impact of dental insurance on oral health ...1.6.2.3 periodontal status 1 h.2.4 burden of dental...
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IMPACT OF DENTAL INSURANCE ON ORAL HEALTH
STATUS OF OLDER ADULTS IN DURHAM HOMES FOR THE
AGED
by
Albert Oluwayanmife Adegbembo
A thesis submitted in conforrnity with the requirernents for the degree of Master of Science (Community Dentistry)
Graduate Department of Dentistry University of Toronto
Q Copyright by Albert Oluwayanmife Adegbembo (2001)
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ACKNOWLEDGEMENTS
1 am greatly indebted to the Faculty and the Dean of Graduate Studies, Dr R. Ellen, for providing
financial assistance that enableci me to complete this program. 1 am also gratefid to Mrs L. Mockler for
her encouragement and support.
My special thanks goes to Dr. J.L. Leake, my supervisor and mentor, for patiently guiding me
through the several revisions of this thesis and for extending his wonderfùl hospitality to me. My
profound appreciation goes to other members of my Graduate Advisory Cornmittee - Drs P. Main, H.
Lawrence, and M. Chipman, for their invaluable advice on this thesis. My appreciation also goes to the
Faculty of Dentistry, University of Toronto, for providing fhding for the research upon which this thesis
was based. Many thanks to Ms. S. Deshmuhk who proof read this thesis.
My sincere appreciation goes to the Director of Dental Sentices in Durham Region, Dr. P. Main,
who provided fun& for the interviewers and other logistic supports to ensure the completion of the data
collection phase of this study. Many thanks to the staff of the Durham Region's Dental Department who
tirelessly conducted al1 interviews and especially Mrs. M. Embleton, L. Napper, and P.paquette who also
acted as recorders during the clinical phase of the study. 1 am gratefül for the support provided by the
Directors and staff members of the Municipal Homes for the Aged in Durham Region - Hillsdale,
Fairview, and Lakeview Manors. My gratitude is extended to residents of these Homes who participateci
in this study.
1 acknowledge the immense suppcic of my wife, Boun and children - Busayo, Bimpe, Bukun,
B o h - and other members of my family and friends. Finally, I thank God for strength, courage, and His
sustenance during the entire period of this program.
iii
IMPACT OF DENTAL INSURANCE ON ORAL HEALTH STATUS OF OLDER ADULTS
IN DURHAM HOMES FOR THE AGED
M Sc. (Dental Public Health) November 2001 Adegbembo, Albert O. Graduate Department of Dentistry Faculty of Dentistry University of Toronto
ABSTRACT
The purpose of this study was to describe oral health status and to assess the influence of dental
insurance on oral health. A cross-sectional survey was conducted in older adults in Durham's Regional
Homes (n=788; mean age = 81.9 years) for the Aged. Oral health status was assessed with a composite
patient-based measure. The x2. ANOVA, odds ratios, and the Cochran and Mante1 Haenszel's odds ratio
were used to assess the influence of dental insurance on oral health. 504 residents participated in the
interview and 275 completed both the interview and the clinical examination. Among interviewecl
participants 26% were in a poor oral health state (composite measure), 56% were edentulous and 28% had
had dental insurance continuously since 1974. Given the many statistical tests conducted, we found only
a tendency for the effect of dental insurance on oral health status to be modified by gender, marital status,
and residents' access to a regular source of dental care.
TABLE OF CONTENTS
ACKNOWLEDGEMENT
ABSTRACT
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF APPENDICES
CHAPTER 1 INTRODUCTION
1.1 Scope and Nature of Problem
1.2 Furpose of the Study
1.3 Demographic Change in Canadians
1.4 The Population of Durham Region
1.5 Effect of Dental insurance on Oral Health Outcomes and Detenninants 1.5.1 Effect of Dental insurance on Older Adults' Use of Dental Services 1 S.2 E f k t of Dental Insurance on Oral Health Outcornes 1 S . 3 Effect of Health Insurance on General Health Outcornes
1.6 Oral Health Status and Quality of Life of Older Adults 1.6.1 Theory of Measurement of Oral Health 1 h.2 Dental Status and Burden of Dental Diseases in Canadian Older Adults 1.6.2.1 Prevalence of Edentulism 1.6.2.2 Prevalence of Coronal and Root Surface Caries 1.6.2.3 Periodontal Status 1 h.2.4 Burden of Dental Disease on Older Canadians
CHAPTER 2 MATERLALS AM) METHODS
2.1 Data Collection
2.2 Quality Assurance in Data Collection
2.3 Sample Size Estirnates and Selection of Participants
2.4 Study Design
2.5 Data Manipulation 2.5.1 Measurernent of Outcome 2.5.1.1 Denvation of The Composite Oral Health Status Outcome Measure 2.5.1.2 The Global Rating of Oral Health Status 2.5.1.3 The Intemediate Oral Health Status Outcorne Measures 2.5.2 Measuement of Exposure 2.5.3 Measurement of other Covariates
Statistical Analysis Assessrnent of Criterion and Convergent Validity of Oral Health Measures Analyses of The Influence of Dental Insurance on Oral Health Outcornes
2.7 Study Hypothesis
2.8 inclusion/Exclusion Criteria
2.9 Ethical Approval and Informeci Consent
CHAPTER 3 RESULTS
3.1 Study Response Rates
3.2 Characteristics of Study Participants
3.3 Development of a Composite Index of Oral Health Status
3.4 Bivariate Analysis of the Effect of Model Determinants on Poor Oral Health Status
3.5 Cornparison of Residents' Characteristics By Dental Insurance Exposure
3.6 The Effect of Dental Insurance on Oral Health Statu 3.6.1 Unadj usted E ffect s 3.6.2 Adjusted Effects of Dental insurance and other Factors
3 -7 The Effect of Dental insurance of Dental insurance on Edentulism and other Clinical Outcomes
3.7.1 Bivariate Analysis of the Effect of Mode1 Detenninants on Edentulism 3.7.2 Adjusted Effects of Dental insurance and other Factors 3.7.3 The Effect of Dental Insurance on other Clinical Outcomes
CHAPTER 4 DISCUSSION
4.1 Surnmary of Study Findings
4.2 Threats to Extemal Validity
4.3 Threats to intemal Validity
4.4 Oral Health Status (Biophysical Measures) Compared to Other Ontario Studies
4.5 The Effect of Dental Insurance on Oral Health Status
4.6 Need for Future Research
4.7 Conclusion
REFERENCES 98
LIST OF TABLES
Table 1.1
Table 1.2
Table 1 -3
Table 1.4
Table 2.1
Table 3.1
Table 3.2
Table 3.3
Table 3.4
Table 3.5
Table 3.6
Table 3.7
Table 3.8
Table 3.9
Table3.10
Table 3.1 1
Table 3.12
Table 3.13
Table 3.14
Table 3.15
Table 3.16
Prevalence of coronal dental caries in Canadian older adult population
Prevalence of root caries in Canadian older adult population
Prevalence of periodontal disease in Canadian older adult population
Burden of dental disease on older adults in Ontario
Sample size determination using previously reported data
Residents' participation in the study
Characteristics of interviewed residents
Cornparison of the c haracteristics of residents who participated in both the i n t e ~ e w and the clinical examination, and interviewed residents who refused furtl~er participation afler the inteniew
Age distribution of the target population and participants at the two study levels 55
Dental status of residents (n=499) obtained from interview 55
Dental status of residents (n=282) obtained from clinical examination 55
Reliability of informat ion on resident's dentition status collected during interview
Association between perceived general and oral health statu 57
Resident's reported satisfaction (96) with three sub-scale items in oral satisfaction dornain
Ability to chew five selected food-items 58
Construction of index of chewing ability using five-food items (elirninating ability to chew fiesh carrot)
Ranking of residents by the ability to chew five food-items 60
Cornparison and association between the global rating and the denved composite index of oral health status
Convergent validity of the composite index of oral health and the global rating of oral health
Analysis of the odds of poor composite health related to cognitive status of residents controlling for age, gender, and dental status. 64
Poor oral health (composite measure) related to chamcteristics of residents 66
