Multiple Marginalization: Quantifying Intersectional Inequalities in Utilization of Dental Care

Inequitable utilization of regular dental care is known to be a key driver for inequalities in oral health outcomes. The aim of this study was to investigate inequalities in adolescent dental care, at the intersections of sex, race and ethnicity, and sexual identity.

We analyzed pooled data from the 2021 to 2023 national Youth Risk Behavior Survey, comprising 27,692 participants. A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was performed, defining 20 intersectional strata by sex, race and ethnicity, and sexual identity. Two binary outcomes pertaining to dental service utilization were assessed: (i) not having visited a dentist in past 12 months, and (ii) never having visited a dentist.

There was evidence of modest between-stratum heterogeneity with regards to dental visits in the past 12 months, and substantial heterogeneity for never having visited a dentist. The fixed effects of sex, race and ethnicity, and sexual identity explained approximately 93% to 97% of the between-stratum variance. The median odds ratio indicated that, depending on intersectional identity, the odds increased by 35% for not having visited a dentist in the past 12 months and 108% for never having visited a dentist. Discriminatory accuracy was poor for both outcomes.

Inequalities in adolescent dental attendance may be substantial, particularly among Black and sexual minority individuals. Under specific MAIHDA modeling assumptions, we find that the inequalities across intersectional strata appear to be largely additive in nature.