Oral Health Status of Immigrant and Refugee

Children in North America: A Scoping Review

Mona Reza, BSc; Maryam Amin, DMD, MSc, PhD; Adam Sgro, ; Angham Abdelaziz, DDS; Dick Ito, DDS, MSc,
FRCD(C); Patricia Main, DDS, MSc, FRCDC(C); Amir Azarpazhooh, DDS, MSc, PhD, FRCD(C);

Cite this as: J Can Dent Assoc. 2016;82:g3

Abstract
Objectives: The aim of this scoping review was to assess the oral health status of
the children of refugees and immigrants (“newcomers”); the barriers to appro-
priate oral health care and use of dental services; and clinical and behavioural
interventions for this population in North America.

Methods: Explicit inclusion and exclusion criteria were used in searching elec-
tronic databases to identify North American studies between 2007 and 2014
that reported oral health status, behaviours and environment of children of
newcomers. Additional studies from 1995–2008 were found in a recently pub-
lished review. Pertinent data from all selected studies were summarized.

Results: Overall, 32 relevant North American studies were identified. In gen-

eral, children of newcomers exhibit poorer oral health compared with their
non-newcomer counterparts. This population faces language, cultural and
financial barriers that, consequently, limit their access to and use of dental
services. Intervention programs, such as educational courses and counseling,
targeting newcomer parents or their children are helpful in improving the oral
health status of this population.

Conclusions: Children of newcomers are suffering from poor oral health and
face several barriers to use of dental care services. The disparity in dental
caries between children of newcomers and their counterparts can be reduced
by improving their parents’ literacy in the official language(s) and educating
parents regarding good oral health practices. An appropriate oral health
policy remains crucial for marginalized populations in general and newcomer
children in particular.

D
ental caries is a major children’s oral health concern in Canada: among
6–19-year-olds, the prevalence is approximately 60% and the mean
number of affected teeth is 2.5.1,2 Children suffering from pain caused
by dental problems are more likely to perform poorly at school, as they may
be inattentive or miss classes.3 They may be more prone to functional and
cognitive problems (e.g., speech impairment, learning and eating problems)4
or psychological issues arising from poor self-image in a social setting.3 In
particular, disadvantaged children, such as most refugee and immigrant
(“newcomer”) children, appear to be at higher risk for dental diseases.5 This
has implications for countries, such as Canada, where immigrants represent
20.6% (6 775 800) of the total population and immigrant children under 14
years of age represent 19.2% of the recent immigrant population.6

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Dental diseases are among the most costly diseases to were excluded in terms of evidence-based recommen-
treat in Canada, as they affect the general economy dations, although they were used to identify relevant
through lost work and lost school days.7 Such diseases references. The study population had to be children
are disproportionately concentrated among newcomer (ages 0–18 years) of newcomers living in North America.
children.6 This might be a result of untreated oral diseases
To allow us to assess the oral health status of newcomer
in their home country as well as various barriers to appro-
children, their use of dental services, the effects of various
priate oral health they face when they arrive in a new
barriers to optimal oral health and effective health
country.8 Cutbacks in public dental funding have imposed
promotion activities to reduce these barriers, studies had
more financial pressures on low-income families, especial-
to report on the following specific outcome measures:
ly those with no or limited dental insurance.9 Inadequate
access to care for newcomer populations is common, • Oral health status measured by caries prevalence
as many are challenged by barriers of culture and and relevant indices, such as decayed/missing/
language, along with a lack of financial resources.6 filled teeth/surface scores (in primary and/or
permanent dentition), gingivitis and periodontitis
Promoting the oral health status of newcomer children
in North America requires timely knowledge about the • Oral health behaviour, either protective (such as
underlying factors affecting their access to oral health regular dental visits, adequate oral hygiene practices,
care. Updated information would assist us in identi- use of toothpastes with fluoride) or harming (such
fying the issues and in developing effective health as diets rich in sugar, use of nursing bottles)
promotion strategies to address these problems. This • Oral health environment that either promotes the child’s
scoping review of selected studies on newcomer oral health status or places it at higher risk, including
children in the United States and Canada specifi- availability of dental services, publicly funded dental
cally addresses the following research questions: programs, community dental care programs, geograph-
• What is the oral health status of children of newcomers? ic or language isolation or harmful health beliefs
• What are potential barriers to their Data Collection and Analysis
use of dental services?
Search results were exported to EndNote (Version X7,
• What interventions have been developed and Thomson Reuters, Philadelphia, PA) and duplicates were
implemented to improve their oral health? removed. Selection of relevant papers was carried out in
2 stages and both stages were performed independently
by 2 reviewers (MR, A Abdelaziz). In the first stage, both
reviewers read the titles and the abstracts to select poten-
Methods tially relevant papers according to the inclusion criteria.
Disagreements were resolved through discussion and
Search Methods Used to Identify Studies consensus with the other review author (A Azarpazhooh).
Our preliminary search revealed a systematic review that In the second stage, the full texts of the included articles
evaluated cultural competencies in oral health research were evaluated. The PRISMA 2009 checklist was used to
on immigrant children, worldwide.10 Although the scope assess the availability of required and relevant items.11 We
of that review was different from ours, it included overall used the retrieved information in the form of a scoping
research on the oral health of newcomers from 1995 until review; no critical appraisal of individual studies was done.
2008. From the pool of papers reviewed in that study, we
selected the relevant North American studies and adapted
the search strategy to find more recently published research
from 2007 to September 2014 in the following databases: Results
Ovid MEDLINE (in-process and non-indexed citations);
Embase, Web of Science and Scopus. The search terms Search Results
(Appendix 1) were initially established using MEDLINE and From an initial total of 3223 articles from databases
modified while exploring other databases. We imposed and 58 from Riggs et al.,10 several stages of screening
no language or publication restriction. In addition, we reduced the number that met our criteria to 32 studies
searched references in retrieved articles to identify published between 1996 and 20143-5,8,12-39 (Fig. 1). Six studies
studies not captured by our primary search strategy. were conducted in Canada (3 in Edmonton,12,13,35 1 in
Vancouver,19 1 in Montréal [with a comparison to Talca,
Inclusion Criteria Chile]30 and 1 in Toronto37) and 26 in the United States (7 in
We included any cross-sectional, cohort, intervention, California,8,18,21,23,25,26,34 5 in Massachusetts,4,5,14,16,33 3 in New
case control or qualitative/mixed-methods study. Reviews, York,15,28,36 2 in North Carolina27,31 and 1 each in Washing-
clinical case studies, case reports, letters and editorials ton,17 Virginia,31 Georgia,32 Main,20 Vermont3 and Utah22).

