Reshaping Oral Health Inequities- Pandemic Impact (COVID-19) on Geo-Spatial Structures of Geriatric Tooth Loss

Background: Tooth loss is a relevant oral health indicator among older adults, as it captures cumulative disadvantage and has demonstrated patterning by race/ethnicity and socioeconomic conditions. How these geographic disparities evolved during the COVID-19 period has received less attention. Objective: We aimed to describe changes in the spatial distribution of total tooth loss among adults aged ≥65 years in the United States across three time periods: pre-pandemic (2018), peak-pandemic (2020), and post-pandemic recovery (2022) at the ZIP Code Tab-ulation Area (ZCTA) level. Methods: We conducted repeated cross-sectional ecological analyses, linking CDC PLACES estimates of tooth loss prevalence to ZCTA-level covariates from the American Community Survey for 2018, 2020, and 2022 (contiguous US). We summarized year-specific distributions, estimated pooled OLS models with year and year×race/ethnicity-majority interactions, and fitted year-specific spatial models (SLM/SEM), geographically weighted regression (GWR), and Getis–Ord Gi* hot spot analyses with Queen contiguity weights. Results: Mean prevalence decreased from 15.9% (2018) to 14.4% (2022), and geographic clustering persisted across years. Black-majority ZCTAs consistently had higher preva-lence than other majority categories. Spatial dependence was strongest in 2020, when spatial lag effects were larger and GWR results suggested substantial geographic het-erogeneity in the associations between socioeconomic covariates and tooth loss. Hot spot maps reveal persistent clustering in the Southeast region, with a wider spatial footprint in 2020 and partial re-emergence of cold spots by 2022. Conclusions: Tooth loss prevalence remained geographically clustered and unevenly distributed across the pre-pandemic, peak-pandemic, and recovery years examined. The pandemic period was associated with stronger spatial dependence and wider geographic clustering of high-prevalence areas, highlighting the importance of place-sensitive oral health strategies.