dental treatment needs in the canadian population...in canada, dental services are predominantly...
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Dental Treatment Needs in the Canadian Population
by
Chantel Ramraj
A thesis submitted in conformity with the requirements for the degree of Master of Science in Dentistry
Graduate Department of Dentistry University of Toronto
© Copyright by Chantel Ramraj 2012
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Dental Treatment Needs in the Canadian Population
Chantel Ramraj
Master of Science in Dentistry
Graduate Department of Dentistry University of Toronto
2012
Abstract
Objective: To determine the dental treatment needs of Canadians and how they are
distributed. Methods: A secondary analysis of data from the Canadian Health Measures
Survey was undertaken. Weights were applied to make the data nationally representative.
Bivariate and multivariate regressions were used to identify predictors of need.
Sensitivity, specificity, positive and negative predictive values were calculated to
compare self-reported and clinically determined needs. Results: Of the 34.2% who
required dental treatment, most needed restorative (20.4%) and preventive (13.7%) care.
The strongest predictors of need were having poor oral health, reporting a self-perceived
need for treatment and visiting the dentist infrequently. A discrepancy was found between
clinical and self-reported needs. Conclusions: Roughly 12 million Canadians have unmet
dental needs. A number of factors are predictive of having unmet dental conditions.
Program and policymakers now have information by which to assess if their programs
match the dental needs of Canadians.
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Acknowledgments
First and foremost, it is with heartfelt gratitude that I acknowledge my supervisor, Dr.
Carlos Quiñonez. He is an amazing educator and researcher, and his guidance,
enthusiasm and patience have truly been invaluable to me during this learning endeavor. I
would like to extend my sincerest appreciation to my advisory committee members, Dr.
Amir Azarpazhooh and Dr. Laura Dempster. Their expertise and insightful comments
have made significant contributions to this research. I would also like to thank Dr. Vahid
Ravaghi for all of the statistical help and direction he provided.
To my colleagues in the Dental Public Health program, thank you for creating a
stimulating and fun environment in which to learn and grow. Brandy Thompson, Dr.
Alyssa Hayes and Dr. Abeer Khalid, I cannot thank you enough for the motivating
discussions and great company you have provided me over the past two years of this
Masters program. I feel so lucky to have formed friendships with all of you.
To my parents, Savita and Ramesh and my sister Sasha, thank you for your endless
support and encouragement throughout the duration of my studies. I would also like to
acknowledge my family and friends, especially Ujash, who continues to inspire me to
work hard and to reach my full potential.
I further extend my appreciation to the funders of this project: The Population Health
Improvement Research Network (PHIRN), of the Applied Health Research Network
Initiative (AHRNI), of the Government of Ontario and the University of Toronto Open
Fellowship (2010-2012).
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Table of Contents
Abstract........................................................................................................................................... ii!
Acknowledgments ......................................................................................................................... iii!
Table of Contents............................................................................................................................iv!
List of Tables ............................................................................................................................... viii!
List of Figures..................................................................................................................................x!
List of Appendices ..........................................................................................................................xi!
Chapter I: Introduction ................................................................................................................1!
1.1! The importance of assessing oral health needs in the Canadian population........................1!
1.2! Using the Canadian Health Measures Survey (CHMS) to assess oral health......................3!
1.3! Summary statements ............................................................................................................3!
1.4! Rationale for this study ........................................................................................................4!
1.5! Conceptual framework for this study...................................................................................4!
1.6! Aims and objectives of this study ........................................................................................9!
1.6.1! Overall Aim .............................................................................................................9!
1.6.2 Specific Objectives ..................................................................................................9!
1.7! Summary of expectations ....................................................................................................9!
Chapter II: Literature Review....................................................................................................11!
2.1! Previous clinical reports and findings on the oral health needs of Canadians...................11!
2.2! Previous self-reported information on the dental needs of Canadians ..............................14!
2.3! Unreliability of self-reported treatment needs ...................................................................15!
2.4! Significant variables related to treatment needs ................................................................16!
2.5! The need for clinical assessment of dental needs in program planning.............................17!
2.6! Summary statements ..........................................................................................................18!
Chapter III: Materials and Methods .........................................................................................20!
3.1! Study design and protocols ................................................................................................20!
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3.2! Population and study sample .............................................................................................20!
3.3! Collection of data...............................................................................................................20!
3.3.1! Household interview..............................................................................................21!
3.3.2! Clinical assessment ................................................................................................21!
3.4! Examiner calibration..........................................................................................................23!
3.5! Data variables ....................................................................................................................23!
3.5.1! Predisposing characteristics...................................................................................23!
3.5.2! Enabling variables..................................................................................................24!
3.5.3! Need variables........................................................................................................25!
3.5.4! Personal dental health practice variables ...............................................................25!
3.5.5! Use of dental service variables ..............................................................................25!
3.6! Data Analysis.....................................................................................................................26!
3.6.1! Weighting of data ..................................................................................................26!
3.6.2! Statistical tests .......................................................................................................27!
Chapter IV: Results........................................................................................................................32!
4.1! Sample characteristics........................................................................................................32!
4.1.1! Predisposing factors...............................................................................................32!
4.1.2! Enabling factors .....................................................................................................32!
4.1.3 Need factors ...........................................................................................................34!
4.1.4! Personal dental health practice factors...................................................................34!
4.1.5! Use of dental service factors..................................................................................35!
4.2! Clinically determined treatment needs ..............................................................................36!
4.2.1! Type of dental treatments ......................................................................................36!
4.3 The odds of needing at least one dental treatment ..............................................................38!
4.3.1! Predisposing factors...............................................................................................38!
4.3.2! Enabling factors .....................................................................................................38!
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4.3.3! Need factors ...........................................................................................................42!
4.3.4! Personal dental health practice factors...................................................................42!
4.3.5! Use of dental service factors..................................................................................42!
4.4 The odds of needing a specific treatment type....................................................................48!
4.4.1! Preventive needs ....................................................................................................48!
4.4.2! Restorative needs ...................................................................................................50!
4.4.3! Surgical needs ........................................................................................................52!
4.4.4! Periodontic needs...................................................................................................54!
4.4.5! Endodontic needs...................................................................................................54!
4.4.6! Prosthodontic needs ...............................................................................................56!
4.4.7! Orthodontic needs ..................................................................................................58!
4.4.8! Urgent needs ..........................................................................................................58!
4.5! Determining the strongest predictors of dental treatment need .........................................59!
4.5.1! Model 1 – Predisposing factors .............................................................................59!
4.5.2! Model 2 – Predisposing and enabling factors........................................................59!
4.5.3! Model 3 – Predisposing, enabling and need factors ..............................................60!
4.5.4! Model 4 – Predisposing, enabling, need, and personal dental practice factors ....................................................................................................................60!
4.5.5! Model 5 – All factors (predisposing, enabling, need, personal dental practice and use of dental service factors) .............................................................61!
4.6! Comparing self-reported and clinically determined treatment needs ...............................65!
4.6.1! Using sensitivity and specificity ............................................................................65!
4.6.2! Using positive predictive vale (PPV) and negative predictive value (NPV).....................................................................................................................66!
4.7 Summary of results .............................................................................................................67!
4.7.1! Objective I: What are the dental treatment needs of Canadians? ..........................67!
4.7.2! Objective II: What characteristics are predictive of having an unmet dental need, and each type of treatment?...............................................................67!
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4.7.3! Objective III: What are the strongest predictors of having an unmet need? ......................................................................................................................68!
4.7.4! Objective IV: Comparing self-reported and clinically determined treatment needs ......................................................................................................68!
Chapter V: Discussion ...................................................................................................................69!
5.1! Key findings.......................................................................................................................70!
5.1.1! The need for dental treatment in Canada ...............................................................70!
5.1.2! Consequences of untreated dental disease .............................................................71!
5.1.3! Predicting those at greatest risk for needing dental treatment ...............................72!
5.1.4! Using self-reported dental need to predict actual need..........................................73!
5.2 What do these findings mean to dental public health policy? ............................................75!
5.3 Limitations of the study ......................................................................................................77!
5.4 Recommendations...............................................................................................................78!
Chapter VI: Conclusion .................................................................................................................81!
References......................................................................................................................................83!
Appendices ....................................................................................................................................97
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List of Tables
Table 1. Criteria used to assess each treatment type......................................................................22!
Table 2. Income adequacy categories defined ...............................................................................25!
Table 3. Example of 2x2 table constructed to calculated sensitivity, specificity, positive and negative predictive value ........................................................................................................29!
Table 4. Sample characteristics by predisposing factors ...............................................................33!
Table 5. Sample characteristics by enabling factors......................................................................33!
Table 6. Sample characteristics by need factors ............................................................................34!
Table 7. Sample characteristics by personal dental health practice factors...................................35!
Table 8. Sample characteristics by use of dental service factors...................................................35!
Table 9. Percent and unadjusted odds ratio of individuals who have clinically ! determined treatment needs by predisposing factors…………………………………….............39!
Table 10. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by enabling factors............................................................................39!
Table 11. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by need factors..................................................................................43!
Table 12. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by personal dental health practices...................................................43!
Table 13 Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by use of services.................................................................................................44!
Table 14. Percent and unadjusted odds ratio of individuals who have preventive needs..............49!
Table 15. Percent and unadjusted odds ratio of individuals who have restorative needs..............51!
Table 16. Percent and unadjusted odds ratio of individuals who have surgical needs ..................53!
Table 17. Percent and unadjusted odds ratio of individuals who have periodontal needs ............55!
Table 18. Percent and unadjusted odds ratio of individuals who have endodontic needs.............56!
Table 19. Percent and unadjusted odds ratio of individuals who have prosthodontic needs.........57!
Table 20. Percent and unadjusted odds ratio of individuals who have orthodontic needs ............58!
Table 21. Percent and unadjusted odds ratio of individuals who have urgent needs ....................58!
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Table 22. Multivariate logistic regression predicting the odds of having at least one clinical need including predisposing, enabling and need factors...................................................62!
Table 23. Multivariate logistic regressions predicting the odds of having at least one clinical need including predisposing, enabling, need, personal dental health practice and use of service factors......................................................................................................................63!
Table 24. Comparing self-reported versus clinically determined treatment needs using sensitivity and specificity ..............................................................................................................66!
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List of Figures
Figure 1. Different aspects of needs (Adopted from Wright et al., 1998) .....................................13!
Figure 2. Andersen's Emerging Model (taken from Andersen, 1995).............................................7!
Figure 3. Operational model - Modification of Andersen's Emerging Model (adapted from Andersen, 1995) ......................................................................................................................8!
Figure 4. Distribution of clinically determined treatment needs ...................................................36!
Figure 5. Percent of type of dental treatment in the Canadian population ....................................48!
Figure 6. Unadjusted odds ratio of individuals who have clinically determined treatment needs by predisposing factors ........................................................................................................51!
Figure 7. Unadjusted odds ratio of individuals who have clinically determined treatment needs by enabling factors...............................................................................................................52!
Figure 8. Unadjusted odds ratio of individuals who have clinically determined treatment needs by need factors.....................................................................................................................56!
Figure 9. Unadjusted odds ratio of individuals who have clinically determined treatment needs by personal dental health practice factors............................................................................57!
Figure 10. Unadjusted odds ratio of individuals who have clinically determined treatment needs by use of service factors ......................................................................................................58!
xi
List of Appendices
Appendix A. Coding for all of the independent and dependent variables in this study ................86!
Appendix B. Coding for all independent and dependent variables ...............................................92!
1
Chapter I: Introduction
1.1 The importance of assessing oral health needs in the Canadian population
Prior to the 2007/09 Canadian Health Measures Survey (CHMS), there was no nationally
representative clinical data on the oral health needs of Canadians since the 1970/72
Nutrition Canada National Survey (Health Canada, 2010). This is of concern because
identifying the needs of the population is the primary step in the development of any
program plan (Timmreck, 2003).
In Canada, dental services are predominantly delivered in the private sector on a fee-for-
service basis. Since Canadians are largely responsible for financing their own dental care,
enabling resources for obtaining care, such as income and insurance, dictate the use of
dental services instead of the need for treatment. In this regard, it is especially important
to identify the subgroups that have the greatest amount of unmet needs, in order to
determine priorities for the most effective use of resources. Without a clear picture of the
burden of oral disease and how it is distributed, the danger of a top-down approach to
providing health services arises, which relies heavily on what a few people perceive to be
the needs of the population rather than what they actually are (Wright et al., 1998).
In recognition of the scarcity of resources available to meet the oral health needs of the
population, Wright et al., (1998) use the diagram below to show how health needs in
general are often differentiated as needs, demands, and supply (Figure 1).
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Wright et al., (1998) defines ‘need’ as ‘the capacity to benefit’, and further say, “If health
needs are to be identified then an effective intervention should be available to meet these
needs and improve health.” ‘Demand’ is ‘what patients ask for’ and depends on the
characteristics of the patient (Wright et al., 1998). Lastly, ‘supply’ is the oral health care
provided and depends on the interests of oral health professionals, the priorities of policy
makers, and the amount of money and resources available (Wright et al., 1998).
Ultimately, with the rising costs of dental care making access to dental services more and
more unattainable for people who lie on the social margin (Haley et al., 2008) it is
imperative to highlight the areas of unmet need and to identify the exact needs of the
population in order to pinpoint wasted resources and to develop or refine targeted oral
health programs.
Figure 1. Different aspects of needs (Adopted from Wright et al., 1998)
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1.2 Using the Canadian Health Measures Survey (CHMS) to assess oral health
Prior to Statistics Canada’s Canadian Health Measures Survey (CHMS) there was no
current, nation-wide, clinical information on the oral health of Canadians (Health Canada,
2010). This information provides a baseline of the current oral health status of Canadians
and can be used to describe the severity and distribution of oral disease, as well as outline
the precise dental treatment needs of the population. With further analysis of this data, the
relationships between oral health and known risk factors (age, smoking, etc.) as well as
the effect of socioeconomic factors (low income, education, etc.) can be investigated to
help understand disparities in oral health and ascertain who are the most vulnerable.
Ultimately, we now have data that helps us differentiate the notion of need as described
by Wright et al. (1998), as the CHMS collected data on expressed and normative dental
treatment needs. Again, this information can be used to inform dental public health policy
and programming in an effort to improve the oral health of the Canadian population and
subgroups at particular risk.
1.3 Summary statements
! We generally have little to no data on the oral health needs of Canadians at the
population level.
! In order for the proper planning and provision of oral health care services and
programs in Canada, an assessment of the dental needs of the population is
necessary.
! Highlighting the areas of unmet need and identifying the exact needs of the
population can be used to develop or refine targeted oral health programs.
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! The CHMS provides a baseline of the current oral health status of Canadians
and can be used to describe the severity and distribution of oral disease, as well as
outline the precise dental treatment needs of the population. Analysis of this
information can assist in the development of dental public health policy and
programming.
1.4 Rationale for this study
There is little to no nationally representative information on clinically assessed dental
treatment needs in Canada. This information is important in terms of policy and program
planning, as it can help governments understand the distribution of population needs,
allowing them to compare current approaches to publicly financed dental care with actual
treatment needs.
1.5 Conceptual framework for this study
The selection of variables used in this study was based on the information collected in the
CHMS and on Andersen’s emerging model of health services (see Figure 2). This model
depicts the use of health care services as a complex set of interconnected feedback loops
classified as environment, population characteristics, health behaviour, and outcomes.
Andersen’s original behavioural model of health services use was developed in the late
1960’s to examine the use of health services by families and to define, measure, and
promote equitable access to health care (Andersen, 1995). The initial model proposed that
an individual’s “use of health services is a function of their predisposition to use services,
factors which enable or impede use, and their need for care” (Andersen, 1995). Since
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then, the model has undergone a number of revisions in attempts to incorporate all
components of modern health seeking behaviour (Andersen, 1995).