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Figure 1: Selection of studies based on the inclusion/exclusion criteria Health Needs Assessment25 and the Survey of Income
and Program Participation.39 Of all the studies,
4 reported the use of validated questionnaires.13,26,27,30

Oral Health Status of Children of Newcomers

Children of newcomer families tend to exhibit poorer
oral health compared with their non-newcom-
er counterparts (Table 2), especially those whose
families speak languages other than English at
home.5,25,26,29,37 For example, in a sample of African
newcomer children in Edmonton, 64% had untreated
caries (mean decayed/extracted/filled surfaces
of primary teeth  = 11.2 ± 12.9, of which mean
decayed surface = 6.9 ± 8.5).13 When compared
with children of Canadian-born parents, children
of newcomers presented higher mean decayed/
extracted/filled primary teeth scores (3.05 vs. 1.83,
p < 0.05) mean decayed/missing/filled permanent
teeth scores (0.73 vs. 0.42, p < 0.05).37 Similarly, in the
United States, compared with children of US-born
parents, children of immigrants had a significantly
larger number of carious surfaces (11.5 vs. 9.4, p =
0.01)5 and twice the prevalence of early childhood
caries (odds ratio 2.06; 95% confidence interval
1.47–2.88).4 The situation was even worse among
refugee children, who exhibited a greater number
of untreated caries (up to about 75%).14,16,20,26,32

Use of Dental Services for Children

A smaller proportion of children of newcomer
families have regular dental visits compared with
non-newcomers (Table 2).4,13,24, 26-28,36-39 Children
of non-permanent residents have the lowest utili-
zation rate (only 32% had 1 or more dental visits
in a year), followed by children of permanent
residents (41%), naturalized parents, i.e., foreign-
born with United States citizenship (50%) and
US-born parents (> 50%).39 Similar findings were
noted in a sample of African newcomer children
in Edmonton, Alberta,13 and Latino newcomers in
Of the included studies, 22 were cross-sectional,4,13-18,20,22,24-35,37 North Carolina,27 where over 50% had never had a
5 were cohort,5,8,19,38,39 4 were qualitative12,21,23,36 and 1 was dental visit. In addition, newcomer children are most likely
descriptive3 (Table 1) Six of the studies included consulta- to visit a dentist for emergencies or when in pain.26,28,31,36-38
tion services (for example group discussions or one-on-one It seems that parental education remains a
counseling)3,8,12,15,19,21 and 1 study included free dental care.5 predictor of dental care utilization. A study among
Questionnaires were used to collect data in all of the Chilean newcomer families in Montréal shows that
studies; in 15, they were administered by interview- children of parents with a university education
ers.5,12-15,17,18,23,28,31,34-37,39 Data collected from dental examina- are twice as likely to visit a dentist compared with
tions were used in 12 of the studies.4,5,13,14,16,19,25,26,32,33,35,3 children of parents without higher education.30
7
External data sources used in the studies included the Newcomer families are also less likely than non-new-
California Health Interview Survey,18 the National Survey comers to visit the same dental office.17 In a group of
of America’s Families,24 the Migration Transitions Study,27 recent newcomer mothers who had children enrolled
the NYC Child Community Health Survey,28 the Medical in Medicaid, only 38% reported having a regular dental
Expenditure Panel Survey,29 the DeKalb County Board of office, 27% had a regular dentist, fewer mothers saw the
Health,32 the New Immigrant Survey,38 the California Oral

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 Oral Health Status of Immigrant and Refugee Children in North America: A Scoping Review
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same dentist at each visit and an even smaller number uninsured18,22,24,26,34 and more likely to rely only on public
remained with the same dentist for 1 year or more.17 health insurance or no insurance at all.22 For example in
the United States, the highest proportion of those with
Limited English proficiency has also been shown to hinder
no insurance was seen among foreign-born children
access to dental care for children of newcomer families.12,13
with non-naturalized parents (52.3%), followed by
In particular, those who speak a non-English language
US-born children with non-naturalized parents (34.37%),
at home are less likely to visit a dentist for preventive
US-born children with US naturalized parents (15.34%)
or other services and more likely to visit only when their
and, finally, foreign-born children with naturalized US-cit-
child is in pain.12,13,29,31,36,37 Similarly, higher rates of caries
izen parents (12.86%).24 In both insured and uninsured
have been found among children of newcomer families
groups, newcomer children are less likely to use dental
speaking languages other than English at home.5,25,26,29,37
services compared with non-newcomer children.18
The dental care provider may present another barrier
to newcomer parents seeking treatment for their
Barriers to Appropriate Oral Health for children. One study26 reported the characteristics of
Newcomer Children dental care providers that act as a barrier. Most of the
children in this study were from a population of poor
Risk factors reported to act as barriers to achieving
and newcomer families (43% lived in non-English-speak-
and maintaining adequate oral health for
ing households and 10% were born outside the United
children of newcomers were grouped into 3
States) and visited dentists only if the dental office was
levels: child, family and community (Table 2).
near their home. Their parents reported that almost 50%
Child level (oral hygiene practices): Children of newcomers of children had to travel 5 or more miles to get dental
and foreign-born parents differ from non-newcomers in treatment on their last visit and about 20% of dentists
their oral hygiene practices; tooth brushing or flossing were not fluent in the language spoken by the child.26
is not carried out regularly (or at all),14,37,40 nor are these
practices valued by the children or their parents.12 Interventions for Newcomer Children
Three studies3,8,19 explored intervention programs developed
Family level (parenting practices, oral health percep- to improve the oral health status of newcomer children; 2 of
tions): A higher percentage of foreign-born mothers them targeted parents and the other targeted children.
of 19-month-old infants in Alberta reported the use of
nursing bottles compared with Canadian-born mothers Programs for parents: An educational program among
(85% vs. 62%).35 More important, foreign-born mothers 20 newcomer Latino parents of low socioeconomic
reported more riskier practices, such as propping of status was successful in improving the knowledge of 10
bottles against the child’s mouth, leaving the baby participants; however, only 5 showed an improvement
unattended with a bottle and giving a bottle as soon in reported behaviour.8 In a health promotion program
as the child cries. A smaller number of foreign-born in Vancouver, British Columbia, designed to educate
mothers reported cleaning their children’s teeth.35 Vietnamese mothers of preschool children with extensive
tooth decay, mothers who had more than 1 counsel-
Foreign-born parents may have different views on the ing session reported significant reductions in the use of
significance of preventive oral care compared with native- a nursing bottle for their children during both sleep time
born parents. For example, about 75% of a sample of and day time.19 Children of these mothers also demon-
African newcomer parents in Edmonton reported that they
strated a significant reduction in the prevalence of caries
didn’t need professional dental care for young children.13
compared with other children of similar age at baseline.19
Similar findings were reported in a sample of Chinese
parents of children with extensive caries living in New Programs for children: In a school-based program,
York; the majority (75%) did not value dental treatment dental services provided for newcomer and impover-
for primary teeth and considered dental examinations as ished children were successful in reducing the need for
a financial burden.40 In another study,21 no members of restorative care in the second year of its implementa-
ethnic minority groups (African-American, Chinese, Latino tion. Although in the first year, 52% and 22% of children
and Filipino) in San Francisco obtained early preventive received preventive and restorative care, respectively,
care for their children because of lack of knowledge in the second year, the figures were 60% and 11%.2
about the importance of primary teeth. Such percep-
tions may be a result of an illness reaction (as opposed to
illness prevention) parental approach to oral health.12
Discussion
Community level (dental insurance, dental care
provider): Newcomer populations are more likely to be This scoping review aimed to provide a better under-