vii
Table 3.17
Table 3.18
Table 3.19A
Table 3.19B
Table 3.20
Table 3.2 1
Table 3.22A
Table 3.228
Table 3.23
Table 3.24
Characteristics of inteniewed residents related to a history of continuous dental insurance exposure
The effect of dental insurance exposure (uninsureci as reference group) related to oral health outcomes among residents
The odds of continuous dental insurance exposure on poor oral health status controlling for the effect of factors in the Atchison and Gift's (139) model
The odds of continuous dental insurance exposure on poor oral health status controlling for the effect of factors in the Atchison and Gift's (139) model
Consistency of trends towards a modimng effect of access to regular source of care on the effect of dental insurance on oral health status
Prevalence of edentulism related to participants' characteristics
The odds of continuous dental insurance exposure on edentulism controlling for the effect of factors in the Atchison and Gifi's (1 39) model
The odds of continuous dental insurance exposure on edentulism controlling for the e&t of factors in the Atchison and Gifi's (1 39) model
Dental status related to residents ' previous exposure to dental insurance
Exposure to dental insurance related to clinical oral health outcomes
LIST OF FIGURES
Figure 1.1
Figure 1.2
Figure 1.3
Figure 1.4
Figure 1.5
Figure 1.6
Figure 1.7
Figure 1.8
Figure 1.9
Figure 1.10
Figure 1.11
Figure 3. t
Figure 3.2
Population growth projections in Canada (Population In 1999 = Base)
Canadian age population pyrarnid in 1999 and projection for 2026
Age and gender composition of 6S+ years old Canadians in 1999
Average annual after tax income in Canada by family type in 1997
Map of the Regional of Durham
Mode1 of health developed by Locker (1 18)
Health status concepts and measures
Prevalence of edentulism and (average age) reported fiom studies conducted in independently living older adults in Ontario
Prevalence of edentulism and (average age) reported from studies conducted in institutionalized older adults in Ontario
Cohort effect on the prevalence of edentulism among older adults in Ontario
Prevalence of edentulism and (average age) reported fiom recent studies conducted in older adult Canadians
Participation of residents of Durham's Regional Homes for the Aged in this study
Proportion of residents who could not chew al1 five food items related to dental status
LIST OF APPENDICES
Appendix 2 Cover letter for informed consent
Appendix 2A Inforrned consent (substitute decision-maker)
Appendix 2B Inforrned consent (resident)
Appendix 2C interview schedule
Appendix 2D Clinical protocol
Appendix 2E Ethical Approval from the University of Toronto
Appendix 2F Approval fiom Durham Region
Appendix 2G Funding and Scientific Approval fiom the Faculty of Dentistry, University of Toronto
Appendix 2H List of Occupational and Educational Codes
CHAPTER 1
INTRODUCTION
1.1 Scope and Nature of Problem
Public health authorities have a responsibility to assess oral health status and the factors that
contribute to the oral health status of residents in their communities. Such assessrnent provides a bais for
inforrned policy development to enhance and protect the health of community residents' ( 1). The oral
health status of older adults in Durham Region Ontario has not been assessed previously. There are three
Regional Homes for the Aged in Durham. To plan for the needs of its institutionalized older aduIt
population, authorities in the Region were interested in canying out an oral epidemiological survey to
assess the oral health status and treatment needs of institutionalized older aduits in its Regional Homes.
Studies conducted in Europe and North America have repeatedly shown that dental disease
negatively impacts on the health and quality of life of older adults (2-12). Investigators consistently find
high levels of dental diseases and unmet normative dental treatment needs in older adults (2, 3, 5,6, 8, 13-
33). Those who are homebound or living in institutions are worse off (5, 6, 13, 23-27). Slade et al. (27)-
however, reported that social and demographic factors that determine institutionalization are responsible
for the high probability of dental disease reported arnong institutionalized older adults. However, only one
Ontario jurisdiction, North York, has assessed dental treatment needs (28) and dental status of the oldest-
old (28,29).
The proportion of older adults' population is growing faster than the rest of the population and the
fastest of these is the oldest old: i.e., those 80+ years of age. in most developed countries, only limited
oral health care programs are available for this cohort (13, 34-37). When clinical - normative - needs
were placed on a hierarchy, Otchere et al. (38) observeci a concurrence with the elders' subjective
perception of their own oral health status and perceived need. Yet, older adults use dental services less
frequently when compared to other age cohorts (11,23,35,39-42).
Dental insurance is an enabling factor that facilitates access to dental care (43, 44). The RAND
Health insurance Experiment showed that dental insurance improved the use of dental services and health
outcomes in families of working age in the USA (45, 46). in a cross-sectional survey in Australia that
examined the treatment provided to insured and uninsureci persons (47), insured persons received better
treatment when compared to the uninsured. The insured were more likely to have received preventive
care (OR= 1.3 7), crown and bridge treatment (OR=2.25), and endodontic treatment (OR= 1.27), but less
likely to have received extraction services (OR=0.52) when compared to their uninsured counterparts. As
in dentistry, medical insurance coverage positively influenced the use of preventive medical services
among elderly Americans (49,50).
hprovement in access to dental services should lead to lower normative needs and better
clinically assessed oral health status. In North York, the need for dental extraction or urgent dental care
was lower in those who visited the dentist within the previous year (29) when compared to those who did
not. Sheiham et al. (5 1) reported that the frequency of dental visits was positively associateâ with the
number of fùnctioning teeth and filled teeth, but was inversely related to tooth loss and the number of
teeth with active decay. However, lower need and improved dental status that can result fiom dental
attendance may not necessarily result in patients' positive assessrnent of their health status. To that
extent, it is not surprising that Cushing et ai. (52) found that the impact of dental disease on the wellbeing
of a population of industrial workers in North England was not infiuenced by dental attendance.
The effect of dental attendance on the elderly rnay also depend on the perspective used to view
the impact of dental conditions on an individual's quality of life. McGrath and Bedi (10) who viewed the
impact of dental conditions on an individual's quality of life as general (negative a d o r positive),
enhancing or detracting, reported that dental attendance within the last year - 'regular dental visit' -
enhanced the quality of life of adults in the United Kingdom (10, 53). The effect of factors - such as
dental insurance - that influence dental attendance on oral health status may, therefore, differ depending
on whether clinical or patient rated measures of oral health are used as outcomes, and also the perspective
with which dental impact is assessed.
Dental insurance is often an employment-related benefit; hence, low levels of coverage were
often reported among older adults (35, 39, 40, 41, 48). About one-fifth (21%) of Canadian seniors had
dental coverage, compared to 45-64% arnong those aged 15-64-years-old (4 1). Dental insurance
coverage is higher in the USA. Nearly half (44.3%) of those aged 65+ years old were insured in 1995
(54)-
It has been suggested that oral health programs for the elderly shouid focus on the improvement
of quality of life (13, 55-57), i.e., reduction of fimctional impainnent, disability and discornfort.