Figure 2 is the fourth and final phase of the model which shows that an individual’s
access to, and use of health services is considered to be a function of three characteristics:
Predisposing, enabling and need factors. Predisposing factors, including age, sex, and
education, exist prior to an individual’s illness and influence the likelihood that they will
need health services (Andersen, 1995). Enabling factors are prerequisites for obtaining
care and include income and insurance (Andersen, 1995). Finally, need factors, in the
context of Andersen’s model, includes how individuals view their health (perceived need)
as well as how health professionals judge people’s health status and their need for care
(evaluated need) (Andersen, 1995). Although the use of health services was the main
outcome of the preceding models, the final phase emphasizes the dynamic and recursive
nature of a health services use model that includes health status outcomes (Andersen,
1995). Feedback loops show that outcomes, in turn, affect subsequent predisposing
factors and perceived need for services as well as health behaviors (Andersen, 1995).
For the purposes of this study, modifications were made to Andersen’s emerging model
(see Figure 3). Instead of predicting healthcare usage, a modified version was created a
priori to help understand and categorize the factors that influence an individual having
unmet dental treatment needs. In the population characteristics category, only ‘perceived’
needs were included as the outcome in this modified model was the professional’s
evaluation of the patient’s dental treatment needs. The feedback loops were also modified
from Andersen’s emerging model, which included the addition of an arrow directly from
population characteristics to health behaviour and outcomes. Using this modified model,
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this study evaluated the extent to which predisposing characteristics, enabling
resources, perceived need, personal dental health practices and dental service use affected
the evaluated dental treatment needs.
7
Figure 2. Andersen's Emerging Model (taken from Andersen, 1995)
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Figure 3. Operational model - Modification of Andersen's Emerging Model (adapted from Andersen, 1995)
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1.6 Aims and objectives of this study
1.6.1 Overall Aim
To determine the dental treatment needs of Canadians and how they are distributed using
data collected by the CHMS.
1.6.2 Specific Objectives
I To outline the specific treatment needs (prevention, restorations, surgery,
periodontics, endodontics, prosthodontics, orthodontics, other and urgent needs)
of Canadians as determined by the CHMS clinical oral health examination.
II To examine if any characteristics (predisposing, enabling, need, personal dental
practices and use of services) are predictive of having an unmet dental treatment
need and the type of treatment needed.
III To apply a modified version of Andersen’s emerging model to determine which
factors (predisposing, enabling, need, personal dental practices and use of
services) are the strongest predictors of having at least one clinical need.
IV To compare clinically determined treatment needs with self-reported needs.
1.7 Summary of expectations
It is expected that a significant proportion of the clinically determined treatment needs
will consist of fillings and prevention. Participants who are older in age, have a lower
education and lower income, are uninsured, born outside of Canada, Aboriginal, are
current smokers, report their health as poor and oral pain as frequent, rarely brush and/or
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brush their teeth, avoid dental treatment due to costs and visit the dentist rarely or never
will all be more likely to have at least one unmet dental treatment need. Those of lower
income, education, have no dental insurance and visit the dentist infrequently will require
more fillings and endodontic treatment. Older populations will be more likely to need
prosthodontic treatment whereas younger populations will be more likely to need
orthodontics and prevention. Current smokers will be more likely to need periodontal
treatment. Enabling variables (income and insurance) will be the strongest predictors of
treatment need. Lastly, there will be discrepancies between the clinically determined
(evaluated) treatment needs and self-reported (perceived) needs.
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Chapter II: Literature Review
2.1 Previous clinical reports and findings on the oral health needs of Canadians
Prior to the Canadian Health Measures Survey there had been a lack of direct baseline
information on Canadian oral health. Leake (2006) highlights this point:
“For more than 25 years, the public health system has not been able to assess
the oral health of Canadians consistent with the international standards of, for
example, the Word Health Organization/National Institutes of Health’s
International Collaborative Study or the National Health and Nutrition
Examination Surveys in the United States, or even the standards set out by the
Canadian Dental Association in the late 1960s” (p. 317g).
For this reason, there is limited literature on the clinically assessed treatment needs of the
Canadian population. Prior studies that examined treatment needs primarily focused on
children and the elderly. Other studies based on needs heavily relied on self-reported
information with no clinical basis.
Leake and colleagues (2001) examined data collected from the Dental Indices Survey
(DIS) conducted in Toronto during the 1999-2000 school year. This survey gathered
information on the oral health status and treatment needs of children aged 5, 7 and 13
through direct clinical assessments. A total of 3,657 examinations were analyzed and the
results showed that many children did not enjoy a healthy state. Over 10% of 5 year olds
needed 2 or more teeth treated for cavities and about 7% of both 5 and 7 year olds needed
urgent care. By age 13, urgent needs had fallen to 1.7% but periodontal conditions
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increased with 38% of 13 year olds needing treatment to remove calculus from their
teeth.
Similarly, a clinical dental health screening was conduced in Saskatchewan during the
2008-2009 school year to assess oral health status and identify children in grade one and
seven with unmet dental needs (Pilly, 2010). Out of 17,914 students, 4.1% of first graders
and 0.9% of seventh graders had urgent dental treatment needs. A total of 23.1% and
10.5% of first and seventh graders respectively, were referred to see their dentist for
treatment as soon as possible. In total, this study found that 27.1% of grade one students
and 11.4% of grade seven students in Saskatchewan had unmet dental needs.
Through a self-completed questionnaire and a clinical examination, Locker and
colleagues (1998) gathered data on the dental needs of student’s aged 13 and 14 years
(Grade 8) attending elementary schools in the City of North York, Ontario. From the 824
grade 8 students who participated, only 3.5% of those born in Canada, compared to
22.9% of those who had immigrated to Canada in the previous 2 years, needed
restorations (Locker, Clarke and Murray, 1998). Less than one percent (0.5%) and 10.4%
of these groups needed immediate/urgent treatment, respectively.
Generally, the oral health status of these particular groups of children and adolescents
appears to be poor resulting in the need for several treatments including urgent,
restorative, periodontal and preventive care (Leake et al., 2001; Pilly, 2010; Locker,
Clarke and Murray, 1998). We also see a variation in the type and amount of need based
on age, with younger children requiring more urgent treatment and having more unmet
dental needs in general than their older counterparts (Leake et al., 2001; Pilly, 2010;
Locker, Clarke and Murray, 1998). We also see a discrepancy of need between
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adolescent groups born outside and within Canada, with those who are immigrants to
Canada being worse off.
In terms of the elderly, Kuc and colleagues (1990) evaluated the dental needs those
around the age of 70 from different sections of Edmonton, Alberta. Sixty-seven percent
of the population required dental treatment, with 45% of denture wearing individuals
having a treatment need, yet none required emergency intervention (Kuc et al., 1990).
Over 49% of the dentate population required prophylaxis and 16% required periodontal
treatment.
A study done by Galan, Brecx and Heath (1995) looked at the treatment needs of a
sample of 170 responsive residents of seniors housing centres in Winnipeg, Manitoba
who were over the age of 65. Overall, they found that all of the dentate subjects and 90%
of the edentulous subjects required dental treatment. Fifteen percent of dentate subjects
and 52% of the edentulous population required emergency treatment for the management
of oral infections or biopsies. Looking specifically at the dentate subjects, 95% needed
prophylaxis or periodontal treatment and 79% required restorative treatment. As for the
edentulous subjects, 77% needed prosthodontic care (i.e. mainly relines or repairs of
existing dentures).
From 1982 to 1992, Hawkins, Main and Locker conducted an ongoing oral health survey
of 1,375 adults aged 85 and older living in North York, Ontario. Their sample consisted
of subjects living in nursing homes and living independently. Regarding clinically
defined treatment needs, high levels of unmet need were found in subjects from both
types of residences. Among nursing home residents, approximately 45% of dentate
subjects required tooth extraction, and 56% required prosthodontic treatment. In
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comparison, only 27% of dentate independently living subjects required tooth
extraction, but over 60% needed restorative treatment. In regards to the edentulous
subjects, 70% of nursing home residents and 51% of independently living residents,
required prosthodontic treatment.
On the whole we see very high levels of unmet need among older adults regardless of
whether they live in an institution or are homebound. The treatments they require consist
of urgent, preventive, periodontal, restorative and prosthodontic care. The older dentate
generation was found to be consistently worse off by having more unmet dental needs
than the edentulous population.
Overall, the selected studies provide only a snapshot of the dental treatment needs
required by selected groups of Canadians (children and older adults). Along with these
findings being fairly dated and variable in magnitude, these studies have only covered
specific areas of Canada. Using data from the CHMS, the current study is the first to
comprehensively examine the dental treatment needs of all Canadians (children,
adolescence, adults and older adults) at a population level.
2.2 Previous self-reported information on the dental needs of Canadians
Quiñonez and Locker (2007) collected data on general dental care behaviours and
perceived need from 1,006 Canadian adults through a telephone interview survey. A
question included in the survey asked Canadians if they had ever needed dental services
in the past that they could not afford, and if so, which services they thought they needed.
Twenty-six percent of Canadians found dental care cost-prohibitive and on average, 2
items were deemed unaffordable per respondent, with fillings (36.0%), cleanings (32.8%)
15
and check-ups (28.4%) mentioned by most. Since cost was found to impede the use of
these services, they can be assumed to be needed the most by the population.
2.3 Unreliability of self-reported treatment needs
Previous studies using self-reports (like the aforementioned), dental insurance claims and
other administrative data have been useful in alerting policy makers to the oral health
status of individuals and inequalities in oral health and oral health care. Although patient
self-reports are the most convenient mechanism for obtaining first-hand health outcome
information, it has been found to be heavily influenced by personal beliefs, cultural
background, and social, educational, and environmental factors (Liu et al., 2010).
Furthermore, regarding treatment needs, self-reports have been found to often provide
different assessment and values from those of clinically determined standards (Liu et al.,
2010). For example, a study conducted by Liu and colleagues (2010), examined data
from the 1999-2000 and 2001-2002 waves of the U.S. National Health and Nutrition
Examination Survey (NHANES) and found that patients are less likely to adequately
assess their periodontal status and the presence of caries than they are to assess the
number of their teeth, restorations, and the presence of fixed and removable prosthetics.
This study is congruent with a previous study by Gilbert and Nuttall (1999), which
concluded that people are usually unable to report signs and symptoms related to their
periodontal conditions.
Although we have seen in the literature that people have difficulty assessing their clinical
needs, their perceptions of need play an important role in evaluating the outcomes of
dental care and understanding their health behaviours, which is important to keep in
mind. Nevertheless, the CHMS now provides direct measurements of oral health, and
16
from a policy perspective, we no longer need to depend on self-reported information to
assess treatment need in the population.
2.4 Significant variables related to treatment needs
Although studies gathering self-reported information and data on the clinically assessed
needs of children and the elderly cannot be used to assess dental treatment need at the
Canadian population level, they highlight important factors that have been found to be
related to having unmet treatment needs. For example, several studies have found that
those who are older in age, less educated, uninsured and of low income have poorer oral
health, and therefore, greater treatment needs, than their comparable counterparts (Liu et
al., 2010; Robinson, Nadanovsky and Sheiham, 1998). These studies have also found that
a cohort effect appears to exist so that the discrepancy between self-reported and
clinically determined need is greater amongst older people who tend to overestimate their
own oral health (Liu et al., 2010; Robinson, Nadanovsky and Sheilham, 1998).
In addition, while the majority of the literature on clinically assessed dental treatment
needs consists mainly of U.S. studies, the factors that have been found to be associated
with dental treatment needs provide some insights for the Canadian situation. For
example, in an overview of The U.S. Surgeon General’s Report conducted in 2000,
Lawrence and Leake (2001) examined key findings of the report and related these
findings to the Canadian situation. They noted that similar to the United States, sex, age,
income, and race/ethnicity are important determinants of oral health status in Canada.
In regards to specific treatments, a study by Ramraj and Quiñonez (In Press) explored in-
depth the dental services that are reported as needed but deemed inaccessible to certain
socio-demographic groups due to cost. They found dentures and extractions to be related
17
to educational level, with those with equal to or less than a high school education
selecting both services more frequently. Therefore, there appears to be a significant link
between having a lower educational level and requiring treatments that reflect poor oral
health like dentures and extractions.
2.5 The need for clinical assessment of dental needs in program planning
Decision makers in the areas of dental health policy, resource allocation, and human
resource requirements must rely on estimations of treatment needs in order to base their
programs (McGuire, 1992). This information is important, especially in the Canadian
dental care system where utilization of dental services is inconsistent with the needs of
the population (CDHA, 2010). Several studies have alluded to the “inverse care law”
whereby those with the highest need (e.g. the poor, uninsured and less educated),
underutilize the dental system and are not receiving the care they require due to financial
and access barriers (CDHA, 2010; Leake, 2006; Heart, 1971). In order to improve policy
and allow oral health care to become equitably utilized and in turn, reduce the presence of
unmet need, public programs need to focus on increasing the affordability and
accessibility of dental services (Leake, 2006). However, this can most efficiently be
achieved if policymakers are provided with specific information on the types and
complexity of dental procedures required by the Canadian population. Since Canadians
have lacked an ongoing surveillance system to measure current oral health status and
treatment needs prior to the CHMS, the capacity to develop dental health policy based on
evidence has been limited. The current study will help fill that gap in the literature by
providing a valid, consistent and representative assessment of dental treatment need in the
Canadian population as a whole.
18
2.6 Summary statements
! There is limited literature on the clinically assessed treatment needs of the
Canadian population. Prior studies that examined treatment needs primarily
focused on children and the elderly. Other studies based on needs heavily relied
on self-reported information with no clinical basis.
! Overall, the oral health status of particular groups of Canadian children and
adolescents appears to be poor resulting in the need for several treatments
including urgent, restorative, periodontal and preventive care.
! There appears to be a high level of unmet need among older adults. The most
frequent treatments this population requires consist of urgent, preventive,
periodontal, restorative and prosthodontic care.
! A considerable discrepancy is seen in the literature between self-reported needs
and clinically determined standards. A cohort effect appears to exist so that this
discrepancy is greater amongst older people who tend to overestimate their own
oral health.
! Several studies have found that those who are older in age, less educated,
uninsured and of low income have poorer oral health, and therefore, greater
treatment needs, than their comparable counterparts.
! Decision makers in the areas of dental health policy, resource allocation, and
human resource requirements must rely on estimations of treatment needs on
which to base their programs.
! This current study is the first to comprehensively examine the dental treatment
needs of all Canadians (children, adolescence, adults and older adults) at a
population level.
19
! This current study will help fill a gap in the literature by providing a valid,
consistent and representative assessment of dental treatment need in the Canadian
population as a whole.
20
Chapter III: Materials and Methods
3.1 Study design and protocols
This study was a secondary data analysis of the Canadian Health Measures Survey
(CHMS), Cycle 1 Household and Clinic Questionnaires, which was a cross-sectional
survey. This information was accessed from Statistics Canada’s Research Data Centre
(RDC) in Toronto. The RDC operates through a partnership with the Social Sciences and
Humanities Research Council (SSHRC), Canadian Institutes of Health Research (CIHR),
Canada Foundation for Innovation (CFI) and a consortium of universities across the
country including the University of Toronto. The RDC provided access, in a secure
university setting, to the confidential micro data files from the CHMS.
3.2 Population and study sample
The CHMS collected health measures from approximately 5600 people, which can
statistically represent 97% of the Canadian population between 6 and 79 years of age.