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 Oral Health Status of Immigrant and Refugee Children in North America: A Scoping Review
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standing of the oral health of newcomer children in North these children is needed to identify which group is in the
America. In the Canadian setting, oral health has tradition- majority: Canadian-born children of newcomer parents,
ally received low priority in public policy discussions and has foreign-born children who have been raised in Canada
not been subjected to the tenets of the Canada Health or foreign-born children recently moved to Canada. This is
Act, i.e., comprehensive, accessible, portable, universal important because, if those born or raised in Canada exhibit
and publicly funded and administered. As a result, almost more disease, this would reflect the need for prevention
all Canadians are burdened with financing their own dental and treatment programs that target such children as early
care.6 Although various oral health strategies, including as possible (e.g., school-based oral health programs).
increased accessibility and some publicly funded dental
services (usually for emergency care) are in place for Variations in Oral Health Status by Location
children from low-income families or those on social assis- Children of newcomers living in different parts of the
tance,41 many Canadians still do not have easy or afford- new country may exhibit different oral health charac-
able access to dental health services. Successive reductions teristics.3,4 Hence, a general policy may not be applic-
in public dental funding, especially for disadvantaged able to all newcomer children in all regions. A targeted
populations, has left Canada ranked second to last among approach to the delivery of dental services for particular
Organisation for Economic Co-operation and Develop- groups may allow the best use of the limited resources.
ment nations in terms of public funding of dental care.6
Language Literacy
A case in point is the proposed cuts to dental benefits
Newcomer children are less likely to receive routine or
for newcomers to Canada under the Interim Federal
preventive dental care.29 Various reasons have been
Health Program.9 The limitations and problems with this
associated with this, including language and cultural
program, for both providers and newcomer patients, have
barriers.12,13,25,36,37 Language barriers have been consistent-
been outlined in a report by Amin and colleagues.42 A
ly associated with less use of dental care29 and issues of
symposium mentioned by these researchers revealed that
communication with health care providers.34 An inter-
newcomers to Canada have many pressing concerns,
esting finding from Noyce and colleagues29 indicates
such as housing, employment, education and general
that, among a group of people of the same race/
health; thus, preventive oral health may not be high on
ethnicity, those who speak English at home are more
their priority list.42 The following discussion of the findings
likely to seek dental care. Although it is not possible to
from our review should be considered in this context.
separate the impact of the language barrier from other
Regardless of their birthplace, many studies have shown socioeconomic factors, such as parental education,
that children of newcomers have worse oral health than household income and health insurance status, general
their non-newcomer counterparts.5,16,37 Several barriers education programs to improve language literacy (in 1 of
play a role, such as cost of regular dental care, insuffi- the official languages) as well as more specific programs
cient dental insurance coverage, language and parental to improve oral health literacy could overcome cultural
beliefs and practices that put the children at higher beliefs and practices that are harmful to the oral health
risk for dental diseases.26,36,37 Consequently, newcomers of children and help increase the use of dental services.
rank lower in terms of use of dental services.18
To make interventional and educational programs more
The data obtained from the studies included in this review effective, large public health units and private offices
reveal a number of key findings that will familiarize clini- could make use of internal staff resources for inter-
cians, researchers and public health policymakers with preting or use a company or organization providing
evidence-based information on the oral health status telephone interpretation services,42 e.g., Can Talk Canada.
of newcomer children in both Canada and the United However, even when these services are available, public
States, although most of the studies were conducted health facilities and private offices may insist that the
in the United States. This scoping review aimed to map patient or their parents bring an interpreter along to
available research, without necessarily ranking individ- visits. The availability of more multicultural and multi-lan-
ual articles based on design or quality. As many of the guage providers may prove beneficial in creating a
studies used questionnaires or interviews to obtain infor- better understanding of oral health messages.42
mation, this could have introduced recall bias by parents
trying to remember details of the child’s oral health and Awareness of the Importance of Oral Health
social acceptance bias by parents trying to respond to Although dental insurance is an important determinant
questions in a way that would please the researcher. of the use of dental care services, newcomer children
use dental care less, regardless of their insurance status.18
Higher Levels of Caries This may be related to newcomer children relying mainly
Newcomer children have consistently been shown to on publicly funded dental programs, where practitioner
have higher levels of caries.33 A more detailed study of reimbursement rates are relatively low.22 In addition, as

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newcomer children usually come from low-income families, The dental profession in Canada can contribute to
the required co-payments may be a financial burden. improving the oral health of newcomers and disadvan-
taged populations by treating patients covered under
It is essential to realize that less use of dental services may be
publicly funded dental programs and supporting the work
a result of lack of parental understanding of how preventive
of organizations seeking to expand and improve these
services and routine regular dental visits can be effective
programs by advocating appropriate oral health policies.
in improving the oral health of their children. It may also
be caused by a lack of understanding or knowledge of
health care resources24 or fear or suspicion of government.
Therefore, effective educational and supportive programs
are important to help raise awareness among immigrant
parents and their children of the importance of maintaining THE AUTHORS
good oral health through regular preventive care. However,
as mentioned above, newcomers in Canada have to Ms. Reza is student, faculty of dentistry, University
focus on urgent needs related to housing, employment, of Toronto, Toronto, Ontario.
language barriers, education and acute health care issues;
thus, preventive dental care may not be a priority.39

Comprehensive Accessible Dental Care

Newcomer children are at higher risk of dental caries
compared with non-newcomer children. They are also
Dr. Amin is associate professor, division of pe-
more likely to live in poverty or come from low-income diatric dentistry, school of dentistry, faculty of
households where the cost of dental care is a burden.24 medicine and dentistry, University of Alberta,
Providing free (or perhaps affordable) accessible and Edmonton, Alberta.
comprehensive dental care may be the most efficient
way to eliminate caries in newcomer children who are
in urgent need of dental care.42 It is important to ensure
access to care for this population (and other marginalized
populations) through effective oral public health policies. Mr. Sgro is research assistant, discipline of dental
public health, faculty of dentistry, University of
Toronto, Toronto, Ontario.

Conclusion Dr. Abdelaziz, at the time of this research, was

research assistant, discipline of dental public
Children of newcomers are associated with worse oral
health, faculty of dentistry, University of Toronto,
health outcomes, including lower utilization rates, higher Toronto, Ontario.
dental status scores and higher prevalence of caries
compared with their non-newcomer counterparts.
Barriers that play a role include cost of regular dental
care, insufficient dental insurance coverage, communi-
cating with dental care providers because of language Dr. Ito is assistant professor, discipline of dental
barriers and parental beliefs and practices that put public health, faculty of dentistry, University of
Toronto, Toronto, Ontario.
these children at a higher risk of dental diseases.18,26,36,37
The increase in disparities between newcomer and
non-newcomer children can be reduced through:
• implementation of more effective preschool and
school-based oral health programs for young children
• improving newcomer parents’ literacy Dr. Main is dental public health consultant, Toron-
to, Ontario.
in the official language(s)
• educating newcomer parents regarding
good oral health practices
• providing affordable (ideally free) comprehensive
dental care (the most efficient way to eliminate
caries in children who are in urgent need of care)

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Dr. Azarpazhooh is assistant professor, discipline of 10. Riggs E, Gussy M, Gibbs L, van Gemert C, Waters E, Priest N,
dental public health, faculty of dentistry, Univer- et al. Assessing the cultural competence of oral health
sity of Toronto; and assistant professor, Institute research conducted with migrant children. Community
Dent Oral Epidemiol. 2014;42(1):43-52.
of Health Policy, Management and Evaluation,
faculty of medicine, University of Toronto, Toronto, 11. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred
Ontario. reporting items for systematic reviews and meta-analyses:
the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
12. Amin M, Perez A. Is the wait-for-patient-to-come approach
suitable for African newcomers to Alberta, Canada?
Correspondence to: Dr. Amir Azarpazhooh, Faculty of Dentistry, Community Dent Oral Epidemiol. 2012;40(6):523-31.
University of Toronto, Room 515-C, 124 Edward St., Toronto ON M5G 13. Amin MS, Perez A, Nyachhyon P. Parental awareness and
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Acknowledgements: This review was supported by the Canadian
14. Cote S, Geltman P, Nunn M, Lituri K, Henshaw M, Garcia RI.
Institutes of Health Research (FRN 126751). The authors thank Ms. Dental caries of refugee children compared with US
Maria Buda at the faculty of dentistry library in the University of children. Pediatrics. 2004;114(6):e733-40.
Toronto for her professional contribution.
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This article has been peer reviewed.
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27. Nahouraii H, Wasserman M, Bender DE, Rozier RG.