Therefore, in this study, patient rated measures of oral health are treated as end-outcomes while clinical
measures are treated as intermediate outcomes to health. The extent to which lifetime exposure to dental
insurance is capable of continuously reducing barriers to dental care, m o d i m g dental treatment options,
enabling care to be delivered, and then improving oral health status and quality of life of older adults is
unknown. Indeed, very little is known about the oldest-old (56).
Although the oral health status of older adults fiom various jurisdictions in Ontario has been
studied within the last decade (17, 18, 23, 24, 27-29), no studies have been conducted in the highly
insured Durham Region. Therefore, it is appropriate both to assess the oral health status of residents of
these Regional Homes and to use such a study to examine the influence of 25 years continuous access to
dental insurance on oral health status.
Older adult residents of Durham's three Regional Homes for the Aged are unique in their lifetime
exposure to dental insurance. At the tirne this study was proposed, about half of the 780 residents were
believed to have retired from the General Motors Assembly Plant in Oshawa. Their dental insurance
benefits extend into retirement, thus the assessrnent of the oral health status of older adults in Durham's
Regional Homes for the Aged provided an opportunity to investigate the effect of dental insurance on oral
health outcomes in the elderly. No study has been f o n d that examines the influence of dental insurance
on the oral health of the oldest-old.
The purposes of this study were to describe the oral health status of older adults living in
Durham's Regional Homes for the Aged and to examine the influence of dental insurance on the oral
health of these elders using a cross-sectional obset-vational study design.
Given the current demographic change, this thesis begins by reviewing the dernographic and
social characteristics of older adults in Canada. The characteristics of older adults in Durham are
contrasted to the rest of the province in the next section. First, the existing literatwe is reviewed to
identie the influence of dental insurance on oral health outcomes. Following this is a review of oral
health measures. This review serves as the basis for the development of a composite oral health measure
that is used as the end-outcome measure in this study. This introductory chapter concludes with a review
of dental morbidity patterns and the burden of dental disease in older Canadians.
The second chapter of this thesis presents the study design, statistical treatment of the data, and
the derivation of a composite outcome rneasure of oral health. The results of this study are presented with
respect to two oral health outcome measures in the third chapter. These outcornes are an intermediate
outcome (edentulism), and a patient-based end oral health outcome (a composite oral health index or a
self-reported rating of oral health). The effect of dental insurance on other intemediate dental outcomes
- dental morbidity measures - are presented in the concluding section of the third chapter. Finally, the
results of thîs study are discussed in the fourth chapter. implications of study findings are discussed and
the areas of fùture research needs are identified.
1.2 Purpose of t be Study
The aims of this study were, firstly, to describe the oral health status of institutionalized older
adults in Durham's Regional Homes for the Aged. This study then uses a cross-sectional observational
approach to examine whether continuous exposure to dental insurance intluenced oral health status in this
population.
1.3 Demograpbic Change in Canadians
Planning of public health seMces for the aged is a major public policy issue in this millennium.
The elderly are mostly female, medically compromised and are expected to live several years beyond
their 65'h birthday. The Report on the Health Status of the Residents of Ontario (58) showed that, despite
stable ageadjusted incidence rates of chronic medical conditions that afflict the elderly, there has been an
absolute increase in the number of people at risk. This is due to the growth in the population of those 65-
years-old and older. With the increase in the number of elderly people, the public is concerned over the
availability of services for cancer treatment, heart surgery, nming home beds, and the management of
0th- conditions related to aging. Similady, there is concern about the dental needs of the elderly. This is
because the next generation of older adults is expected to retain more of their teeth. However, many of
the teeth retained are in varying States of disrepair (3, 5, 6, 13-33) that constitute a burden to the elderly
(2, 8). Access to dental care and maintename of oral function in this cohort is a challenge to dentistry
(18,20,23,24,30,35,59,60).
The population of older adults is growing faster than the rest of the population in Canada. Data
from Statistics Canada's website (6 1-63) show that the Canadian population in 1999 was 3O,49 1,294.
This population is projected to increase by 18.7% to 36,205,300 in 2026. During this interval, 1999 to
2026, those 65-years-old and older old will grow fiom 12.4% to 2 1.4% of the population. For the oldest-
old, the increase will be fiom 2.9% to 5.0% of the entire population. Using 1999 population figures as the
base, Figure 1.1 compares of the growth of the population of older adults with the national population.
Although the base of the population age pyramid, i.e., the younger segment of the population, is projected
to become narrower, its apex composed of older people is expected to get wider (Figure 1.2).
These national trends are also reporteci in Ontario; in 1999, 12.5% of the population of
1 1,s 13,808 was oIder than 64 years (6 1-63). Ontario's population is expected to grow by 10.1% between
1996 and 2003. The national growth rate of 3.9% for those aged 65-74 years is lower than the provincial
average. The 74+ years age cohort is expected to grow faster at 32.2% (64).
This change, i.e., aging of the population, is not unique to Canada. The world's population will
age much faster in the next half-century than previously. Compared to 1950 when the average age in the
Northern Amencan continent was 29.8 years, the average age in the continent is projected to increase to
42.1 years by 2050 (65). The fastest growing segment of this population is the "oldest-old", Le., those
80+ years old (66).
Figure 1 . 1 Population growth projections in Canada (Population in 1999 = Base)
Canada - AI1 Ocanada - 65+
and over
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
Base years: 1999 (Population = 30.4 Million)
Figure 1.2 Canadian age population pyramid in 1999 and projection for 2026
3 .O00 O 1,000 2,000 3,000
Population * 1,000
7
The oldest-old age cohort, as in most western societies (66), is composed mostly of females. For
this oldest-old age cohort in Canada, there were 100 males to 190 females in 1999. The age and gender
composition of older adults is presented in Figure 1.3. h i e to improvernent in Canadian male's life
expectancy, this ratio is estirnateci to rnarginally increase to 100 males to every 160 females in 2026 (63).
Figure 1.3 Age and gender composition of 65+ years old Canadians in 1999
90 and over 1
2
Population * 1,000
For the curent oldest-old age cohort, access to dental insurance is expected to be a major issue
since women's participation in the labor market is generally less than that for their male counterparts. If
dental plans do not cover spouses of deceased beneficiaries, then women in this age cohort will have a
poor level of dental insurance coverage when they become widowed.
The following section reviews health expectancy and some health-related risk factors. Income is
related to access to dental insurance. Compared to the lowest and lower middle income brackets,
Canadians in the highest household income brackets were 7.4 times more Iikely to have dental insurance
coverage (4 1). Incorne is also an important determinant of dental status. Locker and Leake (67) observed
that income was related to edentulism, reponing of hctional limitation and subjective assessment of oral
health among dentate 5 0 t years old Ontarians; but not among the edentulous. Therefore, the unattached
elderly who have poor incomes may be expected to be disadvantaged.
For elderly Canadian families, the average annual income afier tax, measured in 1997 constant
dollars, was stable between 1993 and 1997. NevertheIess, as seen in Figure 1.4, the average income of
elderly farnilies ($37,124) was less than that for non-elderly families. Unattached elderly had nearly half
the income of other elderly persons and their income was less than that of unattached non-elderly persons.
For every family type, the elderly earned less in 1997. Arnong the elderly, unattached elderly females
who earned $16,8 1 1 in 1997 were financially worse-off when compared to unattached elderly males (68).