This consisted of those living in privately occupied dwellings in the ten provinces and the
three territories. Those excluded from the survey included persons living on Indian
Reserves or Crown lands, residents of institutions, full-time members of the Canadian
Forces and residents of certain remote regions (Health Canada, 2010). For this study, the
sample of those with treatment needs included all of the age groups 6-79 years of age,
therefore covering children, adolescents, young adults and older adults.
3.3 Collection of data
The CHMS data collection was conducted by Statistics Canada between March 2007 and
February 2009. First, a personal interview using a computer-assisted interviewing method
21
was employed and second, a visit to a mobile examination centre was required for the
direct clinical measure of oral health.
“The country was divided into 257 potential collection sites each with a
population of >10,000 where each potential respondent had a maximum travel
distance to the clinic of 100 km or less. The region and urban/rural nature of each
site was identified and then 15 sites were systematically selected in proportion to
the size of their population. Within each site, dwellings with known household
composition (from the 2006 census) were divided into 6 strata to obtain sufficient
numbers of people in each of the targeted age groups and a random sample of
dwellings from each stratum was taken” (Health Canada, 2010).
3.3.1 Household interview
For the household interview, the interviewer randomly selected one or two respondents
and conduced a health interview lasting about 45 to 60 minutes. 34 specific oral health
questions were asked that gathered data related to oral health such as oral symptoms,
dental care habits and source of funds to pay for dental care. Additionally, relevant
sections of the interview gathered information on socio-demographic information (Health
Canada, 2010).
3.3.2 Clinical assessment
The mobile examination centers consisted of two sets of two trailers, in each set one
trailer was used as an administration area and the other was used as the clinic, connected
by an enclosed pedestrian walkway. Following registration, participants were taken to
stations in the clinic area where one of the stations measured oral health. Prior to the start
of the oral assessment, the examining dentist asked the participant 18 questions regarding
dental symptoms (pain, bleeding, dry mouth, etc) (Health Canada, 2010). Additionally,
15 medical history questions were asked to ensure that the participant was able to
22
undergo the clinical evaluation and those with acute or chronic conditions were not
examined (Health Canada, 2010). Overall, the oral health assessment was completed on
5,586 people (Health Canada, 2010).
During the inspection, the dentist used an explorer and mirror to assess the condition of
the teeth, gums and tongue of every eligible participant. The treatment needs of the
participant was also assessed (assuming there were no financial barriers) and ranked
according to urgency (Health Canada, 2010). Specific criteria were used in order to
appropriately classify each type of treatment need (see Table 1.0). As a thank you for
their involvement, recommendations for future care were provided to each participant.
Once the participant had left the room, the dentist completed the “urgent needs” section
of the component, which was indicative of the treatment being needed within one week.
Table 1. Criteria used to assess each treatment type
Description Examples
Preventive Examination; prophylaxis; fluoride; sealant; radiographs
Restorative Fillings; crowns; bridges for restoration of carious lesions
Periodontic Scaling; root planning; periodontal surgery
Endodontic Root canal therapy
Prosthodontic Removable/fixed, partial/full dentures; implant, bridge or crown
Orthodontic Under treatment, requiring orthodontic care as defined
Other Something of significance not otherwise able to be coded; TMD, esthetics and soft tissue (added for this study)
Urgent Treatment needed within a week
Note: Adapted from The Oral Health Needs Assessment took kit provided by Health Canada: http://www.fptdwg.ca/ohnat/index.php
23
3.4 Examiner calibration
The Department of National Defence supplied 12 dentist-examiners for the two-year
collection period who were calibrated to World Health Organization standards by a gold
standard trainer (Health Canada, 2010). Inspections of all clinic staff and on all
components of the examination were performed at regular intervals to provide a direct
assessment of protocol adherence, communication with participants, overall data
collection quality and operation of the clinic (Health Canada, 2010).
3.5 Data variables
The dependent variable in this study was the evaluated dental treatment need(s) of the
participant. In some of the analysis this outcome variable was dichotomized into ‘yes’ (if
the participant had at least one treatment need) and ‘no’ (if the participant had no
treatment needs). In other sections of the analysis, the outcome variable was displayed by
type of treatment (prevention, fillings, surgery, periodontics, endodontics, prosthodontics,
orthodontics, other and urgent needs).
All of the independent variables were dichotomized or categorized based on logical cut
off points in terms of the standards used in other studies. The independent variables
selected for this study were based on a modified version of Andersen’s emerging model.
This model arranges variables under five headings: Predisposing, enabling, need,
personal dental health practices and use of dental services. Each variable was classified
under one of the main headings as follows:
3.5.1 Predisposing characteristics
Variables included in this section were seen to predispose a person to having unmet
dental needs. These included demographic factors such as, sex (males/females) and age
24
(grouped into the following categories: 6 to 11, 12 to 19, 20 to 39, 40 to 59 and 60 to
79). The CHMS collected the sex and age variables twice, first for the household
questionnaire and second for the clinical exam. Since the most important variable of
interest in this study was clinically recorded, age and sex for the clinical module was
used. Variables related to social structure were also included such as, education (having
less than a degree/diploma or greater than a degree/diploma), immigrant status (born
outside of Canada/born in Canada), and Aboriginal status (yes/no). Smoking status also
fell under the predisposing heading (non-smoker, current smoker and past smoker).
3.5.2 Enabling variables
This category included variables that were considered prerequisites for obtaining dental
care, such as income and insurance. Income adequacy was based on the total household
income and the number of people living in the household. Table 2 shows the criteria used
by the CHMS to differentiate between each income category. For insurance, participants
who had an employer-sponsored plan or a private dental plan were grouped to form the
‘privately insured’ group. Those included under ‘publically insured’ were covered under
a provincial program (for children or seniors), or a government program for social service
(welfare) clients or First Nations and Inuit people. Those who had no public/private
coverage and paid for dental care out-of-pocket were ‘non-insured.’
25
Table 2. Income adequacy categories defined
Description Household Size Household Income
Lowest income grouping
1 or 2 people
3 or 4 people
>4 people
$0-$14,999
$0-$19,999
$0-$29,999
Middle income grouping
1 or 2 people
3 or 4 people
>4 people
$15,999-$59,999
$20,000-$79,999
$30,000-$79,999
Highest income grouping
1 or 2 people
>2 people
$60,000-$100,000+
$80,000-$100,000+
3.5.3 Need variables
Need factors related to how individuals viewed their own oral health. They included, self-
perceived oral health (excellent/good or fair/poor), general health (excellent/good or
fair/poor), persistent or ongoing oral pain (experienced rarely/never or often/sometimes)
and having a self-perceived need for treatment (yes/no).
3.5.4 Personal dental health practice variables
This category included brushing and flossing frequency. The CHMS derived a variable
that recorded the number of times per year that the participant brushed and flossed. Using
this variable, the number of times per day of brushing and flossing was calculated and
categorized as ‘more than once a day,’ ‘once a day,’ ‘less than once a day’ and ‘never.’
3.5.5 Use of dental service variables
The variables included under this heading related to the participant’s dental behaviour.
Participants were asked if they had avoided having all recommended dental treatment in
26
the past year due to cost (yes/no). Other questions in the household survey asked about
their last dental visit (being in the last year or more than one year ago), how often they
visit the dentist for check-ups or treatment (more than or equal to once a year, less than
once a year, only for emergency or never), and if they had ever taken time away from
work, school or other normal activities for dental check-ups or treatments or problems
with their mouth (yes/no).
*See Appendix A for the full coding of variables
3.6 Data Analysis
All of the relevant variables used in this study were imported into a computer program
called Statistical Package for the Social Sciences (SPSS) for Windows (release 18.0, IBM
Corporation, Armonk, NY) from the original CHMS Wave 1 master data file. Household
and mobile examination centre data were merged via a unique personal identifier
assigned to each participant. The variables were then recoded and grouped into the
aforementioned categories. The SPSS data file containing all of the variables of interest
was then imported into STATA for Windows (release 12.0, StataCorp LP 2012) for data
analysis. All cases where participants were not clinically examined (N=18) were
excluded from the analysis. As specified by Statistics Canada, all analysis that produced
small cell sizes (<10) could not be released.
3.6.1 Weighting of data
The CHMS was a sample survey, meaning that each participant represented many other
Canadians not included in the survey. In order for the results of the survey to be
representative of the population, the CHMS methodologists assigned a unique weight to
each participant that corresponded to the number of people represented by that participant
27
in the population as a whole. For example, in a simple random 2% sample of the
population, each person in the sample represents 50 persons in the population; therefore
each person has a weight of 50. These survey weights were applied during the data
analysis for this study so that estimates for the entire population could be created. To
account for the complex sampling design, in addition to survey weights, bootstrap
weights were also applied prior to any statistical analysis to obtain reliable estimates and
variances representative of Canada. A total of 500 bootstrap weights were applied since
the sample was allocated over 10 age- sex groups, and it was estimated that 500 units per
group was required to produce national estimates, for a total of 5,000 reporting units.
3.6.2 Statistical tests
Descriptive frequencies were obtained to examine the sample characteristics and to
examine the treatment type (prevention, restorations, surgery, periodontics, endodontics,
prosthodontics, orthodontics, other and urgent) needed by the population.
Logistic regressions were used to see if any characteristics (predisposing, enabling, need
etc.), were predictive of having an unmet dental treatment need, and of having a specific
treatment type (prevention, restorations, surgery, etc.). These were bivariate regressions
and therefore did not adjust for the other factors in each model. The unadjusted odds
ratio, 95% confidence interval and p-value were recorded.
Multivariate logistic regressions were employed to determine which factors
(predisposing, enabling, need, etc.), were the strongest predictors of having at least one
clinical need. Using the modified version of Andersen’s emerging model, five models
were used to compute odds ratios for having an unmet need. These models progressively
adjusted for predisposing, enabling, need, personal dental health practice and use of
28
dental service factors as done by Al Snih et al., (2006). Prior to being put into the
model, each independent variable was regressed on all of the other independent variables
to check for any possible correlation amongst and between the predictor variables. The
variance inflation factor (VIF), which quantifies the severity of multicollinearity, was
found to be low (<3) for each variable and all of variables were found to be significant
(p<0.25) at the bivariate level. Therefore, every variable outlined in the modified
Andersen model was entered simultaneously as blocks into multivariate logistic
regressions to assess the dominant predictors for having a dental treatment need. Model 1
included only the predisposing factors (sex, age, education, smoking status, immigrant
status and Aboriginal status). Model 2 added the enabling factors (income adequacy and
dental insurance coverage) with all of the previously entered predisposing factors. Model
3 added in the perceived need variables (self-reported oral health, general health and oral
pain and self-perceived unmet needs). Model 4 added the personal dental health practices
(brushing and flossing frequency). Finally, Model 5 added in the use of dental service
variables (avoided dental treatment due to cost, last dental visit, frequency of dental
visits, and work/school days lost). The adjusted odds ratio, 95% confidence interval and
p-value were recorded for the variables in each model.
Prior to the clinical examination by the dental-examiner, each respondent was asked if
they thought they had any untreated dental conditions and if so, which condition(s) they
thought they had. Along with the dental-examiner’s evaluation of treatment need (gold
standard), the self-reported information obtained was summarized in a conventional two-
by-two (2x2) table (see Table 3). Sensitivity, specificity, positive predictive value and
negative predictive value were calculated to compare self-reported needs and clinically
determined needs. Table 3 was completed for each treatment type that the CHMS
29
collected both self-reported and clinically determined information on.
Temporomandibular joint disorder (TMD), esthetic and soft tissue treatment were all
added into the ‘other’ category. This table was also constructed for having a perceived
unmet need (yes/no) and having a clinical need (yes/no), in general.
Table 3. Example of 2x2 table constructed to calculated sensitivity, specificity, positive and negative predictive value
Clinically determined need (gold standard)
Yes No
Yes A (True positive)
B (False positive) Self-reported
need No C (False negative)
D (True negative)
In cell ‘A’ those who correctly diagnosed their treatment need (as determined by the gold
standard) were entered. Their assessments were positive for having self-reported need
and accurate for the treatment need, making them ‘true positives’.
In cell ‘B’ those who said they had the treatment need but were inaccurate according to
the gold standard were entered. These individuals wrongly diagnosed the type of
treatment they needed, making them ‘false positives’.
In cell ‘C’ those who were clinically diagnosed as having the treatment need but did not
correctly predict it, were entered. These individuals were incorrect in labeling themselves
healthy (not requiring the treatment), making them ‘false negatives’.
Lastly, in cell ‘D’ those who were clinically diagnosed as healthy (not having the
treatment need) and correctly perceived no need for that treatment were entered. On both
30
accounts, these people were accurate in saying they were healthy and were also
clinically found to be healthy, making them ‘true negatives’.
Sensitivity
Sensitivity is defined as the proportion of people with the disease who have a positive test
for the disease (Fletcher and Fletcher, 2005). In other words, it is the proportion of people
who correctly diagnosed their dental treatment need. A sensitive test will rarely miss
people with the disease (Fletcher and Fletcher, 2005). Sensitivity was calculated with the
following equation:
!
Sensitivity =Number of true positives A( )
Number of true positives A( ) + Number of false negatives C( )
Specificity
Specificity is defined as the proportion of people without the disease who have a negative
test (Fletcher and Fletcher, 2005). In other words, it is the proportion of people who
correctly diagnosed that they did not need the dental treatment. A specific test will rarely
misclassify people as having the disease when they do not (Fletcher and Fletcher, 2005).
Specificity was calculated with the following equation:
!
Specificity =Number of true negatives D( )
Number of true negatives D( ) + Number of false positives B( )
Positive predictive value (PPV)
Positive predictive value is the probability of disease in a patient with a positive test
result (Fletcher and Fletcher, 2005). This tells us how accurate self-reported treatment
needs are, as a diagnostic tool, in determining actual treatment needs. PPV was calculated
31
as followed:
!
Positive predictive value =Number of true positives A( )
Number of true positives A( ) + Number of false positives B( )
Negative predictive value (NPV)
Negative predictive value is the probability of not having the disease when the test result
is negative (Fletcher and Fletcher, 2005). In other words, this tells us how accurate self-
reported information is, as a diagnostic tool, in determining those who do not need dental
treatment. NPV was calculated as followed:
!
Negative predictive value =Number of true negatives D( )
Number of true negatives D( ) + Number of false negatives C( )
32
Chapter IV: Results
4.1 Sample characteristics
The final sample included 5,586 participants, representing 29,157,460 Canadians when
weighted. With a current population of 33,476,688 (Statistics Canada, 2012 Census of
Population) this statistically represents approximately 87% of the Canadian population.
4.1.1 Predisposing factors
Table 4 shows the predisposing characteristics of the sample population. There were an
even number of males (49.9%) and females (50.1%), the majority of the sample were 20
to 39 (30.9%) and 40 to 59 (33.5%) years of age, and slightly over half the sample had
never smoked (52.6%). Looking at education, roughly an equal proportion of the
population had a degree or diploma (49.6%). As for immigrant status, the majority of the
population was born in Canada (79.0%) and non-Aboriginal (96.9%).
4.1.2 Enabling factors
Table 5 presents the demographics for the enabling factors of income and insurance. It
was found that most of the population was of highest income (47.9%) and had private
insurance coverage (62.3%). A significant minority of the population was of the lowest
income (20.3%) and non-insured (31.9%).