Social support and dental utilization among children
of Latina immigrants. J Health Care Poor Underserved.
2008;19(2):428-41.
28. Norton JM, Jasek JP, Kaye K. Preventive dental care
among New York City children, 2009. J Community Health.
2013;38(4):670-8.
29. Noyce M, Szabo A, Pajewski NM, Jackson S, Bradley TG,
Okunseri C. Primary language spoken at home and
children’s dental service utilization in the United States.
J Public Health Denti. 2009;69(4):276-83.
30. Núñez L, Icaza G, Contreras V, Correa G, Canales T,
Mejia G, et al. [Factors associated with dental consultation
in children in Talca (Chile) and in Chilean immigrants
in Montreal (Canada)] [Article in Spanish]. Gac Sanit.
2013;27(4):344-9.
31. Quandt SA, Clark HM, Rao P, Arcury TA. Oral health
of children and adults in Latino migrant and seasonal
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entering DeKalb County, Georgia. J Immigr Minor Health.
2014;16(5):959-67.
33. Soncini JA, Kanasi E, Lu SC, Nunn ME, Henshaw MM,
Tanner AC. Oral microbiota of children in a school-based
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34. Stevens GD, West-Wright CN, Tsai KY. Health insurance and
access to care for families with young children in California,
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Minor Health. 2010;12(3):273-81.
35. Weinstein P, Smith WF, Fraser-Lee N, Shimono T, Tsubouchi J.
Epidemiologic study of 19-month-old Edmonton, Alberta
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1996;63(6):426-33.
36. Wong D, Perez-Spiess S, Julliard K. Attitudes of Chinese
parents toward the oral health of their children with caries:
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37. Woodward GL, Leake JL, Main PA. Oral health and
family characteristics of children attending private or
public dental clinics. Community Dent Oral Epidemiol.
1996;24(4):253-9.
38. Yun K, Fuentes-Afflick E, Curry LA, Krumholz HM, Desai MM.
Parental immigration status is associated with children’s
health care utilization: findings from the 2003 new
immigrant survey of US legal permanent residents. Matern
Child Health J. 2013;17(10):1913-21.
39. Ziol-Guest KM, Kalil A. Health and medical care among the
children of immigrants. Child Dev. 2012;83(5):1494-500.
40. Sarri G, Evans P, Stansfeld S, Marcenes W. A school-
based epidemiological study of dental neglect among
adolescents in a deprived area of the UK. Br Dent J.
2012;213(10):E17.
41. Government dental programs. Canadian Association of
Public Health Dentistry; 2014 [cited 2014 Dec 8]. Available
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42. Amin MS, Elyasi M, Schroth RJ, Azarpazhooh A, Compton S,
Keenan L, et al. Improving the oral health of young children
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2014;80:e64.

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Table 1 Description of the included studies

Authors, date Location Method for data collection Study type

Amin and Edmonton, Focus groups of participants were led by trained community health workers. An interview guide was Qualitative
Perez 201212 Alta., Canada developed from literature on barriers to oral health care and the opinions of health care workers.
The interviews were then coded and codes were assigned to different categories of barriers.
Amin et al. Edmonton, Dental assessments were made by 2 dentists; inter- and intra-examiner agreement > 90%. WHO criteria used Cross-sectional
201513 Alta., Canada for recording caries data. Validated questionnaires administered by bilingual trained community workers.
Brown et Northern Califor- Educational intervention program, consisting of 2 1.5-h lessons given in Spanish by a school nurse over Cohort
al. 20058 nia, Calif., USA 2 consecutive weeks, was aimed at improving oral health knowledge. Pre- and post-tests (developed
with the assistance of a dentist) were administered before and 2 weeks after course completion.
Cote et al. Mass., USA A visual examination was conducted by a dental hygienist and the refugee parent or child Cross-sectional
200414 was interviewed (interpreters available). Oral examination was based on the Basic Screening
Survey of the Association of State and Territorial Dental Directors. Comparisons were made
with NHANES III data; however, a probe was also used during examination.
Cruz et al. 200515 New York, NY, USA A 33-item survey tool (in English and Spanish) was pilot tested to evaluate the needs of the partic- Cross-sectional
ipants regarding oral health, then administered by trained interviewers. A program was then
developed based on their needs and delivered at maternal infancy care centres.
Geltman et Mass., USA A visual examination of refugees’ dentition was conducted within 90 days of arrival by Cross-sectional
al. 200116 Refugee Health Assessment Program, Mass Department of Public Health.
Grembowski Wash., USA The Social and Economic Science Research Center conducted surveys by phone, mail or Internet as Cross-sectional
et al. 200717 per Dillman’s protocol. Survey instrument (in 4 languages) constructed from items in the Community
Tracking Study, the Medical Expenditure Panel Survey and Access to Baby and Child Dentistry Study.
Guendelman Calif., US Data were obtained from the California Health Interview Survey from Nov. 2000 to Sept. 2001. Inter- Cross-sectional
et al. 200518 views in 7 languages were conducted over the telephone using random digit dialing.
Harrison and Vancouver, Beginning in 1994, one-to-one consulting sessions were held between mothers and community Cohort
Wong 200319 BC, Canada dental health worker (CDHW) at immunization appointments. 4 follow-up dental examina-
tions (1996–2001) were performed by a dentist, using mirror and explorer.
Hayes et al. Portland, Me., USA Charts from immigrants’ initial medical reviews were obtained and reviewed. Cross-sectional
199820
Hilton et al. San Francisco Input and advice from a community advisory board for each of the 4 groups. Group discus- Qualitative
200721 Calif., USA sions (22), conducted in the presence of a facilitator, centred around oral health of parents
and their children. A small set of questions was based on the research team’s opinions.
Hobson et Salt Lake City, Participants were given a pilot-tested survey in English or Spanish regarding Cross-sectional
al. 200722 Utah, USA water consumption at the health centre during a 2-week period.
Horton and Mendota, Parents interviewed regarding oral disease, oral hygiene, infant feeding practices and child dental experience. Qualitative
Barker 201023 Calif., USA Dentist providers interviewed regarding DentiCal reimbursement policies. Young adult farmworkers interviewed.
Huang et al. USA Data were collected from the 1999 National Survey of America’s Families. Among Cross-sectional
200624 other topics, this study targeted the health of the participants.
Maserejian Boston, Mass., USA Interviews were conducted as part of the New England Children’s Amalgam Trial (NECAT) by interviewers certified Cohort
et al. 20085 by New England Research Institutes’ Survey Research Center. Free semi-annual dental care was offered as
part of the research, for a 5-year period. After initial examination, NECAT dentist restored all caries at baseline
according to protocol. Each following examination included restoration of lesions based on D2 threshold.

