental
offices that stopped submitting Medicaid claims [8]. Additionally, many places that do not offer
dental coverage for adults with Medicaid force patients to rely on emergency departments for dental
treatments which are not equipped to provide preventive and specialized dental care [7]. Provider
discontinuity [9], income level, normative treatment needs, and self-reported oral health status [5]
are other characteristics that have been found to be associated with people with unmet dental needs
as well.
Research has been conducted to investigate the effect of dental insurance coverage on self-reported
oral health. It found that those who were insured were more likely to be capable of performing all
activities of daily living, and more likely to receive regular dental care [10]. This shows that lower dental
cost due to the presence of dental insurance can lead to more regular dental visits and, consequently,
less unmet dental needs.
Geographic barriers also play a role in perpetuating unmet needs and lower quality of care.
Residents of rural areas in the United States have been found to be more likely to have unmet dental
needs than city dwelling residents [11]. This correlates with the attitudes of the respective residents
towards healthcare, and the distribution of dental professionals, with dentists favoring high income
urban areas [12]. Currently, there are more than 4000 areas suffering from a shortage of providers.
As such, many preventable diseases go untreated due to this lack of accessibility [13].
Although there is a preponderance of research studies examining the association between social
determinants of health [14,15], there have been none so far utilizing a large national representative
sample and a large array of factors to explore disparities of dental care needs. More specifically, there is
a lack of studies employing a risk predictive model that can identify unmet dental care needs on an
individual level using deep learning. Deep learning [4], a tool in artificial intelligence, has already
revolutionized the areas of business, robotics, gaming, and computation. It is currently making rapid
strides in medical diagnosis, molecular activity determination, genomic analysis, and image and sound
recognition. It represents an emerging and promising analytical approach in dentistry.
In this study, we were interested in exploring what affects the quality of healthcare, particularly
as it relates to unmet dental care needs. The purpose of this study was threefold: (1) To examine the
difference of social determinants of health between those who had unmet dental care needs and those
who did not have unmet dental care needs, (2) to identify factors predictive of unmet dental care needs,
and (3) to develop a risk prediction model to predict unmet dental care needs on an individual level
using deep learning. This study can aid dentists and health care professionals to identify high-risk
individuals for appropriate courses of dental treatment. It can also provide more insight into health
care disparities and social determinants of health, and the effects and effectiveness of government
healthcare reform.

2. Materials and Methods

2.1. Study Design

We used the 2016 Medical Expenditure Panel Survey (MEPS) [16] data for conducting this study.
MEPS is a nationally representative survey, sponsored by the Agency for Healthcare Research and
Quality, which measures access, use and cost of healthcare services. MEPS is the most complete
source of data on the cost and use of health care and health insurance coverage. The survey consists
of three major components, namely (1) household, (2) medical provider, and (3) health insurance.
Int. J. Environ. Res. Public Health 2020, 17, 7286 3 of 13

The household component (HC) samples are drawn from the respondents to the National Health
Interview Survey by the National Center for Health Statistics [16]. The medical provider component
covers hospitals, physicians, home health care providers, and pharmacies identified by MEPS-HC
respondents. The health insurance component contains data from a sample of private and public sector
employers on health insurance plans they offer their employees, also known as the Health Insurance
Cost Study. This study utilized data from the MEPS-HC and included samples of all ages, who had no
missing data for these two variables indicative of the outcome “unmet dental care needs”: (1) Unable
to get necessary dental care (yes/no); (2) delayed in getting necessary dental care (yes/no). For those
who were under the age of 18 years old, a household adult member responded to the MEPS-HC’s
survey questions for the minor.

2.2. Outcome
The target variable was unmet dental care needs, with a binary outcome of either yes or no.
This variable was created using two self-reported questions from participants at the end of the year 2016:
(1) Unable to get necessary dental care, (2) delayed in getting necessary dental care. If a participant
responded “yes” to at least one of these two self-reported questions, they were considered as having
unmet dental care needs. Otherwise, they did not have unmet dental care needs.

2.3. Predictors
The 2016 MEPS dataset consisted of 1941 variables. We excluded the outcome variable and all
of the variables (e.g., replicated variables that have different scales or measured at different survey
rounds, IDs, weights, respondent units, imputation flags) that were not useful as predictors for unmet
dental care needs. Based on expert knowledge and team consensus, a total of 237 relevant variables
were selected and kept as potential predictors to predict unmet dental care needs. These 237 predictors
included categories of demographic characteristics, physical health status, mental health status,
socioeconomic indicators, employment, insurance coverage, healthcare providers, visits, and charges.
They were measured at the beginning of the year 2016.