33
Table 4. Sample characteristics by predisposing factors
Table 5. Sample characteristics by enabling factors
N= 29,157,460 % Sex
Male Female
49.9 50.1
Age 6 to 11 12 to 19 20 to 39 40 to 59 60 to 79
7.4 11.4 30.9 33.5 16.8
Smoking Status Never smoked Past smoker Current smoker
52.6 27.1 20.3
Education Degree/diploma <Degree/diploma
49.6 50.5
Immigrant Status Born in Canada Not born in Canada
79.0 21.0
Aboriginal Status Non-Aboriginal Aboriginal
96.9 3.10
N= 29,157,460 % Income adequacy
Highest income Middle income Lowest income
47.9 31.9 20.3
Dental insurance Private coverage Public coverage Non-insured
62.3 5.8 31.9
34
4.1.3 Need factors
Table 6 displays the population’s need factors. The majority of the population reported
their oral health and general health as excellent or good (respectively, 84.5% and 91.9%).
The majority also reported rarely or never experiencing oral pain (88.4%) and most of the
population did not perceive a need for dental treatment (67.0%).
Table 6. Sample characteristics by need factors
4.1.4 Personal dental health practice factors
Table 7 shows the population’s brushing and flossing frequencies. The majority of the
population said that brush their teeth and/or dentures more than once a day (72.0%) and
most said that they floss less than once a day (42.0%) or never (28.1%).
N= 29,157,460 % Self-reported oral health
Excellent/good Fair/poor
84.5 15.5
Self-reported general health Excellent/good Fair/poor
91.9 8.1
Self-reported oral pain Rarely/never Often/sometimes
88.4 11.6
Self-perceived unmet needs No needs Has at least one need
67.0 33.0
35
Table 7. Sample characteristics by personal dental health practice factors
4.1.5 Use of dental service factors
Table 8 displays the use of service factors. The majority of the population said that they
have not avoided recommended dental treatment in the past year due to cost (83.5%), and
have visited the dentist in the last year (74.5%). Most of the population said they usually
visit the dentist more than once a year (42.6%) or once a year (31.7%). Lastly, 60.9% of
the population said that they have not lost time away from their work, school or normal
daily activities to visit the dentist or undergo treatment.
Table 8. Sample characteristics by use of dental service factors
N= 29,157,460 % Avoided dental treatment due to cost
No Yes
83.5 16.5
Last Dental Visit In the last year More than one year ago
74.5 25.5
Dental Visit Frequency > Once a year Once a year
<Once a year Only for emergency Never
42.6 31.7 9.2 13.3 3.2
Work/School Days Lost No Yes
60.9 39.2
N= 29,157,460 % Brushing frequency
>Once/day Once/day <Once/day or Never
72.0 24.6 3.4
Flossing Frequency >Once/day Once/day <Once/day Never
8.6 21.4 42.0 28.1
36
4.2 Clinically determined treatment needs
Figure 4 displays information on the clinically determined dental treatment needs of the
population. Most of the population was classified as having no treatment needs (65.8%).
Of the 34.2% who did require treatment, 19.4% were found to have one dental treatment
need and 14.6% (which is close to 5 million people) required more than one need.
Figure 4. Distribution of clinically determined treatment needs
4.2.1 Type of dental treatments
Figure 5 shows the percent of each type of dental treatment that was required by the
population. Most of the population needed restorative (20.4%) and preventive (13.7%)
care. Approximately 6.0% of the population, which is represents nearly 2 million people,
had an urgent need (i.e. treatment was required within one week).
37
Series1; Prevention ; 13.7
Series1; Restorative; 20.4
Series1; Surgery ; 7.4
Series1; Periodontics; 5.1
Series1; Endodontic; 2.0 Series1; Prosthodontics ;
2.0 Series1; Orthodontics ; 2.1 Series1; Other ; 1.2
Series1; Urgent Need; 5.9
Prop
ortio
n of
pop
ulat
ion
(%)
Dental treatment need
Figure 5. Percent of type of dental treatment required in the Canadian population
38
4.3 The odds of needing at least one dental treatment
Logistic regression analyses were undertaken to evaluate the odds of having at least one
dental treatment need.
4.3.1 Predisposing factors
Table 9 shows the percent and likelihood of an individual having an unmet need by
predisposing factors. Immigrant status was not predictive of treatment need (OR=1.2,
95% CI=0.9-1.7, P=0.174). It was found that females were less likely than males to have
a need (OR=0.7, 95% CI=0.6-0.9, P=0.002). Those who were aged 20 to 39 (OR=1.5,
95% CI=1.2-1.8, P=0.002) and 40 to 59 (OR=1.5, 95% CI=1.3-1.8, P=0.001) were more
likely than those aged 6 to 11 to have an unmet need. Current smokers were 2.1 times
more likely than non-smokers to need dental treatment (95% CI=1.6-2.6, P=0.001).
Lastly, those of lower education (OR=1.4, 95% CI=1.1-1.9, P=0.016) and Aboriginal
participants (OR=1.8, 95% CI=1.0, 3.3, P=0.044) were more likely to have unmet dental
needs when compared to their counterparts. Figure 6 displays these results graphically.
4.3.2 Enabling factors
Table 10 displays the percent and likelihood of an individual having an unmet need by
enabling factors. Those of middle (OR=1.6, 95% CI=1.3-1.9, P=0.001) and lowest
(OR=2.1, 95% CI=1.6-2.9, P=0.001) incomes were more likely than those of the highest
incomes to have a dental need. Looking at dental insurance, those with public coverage
(OR=2.4, 95% CI=1.6-3.6, P=0.001) and no insurance (OR=1.9, 95% CI=1.5-2.3,
P=0.001) were more likely to have a dental need than those with private coverage. Figure
7 displays these results graphically.
39
Table 9. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by predisposing factors
Table 10. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by enabling factors
% Unadjusted OR (95% CI) P-value
Predisposing Factors Sex
Male (Reference) Female
36.3 29.3
0.7 (0.6, 0.9)
0.002 Age
6 to 11 (Reference) 12 to 19 20 to 39 40 to 59 60 to 79
26.3 28.6 34.5 35.1 30.7
1.1 (0.8, 1.5) 1.5 (1.2, 1.8) 1.5 (1.3, 1.8) 1.3 (1.0, 1.5)
0.398 0.002 0.001 0.030
Smoking Status Never smoked (Reference) Past smoker Current smoker
29.4 31.2 46.3
1.1 (0.8, 1.5) 2.1 (1.6, 2.6)
0.590 0.001
Education Degree/Diploma (Reference) <Degree/Diploma
28.9 36.5
1.4 (1.1, 1.9)
0.016 Immigrant Status
Born in Canada (Reference) Not born in Canada
31.8 36.6
1.2 (0.9, 1.7)
0.174 Aboriginal Status
Non-Aboriginal (Reference) Aboriginal
32.4 46.6
1.8 (1.0. 3.3)
0.044
% Unadjusted OR (95% CI) P-value
Enabling Factors Income adequacy
Highest income (Reference) Middle income Lowest income
26.1 35.7 43.0
1.6 (1.3, 1.9) 2.1 (1.6, 2.9)
0.001 0.001
Dental insurance Private coverage (Reference) Public coverage Non-insured
27.2 47.6 41.2
2.4 (1.6, 3.6) 1.9 (1.5, 2.3)
0.001 0.001
40
Figure 6. Unadjusted odds ratio of individuals who have clinically determined treatment needs by predisposing factors
0.7
1.5 1.5
1.3
2.1
1.4
1.8
0.5
1.5
2.5
3.5
Female 20 to 39 40 to 59 60 to 79 Current Smoker
<Degree/Dipoma
Aboriginal
Sex Ref: Male
Age Ref: 6 to 11
Smoking Status Ref: Non-smoker
Education Ref: Degree/Diploma
Aboriginal Status Ref: Non-Aboriginal
41
1.6
2.1
2.4
1.9
1.0
2.0
3.0
4.0
Middle Income Lowest Income Public Coverage Non-Insured
Income Adequacy Ref: Highest Income
Dental Insurance Ref: Private Coverage
Figure 7. Unadjusted odds ratio of individuals who have clinically determined treatment needs by enabling factors
42
4.3.3 Need factors
Table 11 shows the percent and unadjusted odds ratio of individuals who required dental
treatment by need factors. Noted to be the highest odds ratio over all of the factors
reviewed, those reporting a self-reported oral health of fair or poor were 5.9 times more
likely to have an unmet dental need than those reporting excellent or good oral health
(95% CI=4.3-8.0, P=0.001). Those who perceived a need for treatment were 4.6 times to
have a clinical need than those who did not (95% CI=3.7-5.8, P=0.001). These results are
shown in Figure 8 graphically.
4.3.4 Personal dental health practice factors
Looking at personal dental health practices, Table 12 shows the percent and odds of an
individual having an unmet dental need. Those who brush their teeth and/or dentures less
than once a day or never were 2.5 times more likely than those who brush more than once
a day to have a dental need (95% CI=1.7-3.6, P=0.001). Those who never floss were also
at greater odds of having a need compared to those who floss more than once a day
(OR=2.8, 95% CI=1.7-4.4, P=0.001). Figure 9 displays these results graphically.
4.3.5 Use of dental service factors
Table 13 shows the percent and likelihood of an individual having a clinical dental need
by use of service factors. It was found that those who had avoided dental treatment in the
past due to cost (OR=2.7, 95% CI=2.2-3.3, P=0.001), reported seeing the dentist more
than one year ago (OR=3.0, 95% CI=2.3-3.9, P=0.001), and usually visit the dentist less
than once a year or only for emergency or never (OR=3.0, 95% CI=2.4-3.8, P=0.001),
were all more likely to have an unmet dental care need. In contrast, those who had lost
time from work or school or their normal daily activities for dental visits or treatment
43
were less likely to need dental treatment (OR=0.7, 95% CI=0.5-0.8, P=0.001). Figure
10 displays these results graphically.
Table 11. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by need factors
Table 12. Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by personal dental health practices
% Unadjusted OR (95% CI) P-value
Need Factors Self-reported oral health
Excellent/good (Reference) Fair/poor
26.4 67.8
5.9 (4.3, 8.0)
0.001 Self-reported general health
Excellent/good (Reference) Fair/poor
31.4 45.0
1.8 (1.3, 2.6)
0.005
Self-reported oral pain Rarely/Never (Reference) Often/Sometimes
31.4 43.7
1.7 (1.3, 2.2)
0.001
Self-perceived unmet needs No Needs (Reference) Has at least one need
21.5 55.8
4.6 (3.7, 5.8)
0.001
% Unadjusted OR (95% CI) P-value
Personal Dental Health Practices Brushing frequency
>Once/day (Reference) Once/day <Once/day or Never
28.9 42.0 50.0
1.8 (1.5, 2.1) 2.5 (1.7, 3.6)
0.001 0.001
Flossing Frequency >Once/day (Reference) Once/day <Once/day Never
22.4 29.1 29.2 44.2
1.4 (0.9, 2.2) 1.4 (0.9, 2.4) 2.8 (1.7, 4.4)
0.102 0.153 0.001
44
Table 13 Percent and unadjusted odds ratio of individuals who have clinically determined treatment needs by use of services
% Unadjusted OR (95% CI) P-value
Use of Services Avoided dental treatment due to cost
No (Reference) Yes
29.0 52.5
2.7 (2.2, 3.3)
0.001 Last Dental Visit
In the last year (Reference) More than one year ago
26.0 51.3
3.0 (2.3, 3.9)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
26.3 51.8
3.0 (2.4, 3.8)
0.001 Work/School Days Lost
No (Reference) Yes
36.5 27.1
0.7 (0.5, 0.8)
0.001
45
5.9
1.8 1.7
4.6
1.0
3.0
5.0
7.0
9.0
Fair/Poor Fair/Poor Often/Sometimes At least one need
Self-reported oral health Ref: Excellent/good
Self-reported general health
Ref: Excellent/good Self-reported oral pain
Ref:Rarely/Never
Self-perceived unmet needs
Ref: No Needs
Figure 8. Unadjusted odds ratio of individuals who have clinically determined treatment needs by need factors
46
Figure 9. Unadjusted odds ratio of individuals who have clinically determined treatment needs by personal dental health practice factors
1.8
2.5
2.8
1.0
2.0
3.0
4.0
Once/day <Once/day or Never Never
Brushing Frequency Ref: >Once/day
Flossing Frequency Ref: >Once/day
47
Figure 10. Unadjusted odds ratio of individuals who have clinically determined treatment needs by use of service factors
2.7
3.0 3.0
0.7
0
1
2
3
4
Yes > one year ago < Once a year/Emerge/Never
Yes
Avoided dental treatment
Ref: No
Last Dental Visit Ref: In the last year
Dental Visit Frequency Ref: >/= Once a year
Work/School Days Lost
Ref: No
48
4.4 The odds of needing a specific treatment type
4.4.1 Preventive needs
Table 14 displays the percent and unadjusted odds ratio of individuals who were clinically
assessed to have preventive needs. All of the observed characteristics were independently
predictive of this need except for some predisposing factors. Data is not shown for the
insignificant variables of education, immigrant and Aboriginal status. It was found that current
smokers were almost two times more likely than non-smokers to need preventive treatment
(OR=1.9, 95% CI=1.4-2.5, P=0.001). Those of lowest income (OR=2.6, 95% CI=1.7-3.8,
P=0.001) and public insurance (OR=2.7, 95% CI=1.6-4.4, P=0.001) were more likely than
their counterparts to need this type of care. Being the highest odds ratio, those who reported
their oral health as poor or fair were 3.9 times more likely to need prevention than those who
reported excellent or good oral health (95% CI=2.7-5.6, P=0.001). Also, those who brushed
less than one a day or never (OR=3.7, 95% CI=2.3-5.7, P=0.001) and visited the dentist more
than one year ago (OR=3.7, 95% CI=2.6-5.3, P=0.001) were more likely than their
counterparts to need preventive care.
49
Table 14. Percent and unadjusted odds ratio of individuals who have preventive needs % Unadjusted OR
(95% CI) P-value
Sex Male (Reference) Female
17.3 10.3
0.6 (0.4, 0.7)
0.001 Age
6 to 11 (Reference) 12 to 19 20 to 39 40 to 59 60 to 79
8.7 12.2 15.3 14.8 12.1
1.5 (0.9, 2.5) 1.9 (1.4, 2.5) 1.8 (1.3, 2.6) 1.4 (1.1, 2.0)
0.145 0.001 0.004 0.027
Smoking Status Never smoked (Reference) Past smoker Current smoker
11.9 13.9 20.3
1.2 (0.8, 1.8) 1.9 (1.4, 2.5)
0.307 0.001
Income adequacy Highest income (Reference) Middle income
Lowest income
9.6 15.3 21.3
1.7 (1.1, 2.6) 2.6 (1.7, 3.8)
0.020 0.001
Dental insurance Private coverage (Reference) Public coverage
Non-insured
10.0 22.8 19.5
2.7 (1.6, 4.4) 2.2 (1.7, 2.8)
0.001 0.001
Self-reported oral health Excellent/good (Reference)
Fair/Poor
10.5 31.4
3.9 (2.7, 5.6)
0.001 Self-reported general health
Excellent/good (Reference) Fair/Poor
13.0 19.3
1.6 (1.0, 2.5)
0.042 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
12.9 20.1
1.7 (1.1, 2.7)
0.024 Self-perceived unmet needs
No Needs (Reference) Has at least one need
9.7 22.0
2.6 (1.8, 3.8)
0.001 Brushing frequency
>Once/day (Reference) Once/day <Once/day or Never
10.9 19.6 30.9
2.0 (1.5, 2.7) 3.7 (2.3, 5.7)
0.001 0.001
Flossing Frequency >Once/day (Reference) Once/day <Once/day Never
7.9 11.5 12.4 19.3
1.5 (0.7, 3.1) 1.6 (0.8, 3.4) 2.8 (1.3, 6.0)
0.232 0.154 0.013
50
Table 14. (Continued)
4.4.2 Restorative needs
Table 15 displays the percentage and likelihood of an individual to have a restorative need.