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Authors, date Location Method for data collection Study type

Mejia et al. Calif., USA Dental screening by trained and calibrated dentists and dental hygienists (or specially Cross-sectional
201125 trained school nurses) in Los Angeles County for the 2004–2005 California Oral Health Needs
Assessment, which included a 6-item questionnaire completed by parents.
Melvin 20063 Vt., USA Dental service program (tooth tutor program, Vermont Department of Health) started in the fall of 2001 and focused Descriptive
on providing at-risk children with in-school preventive services and referral to dental offices for needed care.
Mulligan et Los Angeles, Surveys in 4 languages were sent out to the participants. Validated by advisory board (public health profes- Cross-sectional
al. 201126 Calif., USA sionals, community organizers, school teachers, nurses, dental faculty). Two calibrated university faculty
dentists performed clinical examinations under an adapted Association of State Dental Directors protocol.
Nahouraii et NC, USA Data were collected from the Migration Transitions Study conducted between August Cross-sectional
al. 200827 2002 and May 2003, using a validated Spanish ethno-survey instrument.
Norton et New York City, Data were collected from the 2009 NYC Child Community Health Survey and an indepen- Cross-sectional
al. 201328 NY, USA dent survey. Computer-assisted random digit dialing telephone interviews (in 4
languages) were based on 1 randomly selected child in the household.
Noyce et al. USA Data were collected from the Medical Expenditure Panel Survey Household Component Cross-sectional
200929 for 2002–2004. The survey included demographic and health data. The 2 outcome
variables were having a preventive dental visit and having a routine dental visit.
Nunez et al. Talca, Chile Survey of children and their parents was performed in the 2 cities from 2009 to 2011 using validated Cross-sectional
201330 and Montréal, questionnaires developed for the New Canadian Children and Youth Study 2005.
Que., Canada

Nunn et al. 20094 Boston, Mass., USA Definition of early childhood caries (ECC) = 1 primary maxillary incisor decayed, missing due Cross-sectional
to decay or filled. ECC study: dental exam with penlight conducted by trained and calibrat-
ed dental hygienists. NHANES III: examinations were conducted by physicians and dentists.
Quandt et NC and south- In conjunction with a community-based participatory research project, face-to-face interviews Cross-sectional
al. 200731 western Va., USA on oral health were conducted in October and November 2004 by trained native Spanish-speak-
ing interviewers. Interviews covered oral health and oral health behaviours of mother, spouse and
child > 5 years or closest to 5 years. Questionnaires were pretested and revised before use.
Shah et al. DeKalb County, Data were collected from DeKalb County Board of Health records when refugees Cross-sectional
201432 Ga., USA presented for initial screenings. Nurses performed visual dental examinations.
Soncini et Boston, Mass., USA Students’ teeth were examined in school dental clinics. Microbial assays of samples from 3 intraoral Cross-sectional
al. 201033 sites were obtained using whole genomic probes. Self or parent report on demographics.
Stevens et Calif., USA Telephone interviews were conducted in the language of the participant (7 languages). Only Cross-sectional
al. 201034 data from parent–child dyads were used; only 1 child’s data per family were used.
Weinstein et Edmonton, Interview and dental examination. Clinical examination was visual with a mirror and Cross-sectional
al. 199635 Alta., Canada included all erupted teeth. Caries activity was measured using Cariostat. The interview instru-
ment was based on previous research by Weinstein et al. and Lopez del Valle et al.
Wong et al. New York City, Qualitative interview, conducted with the aid of an interpreter by a pediatric dental resident, was Qualitative
200536 NY, USA based on 4 areas. Transcribed interviews were analyzed using standard thematic analysis.
Woodward et Toronto, Ont., Dental examination was conducted, as well as a telephone interview with the parent Cross-sectional
al. 199637 Canada and a questionnaire sent to the dentist. Trained and calibrated examiners.
Yun et al. 201338 USA Data were collected from the 2003 New Immigrant Survey, which is a 1-to-1 computer-assisted telephone Cohort
survey in 18 languages that gathers parental demographic information and child health data.
Ziol-Guest et USA Data collected in interviews at 4-month intervals in the Survey of Income and Cohort
al. 201239 Program Participation included socioeconomic and health information.
Note: NHANES = National Health and Nutrition Examination Survey, WHO = World Health Organization

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Table 2 Summary of data from North American studies addressing the oral health status of newcomers and barriers to their children’s use of dental care.

Author, date Population Oral health status Barriers to use of dental services
Amin and 7 focus groups of Ethiopian, Eritrean and Professional dental assessment was
Perez 201212 Somali immigrant (< 5 years) mothers not a priority among participants,
of children 3–5 years old recruited by as home diagnosis was thought to
Multicultural Health Brokers Co-op be as effective. Flossing and regular
and given $20 incentive (n = 48) dental visits not valued. Barriers
included cost of dental insurance
(because of absence of knowledge
of publicly funded programs), lack of
trust in dentists, lack of knowledge of
dental services, low English profi-
ciency, constraints, such as time,
transportation, lack of family support,
and lack of insurance. The study
concluded that a “wait-for-the-pa-
tient-to-come approach” is ineffec-
tive for these immigrant families.
Amin et al. Children (< 6 years) of African parents Examination revealed 63.7% Never visited dentist: 52%. Parental
201513 (in Canada < 10 years); pairs of parents with untreated caries. Mean perception: Children have no dental
and children (n = 125). Convenience defs of children with untreated caries (52.8%), not sure (26.4%). 61.6%
sample of participants obtained from caries 11.2 ± 12.9. Overall of parents unaware of children’s
community settlement agencies. mean defs 7.2 ± 11.6. dental status. Dental attendance
significantly associated with age
Mean ds of children with 49­–72 months (p = 0.04), family in
untreated caries 6.9 ± 8.5. Canada > 5 years (p = 0.04) and
having dental coverage (p = 0.03).
Cote et al. Refugees 6 months to 18 years of age NHANES III vs. refugee Refugee children from Africa were
200414 (n = 224). Oral health assessment within the least likely to have ever been
1 month of arrival between January No untreated caries: 77.2% to a dentist (12.8%) and the least
2001 and September 2002, under the vs. 51.3% (p < 0.001) likely to have used a toothbrush
Refugee Health Assessment Program, ≥ 10 carious surfaces: 3.1% in their home country (10.2%).
Mass Department of Public Healt vs. 14.3% (p < 0.001) Distribution of treatment urgency,
caries experience, untreated
Comparison with NHANES III US-born No oral pain: 99.8% vs. caries and dental caries varied
children, ages 2–16.9 years (n = 11 296) 88.8% (p < 0.001) significantly by region of origin.
Oral pathology: no signif-
icant correlation
No gingival bleeding: 35.5%
vs. 69.6% (p < 0.001)
No calculus: 50.9% vs.
22.6% (p < 0.001).

Cruz et al. Pregnant low-income immigrant Participants did not have

200515 mothers (n = 486) and US-born mothers appropriate knowledge
(n = 241) attending maternal–infant regarding oral health.
care centres between November Although almost all thought
2001 and June 2002 were included in oral health and visiting a
the initial survey as a single cohort dentist were important, only
about 50% reported having
regular dental care and 59%
thought dental care was
“okay” during pregnancy.
Need for dental care reported
by 62%. Dental insurance
(mostly Medicaid) while
pregnant reported by70%
and by 34% post-partum.