2.4. Analyses
We intentionally used the measurement at the beginning of the year for the predictors and
measurement at the end of the year for the outcome in order to establish temporal precedence for
causal relationship inference. Descriptive statistics were computed to examine sample characteristics
using mean, standard deviation, count and proportion as appropriate. Sampling weights were applied
to obtain prevalence estimates that were representative of the United States population.
To prepare the data for pre-processing, responses containing negative values were assigned as
not applicable, which were considered as missing in data analyses. Afterward, variables containing
more than 20% missing were dropped. Non-predictor variables such as data collection variables
(e.g., responding unit, imputation flags) as well as respondent IDs were excluded. Redundant variables
(e.g., income as both categorical and continuous, multiple variables to indicate race and ethnicity) were
also excluded. Since responses were collected multiple rounds throughout the year, only variables
collected on the earliest round were included for the predictors, and on the latest round for the outcome.
Specific variables (e.g., total amount paid by Medicare, total amount paid by Medicaid) adding up to a
general variable (e.g., total healthcare expenditure) were removed to eliminate redundancy.
The outcome variable contained highly unbalanced classes of data. It is highly skewed towards
individuals with met dental needs. In order to prepare the data to input into the machine learning
models, cases with unmet dental need were replicated using oversampling to achieve balance.
One-hot-encoding was applied towards the categorical variables to turn them into binary variables. It is
a common technique to covert categorical data into numerical form to enable efficient implementation
of machine learning algorithms. All data were normalized so that the predictor variables were on the
same scale. The data were then split into 60% training and 40% test sets.
Int. J. Environ. Res. Public Health 2020, 17, 7286 4 of 13

2.4.1. Social Determinants of Health

The differences of social determinants of health between those who had unmet dental care needs
and those who did not have unmet dental care needs were examined using chi-square tests for the
categorical variables.

2.4.2. Top Predictors of Unmet Dental Care Needs

A machine learning method [17–19] called decision tree classifier [20,21] was used to determine
the top features (i.e., variables) that were predictive of unmet dental care needs. There are two general
types of decision trees in the Scikit package utilized in this study: classification and regression trees
(CART). [22] Under the general umbrella of CART, classification is suitable for use in discrete outcome
variable and regression is appropriate for continuous outcome variable. Since the outcome variable for
this study was discrete in nature (e.g., had unmet dental care needs versus did not have unmet dental
care needs), DecisionTreeClassifier (e.g., classification) in Scikit [23,24] was used with a maximum
depth of 8, maximum leaf node of 300, minimum sample split of 100, and minimum samples leaf of 20.
Relative variable importance scores were computed for the top predictors. The decision tree classifier
was chosen due to its interpretability and flexibility for simultaneous inclusion of both categorical and
numerical values and its ability to sum feature importance of a set of features and normalize them.

2.4.3. Model for Risk Predictor of Unmet Dental Care Needs

A machine learning method called deep learning [25–27] was used to generate a model for risk
prediction of unmet dental care needs for individuals. Deep learning is a major breakthrough in the
field of artificial intelligence that has the ability to perform exceptionally well with large and complex
data. It was chosen over traditional machine learning methods (such as support vector machine,
k-nearest neighbors, etc.) in this study because traditional methods were suitable for simpler data
and more straightforward feature engineering, but deep learning was more appropriate for complex
feature engineering such as images and videos and/or large amount of data like what we had in our
study. Additionally, deep learning has the ability to produce highly accurate model in the face of
complex data where traditional methods fall short. Since model accuracy was regarded as the key
performance indicator in this study, deep learning was the method of choice.
The deep learning model had three middle layers with 100 nodes in each layer. Bayesian
optimization was applied to deep learning to fine tune the model. Sklearn Pipeline and Keras Wrappers
were combined for fine tuning hyperparameters that were arranged in five sequential blocks with one
fully connected hidden layer of 100 nodes and rectified linear unit activation for learning initialization
followed by a fully connected output layer with 10 nodes of rectified linear unit activation, in addition
to the softmax layer of 2 nodes at the end of the model. Several key performance indicators such as
sensitivity, specificity, accuracy, precision, and area under the curve (AUC) were computed.
Analyses in this study were performed using R (R Foundation for Statistical Computing, Vienna,
Austria) [28] for traditional statistics and using Python (Python Software Foundation, Beaverton, OR,
USA) [29] for decision tree classifier and deep learning. Statistical tests with p < 0.05 two-sided were
considered as significant.