Again, most of the characteristics were significant predictors of restorative need with the
exception of sex, education and immigrant status (results not shown). The analysis showed
that those reporting their oral health as fair or poor and those that perceived a need for dental
treatment were 4.6 (95% CI=3.7-5.7, P=0.001) and 4.5 (95% CI=3.4-6.1, P=0.001) times more
likely than their counterparts respectively, to require restorative treatment. Also, those who
saw a dental professional more than one year ago (OR=3.0, 95% CI=2.3-3.8, P=0.001) and
tend to visit the dentist less than once a year or only for emergency or never (OR=3.0, 95%
CI=2.3-3.8, P=0.001) were both more likely than their counterparts to need restorative care.
% Unadjusted OR (95% CI) P-value
Avoided dental treatment due to cost
No (Reference) Yes
12.3 21.1
1.9 (1.3, 2.8)
0.003 Last Dental Visit
In the last year (Reference) More than one year ago
8.8 26.2
3.7 (2.6, 5.3)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
9.5 26.0
3.3 (2.5, 4.4)
0.001 Work/School Days Lost
No (Reference) Yes
16.2 9.9
0.6 (0.5, 0.7)
0.001
51
Table 15. Percent and unadjusted odds ratio of individuals who have restorative needs % Unadjusted OR
(95% CI) P-value
Age 6 to 11 (Reference) 12 to 19 20 to 39 40 to 59 60 to 79
14.1 14.8 22.6 23.2 17.5
1.1 (0.6, 1.8) 1.8 (1.3, 2.5) 1.8 (1.4, 2.5) 1.3 (1.0, 1.6)
0.827 0.003 0.001 0.028
Smoking Status Never smoked (Reference) Past smoker Current smoker
18.1 20.4 28.7
1.2 (0.8, 1.7) 1.8 (1.2, 2.7)
0.406 0.007
Aboriginal Status Non-Aboriginal (Reference)
Aboriginal
20.0 31.6
1.8 (1.1, 3.0)
0.020 Income adequacy
Highest income (Reference) Middle income
Lowest income
15.8 22.2 28.3
1.5 (1.2, 1.9) 2.1 (1.6, 2.8)
0.001 0.001
Dental insurance Private coverage (Reference) Public coverage
Non-insured
16.9 31.4 25.2
2.3 (1.3, 3.8) 1.7 (1.3, 2.1)
0.006 0.001
Self-reported oral health Excellent/good (Reference)
Fair/Poor
15.7 46.0
4.6 (3.7, 5.7)
0.001 Self-reported general health
Excellent/good (Reference) Fair/Poor
19.6 28.2
1.6 (1.1, 2.5)
0.032 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
18.9 31.5
2.0 (1.5, 2.7)
0.001 Self-perceived unmet needs
No Needs (Reference) Has at least one need
11.8 37.8
4.5 (3.4, 6.1)
0.001 Brushing frequency
>Once/day (Reference) Once/day <Once/day or Never
17.5 26.8 36.1
1.7 (1.4, 2.1) 2.7 (1.4, 4.9)
0.001 0.005
Flossing Frequency >Once/day (Reference) Once/day <Once/day Never
14.0 18.8 17.6 27.9
1.4 (0.8, 2.4) 1.3 (0.8, 2.1) 2.4 (1.6, 3.6)
0.165 0.245 0.001
52
Table 15. (Continued)
4.4.3 Surgical needs
Table 16 displays the percent and unadjusted odds ratio for individuals who were clinically
assessed to have surgical needs. Education, immigrant status, self-perceived general health,
flossing frequency and time loss for dental treatment were all found to be insignificant
predictors of this need (data not shown). Notably, those aged 20 to 39 were close to 7 times
more likely than those aged 6 to 11 to need surgical treatment (OR=6.9, 95% CI=2.8-16.6,
P=0.001). Those who reported their oral health as poor to fair were more likely to need this
treatment (OR=6.0, 95% CI=4.1-9.0, P=0.001). With the highest unadjusted odds ratio, those
who perceived a need for treatment were 9.2 times more likely to require surgical treatment
than those who said they did not require any treatment (95% CI=5.2-16.3, P=0.001).
% Unadjusted OR (95% CI) P-value
Avoided dental treatment due to cost No (Reference)
Yes
17.1 36.8
2.8 (2.1, 3.7)
0.001 Last Dental Visit
In the last year (Reference) More than one year ago
15.1 34.7
3.0 (2.3, 3.8)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
15.3 34.9
3.0 (2.3, 3.8)
0.001 Work/School Days Lost
No (Reference) Yes
23.2 15.8
0.6 (0.5, 0.7)
0.001
53
Table 16. Percent and unadjusted odds ratio of individuals who have surgical needs % Unadjusted OR
(95% CI) P-value
Sex Male (Reference) Female
9.5 5.4
0.5 (0.4, 0.8)
0.002 Age
6 to 11 (Reference) 12 to 19 20 to 39 40 to 59 60 to 79
2.0 3.9
12.2 5.9 6.6
2.0 (0.7, 5.6) 6.9 (2.8, 16.6) 3.1 (1.1, 9.2) 3.5 (1.5, 8.1)
0.153 0.001 0.040 0.008
Smoking Status Never smoked (Reference) Past smoker Current smoker
6.6 5.7
14.1
0.9 (0.5, 1.6) 2.3 (1.6, 3.4)
0.617 0.001
Aboriginal Status Non-Aboriginal (Reference)
Aboriginal
7.2
13.3
2.0 (1.1, 3.5)
0.027 Income adequacy
Highest income (Reference) Middle income
Lowest income
4.9 9.1
10.9
1.9 (1.1, 3.4) 2.4 (1.4, 4.2)
0.024 0.006
Dental insurance Private coverage (Reference) Public coverage
Non-insured
5.2
12.0 11.0
2.5 (1.6, 4.0) 2.3 (1.4, 3.7)
0.001 0.004
Self-reported oral health Excellent/good (Reference)
Fair/Poor
4.6
22.7
6.0 (4.1, 9.0)
0.001 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
6.9
11.9
1.8 (1.4, 2.4)
0.001 Self-perceived unmet needs
No Needs (Reference) Has at least one need
2.3
17.9
9.2 (5.2, 16.3)
0.001 Brushing frequency
>Once/day (Reference) Once/day <Once/day or Never
5.9
10.6 16.6
1.9 (1.4, 2.6) 3.2 (1.0, 10.5)
0.001 0.059
Avoided dental treatment due to cost No (Reference)
Yes
5.8
15.9
3.1 (1.9, 4.9)
0.001 Last Dental Visit
In the last year (Reference) More than one year ago
4.9
13.4
3.0 (1.8, 5.1)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
5.0
14.5
3.2 (2.2, 4.7)
0.001
54
4.4.4 Periodontic needs
Table 17 shows the percent and likelihood of an individual needing periodontal treatment.
Sex, age, education, Aboriginal status, self-reported oral health and pain, as well as
brushing and flossing, were not significant predictors of periodontal need (data not
shown). Immigrants to Canada were 4.2 times more likely than those born in Canada to
require this need (95% CI=2.2-8.1, P=0.001). Also, those non-insured (OR=3.6, 95%
CI=2.3-5.7, P=0.001) and those who reported their oral health as poor or fair (OR=4.1,
95% CI=2.6-6.4, P=0.001) were more likely than their counterparts to have periodontal
needs.
4.4.5 Endodontic needs
Table 18 displays the percentage of individuals who have an endodontic need along with
the significant predictors of having this need. Several characteristics were found to be
insignificant therefore the data for these variables (sex, age, education, immigrant and
Aboriginal status, self-reported general health, brushing and flossing frequency and
work/school days lost due to dental treatment) are not shown. Those who perceived a
need for dental treatment were 13.2 times more likely than those who did not to have an
endodontic need, being the highest odds ratio (95% CI=3.5-49.4, P=0.001). Also, those
who reported fair or poor oral health (OR=9.4, 95% CI=3.9, 22.5, P=0.001) and those
who had experienced oral pain often or sometimes were more likely to require endodontic
care.
55
Table 17. Percent and unadjusted odds ratio of individuals who have periodontal needs % Unadjusted OR
(95% CI) P-value
Smoking Status Never smoked (Reference) Past smoker Current smoker
4.5 5.0 8.6
1.1 (0.7, 1.7) 2.0 (1.2, 3.3)
0.624 0.012
Immigrant Status Born in Canada (Reference)
Not born in Canada
3.2 12.2
4.2 (2.2, 8.1)
0.001 Income adequacy
Highest income (Reference) Middle income
Lowest income
3.5 5.1 7.7
1.5 (1.0, 2.1) 2.3 (1.2, 4.5)
0.038 0.019
Dental insurance Private coverage (Reference) Public coverage
Non-insured
2.7 7.3 9.2
2.8 (1.1, 7.2) 3.6 (2.3, 5.7)
0.037 0.001
Self-reported oral health Excellent/good (Reference)
Fair/Poor
3.6 13.1
4.1 (2.6, 6.4)
0.001 Self-perceived unmet needs
No Needs (Reference) Has at least one need
3.7 7.8
2.2 (1.6, 3.1)
0.001 Avoided dental treatment due to cost
No (Reference) Yes
4.5 8.0
1.8 (1.2, 2.9)
0.013 Last Dental Visit
In the last year (Reference) More than one year ago
3.5 9.1
2.7 (1.8, 4.2)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
3.4 9.9
3.2 (2.1, 4.7)
0.001 Work/School Days Lost
No (Reference) Yes
5.9 3.8
0.6 (0.4, 1.0)
0.035
56
Table 18. Percent and unadjusted odds ratio of individuals who have endodontic needs
4.4.6 Prosthodontic needs
Table 19 shows the percent and unadjusted odds ratios of individuals who have
prosthodontic needs. Sex, immigrant and Aboriginal status were not significant predictors
of prosthodontic need (data not shown). Age was found to be a significant predictor for
prosthodontic care however, due to small cell sizes (N<10); this information could not be
released. Those who were publicly covered (OR=3.5, 95% CI=1.5-8.2, P=0.009) and
visited the dentist more than one year ago (OR=3.6, 95% CI=2.6-5.0, P=0.001) were at
the highest odds of needing prosthodontic treatment.
% Unadjusted OR (95% CI) P-value
Smoking Status Never smoked (Reference) Past smoker Current smoker
1.3 2.1 4.2
1.6 (0.8, 3.6) 3.4 (1.3, 9.0)
0.194 0.019
Dental insurance Private coverage (Reference) Public coverage
Non-insured
1.1 2.4 3.5
2.2 (0.5, 10.3) 3.2 (1.9, 5.4)
0.293 0.001
Self-reported oral health Excellent/good (Reference)
Fair/Poor
0.9 7.7
9.4 (3.9, 22.5)
0.001 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
1.1 8.1
7.7 (3.58, 16.4)
0.001 Self-perceived unmet needs
No Needs (Reference) Has at least one need
0.4 5.1
13.2 (3.5, 49.4)
0.001 Avoided dental treatment due to cost
No (Reference) Yes
1.2 6.0
5.5 (2.9, 10.4)
0.001 Last Dental Visit
In the last year (Reference) More than one year ago
1.3 3.7
2.9 (1.7, 4.8)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
1.2 4.1
3.5 (2.0, 6.2)
0.001
57
Table 19. Percent and unadjusted odds ratio of individuals who have prosthodontic needs
% Unadjusted OR (95% CI) P-value
Smoking Status Never smoked (Reference) Past smoker Current smoker
6.6
13.4 16.7
2.2 (1.6, 3.0) 2.8 (1.9, 4.3)
0.001 0.001
Income adequacy Highest income (Reference) Middle income
Lowest income
5.8
12.6 14.4
2.4 (1.6, 3.6) 2.7 (1.6, 4.7)
0.001 0.002
Dental insurance Private coverage (Reference) Public coverage
Non-insured
5.6
17.1 16.5
3.5 (1.5, 8.2) 3.3 (1.9, 5.9)
0.009 0.001
Self-reported oral health Excellent/good (Reference)
Fair/Poor
8.0
19.3
2.8 (1.9, 4.0)
0.001 Self-reported general health
Excellent/good (Reference) Fair/Poor
8.3
21.5
3.1 (2.4, 3.9)
0.001 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
9.3
13.3
1.5 (1.0, 2.2)
0.043 Self-perceived unmet needs
No Needs (Reference) Has at least one need
6.0
17.5
3.3 (2.4, 4.6)
0.001 Brushing frequency
>Once/day (Reference) Once/day <Once/day or Never
7.8
13.8 21.4
1.9 (1.5, 2.3) 3.2 (1.5, 7.0)
0.001 0.007
Flossing Frequency >Once/day (Reference) Once/day <Once/day Never
22.7 8.2 5.3
13.7
0.3 (0.2, 0.5) 0.2 (0.1, 0.4) 0.5 (0.3, 1.1)
0.001 0.001 0.078
Avoided dental treatment due to cost No (Reference)
Yes
8.6
15.7
2.0 (1.4, 2.8)
0.001 Last Dental Visit
In the last year (Reference) More than one year ago
5.8
17.9
3.6 (2.6, 5.0)
0.001 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
5.4
22.2
5.0 (3.6, 6.9)
0.001 Work/School Days Lost
No (Reference) Yes
12.2 5.9
0.5 (0.3, 0.6)
0.001
58
4.4.7 Orthodontic needs
Looking at Table 20, only a few characteristics were predictive of having orthodontic need.
Those who were immigrants to Canada were less likely than those born in Canada to need this
type of care (OR=0.3, 95% CI=0.1-0.8, P=0.025). In contrast, those who perceived a need for
treatment (OR=1.9, 95% CI=1.1-3.2, P=0.027) and those who brush their teeth and/or dentures
less than once a day or never (OR=2.4, 95% CI=1.6-3.7, P=0.001) were more likely to require
orthodontic care.
Table 20. Percent and unadjusted odds ratio of individuals who have orthodontic needs
4.4.8 Urgent needs
Table 21 displays the only significant predictor for urgent needs. Those who reported often or
sometimes experiencing oral pain were 2.4 times more likely than those who reported rarely or
never having oral pain to require urgent treatment (95% CI=1.1-5.2, P=0.030).
Table 21. Percent and unadjusted odds ratio of individuals who have urgent needs
% Unadjusted OR (95% CI) P-value
Self-reported oral pain Rarely/Never (Reference)
Often/Sometimes
4.9 10.9
2.4 (1.1, 5.2)
0.030
% Unadjusted OR (95% CI) P-value
Immigrant Status Born in Canada (Reference)
Not born in Canada
0.6 3.6
0.3 (0.1, 0.8)
0.025 Self-perceived unmet needs
No Needs (Reference) Has at least one need
1.6 3.0
1.9 (1.1, 3.2)
0.027 Brushing frequency
>Once/day (Reference) Once/day <Once/day or Never
1.8 2.5 4.3
1.4 (0.7, 2.9) 2.4 (1.6, 3.7)
0.369 0.001
59
Overall, the need and use of service factors were significant predictors for most of the dental
treatment types. Those who reported their oral health as fair to poor, had perceived a need for
treatment, had not seen the dentist for over a year and tend to visit the dentist less than once a
year or only for emergency or never, were all at a greater odds of requiring any treatment.
4.5 Determining the strongest predictors of dental treatment need
The next set of models progressively adjusted for the factors in the modified Andersen model
(predisposing, enabling, need, personal dental health practice and use of dental service factors)
to determine which factors were the strongest predictors of having a clinical need. Due to small
cell sizes when added into the multivariate model with the variable smoking status, the age
group of 6 to 11 was collapsed with ages 12 to 19 to form the new reference group of age 6 to
19 for this part of the analysis.