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Author, date Population Oral health status Barriers to use of dental services
Geltman et Refugees under 18 years of age (n = 1825) 62% of all refugee groups
al. 200116 from 19 countries and 15 newly independent had dental abnormalities
states of Soviet Union. Screened between (mainly caries). Dental
July 1995 and June 1998 at 16 sites. abnormalities positively
associated with overweight
or risk of overweight (OR =
2.6, 95% CI 1.2–4.4).
Grembowski Children 3–6 years old in Medicaid (n = Percentage of immigrants: Black
et al. 200717 11 305); mothers (n = 4762) selected (9%), Hispanic (73%), White (6%),
through disproportionate strati- Asian (83%), Native American (1%).
fied sampling by race/ethnic group;
Black, White, Hispanic and other Percentage with regular dentist:
Black (25%), Hispanic (25%), White
(32%), Asian (28%), Native American
(31%) (p < .001).

Percentage with regular location for

dental care: Black (37%), Hispanic
(38%), White (38%), Asian (37%),
Native American (48%) (p = 0.78).

Compared with immigrant white

mothers, the odds of having a
regular dentist were lower for Black
and higher for Hispanic mothers. For
Hispanic mothers, those complet-
ing the survey in Spanish had lower
odds of having a regular dentist
than mothers completing in English.
Guendel- Children in working poor families < 18 years Last dental visit 1 month to
man et al. old. Families with annual income < 200% of 2 years: insured immigrants
200518 Federal Poverty Level and not on welfare. (70.5%), uninsured immigrants
US born (n = 3978), immigrants (n = 462) (60.4%), insured non-immi-
grants (81.5%), uninsured
non-immigrants (70.1%);
p < 0.05 for differences
between groups.

Last dental visit > 2 years or

never: insured immigrants
(29.5%), uninsured immigrants
(39.6%), insured non-immi-
grants (18.5%), uninsured
non-immigrants (29.9%);
p < 0.05 for differences
between groups.

Insured immigrant children

> 6 years were more likely
to postpone or never visit
a dentist than same-aged
non-immigrant children (aged
7–11 years: OR = 6.5, 95% CI =
3.2–13.4; aged 12–17 years:
OR = 3.0, 95% CI = 1.5–6.1).
Harrison Convenience sample of Vietnamese Children whose mothers had
and Wong immigrant preschool children. Three > 1 counseling visit fewer
200319 cohorts: baseline (control) (n = 14), caries vs. children whose
comparison (another community) mothers did not. In 1996, defs
(n = 9), experimental (n = 16) baseline (5.1 SD 7.2), compar-
ison (1.9 SD 5.8), experimen-
tal (1.1 SD 4.3). Caries-free
children: baseline (50%),
comparison (42.9%, p < 0.05),
experimental (93.8%). 1998
and 2001 defs significantly
lower than baseline (p < 0.05).

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Author, date Population Oral health status Barriers to use of dental services
Hayes et Immigrant patients aged 2 months to 18 16.7% of the children had
al. 199820 years (n = 132). Health care evaluations at caries based on physical
the International Clinic, 1994 and 1995 examination by pediatric
residents, not by dentists.
Hilton et al. Primary caregivers (≥ 18 years) of children US-born caregivers more likely to take
200721 1–6 years old were selected on the basis their child for preventive dental care
of knowledge or experience and strat- at an earlier age. Some non-US-
ified by age groups. Four racial groups born caregivers more likely to delay
African-American, Chinese, Filipino, Latino treatment and viewed dentists as
immigrants (n = 103), US born (n = 74) unethical and performing unneces-
sary treatment.

Most caregivers only accessed

dental care if there was a problem,
as primary teeth fall out. For many
participants, their own oral health
experience and the views of
extended family members acted
as a barrier to the oral care of their
children.

There was a preference to seek oral

health diagnosis in the medical office.
Hobson et Convenience sample of parents of urban 41.2% of parents never gave tap
al. 200722 public health centre patients (n = 215) water to their children and, of
these, 40% did not consume fluoride
Immigrants 64%, US born 36% supplements. Compared with
non-Latino parents, Latino parents
Origins of immigrants: Mexico (53.1%), never drank tap water (OR 0.26,
South America (6.2%), Central 95%CI 0.10–0.67), their children
America (2.8%), other (1.9%) never drank tap water OR 0.32,
95%CI 0.15–0.70) and avoided tap
water because it “causes illness”
(OR 5.63, 95%CI 2.17–14.54).
Horton 26 Mexican immigrant parents with a child In Mexico, parents had subsistence
and Barker < 6 years of age recruited through a random- diets which changed once in US
201023 ized list and preschool Head Start programs to high sugar and refined foods. As
mothers had to work shifts, switch
12 local dentists who accepted California from breastfeeding to bottle feeding;
Medicaid or DentiCal abetted by low-cost federal baby
formula coupons. Unfamiliarity with
4 farmworker young adults > 18 years born breastfeeding led to inappropriate
to Mexican immigrant farmworker parents infant feeding practices and early
childhood caries.

Low reimbursement rates for

children treated under DentiCal
decreases access to care and
promotes extractions rather than
restoration of teeth. This leads to
inequitable treatment for children
of farmworkers and development of
long-lasting “stigmatized biologies.”
Huang et Children < 18 years, US born (n = ≥ 1 visit to the dentist in the last year:
al. 200624 32 965), immigrant (n = 1027), accessed US born with citizen parents (80.47%,
through a random digit dialing survey SE 0.44), US born with noncitizen
of homes and face to face inter- parents (62.73%, SE 2.81), foreign born
views. 4 subgroups of children: with citizen parents (84.65%, SE 3.42),
foreign born with noncitizen parents
US born with citizen parents (55.59%, SE 2.81).
US born with noncitizen parents
Compared with US-born children
naturalized foreign born with with citizen parents, foreign-born
naturalized parents children with noncitizen parents
were less likely to have visited a
foreign born noncitizen with dentist in the past year (adjusted
noncitizen parents OR 1.76, 95% CI 1.34–2.31)