3. Results
There was a total of 33,929 participants included in the study, representative of 323,141,687 of
the United States population, with an average age of 46.5 years (standard deviation = 18.0 years).
There were 52.3% female and 42.0% white. More than half of the population reported having private
health insurance coverage, but only one third had dental insurance. See Table 1 for more information.
Int. J. Environ. Res. Public Health 2020, 17, 7286 5 of 13

Table 1. Demographic characteristics.

Variable Description N* %* Mean Standard Deviation * Median *

AGE16X Age (year) 25,200 (246,354,311) 46.5 (47.5) 18.0 (18.2) 45 (47)
TTLP16X Person’s total income ($) 22,171 (209,529,021) 31,402 (38,972) 20,800 (41,802) 20,800 (28,000)
Race/Ethnicity
Hispanic 7273 (58,128,006) 29.2 (18.0)
White 10,467 (194,556,659) 42.0 (60.2)
RACETHX
Black 4536 (39,595,626) 18.2 (12.3)
Asian 1923 (18,459,241) 7.7 (5.7)
Other race or multiple race 706 (12,402,154) 2.8 (3.8)
Insurance coverage
Private 18,553 (216,879,523) 53.5 (67.1)
INSCOV16
Public 12,255 (81,653,479) 35.4 (25.3)
Uninsured 3.847 (24,608,684) 11.1 (7.6)
How well person speaks English
Very well 7010 (46,178,975) 58.0 (65.1)

HWELLSPE Well 1929 (10,566,967) 16.0 (14.9)

Not well 2013 (9,281,478) 16.6 (13.1)
Not at all 1139 (4,900,558) 9.4 (6.9)
Person born in US
BORNUSA Yes 27,040 (276,843,356) 78.4 (85.9)
No 7471 (45,524,308) 21.6 (14.1)
Have dental insurance
DNTINS16 Yes 11,834 (139,923,837) 34.4 (43.7)
No 22,565 (180,455,575) 65.6 (56.3)
Int. J. Environ. Res. Public Health 2020, 17, 7286 6 of 13

Table 1. Cont.

Variable Description N* %* Mean Standard Deviation * Median *

Language spoken at home other than English
LANGSPK Spanish 9947 (49,213,364) 74.0 (62.6)
Another language 3497 (29,375,518) 26.0 (37.4)
Sex
SEX Male 16,526 (158,186,085) 47.7 (49.0)
Female 18,129 (164,495,602) 52.3 (51.0)
Marital status
Married 12,139 (130,618,832) 35.0 (40.4)
Widowed 1607 (15,549,509) 4.6 (4.8)

MARRY16X Divorced 2945 (27,603,935) 8.5 (8.5)

Separated 768 (5,247,036) 2.2 (1.6)
Never married 9085 (79,512,517) 26.2 (24.6)
Under 16—Not applicable 8102 (64,609,857) 23.4 (20.0)
Highest degree
No degree 5515 (36,618,014) 16.1 (11.4)
GED 1095 (9,796,007) 3.2 (3.0)
High school diploma 10,805 (107,047,499) 31.5 (33.3)
HIDEG Bachelor’s degree 3946 (48,164,057) 11.5 (15.0)
Master’s degree 1759 (21,623,234) 5.1 (6.7)
Doctorate degree 425 (5,624,308) 1.2 (1.7)
Other degree 1961 (21,716,535) 5.7 (6.8)
Under 16—Not applicable 8813 (70,802,893) 25.7 (22.0)
* Values inside the parentheses are weighted prevalence.
Int. J. Environ. Res. Public Health 2020, 17, 7286 7 of 13

Table 2 displays social determinants of health variables and results related to the differences of
these social determinants of health by unmet dental care needs. There were more people who did
not have dental insurance (5.6%) than those who had dental insurance (3.6%) that reported unmet
dental care needs. There were relatively higher proportions of individuals who had public health
insurance that had unmet dental care needs (5.9%) than those who had private health insurance (4.1%).
Approximately 6.2% of those who were 65 years or older experienced unmet dental care needs, but only
4.7% of those under 65 years old did.

Table 2. Social determinants of health by unmet dental care need.