Figure 1 -4 Average annual income (a fier tax) in Canada by family type in 1 997
families unattached unattachecl male unattacheci female
Family type
Nevertheless, based on Statistics Canada's Low Income Cut-off (1992=Base Year), the
proportion of Canadians and, indeed, older adults, who had low income deciined in 1 997. In 1 993, 1 8 .O%
of Canadians had low income compared to 17.5% in 1997. For the elderly, the figures for the 1993 and
1997 were 22.5% and 18.7%, respectively. Fewer oIder aduits in families had low income: 8.7% and
5.9% for the respective years. When an elderly person becomes unattached, the prevalence of low
income increased rapidly: 5 1.9% and 45.0% among those aged 65+ years old in 1993 and 1997,
respectively. Compared to 1993, however, the absolute number of unattached elderly increased by 4.1%
in 1997 (68).
Oral health status observed in the elderly may be confounded by health-related behaviors.
Smoking is a determinant of oral health status and it is direçtly associated with tooth rnortality (69-71).
Between 1996 and 1997, 12.3% of Canadians aged 65+ years smoked. In Ontario, 10.9% of older adults
smoked (72). Elderly Canadians who reported drinking alcoholic beverages at least once a month was
58.7 percent. Older adult men smoked and drank alcoholic beverages more frequently than their fernale
counterpart s (72).
Arnong the elderly, especially those residing in institutions, access to dental services is of great
concern (48, 73-75). Prevailing complicating medical conditions may limit access to dental care even
when income and other economic-related barriers to dental care are not limiting factors to care.
Functional disability is common in old age, including aged Canadians (76). Info-Age (77) reported
disability in Canadians using, as indicators, limitation in the ability to perfonn five fùnctions. The fmt
indicator was the ability to see well enough to read ordinary newsprint with or without glasses or contact
lenses. The next indicator was the ability to hear what is said in a conversation with one other person in a
quiet room, with or without a hearing aid. Other indicators that were used were: the ability to speak
comprehensibly with those well known to the elderly, the ability to walk around the neighborhood
without mechanical support such as braces or a cane or crutches, and the ability to grasp or handle srna11
objects such as a pencil or scissors.
The number of individuals who had expenenced disability in at least one of the five functions
increased with age, rising steeply afier the age of 75 years. Between the ages of 65 and 69 years, 7.7% of
males and 13.2% of females were unable to perforrn at least one of the five fûnctions. Disability in one or
more fiinctions increased to 46.4% in males and 56.3% in females aged 85+ years. Two or more
disabilities occurred in 12% of persons 85+ years old; this is four times the rate for those aged of 75 and
79 years and nearly ten times the rate reported among those who were between the ages of 65 and 69
years (77).
Cognitive impairment increased fkom 1.7% in 65-69-year-old subjects to 9.1% in Canadians 85
years old and older. Cognitive impairment and at least one of the five physical disabilities occurred in
one of every 200 Canadians aged 65-69 years. By the age of 85 years, the rate had risen to over five in
every hundred (77). In Ontario, those who needed assistance with the five activities of daily living (ADL)
- housework, shopping, heavy chores, preparing meals, and moving around in the house - also increased
with age. Furtherrnore, one in every twenty (4% male and 5% female), required assistance with ADL
between the ages of 20 and 24 years, compared to more than a third (34% fernale and 50% male) by the
age of 75 years (58). Therefore, it was expected that the study population was mostty fernale, became
poor when widowed, suffered some degree of kct ional disability, and had cognitive impainnent.
1.4 The Population of Durham Region
Durham Region is in Ontario's Central East Planning ara (Figure 1.5). The demographic
composition of the population in Durham Region is different from the rest of Ontario. It was therefore
dificult for Authorities in Durham Region to generalize previous findings in North York (28, 29) to the
Region, hence the need for this study.
The population of the Region at July 1, 2000, was 502,708. The population-planning target for
201 1 in Durham is between 590,000 and 620,000. It is projected that the population will increase to
760,000 in 2026, an increase of 51% over cunent population figures. Nearly ten in every hundred,
compared to 13% for the entire province, are older than 64-years-old. As in the rest of the province,
about one in every four older adults lives alone (78, 79).
Residents of Durham are richer and predorninantly Engiish-speaking compared to other
Ontarians. The average family income in Durham was $64,940 compared to $59,830 for Ontarians.
Females and males in Durham had average annual incomes of $22,329 and $37,646, respectively. The
respective incomes for Ontarians were $2 1 ,048 and $33,599. A significant majority - 94% - of residents
had EngIish as their fmt language compared to 82% for the province. Nearly a11 (96%) residents in
Durham Region have Canadian citizenship - 4% more than the provincial average.
Durham Zer;",on (79)
Less than a third (30% in Durham versus 33% in the entire province) of the population did not
complete high school. Half of the residents of Durham - 7% above the provincial average - compkted at
least a high school education. Residents of Durham who had completed at l e s t a universiîy education
were less than the provincial average: 19% had at ieast a university education in Durham, compared to
24% in the province (78).
General Motors has an assembly plant in Oshawa, and rnany residents in Durham's Regional
Homes for the Aged retired fiom this auto plant. The plant introduced dental insurance as a part of its
employment benefits in 1974, and this benefit extends to spouses and widows past retirement. Therefore,
given their current age, some residents would be expected to have had access to dental insurance
continuously fiom their mid to late 50s. This unique population provides an opportunity to study the
long-term effects of dental insurance on oral health status of the elderly.
There are three Regional Homes for the Aged in Durham: Hillsdale (population = 4 3 3 , Fairview
(population = 198) and Lakeview (population = 147). According to authorities in Durham Region, most
of the residents are over 80-years-old, and the average age in the Homes is about 84-years-oid. Most
residents are fernale and might have had access to dental insurance through a retired spouse. The average
length of stay in these institutions is about two years. Staff of the Homes reported that about half of their
residents have dental insurance. Most of those with dental inswance reside in Hillsdale in urban Oshawa,
whereas those without dental insurance were expected to reside mostly in Lakeview Manor, which is
located in Brock Township, a more rural area about 100 kilometers north of Oshawa.
Staff of the Region's Dental Department provides training in oral health education for staff of the
Homes. No dental c h i c was Ioçated in any of the three Homes; however, "Golden Care" a private
dental-care organization, provides residents with initial oral assessrnent and dental care when required on
a fee-for-service basis. Residents rnay also visit their own dentists. In this population of older adults,
non-financial baniers may still limit access to timely dental care especially if working farnily members
have to find the time to accompany the resident to a dental office.
This study was limited to the Regional Homes because of administrative reasons. Aiithorities in
the Region have a duty to plan for the needs of residents in its Homes for the Aged. This study was
therefore initiated by the Dental Division of the Health Department in Durham to meet its public health
mandate for assessrnent and assuring care for the Region's direct wards. Private Homes for the Aged are
not controlied by the Region
1.5 Effect of Dental insurance on Oral Health Outcornes and Determinants
One of the aims of this study was to examine the impact of dental insurance on the oral health
status of older adults. This section presents a synopsis of the documented effect of dental insurance on
oral health outcornes and detexminants, with special emphasis on the elderly.
1.5.1 Effect of dental insurance on OIder Adults' Use of Dental Semces
Prior to the 1980s, the relationship between the utilization of dental services and age was
generally believed to be an inverse 'U'; use of dental services peaked in late teenage years. More recent
studies which involve broad age groups and did not control for dental status still showed that the use of
dental s e ~ c e s increased to a peak among youths and young adults; thereafier, dental services utilization
declines with age (40,4 1, 80-85). Data from the National Population Health Survey showed that 59% of
Canadians 15-years-old and older visited the dentist within the last year compared to 40% among seniors.
Using seniors as the reference group, the odds of having visited the dentist within the last year increased
with decreasing age: OR = 2.2 among 55-64-years-old; OR = 4.0 among those who were 15-24-years-old
(41).