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Author, date Population Oral health status Barriers to use of dental services
Maserejian English-speaking Boston area children 6–10 Children of immigrants vs.
et al. 20085 years of age (n = 283) with untreated caries, non-immigrants ≥ 2 carious
no amalgam fillings, no neuropsychologic or surfaces at baseline. Initial
renal disorders enrolled as part of the New carious surfaces for children
England Children’s Amalgam Trial (NECAT) of immigrants 30% more than
children of US born (β 0.26,
SE 0.1, rate ratio 1.3, 95% CI
1.07–1.59) adjusting for age,
gender, race, ethnicity and
smoking status. No signifi-
cant difference in 5-year
net caries increase between
children of immigrants and
non-immigrants. Children of
immigrants were more likely
to withdraw from NECAT.
Mejia et al. Complex stratified cluster sample Children from homes where no
201125 of children in grade 3 (n = 10 450) English spoken and/or parents with
enrolled in the California Oral Health lower functional health literacy
Needs Assessment, 2004–2005. and/or attending a school with
a higher percentage of children
learning English were more likely
to have no dental sealants.
Mulligan et 59 randomly selected sites (public schools Untreated caries in 73% of Approximately 50% of children had
al. 201126 and early childhood programs) with poor, children. Fillings or crowns in to travel ≥ 5 miles to get dental
migrant and minority children in 3 cohorts 53%. Needing urgent dental treatment on their last visit. About
ages 2–5, 6–8, 14–16 (n = 2313) care: 9%. Never been to a 20% of dentists were not fluent in
dentist: 10% of all partici- the language spoken by the child.
Site selection requirements: > 50% pants but 20% of 2–5 year
students of minority race, > 62% of them olds. Non-white-Hispanic Significant association between
on reduced cost/free meal programs category of children most caries and sociodemographic
likely to have never been factors: race, ethnicity, parents’
to a dentist (p = 0.003). education, English spoken at home,
birth abroad, toothache in the last
6 months, inability to access dental
care and no dental insurance.
Nahouraii et Latina mothers 15–44 years of age (n = 58.0% of mothers described 57.0% of children of Latina mothers
al. 200827 174) selected using a multistage church- the condition of her index had seen a dentist, and 47.4% had
based sampling design. Immigrat- child’s teeth as excellent, dental insurance
ed from Latin America or Caribbean very good or good
and had child ≤ 6 years of age Influential, emotional and material
aid related (p < 0.01) to use of dental
care (OR 3.13, 95% CI 1.67–5.87),
as well as arrival in US before
1997 (OR 4.39, 95% CI 2.14–9.01)
and child age > 2 and < 5 years
(OR 20.14, 95% CI 4.96–81.83).
Norton et Children 2–12 years of age (n = 2435) in No preventive dental visits in past
al. 201328 regard to receiving preventive dental care year more likely among children
born outside US than those born in
Children 6–12 years of age (n = 1416) US (adjusted prevalence ratio 1.73,
regarding having dental sealants 95% CI 1.23–2.42). Place of birth was
not a factor for having no sealants;
however, children with no preventive
visits in the past year were more likely
not to have sealants (adjusted preva-
lence ratio 1.47, 95% CI 1.32–1.63)
Noyce et Data on children from Medical Expenditure Households where the primary
al. 200929 Panel Survey, 2002–2004 (n = 21 049). Age language was not English had lower
groups: 1–3, 4–6, 7–12, 13–15, 16–18 years rates of preventative/routine dental
visits, but not after accounting for
other factors.

Spanish spoken at home was

a barrier to dental access in
educated Hispanic households.
However, this was not the case
for other ethnic households.

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Author, date Population Oral health status Barriers to use of dental services
Nunn et Children 1–3 years of age from 2 urban Boston children had signifi- Urban Boston children were more
al. 20094 medical centres in Boston (n = 787) cantly more missing primary likely from lower-income immigrant
compared with similar-aged US children from teeth than US children. ECC households with no health insurance
NHANES III (n = 3644) conducted 1988–1994 prevalence in children of or only Medicaid than US children.
immigrants in urban Boston
Children of immigrants represent- was 2.3% vs. US children at
ed 62.5% of urban Boston children; 12.3% (p < 0.001). ECC preva-
19.8% of US children (p < 0.001) lence in children of US born
parents in urban Boston was
4.4% vs. US children at 4.9%
(p < 0.001).

US children of immigrants had

greater odds of ECC than
those of US parents (OR 2.06,
95% CI 1.47–2.88).

Urban Boston children of

immigrants had lower odds
of ECC than children of
immigrants in US (OR 0.21,
95% CI 0.08–0.61).
Núnez Children aged 4–7 and 10–13 years Children of parents with university
201330 residing in Talca, Chile (n = 147) paired education in Talca were 2.2 times
with Chilean immigrant children more likely to see a dentist (95%
in Montréal, Canada (n =4). CI 1.3–3.73) than children of parents
with less than university education.
Similarly in Montréal, children of
parents with a university education
were 2.1 times more likely to see a
dentist (95% CI 1.17–3.76). Although
age group was not significant in
Talca children, Montréal children
10–13 years of age were 2.11 times
(95% CI 1.16–3.88) more likely to
see a dentist than 4–7 year olds.
Quandt et Women (n = 108) and spouses (n = 102) from Mother–child dyads. Fair or poor Barriers to access: fees too high (90.6%,
al. 200731 Latino farmworker families, with a child < 13 years oral health: mothers 63.9%, children 61.5%), transportation (15.1%, 23.1%).
(n =79), recruited by 11 lay health promoters 59.9%. Oral pain: mothers 13.9%,
children 6.3%. Gum bleeding: Born in the US associated with
mothers 25.0%, children 6.3%. having a dental visit in the last
Sensitivity to hot, cold: mothers year (χ2 = 4.692, p = 0.03).
Mothers born in Mexico 95.3%,
children born in US 75.2% 22.2%, children 5.1%. In the last Born in the US associated with child’s
year, received dental cleaning: oral condition excellent, very good
37%, 62%, respectively; dental or good (χ2 = 4.078, p = 0.043).
examination: 15.7%, 29.1%; dental
services annually: 17.6%, 17.7%);
every 6 months: 7.4%, 39.2%.

Shah et al. Refugees 0–18 years of age entering the county Dental caries in 44.8% of children.
201432 between October 2010 and July 2011, of
African, Bhutanese or Burmese descent, who Rate of dental caries: African
submitted to dental screening (n = 366) refugees 10.6%, Bhutanese 50.0%,
Burmese 48.0% (p < 0.001).
Soncini et Financially disadvantaged, mostly Hispanic Immigrant vs. US dft + DFT 10.2
al. 201033 children 3–18 years (n = 75) seeking care at vs. 7.7.
school dental clinics. Of the sample, 32% were
immigrants born outside of the US or Canada Increase in caries (dft + DFT) with
age greater among immigrant than
US-born children (p < 0.047). No
significant differences in bacteria
species between immigrant and
non-immigrant children.

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Author, date Population Oral health status Barriers to use of dental services
Stevens et Families (n = 37 236) of children < 18 years identi- Undocumented dyad children less
al. 201034 fied from 2001, 2003 and 2005 California Health likely to have insurance (OR 0.20,
Interview Survey. Immigrant status of parent– 95% CI 0.16–0.26), dental visits
child dyads, broken down into 4 categories: both (OR 0.47, 95% CI 0.35–0.63) or
citizens (n = 30 082), both documented = child regular source of care (OR 0.51,
legal resident or citizen/parent legal resident (n = 95% CI 0.37–0.69) than citizen
4018), mixed = child citizen/parent undocument- dyad children. Documented dyad
ed (n = 2256), both undocumented (n = 880) children less likely to have insurance
(OR 0.70, 95% CI 0.57–0.85) and
a regular source of care (OR 0.78,
95% CI 0.63–0.96) than citizen dyad
children.

Proportion of children insured in

2005: citizens (89.4%), document-
ed (49.8%), mixed (49.8%) and
undocumented (44.1%). Differences
significant (p < 0.01).

Similar differences in insurance

coverage for parents in the dyad
(p < 0.01).