4.5.1 Model 1 – Predisposing factors
The first model included only the predisposing factors (sex, age, education, smoking status,
immigrant status and Aboriginal status). Table 22 shows that when adjusted for each other,
immigrant and Aboriginal status cease to be predictors of treatment need (P>0.05). Notably,
those aged 40 to 59 (OR=1.7, 95% CI=1.1-2.4, P=0.014), current smokers (OR=2.0, 95%
CI=1.6-2.5, P=0.001), and those with less than a degree/diploma (OR=1.8, 95% CI=1.3-2.4,
P=0.002) were all more likely than their counterparts to have a dental need.
4.5.2 Model 2 – Predisposing and enabling factors
The second model added in enabling factors (income adequacy and dental insurance). Table 22
shows that with the added influence of these enabling factors, all of the aforementioned
predisposing factors remained significant along with income and insurance. Those of lowest
income were 1.6 times more likely than those of highest income to require dental treatment
60
(95% CI=1.2-2.0, P=0.004). Individuals with public insurance were twice as likely than those
privately covered to require dental treatment (OR=2.0, 95% CI=1.4-3.0, P=0.002).
4.5.3 Model 3 – Predisposing, enabling and need factors
Need factors (self-reported oral health, general health, oral pain and self-perceived unmet
needs) were added into the third model. Looking at Table 22, it was found that self-reported
general health (P=0.452) and self-reported oral pain (P=0.053) were no longer significant
predictors of need. In contrast, all of aforementioned predisposing and enabling factors
remained as significant predictors with the exception of age and income, which were removed
out of the model. Those who reported their oral health as fair or poor (OR=3.6, 95% CI=2.5-5.2,
P=0.001) and those who perceived a need for treatment (OR=3.6, 95% CI=2.7-4.9, P=0.001)
were more likely to have unmet dental needs. Therefore, the need variables that were added in
were found to be stronger predictors for requiring dental treatment, such that they pushed out
age and income from the model.
4.5.4 Model 4 – Predisposing, enabling, need, and personal dental practice factors
Model 4 incorporates the personal dental practice factors (brushing and flossing frequency).
Table 23 shows that all of the previous predisposing, enabling and need factors remained
significant predictors of dental need. In addition, Table 23 (continued) shows that those who
brush their teeth and/or dentures once a day were 1.4 times more likely than those who brush
more than once a day to have an unmet dental need (95% CI=1.1-1.8, P=0.016). Also, those
who never floss were 2.4 times more likely than those who floss more than once a day to
require dental treatment (95% CI=1.3-4.6, P=0.010).
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4.5.5 Model 5 – All factors (predisposing, enabling, need, personal dental practice and use of dental service factors)
The fifth model contains all of the variables with the addition of the use of dental service factors
(avoided treatment due to cost, last dental visit, dental visit frequency and work/school days
lost). Table 23 shows that all of the previously entered variables that were significant remained
so in the final model with the exception of brushing once a day (P=0.150), which was removed.
As for the newly added factors shown in Table 23 (continued) only the variable of last dental
visit remained a significant predictor of treatment need, with those who visited the dentist over
a year ago being twice as likely to have an unmet dental need than those who visited in the last
year (OR=2.0, 95% CI=1.4-3.0, P=0.002).
In general, as shown in Model 5, the need variables of self-reported oral health and self-
perceived need had the highest adjusted odds ratios overall. Those who reported their oral
health as fair to poor and had a self-perceived need for treatment were close to three (OR=2.9,
95% CI=1.8-4.6, P=0.001) and three–and-a-half (OR=3.4, 95% CI=2.3-4.9, P=0.001) times
more likely than their counterparts respectively, to have an unmet dental need.
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Table 22. Multivariate logistic regression predicting the odds of having at least one clinical need including predisposing, enabling and need factors
Model 1 (N=26496021) Model 2 (N=24561662) Model 3 (N=24168519) OR (95%
CI) P-value OR (95% CI) P-value OR (95%
CI) P-value
Predisposing Factors Sex
Male (Reference) Female
0.7 (0.6, 0.8)
0.001
0.7 (0.6, 0.8)
0.001
0.6 (0.5, 0.8)
0.001 Age
12 to 19 (Reference) 20 to 39 40 to 59
60 to 79
1.6 (1.1, 2.4) 1.7 (1.1, 2.4) 1.3 (0.8, 2.0)
0.029 0.014 0.215
1.5 (1.1, 2.1) 1.6 (1.1, 2.3) 1.0 (0.7, 1.4)
0.028 0.028 0.891
1.1 (0.8, 1.6) 1.3 (0.9, 2.0) 0.9 (0.7, 1.3)
0.401 0.176 0.628
Smoking Status Never smoked (Reference) Past smoker
Current smoker
1.1 (0.8, 1.6) 2.0 (1.6, 2.5)
0.612 0.001
1.1 (0.8, 1.6) 1.8 (1.4, 2.3)
0.591 0.001
1.0 (0.7, 1.5) 1.4 (1.1, 1.7)
0.965 0.012
Education Degree/Diploma (Reference)
<Degree/Diploma
1.8 (1.3, 2.4)
0.002
1.6 (1.1, 2.1)
0.012
1.4 (1.1, 1.9)
0.028 Immigrant Status
Born in Canada (Reference) Not born in Canada
1.4 (1.0, 2.0)
0.053
1.2 (0.8, 1.7)
0.298
1.2 (0.9, 1.7)
0.276 Aboriginal Status
Non-Aboriginal (Reference) Aboriginal
1.5 (0.8, 2.7)
0.175
1.2 (0.7, 2.1)
0.521
1.3 (0.7, 2.3)
0.368 Enabling Factors Income adequacy
Highest income (Reference) Middle income
Lowest income
1.4 (1.2, 1.8) 1.6 (1.2, 2.0)
0.005 0.004
1.2 (1.0, 1.6) 1.2 (0.9, 1.6)
0.050 0.114
Dental insurance Private coverage (Reference) Public coverage
Non-insured
2.0 (1.4, 3.0) 1.7 (1.3, 2.1)
0.002 0.001
2.0 (1.3, 3.2) 1.6 (1.3, 2.1)
0.006 0.002
Need Factors Self-reported oral health
Excellent/Good (Reference) Fair/Poor
3.6 (2.5, 5.2)
0.001 Self-reported general health
Excellent/Good (Reference) Fair/Poor
1.1 (0.8, 1.6)
0.452 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
0.7 (0.5, 1.0)
0.053 Self-perceived unmet needs
No Needs (Reference) Has at least one need
3.6 (2.7, 4.9)
0.001
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Table 23. Multivariate logistic regressions predicting the odds of having at least one clinical need including predisposing, enabling, need, personal dental health practice and use of service factors
Model 4 (N=24168519) Model 5 (N=23456538) OR (95% CI) P-value OR (95% CI) P-value Predisposing Factors Sex
Male (Reference) Female
0.7 (0.6, 0.9)
0.004
0.7 (0.6, 0.9)
0.004 Age
12 to 19 (Reference) 20 to 39 40 to 59
60 to 79
1.2 (0.9, 1.7) 1.4 (0.9, 2.2) 1.0 (0.7, 1.5)
0.220 0.103 0.876
1.0 (0.7, 1.5) 1.3 (0.8, 2.1) 1.0 (0.7, 1.4)
0.841 0.190 0.841
Smoking Status Never smoked (Reference) Past smoker
Current smoker
1.0 (0.7, 1.5) 1.3 (1.0, 1.7)
0.935 0.034
1.0 (0.7, 1.5) 1.3 (1.0, 1.8)
0.940 0.040
Education Degree/Diploma (Reference)
<Degree/Diploma
1.8 (1.3, 2.4)
0.032
1.4 (1.1, 1.8)
0.026 Immigrant Status
Born in Canada (Reference) Not born in Canada
1.2 (0.8, 1.7)
0.285
1.2 (0.8, 1.7)
0.412 Aboriginal Status
Non-Aboriginal (Reference) Aboriginal
1.3 (0.7, 2.4)
0.339
1.4 (0.8, 2.5)
0.236 Enabling Factors Income adequacy
Highest income (Reference) Middle income
Lowest income
1.3 (1.0, 1.6) 1.2 (0.9, 1.6)
0.065 0.179
1.2 (0.9, 1.5) 1.1 (0.8, 1.4)
0.149 0.630
Dental insurance Private coverage (Reference) Public coverage
Non-insured
1.9 (1.3, 3.0) 1.6 (1.3, 2.0)
0.006 0.001
2.0 (1.3, 3.1) 1.4 (1.1, 1.7)
0.005 0.023
Need Factors Self-reported oral health
Excellent/Good (Reference) Fair/Poor
3.3 (2.2, 4.8)
0.001
2.9 (1.8, 4.6)
0.001 Self-reported general health
Excellent/Good (Reference) Fair/Poor
1.1 (0.8, 1.6)
0.443
1.2 (0.8, 1.7)
0.324 Self-reported oral pain
Rarely/Never (Reference) Often/Sometimes
0.7 (0.5, 1.0)
0.063
0.8 (0.5, 1.1)
0.138 Self-perceived unmet needs
No Needs (Reference) Has at least one need
3.6 (2.6, 5.0)
0.001
3.4 (2.3, 4.9)
0.001
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Table 23. (Continued) Model 4 (N=24168519) Model 5 (N=23456538) OR (95% CI) P-value OR (95% CI) P-value Personal Dental Health Practices Brushing frequency
>Once/day (Reference) Once/day
<Once/day or Never
1.4 (1.1, 1.8) 1.0 (0.6, 1.8)
0.016 1.000
1.2 (0.9, 1.7) 0.8 (0.4, 1.7)
0.150 0.577
Flossing Frequency >Once/day (Reference) Once/day <Once/day
Never
1.9 (1.1, 3.1) 1.5 (0.8, 2.7) 2.4 (1.3, 4.6)
0.125 0.147 0.010
2.0 (1.1, 3.6) 1.6 (0.9, 3.0) 2.4 (1.3, 4.6)
0.133 0.108 0.011
Use of Services Avoided dental treatment due to cost No (Reference) Yes
1.2 (0.8, 1.8)
0.313 Last Dental Visit
In the last year (Reference) More than one year ago
2.0 (1.4, 3.0)
0.002 Dental Visit Frequency
>/=Once a year (Reference) <Once a year/emergency/never
1.2 (0.8, 1.8)
0.476 Work/School Days Lost No (Reference) Yes
1.1 (0.8, 1.4)
0.644
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4.6 Comparing self-reported and clinically determined treatment needs
4.6.1 Using sensitivity and specificity
Table 24 displays the sensitivity and specificity for each treatment need (calculation
equations and definition of terms are outlined in the methods section). These results
indicate that only 56% of Canadians who required dental treatment perceived a need for
it, while 78% of people who reported not having any needs correctly had no need for
treatment. Looking at the treatment types, generally for each, the specificity appears to be
consistently higher than the sensitivity. For example, for periodontics, approximately
29% of those who required this treatment perceived a need for it, whereas 92% of those
who did not need periodontal treatment correctly reported no need for it. Therefore
overall, as a test for predicting clinical dental need, self-reported information is highly
specific but not very sensitive. As a result of its low sensitivity (especially for prevention
and periodontics), self-reports are poor at detecting all of the people who do require
treatment and tends to miss the people who say they do not need treatment but actually do
need it (i.e. produces a large number of false negative results). However, according to
Fletcher and Fletcher (2005), since this test is highly specific, it can be used to “rule in” a
hypothesis as it yields very few false positives. In other words, if you get a positive test,
you can count on it being a true positive (Fletcher and Fletcher, 2005). In the case of this
study, if a person said that they needed a treatment with a high specificity, such as
preventive, periodontic, endodontic or orthodontic treatment, they most likely did require
that treatment. It is important to note that sensitivity and specificity are properties of the
diagnostic test and are not influenced by the prevalence of the disease in the population
(Fletcher and Fletcher, 2005).
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4.6.2 Using positive predictive vale (PPV) and negative predictive value (NPV)
Table 24 compares the calculated PPV and NPV for each treatment type (calculation
equations and definition of terms are outlined in the methods section). A higher NPV than
PPV is observed for each category. Therefore, if the patient’s test result is negative, the
chance that the patient does not have the disease is high (Fletcher & Fletcher, 2005). In
other words, a person who said they did not require periodontal treatment had a 94%
chance of not requiring it, while a person who said they needed periodontal treatment
only had a 24% chance of actually needing it. Overall, especially for needs such as
endodontics and orthodontics, if a person said they did not require treatment, they had a
very high chance of not needing it. It is important to note that the PPV and NPV can vary
markedly depending on the prevalence of disease in the population (Fletcher and
Fletcher, 2005). Since the prevalence of each treatment need was found to be low (1% to
20%), the resulting PPVs were low as well.
Table 24. Comparing self-reported versus clinically determined treatment needs using sensitivity and specificity
Sensitivity (%)
Specificity (%)
Positive predictive value (%)
Negative predictive value (%)
Having a self-perceived need and clinical need
56.1 78.3 55.8 78.5
Prevention 25.1 93.8 53.4 81.6 Restorations 78.2 61.8 55.5 82.3 Surgery 53.6 91.7 58.5 90.1 Periodontics 28.8 92.1 23.5 93.8 Endodontics 54.8 95.5 39.4 97.5 Orthodontics 72.6 95.1 31.3 99.1
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4.7 Summary of results
4.7.1 Objective I: What are the dental treatment needs of Canadians?
! Most of the population was classified as having no treatment needs (65.8%). Of the
34.2% who did require treatment, 19.4% were found to have one dental treatment need
and 14.6% required more than one need, which represents close to 5 million people.
! Most of the population needed restorative (20.4%) and preventive (13.7%) care.
Approximately 6.0% of the population, which represents nearly 2 million people, had an
urgent need (i.e. treatment was required within one week).
4.7.2 Objective II: What characteristics are predictive of having an unmet dental need, and each type of treatment?
! All of the variables with the exception of immigrant status were independently predictive
of having an unmet dental need.
! Noted to be the highest odds ratio over all of the factors, those reporting their oral health
of fair or poor were 5.9 times more likely to have an unmet dental need than those
reporting excellent or good oral health. Those who perceived a need for treatment were
4.6 times to have a clinical need than those who did not.
! Those who reported poor oral health, perceived need for treatment and had poor dental
visiting habits, were found to have the highest odds of needing each treatment type with
the exception of: immigrants to Canada, who had the highest odds of requiring
periodontal care, those who were publicly insured and visited the dentist more than one
year ago, who had the highest odds of needing prosthodontic care, and those who
reported often or sometimes experiencing oral pain, who had the highest odds of
requiring urgent treatment.
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4.7.3 Objective III: What are the strongest predictors of having an unmet need?
! Being male, a current smoker, having less than a degree or diploma, having public
insurance coverage, never flossing, and reporting a last dental visit of more than one year
ago were all significant predictors of dental need.
! The strongest predictors of need were: fair or poor oral health and reporting a self-
perceived need for treatment.
! Those who reported their oral health as fair to poor and had a self-perceived need for
treatment were close to three times and three and a half times more likely than their
counterparts respectively, to have an unmet dental need.
4.7.4 Objective IV: Comparing self-reported and clinically determined treatment needs.
! As a test for predicting clinical dental need, self-reported information is highly specific
but not very sensitive.
! As a result of its low sensitivity (especially for prevention and periodontics), self-reports
are poor at detecting all of the people who do require treatment.
! As a result of its high specificity, if a person did respond positively to having a specific
treatment need, they most likely did require that treatment.