The review by Leake (23) and Leake and Otchere (24) reported that older adults who had visited
the dentist within the last year ranged from less than 10% among institutionalized older adults in Prince
Edward Island to 60% in a younger independently living cohort in East York, Toronto. However, most
studies reported that about 30% of older adults had visited the dentist within the past year (23,24). More
recently, Slade et al. (17) reported that 15.3% of 65-74-years-old and 3.0% of older adults 75-years-old
and older who lived independently in Ottawa-Carleton Region, Ontario, had visited the dentist within the
last year. Locker et al. (86) classified 66% of dentate adults 50-years-old and older in East York
(Toronto) and 65 years and older 1 iving independently in Ottawa-Carleton (Ottawa) as regular attendees:
i.e., those who made at least one visit within the last year to the dentist and also had a regular source of
dental care. Only 2% of the edentulous were classified as regular dental c h i c attendees. Overall, 53.5%
had visited the dentist at least one year prior to the study. In a separate study involving four Ontario
communities - Toronto, Sudbwy and districts, North York, and Simcoe - Loc ker et al. ( 1 8) reporteci that
66% of al1 independently living 50-years-old and older had visited the dentist within the last year.
There are both economic and non-economic barriers to older adults' use of dental services.
Findings fiom cross-sectional dental surveys showed that there were significant differences between
income levels of older persons who did or did not use dental senices fiequently (39,40, 74, 87, 88). in a
very limited sample of older adults, Strayer (89 j reported that finance was the most important barrier to
elders' receipt of dental care. Nearly a third (32%) of homebound and 40% of non-homebound older
adults cited finance as the most important barrier to oral health care. The order of importance of finance
as a barrier to dental care receipt by the elderly was variable. Other studies have ranked f m c e , though
at varying levels of importance, as one of the barriers to dental care utilization by the elderly (60, 74, 84).
In examining econornic barriers in the receipt of dental care by the elderly, Kiyak (74, 85) stated that the
difference between users and non-users of dental senices could not be explained by the income
di fference alone.
Though income may be significantly correlated with the use of dental services in the elderly, a
review of the baniers to dental care in this cohort reported that availability of fiee or reduced-cost dental
services only increased utilization slightly (74). Yet, others have reported that insured persons were
likely to use dental senices more fiequently when comparai to their uninsured peers (39, 40, 48, 88).
Barenthin (90) reported an increased use of dental services by the edentulous elderly two years after the
introduction of the Swedish National Dental Insurance Plan. The elderly in Alberta have continued to use
the Provincial Dental Plan for the Elderly (9 1, 92).
Nevertheless, Evashwick et al. (93) were unable to demonstrate any independent effect for dental
insurance or income on the use of dental seMces by the elderly. Conrad (94) reported that the use of
dental services by the elderly did not respond to price changes. Kiyak (87) examined the effect of dental
insurance on the use of preventive versus ernergency care, use versus non-use of low-cost dental service,
and use of private versus public dental services in elderly in SeattleJKing area of the USA. She was also
unable to demonstrate any independent effect of dental insurance on dental visiting. Using a multivariate
analytic approach with many principal factors in the model, Wilson and Branch (95) reported that factors
other than socio-econornic factors predicted the use of dental services by the elderly.
In North York, Ontario (29), among those 85-years-old and older, dentate older adults always
visited the dentist more fiequently than their edentulous counterparts did. Hawkins et al. (29) reported
that 31% of dentate nursing home residents visited the dentist within the last year compared to 12%
among the edentulous. Those who lived independently used dental service more fiequently, especially
the deiitate group. The proportions for independently living adults in the study were 47% for the dentate
and 13% for the edentulous.
Multivariate analysis of the factors that influence the use of dental services by the elderly has
shown that dental status is an important confounding factor. Holst (80) obsewed that the influence of age
on the utilization of dental services was modified by other factors. Declining use of dental services by the
elderly in the study was due to the increasing number of edentulous people in older age cohorts. That
dentate older adults use dental services as fiequently as the younger cohorts is evident in the report that
the proportion of dentate adults 35-years-old and older who visited the dentist within the last 12 months in
1989 in the USA was comparable across ages (40). Similarly, the proportion of older people who made
regular ~Iisits to the dentist did not decline when edentulous people were excluded or controlled in
subsequent analyses (48, 80, 85, 86, 87, 96). Bullen (85) reported that dentate older adults in Ontario
uscd dental services in a sirnilar way to the rest of the population.
Some researchers have argued that, in old age, economic barriers become less important when
compared to other barriers to care in the elderly. These other barriers would include: non-economic
barriers such as the lack of perceived need for care, difficulty in moving around, and difficulty in fmding
information about where to receive care. Health care professionals are also unaware of the needs of older
adults (48, 73, 74, 86, 87, 93, 95, 97, 98). The major reason that older adults did not visit the dentist
regularly was the individuals' lack of a perceived need for dental care (23, 48, 73, 74, 83, 84, 56, 87, 93,
95, 97, 98). On the other hand, a study in USA veterans eligible for Veteran Administration Care
reported predisposing characteristics (dentate status, usuai reason for dental visits, and the importance
placed on oral health), and enabling determinants (current source of dental care, and having a regular
source) as the major determinants of use of dental services (99).
That older adults now experience non-economic baniers that limit access to dental care does not
preclude older adults fiom having residual benefits fiom good access when they were younger. Whether
those benefits, if any, persist into latter years is unknown.
It is presumed that those who visit the dentist regularly will have their dental treatment needs met
promptly and, thus, enjoy good oral health. However, the dental status of regular dental clinic attendees
has not necessarily been better than that of irregular attendees. Lang et al. ( 100) reported that those who
made periodic dental visits had better periodontal health when compared to those who visited the dentist
irregularly. Sheiham et al. (5 1) reported that fkequent dental visits help to postpone tooth loss and
maintain dental function. Similarly, regularity of dental visiting was not significantly related to levels of
attachrnent loss - advanced periodontal disease (101, 102). On the other hand, dental caries (coronal and
root) and high levels of unmet dental treatment needs were prevalent in a group of 79-101 years old
dentate Iowans, three-quarters of who had visited the dentist within the last year (103).
Unequivocal evidence of the effect of dental insurance on oral health status can only be obtained
fiom a randomized controlled tnal. Searches conducted in Medline and Healthstar ( 1975 to May 200 1)
on dental insurance, utilization of dental services and dental visits, yielded only one randomized control
tnal - the RAND Health Insurance Experiment (45, 46). Study families were enrolled fkom six sites in
the USA. Participat ing families were randoml y assigned to four di fferent CO-insurance schemes: 0% (free
scheme), 25%, 50%, or the 95% CO-insurance scheme for al1 health services.
The RAND study excluded the following groups: those with a household head aged 62 years old
and older, those with family incornes in excess of $57,000 (1984 dollars), those eligible for Medicare
disabilities, those in jails, those institutionalized in long-term hospitals, those in the military, and those
with services-related disabilities. Manning, et al. (46) reported that the utilization of dental services
increased significantly as the generosity of coverage increased fiom 95% CO-insurance to the fiee plan.
When visits by enrollees were disaggregated, the probability of any use of prosthodontic treatment was
the most responsive to the plan coverage. Household income influenced the use of dental services on
measures of probability of any use, number of visits, and annual expenditure. The response to cost
sharing was greater for the low-income than the hi&-income groups. Dental expenditures, on the other
hand, were less responsive to household income.