Undocumented dyad children were

less likely to have dental visits than
citizens (OR 0.47, 95% CI 0.35–0.63).
Weinstein et Random selection from health records of children 72.7% of the mothers were born in Dental health behaviours: compared with
al. 199635 born from September 1991 to April 1992 Canada. Canadian-born mothers, a higher percent-
age of foreign-born mothers reported
Children (n = 938) about 18 months of age Both race (p = 0.0008) and current bottle use, bottle propping, leaving
were studied from April to December 1993 mother born outside of Canada baby unattended with bottle to fall asleep
(p = 0.06) were related to higher (p<0.0001); a lower percentage reported
decay rates in children. cleaning the child’s teeth. (p = 0.0004).
Wong et al. Children, < 12 years, of Chinese immigrants with Children had decay in 6–20 This qualitative research study showed
200536 extensive caries (n = 24) referred for dental treatment teeth (median = 11). that immigrant Chinese parents’ own
under general anesthesia childhood did not stress oral hygiene;
many parents feared general anesthe-
Interviews conducted (n = 20) sia and sedation; cultural beliefs
affected some parents’ decision to allow
treatment; parents’ social support systems
often opposed treatment as well.
Woodward 15 randomly selected school children ages 8–9 years NYPHD patients had higher DMFT Absence or presence of decay dependent on
t al. 199637 (difference in means 0.31, 95% years mother in Canada (OR 1.28, 95% CI
total n = 424. Immigrants (n = 169) and CI 0.05–0.57) and deft (difference 1.07–1.55); parent makes dental appointment
Canadian-born patients (n = 255)Patients of in means 1.23, 95% CI 0.57–1.87) (OR 0.14, 95% CI 0.03–0.64); evidence of
private dental practices (PDP; n = 128) , City scores than PDP patients past decay (OR 3.51, 95% CI 1.68–7.33).
of North York Public Health Department
(NYPHD; n = 144) and Others (n=152),
Yun et al. 201338 Parents of children 5–18 years old (n = 2170) Unadjusted results for delayed dental care
where at least 1 parent was not a US citizen (p = 0.019): legalized (17.0%), mixed status
before becoming legal permanent resident. Parent (23.3%), refugee (29.1%), temporary resident
immigration status: legalized (n = 504), mixed (20.1%), undocumented (23.4%).
status (n = 419), refugee (n = 290), temporary
resident (n = 787), undocumented (n = 170) No significant differences were found in the
adjusted results for delayed dental care.
Ziol-Guest and Children < 18 years old residing in low-in- Rate of seeing a dentist was lower for
Kalil 201239 come households (n = 46 148) participat- children with a non-permanent parent
ing in the Survey of Income and Program compared with those with natural-
Participation in 1996, 2001, 2004 and 2008 ized parents (χ2 = 24.51, p < 0.001).
Note: CI = confidence interval, defs = Mean decayed/extracted/filled primary teeth, dft = Mean decayed/filled primary teeth, DFT = Mean Decayed/Filled
permanent Teeth, DMFT = Mean Decayed/Missing/Filled Permanent Teeth, NHANES III = National Health and Nutrition Examination Survey, OR = odds ratio, US =
United States.

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Appendix 1: MEDLINE search strategy

1. Dental Caries/ 16. oral health.mp. [mp = as in 15] 31. exp Refugees/
2. exp Toothache 17. caries.mp. [mp = as in 15] 32. exp “Emigration and Immigration”
3. Dental Care/ 18. (tooth adj2 decay).mp. [mp = as 33. exp Minority Groups/
in 15]
4. Dental Care for Children/ 34. exp Acculturation/
19. (oral adj2 hygiene).mp. [mp = as
5. Dental Caries Susceptibility in 15] 35. migra*.mp. [mp = as in 15]
6. Dental Health Services/ 20. (oral adj2 epidemiology).mp. [mp 36. refugee.mp. [mp = as in 15]
= as in 15]
7. exp Dental Plaque/ 37. cultur*.mp. [mp = as in 15]
21. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
8. exp Dental Health Surveys/ 38. new* arriv*.mp. [mp = as in 15]
or 10 or 11 or 12 or 13 or 14 or 15 or
9. exp Dental Records/ 16 or 17 or 18 or 19 or 20 39. acculturate*.mp. [mp = as in 15]
10. Dental Research/ 22. exp Ethnic Groups/ 40. cultur* competence*.mp. [mp = as
in 15]
11. exp Ethics, Dental/ 23. exp Culture/
41. ethnic*.mp. [mp = as in 15]
12. exp Fees, Dental/ 24. exp Anthropology, Cultural/
25. exp Cross-Cultural Comparison/ 42. 22 or 23 or 24 or 25 or 26 or 27 or 28
13. exp Health Education, Dental/ or 29 or 30 or 31 or 32 or 33 or 34 or
14. exp Oral Health/ 26. exp Cultural Characteristics/ 35 or 36 or 37 or 38 or 39 or 40 or 41

15. dent*.mp. [mp = title, abstract, 27. exp Cultural Deprivation/ 43. 21 and 42
original title, name of substance 44. limit 43 to yr = “2007 – 2014”
28. exp Cultural Diversity/
word, subject heading word,
keyword heading word, protocol 29. exp Cultural Evolution/
supplementary concept, rare
disease supplementary concept, 30. exp “Transients and Migrants”/
unique identifier]

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 Oral Health Status of Immigrant and Refugee Children in North America: A Scoping Review
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Appendix 2: Articles excluded after the full-text reading: 1 = review paper, references were checked; 2 = study did not include relevant data on children of
refugees or immigrants in North America.

Reference and title Reason for

exclusion
Connor et al. 2014. A narrative literature review on the health of migrant farm worker children in the USA. 1
Riggs et al. 2014. Assessing the cultural competence of oral health research conducted with migrant children. 1
Ghiabi et al. 2014. The oral health status of recent immigrants and refugees in Nova Scotia 2
Geltman et al. 2014. Health literacy, acculturation, and the use of preven- 2
tive oral health care by Somali refugees living in Massachusetts
Jang et al. 2014. Dental care utilization and unmet dental needs in older Korean-Americans 2
Beck et al. 2014. The prevalence of caries and tooth loss among partici- 2
pants in the Hispanic Community Health Study/Study of Latinos.
Divaris et al. 2014. Influence of caregivers and children’s entry into the dental care system. 2
Tiwari et al. 2014. Recruitment for health disparities preventive interven- 2
tion trials: the Early Childhood Caries Collaborating Centers
Shaffer et al. 2013. Demographic, socioeconomic, and behavioral factors affecting patterns of 2
tooth decay in the permanent dentition: principal components and factor analyses
Gonda et al. 2013. Predictors of multiple tooth loss among socioculturally diverse elderly subjects 2
Sirois et al. 2013. Understanding Muslim patients: cross-cultural dental hygiene care. 2
Adams et al. 2013. The cultural basis for oral health practices among Somali 2
refugees pre-and post-resettlement in Massachusetts.
Borenstein et al. 2013. Oral health, oral pain, and visits to the dentist: neighbour- 2
hood influences among a large diverse urban sample of adults.
Geltman et al. 2013. The impact of functional health literacy and accultura- 2
tion on the oral health status of Somali refugees living in Massachusetts.
Valencia et al. 2012. Racial and ethnic disparities in utilization of dental 2
services among children in Iowa: the Latino experience
Puertes-Fernandez et al. 2011. Orthodontic treatment need in a 12-year-old population in the Western Sahara 2
Cohen et al. 2011. Behavioral and socioeconomic correlates of dental 2
problem experience and patterns of health care-seeking
Amin et al. 2011. Utilization of dental services by children in low-income families in Alberta 2
Christensen et al. 2010. Oral health in children in Denmark under different public dental health care schemes 2
Manuel Almerich-Silla 2008. Caries and dental fluorosis in a western Saharan population of refugee children 2
Dasanayake et al. 2007. Challenges faced by minority children in obtaining dental care 2
Dong et al. 2007. Perceptions of oral illness among Chinese immigrants in Montreal: a qualitative study 2
Schenk et al. 2007. Oral health behaviour of children and adolescents in Germany. First results of the 2
German Health Interview and Examination Survey for Children and Adolescents (KiGGS)

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