Have Unmet Dental Need

Variable Description p-Value 95% CI of p-Value
Yes No
Dental insurance n (%) n (%)
DNTINS16 Yes 421 (3.6) 11,310 (96.4) <0.001 0.000–0.000
No 1248 (5.6) 20,892 (94.4)
Health insurance coverage n (%) n (%)
Private 754 (4.1) 17,565 (95.9)
INSCOV16 <0.001 0.000–0.000
Public 702 (5.9) 11,234 (94.1)
Uninsured 213 (5.8) 3461 (94.2)
Age n (%) n (%)
AGE16X Under 65 years 1385 (4.7) 27,911 (95.3) <0.001 <0.001
65 years and over 284 (6.2) 4291 (93.8)
Sex n (%) n (%)
SEX Male 687 (4.3) 15,476 (95.7) <0.001 <0.001
Female 982 (5.5) 16,784 (94.5)
Race/Ethnicity n (%) n (%)
Hispanic 425 (3.8) 10,635 (96.2)
White 696 (5.4) 12,245 (94.6)
RACETHX <0.001 0.000–0.000
Black 356 (5.7) 5904 (94.3)
Asian 92 (3.8) 2357 (96.2)
Other race or multiple race 100 (8.2) 1119 (91.8)
Person born in the US n (%) n (%)
BORNUSA Yes 1310 (6.3) 25,156 (93.7) 0.745 0.745
No 358 (5.0) 7013 (95.0)
How well person speaks English n (%) n (%)
Very well 292 (4.2) 6637 (95.8)
HWELLSPE Well 99 (5.2) 1806 (94.8) 0.146 0.140–0.154
Not well 101 (5.1) 1890 (94.9)
Not at all 46 (4.1) 1074 (95.9)

Unmet medical care needs were notably related to unmet dental care needs. Of those who had
unmet dental care needs, 28.4% were delayed in getting necessary medical care, 37.6% were unable to
get necessary medical care, and 31.9% were unable to get necessary prescription medication. There were
15.7% of those who had poor mental health status having unmet dental care needs while only 3.2% of
those who had excellent mental health status had unmet dental care needs (Table 3).
Int. J. Environ. Res. Public Health 2020, 17, 7286 8 of 13

Table 3. Top predictors of unmet dental care needs.

Have Unmet Dental Need

Variable Description p-Value 95% CI of p-Value
Yes No
Delayed in getting necessary medical care n (%) n (%)
MDDLAY42 Yes 277 (28.4) 698 (71.6) <0.001 0.000–0.000
No 1391 (4.2) 31,533 (95.8)
Family having problems paying medical bills n (%) n (%)
PROBPY42 Yes 546 (14.7) 3177 (85.3) <0.001 0.000–0.000
No 1111 (3.7) 29,030 (96.3)
Unable to get necessary medical care n (%) n (%)
MDUNAB42 Yes 225 (37.6) 373 (62.4) <0.001 0.000–0.000
No 1443 (4.3) 31,849 (95.7)
Unable to get necessary prescription med n (%) n (%)
PMUNAB42 Yes 170 (31.9) 363 (68.1) <0.001 <0.001
No 1495 (4.5) 31,847 (95.5)
Limitation work/Housework/School n (%) n (%)
ACTLIM31 Yes 373 (13.9) 2312 (86.1) <0.001 <0.001
No 1251 (4.4) 27,085 (95.6)
Census region n (%) n (%)
Northeast 220 (4.2) 5066 (95.8)
REGION31 Midwest 304 (4.8) 6050 (95.2) 0.009 0.008–0.012
South 651 (5.1) 12,067 (94.9)
West 485 (5.4) 8524 (94.6)
Mental health status n (%) n (%)
Excellent 483 (3.2) 14,458 (96.8)
Very Good 392 (4.6) 8046 (95.4)
MNHLTH31 <0.001 0.000–0.000
Good 498 (6.5) 7143 (93.5)
Fair 217 (11.7) 1633 (88.3)
Poor 69 (15.7) 371 (84.3)
Covered by Medicare managed care n (%) n (%)
Coverage by Medicare managed care 148 (8.9) 1517 (91.1)
MCRPHO31 <0.001 0.000–0.000
Coverage by Medicare—not managed care 220 (7.5) 2699 (92.5)
Not covered by Medicare 1261 (4.5) 27,040 (95.5)