! With low PPVs and high NPVs, self-reported information was found to be more precise
in predicting what people did not require opposed to what they did require. However, the
low PPVs could have been due to the low prevalence of the treatment needs.
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Chapter V: Discussion
This study is the first to comprehensively examine the dental treatment needs of Canadians
using the most recent and nationally representative clinical data available on the Canadian
population. This information is fundamental for the evidence-based development of oral health
care policy. Four specific objectives were met:
! The first was to outline the treatment needs of Canadians as determined by the CHMS
clinical oral health exam, and it was found that the majority of the population had no
treatment needs, and of those who did, restorative and preventive care was required by
the most.
! The second was to examine if any characteristics were predictive of having an unmet
dental treatment need, and it was found that all the variables tested, except immigrant
status, were independently predictive of having a need. Reporting an oral health status of
fair or poor and having a perceived need for treatment were the greatest predictors of
need. In terms of the types of treatments required, need and use of service factors were
significant predictors for most treatments. Those who reported their oral health as fair to
poor, had perceived a need for treatment, had not seen the dentist for over a year, and
tended to visit the dentist infrequently or never, were all at a greater odds of requiring
treatment.
! The third objective involved progressively adjusting for each of the factors in the
modified Andersen model to determine the strongest predictors of having an unmet
dental treatment need. Similar to the results observed at the unadjusted level, once
adjusted, having poor oral health status and a self-perceived need for treatment were
found to be the strongest predictors of need.
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! Lastly, the fourth objective was to compare self-reported and clinically evaluated needs
and a significant discrepancy was found between the two. Using self-reported
information to predict clinical need was found to be highly specific as a test (i.e. the need
for treatment could be ruled in if a person said they needed it). When applied to a
population with a low prevalence of needed treatments, this test yielded high negative
predictive values (i.e. given a person said they did not need treatment, they most likely
did not need it).
5.1 Key findings
5.1.1 The need for dental treatment in Canada
The CHMS found that around 34% of participants, who statistically represent close to 12
million Canadians, needed dental treatment. It is important to recall that certain populations who
are known to have high levels of dental disease and limited access to dental care (e.g. First
Nations and Inuit people and seniors in institutions) were not included in the survey. With the
current study covering approximately 87% of Canadians, this means around 13% of the
population aged 6 to 79 was not represented. Therefore, the 34% of the population found to
require dental treatment is most likely an underestimation of the true need present in the
Canadian population.
The current study found that roughly 19% and 15% required one, and more than one treatment
need, respectively. As expected, these needs predominately consisted of restorative and
preventive care. These findings more or less reflect those of Quiñonez and Locker (2007) who
found that 26% of the Canadian adult population had cost-prohibitive (i.e. unmet) dental needs,
with fillings and preventive procedures (cleanings and check-ups) found to be the most
prevalent unaffordable needs. Considering dental caries is one of the most prevalent chronic
diseases among Canadians (Health Canada, 2010) and has a lifelong impact through the need for
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re-treatment (Steele, O’Sullivan, 2011), the need for restorative care makes sense. Similarly,
several studies have noted that the prevention of dental problems is a critical component of oral
care (Brewer & Correa, 2006), while other studies have stated that not enough emphasis is
placed on prevention and that roughly 90% of dental diseases are preventable with the proper
education and care (CREHS, 2004). Therefore, as was observed, it is reasonable that most
people would have benefitted from a preventive procedure like prophylaxis or a fluoride
treatment.
5.1.2 Consequences of untreated dental disease
Although urgent conditions were found to affect a minority of the population (5.9%), this
amounted to nearly 2 million Canadians in need of immediate care. If left untreated, dental
diseases have been found to negatively impact quality of life and lead to problems in eating,
speaking, sleeping, swallowing and breathing (Locker and Slade, 1988). From a public health
perspective, having an unmet dental need goes beyond the scope of the dental field as it can
impede the self-esteem and mental health of vulnerable populations (Bedos, Levine and
Brodeur, 2009). For example, it has been found that with the decline of their dental health,
people on social assistance experience decreased social interaction and difficulty finding
employment (Bedos, Levine and Brodeur, 2009). In addition, this study found that 39% of
Canadians have lost time away from work, school or their normal activities due to dental visits
or dental sick-days. This produces indirect costs not only to the individual, but also to the
Canadian society as a whole. In a more detrimental context, media has reported on cases of
death due to dental disease that could have been prevented if individuals were able to access
dental care in a timely fashion, a major issue which continues to raise debate in Canada and the
United States (Canadian Academy of Health Sciences, 2008).
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5.1.3 Predicting those at greatest risk for needing dental treatment
This study found that whether adjusting or not adjusting for various predisposing, enabling, and
personal dental practice factors, those who reported having poor oral health, had perceived a
need for dental treatment, and infrequently visited the dentist, were at the greatest risk for
having unmet dental conditions. This seems counterintuitive since one would expect that those
who are conscious of their poor oral health and requirement for treatment would visit the dentist
in order to meet their needs. Here we see the ‘paradox of need’, as cited by Muirhead et al.
(2009), who found that working poor persons who reported the worst self-rated oral health or
who had a perceived need for treatment were low dental service users. Studies have shown that
people with poor oral health and a perceived need for treatment may avoid dental visits because
of the barriers imposed by the costs of dental treatment, the anxiety of potential pain, or concern
about being judged by dentists for their poor oral condition (Muirhead et al., 2009; Bedos,
2005). Unfortunately, aside from avoiding dental treatment for cost reasons, which was found to
be the case for around 17% of the population, the CHMS did not collect information regarding
any other potential reasons for not visiting the dentist (e.g. anxiety, fear of judgement, etc.).
Notably, current smokers were also in the range of two to three and a half times more likely than
non-smokers to require some type of dental treatment. Although studies have found that
smoking is a major risk factor for periodontitis (Tomar and Asma, 2000), the current study
discovered that those who smoke were at the greatest risk for needing endodontic treatment.
This finding corroborates with a longitudinal study done by Krall et al. (2006), which found a
dose-response relationship between cigarette smoking and the risk of root canal treatment.
When compared to never-smokers, current cigarette smokers were 1.7 times more likely to have
root canal treatment and the risk increased with more years of exposure and decreased with
length of abstinence (Krall et al., 2006).
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Interestingly, when adjusted for all of the factors in the modified Andersen model, we saw that
dental insurance, as an enabling resource, was found to be a significant predictor of dental need
while income was not significant. This suggests that dental insurance is a more important
determinant of having unmet dental needs than actual income. Within dental insurance, those
who were publicly insured were found to be at a greater risk of having an unmet dental
condition, even more than the non-insured. This is not surprising considering those who receive
public insurance generally represent the poorest of the poor and arguably face the greatest social
marginalization, which may make accessing dental care a low priority, much less result in the
poorest levels of oral health (CHMS, 2010). To be sure, as demonstrated by Quiñonez and
Figueiredo (2010), working poor individuals reporting a history of social assistance coverage
consistently faired worse across a variety of self-reported outcomes when compared to working
poor individuals with no history of social assistance coverage (e.g. self-reported oral health as
fair to poor, only visit for emergencies, impaired dental functioning, perceived a need for dental
treatment).
5.1.4 Using self-reported dental need to predict actual need
As a diagnostic test, it can be concluded that self-reported information on dental need is useful
in confirming the need for dental treatment if a person says they need it (high specificity), but is
unable to identify everyone who requires treatment (low sensitivity). Therefore, survey
information on self-reported dental needs can be useful in painting a picture of the needs
required by a population, however, the amount of need may be an underestimation. As a result,
the need for clinical testing is still required in order to catch those missed by the self-report test.
When a screening test is applied in a normal clinical setting, it is not known who has the
disease; the test is used to help find out. Therefore, clinicians are more interested in what a
negative or positive test result means for the patient using predictive values (Fletcher and
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Fletcher, 2005). In the case of this study, dental professionals and policymakers are concerned
with whether or not a person requires dental treatment given a self-reported need for care.
According to this study, the accuracy to which a dental need can be correctly predicted varies
with each treatment type. For periodontal treatment, the probability of a person requiring this
treatment following a positive response for needing it was very low. This finding is consistent
with the previously mentioned studies by Liu et al. (2010) and by Gilbert and Nuttall (1999),
who found that people are usually unable to assess their periodontal status. In addition, these
particular conditions are usually asymptomatic which furthermore makes their assessment
difficult. In contrast, for all of the treatment needs, the probability of a person not requiring
treatment following a negative response for needing it was much higher. Therefore, it can be
said that overall, as a diagnostic tool, self-reported information on dental needs was found to be
more precise in dictating which treatments a person did not need rather than what they did
require. Although this information provides insight into the usefulness of self-reported
information in predicting actual dental need, it is important to note that positive and negative
predictive value are influenced by the prevalence of the treatment need in the population. As a
result of only 34% of the population requiring dental treatment, and of this, anywhere from one
to twenty percent having each service need, the positive predictive values obtained were low
and should be interpreted with caution. Therefore, it can be misleading to apply this test in low-
prevalence settings, as many false positive results may be obtained. In order to improve the
positive predictive value of a test, one strategy would be to change from screening everyone
(universal/population screening) to screening selectively. For example, testing only people with
a high risk of unmet dental need (i.e. have low socioeconomic status, or show symptoms that
suggest the disease).
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Further analysis of this data can be done in the future to test hypotheses of trends across
covariates such as age, sex, education, and income, which have been found to be significantly
related to oral health, as well as to the discrepancy between clinical and self-reported dental
needs (Liu et al., 2010). For example, older people are known to have worse oral conditions and
have been found to overestimate their own oral health (Liu et al., 2010). Investigation into such
trends will prove useful in determining the effectiveness of self-reports on predicting actual oral
health status and need.
5.2 What do these findings mean to dental public health policy?
Dental public health professionals and policies aim to improve the oral health of communities
and whole populations rather than focusing on the individual (CAPHD, 2012). Although
significant improvements have been made over the past few decades in reducing dental decay
rates and in improving treatment modalities (FTDPP, 2002), according to this study, nearly 12
million Canadians continue to live with untreated dental conditions. This is of public health
concern since this study established that higher levels of unmet need are found amongst specific
underprivileged groups including the poor, the less educated, immigrants and Aboriginals. For
these groups particularly, it has been found that significant financial, individual and societal
barriers stand in the way of accessing dental services and receiving the care that they need
(FTDPP, 2002).
In attempts to overcome financial barriers to care and reduce oral health care disparities,
governments have created targeted, as opposed to universal, programs (Lawrence and Leake,
2001). Arguably, without any clinical information available on the dental needs of the
population for the past 40 years, these programs can be questioned in terms of their scope and
comprehensiveness. Public programs should be structured to reflect and meet the needs of the
people covered. Since the current study now fully documents the magnitude and types of oral
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health problems experienced by the population, and more specifically, those experienced by
socially disadvantaged groups, an evidence-based evaluation of current programs, in addition to
the development of new oral health care programs, can be made.
In this regard, public health policymakers should be concerned with the fact that most of the
population required restorative and preventive treatment, considering these services are covered
under private and public insurance plans. This alludes to the fact that there exist other issues in
the utilization of and access to dental care aside from simply having the services covered by
insurance. Several studies have found that even with insurance coverage, the dental needs of
people go unmet due to a low prioritization placed on oral health care (Millar and Locker,
1999). This is further supported by the ‘paradox of need’ seen in this study by those who
recognize they have poor oral health and require dental treatment yet are infrequent users of
dental care. As mentioned previously, studies have stated that not enough emphasis is placed on
the need for prevention. Overall, it is in the interest of policymakers to improve their programs
in terms of promoting and educating the public on the importance of oral health, in efforts to
overcome this ‘paradox of need’ and in turn, increase the utilization of dental services as a
whole.
Similarly, and directly related to dental public health policy, this study found that those who had
access to dental public health programs were worse off in terms of having unmet dental needs,
when compared to those with private insurance and without any insurance coverage. This
finding supports a key issue noted by Leake and Birch (2008) who state that although public
funding of dental care provides a means of overcoming the divergence between the ability to
pay for care and need for care, having such coverage is not enough. Further, with restrictions on
prices and the range of services covered, working within in the public sector becomes
unattractive to providers faced with ample private demand for their services (Leake and Birch,
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2008). In turn, as noted by Quiñonez et al., (2010), dentists have consistently voiced their
dissatisfaction with public plans. In turn, discrimination from providers has also been noted to
be a barrier to accessing dental care for the poor and publicly insured (Leake, 2006). Bedos et al.
(2005) found that welfare clients in Montreal felt that comments made by the dentist or
receptionist were hurtful and stigmatizing and in general, the dentists were insensitive to their
problems. Overall, this study’s finding of those publicly insured being at the greatest risk of
having unmet needs supports the fact that solely increasing public subsidies for these groups
may not fully increase their utilization of dental services unless accessibility issues in terms of
provider availability and attitudes of both the patients and providers are also resolved.
Although not a disadvantaged group per se, past and current smokers were found to represent
nearly half of the Canadian population. This is of dental public health concern since this study
found that being a smoker doubled the chances of having unmet dental needs and tripled the
chances of having endodontic needs. This means that co-operation between the dental
profession and other health professions is required in order to continue the strong educational
focus on the negative impacts of smoking.
5.3 Limitations of the study
Firstly, it is difficult to know the true extent of treatment need in the Canadian population
considering the specific details of need were not collected by the CHMS. For example, multiple
treatment needs of the same type were recorded as a single need (e.g. a participant that required
a single restoration was reported similarly to a participant with three restorations). Radiographs
were not taken therefore limiting the assessment of need (e.g. dental examiners were unable to
diagnose the presence of inter-proximal caries).
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The CHMS did not collect information concerning dental health beliefs and anxiety, which have
been previously shown to affect dental care utilization and in turn, influence the need for dental
treatment. In general, this study cannot support conclusions about causal effects of any
predisposing, enabling, need, personal dental health and use of dental service factors on dental
need, since it is based on a cross-sectional survey. Finally, as previously mentioned, the CHMS
excluded people such as the First Nations and Inuit population, infants and young children
(below the age of 6 years), and seniors in institutions. Therefore, the findings from this study are
not reflective of the entire Canadian population.
Despite these shortcomings, this study provides a robust assessment of unmet dental conditions
in the Canadian population. It also gives insight into the factors that affect self-evaluated need
and identifies disparities in need by revealing those who are the most vulnerable. Finally, with
the availability of clinical information, this study is the first of its kind to compare self-reported
needs with actual dental need based on data representative of most of the Canadian population.
5.4 Recommendations
With the results obtained from this study, program and policymakers now have information by
which to assess if their programs match the dental treatment needs of Canadians and of
particular subgroups experiencing excess risk. Improving oral health requires an investment in
the right kind of services and programs and this study points to continuing the focus on
preventive and restorative care with an added emphasis on educating the public to prioritize oral
health. In efforts to place more importance on prevention and increase the utilization of dental
care, oral health promotion strategies need to be further developed and implemented. For
example, this could include the use of media (e.g. through television, campaigns, etc.,) to
convey the negative impacts of poor oral health on one’s quality of life (e.g. affects general
health, self-esteem, employment etc.).
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This study found that there is a significant level of unmet dental need seen in certain groups of
the Canadian population, especially those who were publicly insured. The methods used for
providing dental care in Canada arguably require some level of reconsideration to meet the
special circumstances of this group. As previously discussed, in order to improve policy and
allow oral health care to become equitably provided and utilized, public programs will need to
focus on increasing the accessibility and acceptability of dental services. Conducting qualitative
interviews could provide insights into the specific issues that these disadvantaged populations
have with accessing and utilizing dental care.