To examine the effect of dental insurance on the elderly, results of observational studies on
publicly h d e d insurance programs for the elderly provide trend data. Lewis and Thompson (91. 103),
and Thompson and Lewis (92) reported on findings from a cross-sectional analysis of insurance records
in Alberta, Canada, using historical controls and a cohort analysis. The province of Alberta operates an
extended health benefits dental plan that began in 1973. The aim of the plan is to provide affordable and
accessible dental services to spouses and dependents of Alberta residents who are 65 years old and older.
In 1983, the plan's age coverage was broadened to include the near elderly, i.e., those between the ages of
55 and 64 years. It was estimated that 85% of those who were eligible to participate were 64 years old
and older. The plan is funded entirely by the provincial government, and dental benefits are broad in
scope; major dental services are covered by the plan.
Senices can be obtained from licensed dentists or denturists in Alberta. Nearly al1 (90%) of the
practitioners in the province participate in the program. Payment for services provided is based on the
Alberta Dental Association Fee Guide. The amount that could be paid on behalf of each program
recipient was limited. Other limitations of the universal plan included the number of denture
replacements or reline within a given tirne interval. Orthodontie services require prior approval.
At inception in 1973, 38% of eligible plan members utilized the plan. A review between 1974
and 199 1 reported an increase in plan usage tiom 27% in 1974-75 to 44% in 1990-9 1. During these
periods, the mean number of visits increased from 4.9 to 6.9 (91). Younger cohorts had a 24% higher
plan usage than older cohorts (104). The demand for denture services has also increased at nominal
increase in cost to the provincial governrnent (105). There is a shift in the pattern of plan usage by the
elderly, as more plan users now use the services for preventive care (103). Given the continuity of plan
usage, Thompson and Lewis (103) concluded that the elderly in Alberta did not under-utilize dental
senices.
National Dental Insurance was introduced in Sweden in 1973 and the plan began to operate fully
in January 1 974. The plan paid 50% of cost of services for al1 citizens, and higher payrnents were made
for those who incurred very high costs (90, 106). A before-and-after evaluation of the effect of the plan
showed that the edentulous increased their use of dental services one year afier plan initiation (90).
Subsequent evaluation of the Swedish national dental health insurance program showed that the
use of dental services increased among Swedes 65-years-old and older between 1976 and 1984, especially
arnongst females (106). It would appear that the demand for prosthodontic services is highly sensitive to
dental insurance (46, 90, 104), and the low usage of dental services by edentulous elders may be a result
of dental insurance coverage limitations on prosthodontic services.
1.5.2 Effect of Dental Insurance on Oral Health Outcornes
The positive effect of dental insurance in reducing economic bamiers to care is only of public
health signi ficance if it resutts in an improvement in clinically defined oral health status and quality of life
of insured persons. The RAND Health Insurance Experiment (45) reported the following positive effect
on dental status of enrollees; those on the free plan had fewer decayed teeth at the tirne of exit fiom the
study. Compared to those on the 95% CO-insurance plan, those on the f?ee plan aged 12-17 years and 35-
64 years had 1.4 and 0.3 fewer decayed teeth, respectively. Except for those 35 years old and older, these
differences were statistically significant in al1 other age groups. The results for filled teeth were generally
the opposite for decay findings; i.e., those on the more generous plans had more filled teeth when
compared to those on plans with higher CO-insurance rates. Teenagers from low or average income
families with high baseline periodontal disease had an irnprovernent in their periodontal condition if they
were on the fiee plan. No significant plan differences were reported for missing teeth, although a
tendency was observed for children aged 12 to 1 7 years, on the 50% and 95% plans to have more rnissing
teeth when compared to their counterparts on the fiee plan. Enrollees who were 35 years old and older
showed few plan differences on ail oral health outcornes.
Bailit, et al. (44) concluded that: "that reducing cost sharing for dental services will improve oral
health for those younger than age 35 years and especiaily for subgroups of the population with the poorest
oral health". Nevertheless, the authors (44) cautioned that the duration of the study was short, giving very
limited time for dental diseases and treatment effects to become evident.
However, among the elderly, data fiom the Mortality Morbidity Weekly Rtport (107) showed
that uninsured 65 years old and older adults in the USA were more likely to be edentulous when
compared to their insureci counterparts. This data is based on the Behavioral Risk Factor Surveillance
System, a system that uses telephone interviews to obtain trend data on risk exposure among non-
institutiondized Americans. The prevalence of edentulisrn was 9% higher among the uninsured. Trend
analysis of Swedish data showed that dental insurance contributed to part of the improvement in dental
status of Swedes. The proportion of persons with teeth in good condition, i.e., few or no fillîngs, had
increased afier 1974. Age-specific analysis showed the highest impact in older cohorts (109).
1.53 Effect on Health Insurance on General Health Outcomes
As in dentistry, researchers working in general medical health have also assessed the impact of
health insurance on health, using biophysical measures - morbidity, s u ~ v a l and mortality-based indices
- and indicators of access to care rather than its impact on quality of Iife. In a representative sarnple of 25
years old and older Americans, Franks et al. (1 10) reported that health insurance had an independent
effect on mortality. in a separate study, Sorlie et al. (1 11) reported that those without insurance had a
higher mortality rate than those with employer-provided insurance afier a 5-year follow-up. Balli et al.
(1 12) reported that health insurance was an independent predictor of survival in ovariôn cancer patients.
Older Americans with supplemental private insurance increased their risk of mortality as out-of-pocket
expenses increased ( 1 1 3).
However, Roetzheim, et al. (1 14) reported that health insurance did not have an independent
e f k t on survival arnong patients with breast carcinoma once the stage of diagnosis was controlled in the
analysis. Nevertheless, access to preventive care, including cancer screening, routine checkup, a regular
source of care, and stage of cancer diagnosis al1 depended on health insurance status (49, 50, 1 15, 1 16).
Wfiether or not the impact of insurance continues into later years of life, especially at 80+ years, and in an
oral health setting, needs to be examined. This will assist policy rnakers to identim the extent to which
the uninsured elderly are likely to be burdened by the lack of dental insurance.
1.6 Oral Health Status and Quality of Life of Older Adults
The impact of insurance on health should be examined within a broader definition and concept of
'health'. The World Health Organization (1 17) defined health as 'a state of complete physical, mental
and social well-being and not the absence of disease and ifiITnity'. Given this definition, Locker (1 18)
described a conceptual framework for the measurement of oral health. This hmework builds on health
measurement literature where health is defined in tenns of an eclectic set of characteristics of the
individual: functional capacity, disability, pain and suffering, and cognitive and emotional States.
Measures of health - especially oral health - based on this approach must identim dornains
(concepts) and categories of health that need to be considered in conceptualizing health as a constnict
(1 19). Locker (1 18) used such a framework to develop a conceptual model (Figures 1.6 & 1.7). This
model links the biological level of disease fmt to behavioral and, finally, to social levels of health.
Figure 1.6 Mode1 of oral health developed by Locker (1 18)
Deaîh
Disease --O Irnpainnent limitation
Discomfort
Figure 1.7 Health status concepts and measures
Biop bysical Death Disease
Self report Clinical diagnoses
impairment Functional limitation
Sociolmedical Discomfort
Disability Physical wellbeing
Activity restriction Limitations in social roles
Psychological wellbeing Affective states Cognitive states
Social wellbeing Integrat ion Social contacts Intimacy
Disadvantage inequolity of opportunity
Deprivation
Dissatisfaction
DEFINITION
Mortality rates, life expectancy, potential years of life lost.