Among the 33,929 records and 237 variables entered in the prediction of unmet dental care needs,
the decision tree classifier identified fourteen important variables: (1) Age, (2) personal total income,
(3) total general dentist expenditure, (4) family having problems paying medical bills, (5) family size,
(6) educational level, (7) delayed in getting necessary medical care, (8) emergency room facility visit
charges, (9) covered by Medicare managed care, (10) census region of residence, (11) mental health
status, (12) limitation at work/house/school, (13) unable to get necessary medical care, and (14) unable
to get necessary prescription medication (Table 3 and Figure 1). In other words, these fourteen variables
had the most impact on determining whether an individual had unmet dental care needs or not.
Figure 1 displays the relative variable importance score of all these fourteen variables, with age and
person total income as the top two most important variables. In constructing a prediction model, a
variable is considered as important when the exclusion of this variable causes the prediction model’s
error to increase, because the model relied heavily on this variable for the prediction. The most
important variable is the variable that results in the greatest model error when the variable is taken
away from the model.
 with age and person total income as the top two most important variables. In constructing a
prediction model, a variable is considered as important when the exclusion of this variable causes the
prediction model’s error to increase, because the model relied heavily on this variable for the
prediction. The most important variable is the variable that results in the greatest model error when
the
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2020, the model.
17, 7286 9 of 13

Age
Person Total Income
Total General Dentist Expenditure
Family having prob paying medical bills
Family Size
Educational Level
Variable

Delayed in getting necessary medical care

Emergency Room Facility Visit Charges
Covered by Medicare Managed Care
Census Region
Mental Health Status
Limitation Work/Housework/School
Unable to get necessary medical care
Unable to get necessary prescription med

0 0.05 0.1 0.15 0.2

Relative Importance Score

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Int. J. Environ. Res. Public Health 2020, 17, x 9 of 12
AUC of 0.918 (Figure
AUC of 0.918 (Figure 2). 2).

Figure 2. Receiver operating characteristic curve in risk prediction of unmet dental care needs using
Figure
deep 2. Receiver operating characteristic curve in risk prediction of unmet dental care needs using
learning.
deep learning.

4. Discussion
Unmet dental care needs are a significant public health concern in the United States. Exploring
the intersection between the social determinants of health and unmet dental care needs and
Int. J. Environ. Res. Public Health 2020, 17, 7286 10 of 13

4. Discussion
Unmet dental care needs are a significant public health concern in the United States. Exploring
the intersection between the social determinants of health and unmet dental care needs and developing
a risk prediction model presents an opportunity to more easily identify patients who are at risk of not
receiving necessary care. The use of deep learning in artificial intelligence to develop a risk prediction
model is a significant step forward in improving oral health.
This study demonstrated that social determinants of health are strong risk predictors of unmet
dental care needs. Unsurprisingly, unmet dental care needs were found more often in those who
did not have dental insurance than those who had dental insurance. But an unexpected finding
was that those with no health insurance and those with private health insurance all had a lower
level of unmet dental care needs than those with public dental insurance. This is probably due to
the fact that the number of Medicaid enrollees has increased while the number of dental providers
participating in Medicaid program has concurrently decreased due to their dissatisfaction with the
Medicaid program [8]. Thus, there is a lower capacity of dental providers meeting the dental needs
for those who have Medicaid or public dental insurance in general. The Medicaid program also has
the stress of the increase cost of dental expenditures that surpasses the average inflation rate. In 2016,
the total US dental expenditures were above $124 billion when compared to around $50 billion in 1995,
a 150% increase. The projected US dental expenditures will reach $192 billion by 2026, which is another
50% increase from the 2016 expenditure. The higher annual increase rate will only cause more pressure
on those individuals with unmet dental care.
Our findings also support research conducted by Ku et al. (2008) that uninsured adults appeared
to be somewhat healthier than Medicaid insured recipients [30]. This raises a critical question as to why
the United States is relying on a Medicaid program that is failing to meet the needs or protecting the
health of the public. Perhaps it is time to consider quality care for all, instead of Medicaid or Medicare
for all.
This study also found that females were more likely to have unmet needs than males. Previous
research has suggested that this is due to economic reasons [5,31], and without our society eradicating
gender inequality in the workforce, this can be a discernible trend. Race/ethnicity was also a significant
discriminator of unmet dental care needs, with those reporting other or multiple race/ethnicity had
the highest rate of unmet needs at 10.9%. Past studies have suggested that racial/ethnic dental health
disparities are mainly due to socioeconomic factors [32–34]. Understanding racial/ethnic disparities will
help dental providers to bridge unexplained gaps in our society and suggest strategies for interventions
and public health reformations population-wide.
Of the 237 variables explored in this study, 14 of them were found to be highly predictive of unmet
dental care needs. Figure 1 displays the relative importance of each of the 14 predictors, with age
as the most important predictor. A previous study suggests that older edentulous patients visit the
dentist because they have to, rather than for preventive reasons [35]. With many individuals of the
Baby Boomer generation retiring and relying on public health insurance for dental care needs, age and
socioeconomic status becomes highly relevant in determining whether or not dental care needs are
being met. Naturally, a person’s total income was found to be the second most important predictor.
This confirms what has been shown by Edelstein et al. that children living in poverty consistently suffer
from more tooth decay and have more unmet dental care needs than do their more affluent peers [14].
Additionally, research conducted by Chae et al. confirmed that the socioeconomically vulnerable
elder population were more likely to experience high levels of unmet dental care needs [36]. Both the
geriatric population and populations living in less affluent socioeconomic conditions are more likely to
have public dental insurance such as Medicaid, which contributes to greater unmet dental care.
In this study, the use of machine learning methods such as deep learning helped us to develop
precise computer algorithms to model the risk of unmet dental care needs for the United States
population. Indeed, machine learning helped identify social determinants and risk predictors for
unmet dental care needs, but more importantly it helped us generate algorithms that are able to consider
Int. J. Environ. Res. Public Health 2020, 17, 7286 11 of 13