Increasing the number and type of providers engaged in public programs through incentives
could accomplish this. Incentives could include setting publicly funded payments to the same
rates of remuneration seen in the private systems, however, tight public sector budgets may
prevent this from occurring (Leake and Birch, 2008). Using alternative dental delivery systems
to improve access to prevention and treatment services for people who face difficulties utilizing
the fee-for-service system might also prove effective, such as independent dental hygiene or
dental therapy care, but discussing the details of this are beyond the scope of this study.
In regards to smoking cessation, the role of the dentist needs to be clarified so that both dentists’
and patients’ expectations and needs are met. Several studies conducted in the United Kingdom
have focused on this topic and have argued that dentists are well placed to recognize those who
smoke and further identify the impact of tobacco use in the mouth (Monaghan, 2002). It is
recommended that dentists can help their patients to stop smoking by recognizing oral signs of
tobacco use, informing patients of these and asking patients whether they wish to stop. By
enquiring and providing advice, members of the dental team in addition to other allied health
professionals can help patients consider quitting and provide access to smoking cessation
services.
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Considering the structuring of public programs varies in each province and territory across
Canada, it is recommended to investigate and pinpoint disparities in treatment need that occur at
the provincial/territorial level in further studies. Literature has shown that regional differences in
the use of dental services exist, with residents of Ontario, for instance, being more likely to
receive dental care over the course of a year than otherwise comparable residents of
Newfoundland (Bhatti, Rana and Grootendorst, 2007). Unfortunately, since the CHMS was
designed to provide national estimates only, there were insufficient numbers of participants to
compare at this level in this study. Therefore, futures studies would need to collect this
information at the provincial/territorial level.
Lastly, to assure that oral health research is appropriately supported and to avoid a future gap in
data, governments must make a commitment to invest in oral health data collection on a regular
basis. In order to obtain a more comprehensive picture of the true dental need in the population,
future surveys should also include an assessment of those segments of the population who were
excluded in the CHMS.
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Chapter VI: Conclusion
The current study is the first in 40 years to analyze valid and representative clinical information
on the dental treatment needs of Canadians. We now know that roughly 12 million Canadians
have unmet dental care needs and that most people require restorative and preventive care. We
can also confirm that higher levels of unmet need are found amongst specific underprivileged
groups including the poor, the publicly insured, the less educated, immigrants and Aboriginals.
These groups are of particular concern since they have been found to face substantial barriers to
accessing dental services, and as a result, have untreated dental conditions that negatively
impact their quality of life. Providing dental care to these groups will arguably require some
level of reconsideration in terms of access and acceptability of dental services.
The key factors that are predictive, and can be used to distinguish, which people have unmet
conditions have been delineated in this study. Similar to previous conclusions, we see the
‘paradox of need’ by which those who rate their oral health as poor, perceive a need for dental
treatment, and infrequently visit a dental professional, consequently are at the greatest risk of
having unmet dental conditions.
In addition, the present study is the first to compare self-reported needs with actual dental need
based on data representative of most of the population. These findings allow us to verify that
Canadians are generally accurate at assessing the dental needs they do not require, but when
applied to the population level where the overall prevalence of dental need is low, self-reported
information on this is better at assessing what people do not require rather than what they do
require. Investigation into which groups tend to overestimate or underestimate their oral health
and in turn, their perception of need, will prove useful in determining the true effectiveness of
self-reported information.
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Overall, this study provides valuable baseline information on the exact dental needs of the
Canadian population and furthermore, it highlights the greatest areas of unmet need. This
knowledge can now be used by program and policymakers to develop or refine targeted dental
health programs using evidence-based tactics in efforts to improve the oral health of our
population as a whole.
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Appendices
Appendix A. Coding for all of the independent and dependent variables in this study Questions used from the Household survey: SMK_Q12 At the present time, do you smoke cigarettes daily, occasionally or not at all?
1 Daily 2 Occasionally 3 Not at all
SDC_Q12 Were you born a Canadian citizen? 1 Yes 2 No
SDC_Q22 Are you an Aboriginal person, that is, North American Indian, Métis or Inuit?
1 Yes 2 No
ED_Q04 What is the highest degree, certificate or diploma [Respondent Name] has obtained? 1 No post-secondary degree, certificate or diploma 2 Trade certificate or diploma from a vocational school or apprenticeship training 3 Non-university certificate or diploma from a community college, CEGEP, school of nursing, etc. 4 University certificate below bachelor’s level 5 Bachelor’s degree 6 University degree or certificate above bachelor’s degree
INC_Q21 What is your best estimate of the total income, before taxes and deductions, of all household members from all sources in the past 12 months? (insert respondent answer between 0 and 500,000)
OHM_Q43 Do you have insurance or a government program that covers all or part of your dental expenses? 1 Yes 2 No
OHM_Q44 Is it:
INTERVIEWER: Read categories to respondent. Mark all that apply. 1 .… an employer-sponsored plan? 2 .… a provincial program for children or seniors? 3 .… a private plan? 4 .… a government program for social service (welfare) clients? 5 .… a government program for First Nations and Inuit?
OHM_Q11 In general, would you say the health of your mouth is: 1 .… excellent? 2 .… very good? 3 .… good? 4 .… fair? 5 .… poor?
OHM_Q42 (In the past 12 months,) Have you avoided having all the dental treatment that was recommended because of the cost?
1 Yes 2 No
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OHM_Q23 Remember, by mouth we mean teeth or dentures, tongue, gums, lips and jaw joints. In the past 12 months, how often have you had any other persistent or ongoing pain anywhere in your mouth? 1 Often 2 Sometimes 3 Rarely 4 Never
OHM_Q24 (In the past 12 months,) Have you taken time away from work, school or your normal activities for dental check-ups or treatments or because of problems with your mouth? 1 Yes 2 No
OHM_Q31 How often do you usually brush your teeth and/or dentures? (For example: twice a day, three times a week, once a month) INTERVIEWER: Enter amount only. (insert respondent answer between 0 and 500)
OHM_N31 INTERVIEWER: Select the reporting period. 1 Per day 2 Per week 3 Per month 4 Per year
OHM_Q32 How often do you usually floss your teeth? INTERVIEWER: Enter amount only. (insert respondent answer between 0 and 500)
OHM_N32 INTERVIEWER: Select the reporting period. 1 Per day 2 Per week 3 Per month 4 Per year 5 Never 6 Full set of dentures
OHM_Q33 Do you usually see a dental professional: 1 .… more than once a year for check-ups or treatment? 2 .… about once a year for check-ups or treatment? 3 .… less than once a year for check-ups or treatment? 4 .… only for emergency care? 5 .… never?
OHM_Q34 When was the last time you saw a dental professional? 1 Less than 1 year ago 2 1 year to less than 2 years ago 3 2 years to less than 3 years ago 4 3 years to less than 4 years ago 5 4 years to less than 5 years ago 6 5 or more years ago
GEN_Q11 To start, in general, would you say your health is: 1 .… excellent? 2 .… very good? 3 .… good? 4 .… fair?
5 .… poor?
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Questions used from the Clinic survey: CLC_SEX INTERVIEWER: Enter [Respondent Name].’s sex.
If necessary, ask: (Is [Respondent Name] male or female?) 1 Male
2 Female CLC_AGE What is [Respondent Name].’s age? (insert respondent answer between 0 and 130) OHQ_Q11 Do you think you have any untreated dental conditions?
1 Yes 2 No All respondents, except those meeting the exclusion criteria at the beginning of the Oral Health Component
OHQ_Q12 What untreated dental condition(s) do you think you have? 1 Prevention 2 Fillings 3 Temporomandibular joint disorder (TMD) 4 Surgery 5 Periodontics 6 Esthetics 7 Endodontics 8 Orthodontics 9 Soft tissue 10 Prosthetics .– partial or full denture 11 Prosthetics .– implant, bridge or crown 12 Other
OHE_N51 Instruction: Record the prosthetic needs of the upper arch of the respondent. Mark all that apply. 1 No prosthetics needed 2 Fixed bridge 3 Implant 4 Denture repair or reline 5 New partial denture 6 New full denture
OHE_N52 Instruction: Record the prosthetic status of the lower arch of the respondent. Mark all that apply. 1 No prosthetics needed 2 Fixed bridge 3 Implant 4 Denture repair or reline 5 New partial denture 6 New full denture
OHE_N53 Instruction: Record the treatment currently needed by the respondent. Mark all that apply. 1 No treatment needed 2 Prevention 3 Fillings 4 Temporomandibular joint disorder (TMD) 5 Surgery 6 Periodontics 7 Esthetics
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8 Endodontics 9 Orthodontics 10 Soft tissue 11 Other .– Specify (insert treatment to a maximum of 80 characters)
OHE_N61 Instruction: Record whether the respondent needs fillings urgently (i.e., within a week). 1 Yes 2 No
OHE_N62 Instruction: Record whether the respondent needs treatment for Temporomandibular joint disorder (TMD) urgently (i.e., within a week).
1 Yes 2 No
OHE_N63 Instruction: Record whether the respondent needs surgery urgently (i.e., within a week). 1 Yes 2 No
OHE_N64 Instruction: Record whether the respondent needs periodontics urgently (i.e., within a week). 1 Yes 2 No
OHE_N65 Instruction: Record whether the respondent needs endodontics urgently (i.e., within a week).
1 Yes 2 No
OHE_N66 Instruction: Record whether the respondent needs orthodontics urgently (i.e., within a week). 1 Yes 2 No
OHE_N67 Instruction: Record whether the respondent needs soft tissue treatment urgently (i.e., within a week). 1 Yes 2 No
OHE_N68 Instruction: Record whether the respondent needs other treatment urgently (i.e., within a week). 1 Yes 2 No
Additional questions not used in this study: OHM_Q12 How satisfied are you with the appearance of your teeth and/or dentures?
1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied
OHM_Q21 In the past 12 months, that is, from [date one year ago] to yesterday, how often have you found it uncomfortable to eat any food because of problems with your mouth?
1 Often 2 Sometimes 3 Rarely 4 Never
OHM_Q22 (In the past 12 months) How often have you avoided eating particular foods because of problems with your mouth?
1 Often 2 Sometimes
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3 Rarely 4 Never
OHM_Q25 (In the past 12 months,) How many hours were you away from your normal activities? (insert respondent answer between 0.5 and 95.5) Respondents who have taken time away from work, school, or normal activities for dental check-ups or treatments or because of problems with their mouth [OHM_Q24 = 1]
OHQ_Q21 In the past month, that is, from [date last month] to yesterday, have you had a toothache? 1 Yes 2 No
OHQ_Q22 In the past month, have you had pain in your teeth when consuming hot or cold foods or drinks?
1 Yes 2 No
OHQ_Q23 In the past month, have you had: severe tooth or mouth pain at night?
1 Yes 2 No
OHQ_Q24 In the past month, have you had: pain in or around your jaw joints?
1 Yes 2 No
OHQ_Q25 In the past month, have you had: other pain in your mouth? 1 Yes 2 No
OHQ_Q26 In the past month, have you had bleeding gums when brushing your teeth? 1 Yes 2 No
OHQ_Q27 In the past month, have you had: persistent dry mouth? 1 Yes 2 No
OHQ_Q28 In the past month, have you had: persistent bad breath? 1 Yes 2 No
Oral Health Restriction (OHR) OHR_Q11 Do you have to take antibiotics (for example, penicillin) before you have a checkup or get dental care?
1 Yes (Go to OHR_D25) 2 No
OHR_Q12 Have you ever been diagnosed by a health professional with a heart murmur that requires you to take antibiotics for dental treatment?
1 Yes (Go to OHR_D25) 2 No
OHR_Q13 Have you ever been diagnosed by a health professional with a heart valve problem? 1 Yes (Go to OHR_D25) 2 No
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OHR_Q14 Have you ever been diagnosed by a health professional with: congenital heart disease? 1 Yes (Go to OHR_D25) 2 No
OHR_Q15 Have you ever been diagnosed by a health professional with: bacterial endocarditis?
1 Yes (Go to OHR_D25) 2 No
OHR_Q16 Have you ever been diagnosed by a health professional with: rheumatic fever? 1 Yes (Go to OHR_D25) 2 No
OHR_Q17 Have you had bypass surgery in the past year? 1 Yes (Go to OHR_D25) 2 No
OHR_Q18 Do you have a pacemaker or other automatic defibrillator? 1 Yes (Go to OHR_Q19) 2 No (Go to OHR_Q20)
OHR_Q19 Have you had your pacemaker or other automatic defibrillator for less than one year? 1 Yes (Go to OHR_D25) 2 No
OHR_Q20 Do you have other artificial material in your heart, veins or arteries? 1 Yes (Go to OHR_D25) 2 No
OHR_Q21 Have you ever had a joint replacement? 1 Yes (Go to OHR_D25) 2 No
OHR_Q22 Have you ever received an organ transplant? 1 Yes (Go to OHR_D25) 2 No
OHR_Q23 Do you have kidney disease that requires dialysis? 1 Yes (Go to OHR_D25) 2 No
OHR_Q24 Are you immuno-supressed or are you on immuno-suppression therapy? (For example, chemotherapy.) 1 Yes 2 No
OHR_D25 If respondent answered yes to any of the Oral Health Restriction questions, probing will not be performed.
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Appendix B. Coding for all independent and dependent variables
INDEPENDENT VARIABLES
DEPENDENT VARIABLES
Predisposing Enabling Need Personal dental health practices
Use of services
Smoking status (SMKDSTY) “0” – Never “1” – Past “2” – Current
Income Adequacy (INCDD1A4) “0” – High “1” – Middle “2” – Low
Brushing frequency (OHMD31Y) “0” - >once/day “1” – once/day “2” - <once/day/never
Work/school days lost (OHM_24) “0” – No “1” – Yes
Sex (CLC_SEX) “0” – Male “1” – Female
Avoided dental treatments due to cost (OHM_42) “0” – No “1” – Yes
Age (CLC_AGE) “0” – 6-11 “1” – 12-19 “2” – 20-39 “3” – 40-59 “4” – 60-79
Self-perceived unmet needs (OHQ_11) “0” – None “1” – Prevention “2” – Fillings “3” – TMD “4” – Surgery “5” – Periodontics “6” – Esthetics “7” – Endodontics “8” – Orthodontics “9” – Soft tissue “10” – Other OR “0” – No “1” – Yes
Last dental visit (OHM_34) “0” – In the last year “1” – More than a year ago
Immigrant status (Born outside of Canada) (SDCFIMM) “0” – No “1” – Yes
Self-reported oral health (OHM_11) “0” – Excellent “1” – Good/Fair “2” – Poor
Aboriginal status (SDCFABT) “0” – No “1” – Yes
Self-reported oral pain (OHM_21) “0” – Often “1” – Sometimes “2” – Rarely “3” - Never
Clinically-determined dental treatment needs (OHE_53A-K) “0” – None “1” – Prevention “2” – Fillings “3” – TMD “4” – Surgery “5” – Periodontics “6” – Endodontic “7” - Prosthodontics “8” – Orthodontics “9” – Soft tissue “10” – Other “11” - Urgent OR Dichotomous Variable “0” – No “1” – Yes
Education (EDUDR04) “0” – degree/diploma “1” - < degree/diploma
Dental insurance coverage (OHM_44 A-E) “0” – Private “1” – Public “2” – None
Self-reported general health (GEN_HD1) “0” – Excellent “1” – Good/Fair “2” – Poor
Flossing frequency (OHMD32Y) “0” - >once/day “1” – once/day “2” - <once/day “3” - Never
Dental visit frequency (OHM_33) “0” – More than once a year “1” – Once a year “2” – Less than once a year “3” – Only for emergency “4” – Never