Listings of diagnoses/medical conditions Diagnoses found on cl inical examination Extent of anatomical loss or structural abnormality Extent of loss of function of body parts or systern
Self-reported physical and psychological distress, including pain and other feelings or states not directly observable
Acute/cb~onic restriction in physical ADL Acute/chronic problems in work, school, household management & recreation
Emotional states, anxiety, and depression Problems in concentration reasoning
Participation in cornmunity life Lntegration with family & friends Perceived feelings of closeness/support
Lack of access to social opportunities, including careers, ducat ion Inequality of outcornes in terms of income, self-image & self- esteem With health a d o r overall quality of life
Locker ( 1 1 8)
The editorial by Heath (55) re-iterated this model in a structure for defining oral health outcomes
in the elderly. It was proposed that disease (dental caries) lead to handicap (poor self-esteem/loss of
pleasure/dietary select ion) t hrough disabiiity (aesthetic or c hewing loss) and Unpainnent (tooth/occlusal
loss). The Oral Health Impact Profile - OHIP (7, 120, 121) is based on Locker's ( 1 18) model. The OHIP
(120, 12 1) is a more comprehensive measure of oral health that is based on scores derived from seven
domains or conceptual dimensions of oral health.
1.6.1 Theory of Measurement of Oral Eeaith
Cushing et al. (52) identified four areas where dental conditions can impact on an individual's
oral health: function (eating), social interaction (communication), cornfort and wellbeing (pain andior
discomfort), and self-image (aesthetics). A score of 1 was given when there was a positive response to
any of the items in the four or five areas (when discomfort was treated as a category), giving a total
maximum impact score of 4 or 5. Measwes of oral health, 0 t h than the OHIP, that are based on the
concept of healt h beyond the biophysical ievel, include the Geriatric Oral Health Assessment Index
( G O W ) developed by Atchison and Dolan (122), and the Oral Health Related Quality of Life (OHQoL)
measures developed by Kressin et al. (9).
These oral health indicators involve items derived over many domains of oral health. For
example, the OHIP measures oral health on seven domains using 49 items: functional limitation, physical
pain, psychological discomfort, physical disability, psychological disability, social disability and
handicap (120, 121). A reference population was used to derive weights for the items within each
dornain. Convergent validity was tested against responses to 12 questions based on Cushing et al's (52)
study.
The GOHAI (122) is based on 12 items derived from a 36-item pre-tested instrument and
consultation. The domains included in GOHAI were physical fùnction (eating, speech and swailowing)
and psychosocial f'unction (concem, satisfaction with appearance and avoidance of social contact, and
pain or discomfort). Assessment of the structure of GOHAI showed that it is based on two factors (9,
123). Constmct validation was tested by correlation of GOHAI to number of teeth present, a self-rated
measure of oral health, and chewing ability. GOHAI scores are surnmary scores over al1 the 12 items
( 122).
The 49-item OHIP questionnaire and the GOHAI are inappropriate for some individuals, e.g.,
children or persons with reduced language or cognitive skills ( 120, 122). Consequently, these instruments
are of limited use in this study population. Slade (12 1) produced a 14-item version of the OHIP (OHIP-
14) that considerably reduces fieldwork t h e and burden of interview on respondents; this is yet to be
tested in other populations. As with Cushing et al 's (52) index, scoring for these indexes: OHIP- 14,
OHIP-49, and the G O W were based on summation of domain scores ( 120, 12 1, 122).
Rosenberg et al. (124) developed a 25-item Dental Functional Status questionnaire. The
questionnaire is based on the following three dornains: 1) Self-care, referring to the ability to bmsh and
floss; 2) Mechanical ability, descnbing limitation to an individual's ability to speak, open the mouth, and
consume different types of food due to pain or inability to chew; 3) Ability to perfom the psychosocial
role, assessed by embamassment, make persona1 contacts with others, and lack of confidence due to the
condition of the teeth. The oral health score was also a sumrnary of scores over al1 25 items.
Most of the aforementioned indices generally used struc~ired questions to generate oral health
assessrnent instruments. Item reduction and necessary modifications were carried out on a pool of items
in order to develop a set of items that are used in the final instrument (55, 120-122).
In light of the lack of consensus on the definition of oral health-related quality of life index
construction, McGrath & Bedi (10) changed the theoretical base to a hermeneutic approach. This
approach argues that the interpretation the individual gives to his or her health status is most important.
Therefore, starting from the patient, both researchers obtained 10 dornains after a panel of experts recoded
ari open-ended questionnaire administered to older people. These domains were eating, discornfort,
appearance, carefiee manner, general wellbeing, confidence, speech, mood, socializing, and others
(smiling or laughing, ability to do usual jobs, finances, sleep/relax, personality). Each of these domains
was treated separately during analysis, and it was observed that dental conditions had both positive and
negative impacts on oral health.
Locker and Miller (125) descnbed a battery of items based on eight dornains of oral health. The
following domains were included in the subjective oral health indicator: ability to chew, ability to speak,
oral and facial pain symptoms, other oral symptoms, eating impact scale, communication and social
relations impact scale, activities of daily living impact scale, and worrykoncem impact scale. Concurrent
validation was tested against a global assessrnent of oral health and satisfaction with oral health status.
Constnict validation was tested with other dental status measures and the remaining nwnber of teeth.
Discriminant validity was assessed by examining the ability of the index to differentiate between groups
hypothesized to experience different impacts.
Other indices for measunng oral health using patient-rated oral health indicators were described
in the surnrnary of the proceedings on various conferences on quality of life measures in oral health (126-
28), and the review by Corson et al. (129). Saunders et al. (130) developed a 56-item oral health quality
of life inventory. This encompassed oral health, nutrition, self-rated oral health, and overall quality of
Iife. Kressin et al. (9) developed an instrument based on 3 items that covered the dimensions of daily
activity, social activity and conversation. The domains capturai in the 9-item oral impact of daily
performance descnbed by Adulyanon and Sheiham ( 1 3 1 ) were performance in eating, speaking, oral
hygiene, sleeping, appearance, and emotion. The Dental impact of Daily Living @DL), based on 36
items, covered five domains of oral health. The Dental Health Status Quality of Life Questionnaire @S-
QoL) was derived fiom a generic measure and the EQ-SD was based on five domains, each of wkch was
divided into three levels. Locker et al. (134) have recently combined the self-rating of the oral measure of
oral health with five other oral health status indices - a six-item index of chewing, a nine-item pain
inventory, a 13-item inventory of oral symptoms, and 15-item psychosocial impact scale - to assess oral
health. Finally, the OIDP was based on a conceptual mode1 that assessed the impact of oral health on
seven daily tasks (129). The conference proceedings on "Using oral quality of life measures in geriatric
dentistry" also descnbed the D-E-N-T-A-L screening instrument ( 127).
A global self-rating of oral health has also been used to measure study participants' oral health
status. Respondents are asked to rate their oral health fiom poor to excellent on a 5-point Likert scale.
Matthias et al. (132) used this approach in Los Angeles whereas Dolan et al. (133) used this approach to
study change in oral health among dentate elderly adults in Santa Monica, California. The global rating
was also used as the criterion to validate other composite, and more complex, measures of oral health (9,
52, 125, 132-136).
Rowan (135), in a review of the assessment of global rating in general health with complex
system-specific measures of general heahh status, pointed out that global measures provide infoxmation
that, at the very least, is consistent with that derived from the more complex methods of assessment.
Nevertheless, the global rating of health status obscures information at an individual system (domain)
level. it suffers from a limitation referred to as 'end' effect; this is the tendency of health measures to
identify only people at the extremes of health. Compared to comprehensive health status instruments, the
global rating is stated to have less explanatory power (135).