combinations of variables to assist the dental practitioner in risk assessment in clinical scenarios for the
future. Algorithms developed from machine learning are the driving force behind artificial intelligence
as experienced in self-driving cars, facial identification for unlocking phones, space shuttle, and other
robotics used in our lives. Machine learning has powerful dental public health implications as it can
disrupt and advance areas of diagnosis and treatment in oral health. The machine learning algorithms
can be used in diagnosis in dental practices or in online modules such as teledentistry to provide
recommendations for dental examinations and treatment for those identified as high risk. They may
also be used by non-dental professionals to categorize as high-risk those patients that have limited
access to care, or as seen in our study, are elderly or have limited financial resources. Machine learning
may enable the development of cost-efficient practices in dentistry and has huge implications for the
future of more comprehensive care for individuals.
However, this study was not without limitations. The data collected from MEPS may not represent
the changing population of the United States. Although the data were collected in the year of 2016,
a rapid change in the population dynamics may contribute to changing patient demographics and other
characteristics over time. Onsite clinical validation in the future may be needed to further improve
the algorithms.

5. Conclusions
Unmet dental healthcare needs have a longstanding history in the United States and show no
signs of abatement. Understanding its social determinants allows us to tackle unmet needs with more
focused intensity and better allocation of resources. Innovation using artificial intelligence such as
machine learning is a great way to tackle this age-old problem, which enables the development of more
precise and effective diagnostic modalities for dental practitioners. The model developed in this study
will enable early identification and concentration upon those who are most at-risk for not receiving
dental treatment. On a larger scale, these machine learning algorithms may create more automated
and financially feasible systems of dental healthcare delivery on a national level.

Author Contributions: Conceptualization, M.H., E.S.H., F.W.L.; methodology, M.H., E.S.H., B.R.-N.; software,
M.H., W.S., E.L.; validation, M.H.; formal analysis, M.H., W.S., E.L.; investigation, M.H., E.S.H., B.R.-N., W.S., E.L,
J.X., D.P., J.C., F.W.L., J.P., R.M.; resources, M.H., F.W.L.; data curation, M.H.; writing—original draft preparation,
M.H., B.R.-N., E.L., W.S., E.S.H., R.M., J.X., J.P.; writing—review and editing, M.H., E.S.H., B.R.-N., R.M., W.S., E.L,
J.X., J.P., D.P., J.C., F.W.L.; visualization, M.H., W.S., E.L.; supervision, M.H.; project administration, M.H.; funding
acquisition, M.H. All authors have read and agreed to the published version of the manuscript.
Funding: This work was supported by funding from the Chevron Foundation Research Scholarship.
Acknowledgments: The authors sincerely thank the Clinical Outcomes Research and Education at Roseman
University of Health Sciences College of Dental Medicine for strong support of this study.
Conflicts of Interest: The authors declare no conflict of interest.

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