As can be obsewed Erom above, many measures have been developed and the area is still
growing (1 37). The indices are related, and measure different aspects of study participants' health status.
Dolan et al. (136) conducted a principal component analysis arnong and between items of general health,
mental health, social health, general health, and oral health status indices; the authors concluded that oral
health represented a related but separate dimension of health. Using a similar approach, Kressin (123)
studied the relationships between the OHQoL and the GOHAI, as well as with the SF-38 - a short
measure of an index of general health status. She observed a stronger correlation between SF-38 and both
oral health measures, GOHAI and OHQoL, suggesting that these measures were related to different
dornains of health. The correlation between GOHAI and OHQoL was only 0.25, showing some degree of
independence between these oral health indices.
The relationship between patients' assessment of their oral heaIth status with use of dental
services, income and dental insurance are inconsistent. Dolan, et al. (136) reporteci a weak, but
significant, correlation between the dental health index and income. The sociodental indicators of the
social impact of dental disease developed by Cushing, et al. (52) showed that dental impact was not
affected by dental attendance. The GOHAI was reportedly correlated with income (9, 122). Locker et al.
(86) found that dental insurance did not have an independent effect on dissatisfaction with the oral health
status of elderly Ontarians. Apart fiom functional limitation, dental attendance was significantly related
to al1 other domains of oral health in the OHIP (7). McGrath and Bedi (10, 1 1) had also reported that oral
health status of those who had visited the dentist within the last year was enhanced. In another study, it
was observed that both income and dental insurance were independently related to OHIP scores in
Ontarians 50 years old and older (138). However, Atchison and Gift (139) could not demonstrate a
consistent independent effect for al1 65+ years old subjects tiom every ethnic background.
1.6.2 Dental status and Burden of Dental Diseases in Canadian OIder Aduïts
For this study, a MEDLINE search of studies reported between 1966 and May 2001 was canied
out on the following search terrns: oral health status, and Canada. The yields fiom the searches were then
combined and limited by age (65 years and older) and type of study (review articles). Of the seven
reviews found, two (23, 24) provide relevant data on dental status of the elderly. The following section
presents an update of these reviews.
1.6.2.1 Prevalence of Edentulisrn
Figure 1.8 presents findings fiom the reviews related to independently living older adults.
Using a method simiiar to Leake's (23), we estirnated the average age of participants in the more recent
studies. Leake (23) had calculated the average age of study participants fiorn the reported age distribution
of participants, assuming equal distribution of participants in each class interval. When the average age
of study participants was about 60 years, an 18% decline in edentulism was observed, i.e., from 42 to
24%.
For studies with participants' aged, on average, 70 years in 1969- 1976, the rate of edentulism
varied between 67% and 74%. The rate of edentulism reported in shidies, that are more recent and with
participants of sirnilar average age, range from 35% to 59%. The prevalence of edentulism reported by
Figure 1.9. Prevalence of Edentulism and (average age) reported fiom studies conducted in institutionalized Older Adults in Ontario
Study Location 1 1 Studies Conducteù Between 1977 - 1998
NorthYork-a 1 1 (90 Yrs) -1
NorthYork-b -
Waterloo - c -
Scaborough - d
- Ontario - f
- Kenora-R.R. - g -
East York - h -
-
-
-
Toronto - m 1 1 I 1 I I I l 1 I , I
l I I I I 1 I 1
: 1 (79Yrs)
' 1 (Not Reported)
> 1 (84 Yrs)
r j (8 1 Yrs) (80 Yrs '
*,
Studies Conducted Between 1969 - 1976 -
Chatam-j - London - k -
Percent Edentulous
(8 1 Yrs) ' 1
(80 Yrs) , (77 Yrs)
Sources: a - Hawkins et al. (29); b - Murray et al. ( 147); c - Adams (1 48); d - Ellis et al. (14 1); e - Johnston (149); f - Ryan (1 50); g - Armstrong (1 5 1); h - Leakz and Howley (152);
j - Martinello ( 153); k - Martinello and Leake (1 53); m - Lightman, et al. ( 155). Updated firom Leake (23):
To estimate the year of birth of the study cohort, the average ages of participants in the studies
were subtracted fiom the year the study was conducted. By plotting the rates of edentulism reporteci in
these studies against the year of bhth of the study cohort, the decline in edentulism becomes more evident
(Figure 1. IO). Given the cnide way the year of birth of study cohort was estimated, a wide variation is
expected around the trend lines. Even so, the declining trend in the prevalence of edentulism in both
independently living and institutionalized older adults in Ontario is evident. The decline became marked
and steady from the 1905+ birth cohorts.
Figure 1.10 Cohort e f k t on the prevalence of edentulism among older adults in
5 yrs moving average (Collective Living Center)
- 5 yrs moving average (Independent living)
Cohort's Year of Birth
Figure 1.1 1 Prevalence of edentulism and (average age) in recent studies conducted in older adult Canadians
Shidy independently Living Older Adults 1 Ontario - Fig. 1.8 1-i
~ a t i o i l - h 1: (65+
Quebec - g 1 1 (71 Yrs)
1 institutionalized Older Adults
Ontario - Fig. 1.9 1 1 Nova Scotia - e 1-477 Yrs)
P.E.I. - c 1 (86 Yrs)
- Alberta - d
30 40 50 60 70 80 Percent Edentulous
(83 Yrs) ;
a - MacEntee et al. (156); b - MacEntee et al. (157); c - Jackson & Romcke (158); d - Kuc et al . (159); e - MacInnis et al . ( 160): f - Knazan (161); g - Simard et al. (162); h - Charette ( 163).
Updated firom Leake (23)
Figure 1.1 1 shows the prevalence of edentulism reported in other Canadian studies. Except for
the Quebec study (162), it was observed that, compared to the institutionalized study subjects, the
younger independently living older adults had a lower prevalence of edentulism. Participants in the Nova
Scotia study (160) were members of the order of 'Sisters of Charity' and had b e n continuously insured
by the organization. Among the 144 elderly women, only 3 1% were fully edentulous. Given the fact that
edentulism is higher among females ( 18). This rate of edentulism is remarkably lower than that expected
for those in the same (1915) birth cohort in Ontario. Using the trend in Ontario, a similar age cohort
would be expected to have had more than 40% of its members being fully edentulous. Similarly,
participants in the Quebec study, who were expected to belong the 19 14 birth cohort had alrnost twice the
trend rate for Ontarians with a similar cohort year of binh: 72% compared to about 40% in Ontario.
1.6.2.2 Prevalence of Coronal and Root Surface Caries
Table 1.1 describes coronal dental caries experience among the dentate elderly in Ontario
arrayed according to the living status of the elderly. The studies involved older adults who Iived
independently (W), in collective living centers (CLC), or a combination of both living arrangements
(CLC-IND). Some studies employed a probabili ty (PROB) sampling strategy to select study participants.
Table 1.1, as well as Figure 1.10, shows that the average rate of edentulism in Ontario is declining.
According to Leake's (23) review, the mean number of teeth rernaining in the mouths of dentate elderly
residents living in institutions was between 12.1 and 14.6.
Table 1.1 Prevalence of coronal dental caries prevalence in Canadian older adult population -
# of Teeth Reference 'Institution % Dentate Present DF F/DF ONTARIO Leake (23) CLC-ND 43 14.0 6.4 0.77
CLC 24 - 39 12.1 - 14.6 4.4 - 5.8 0.32 - 0.62
Locker et al. ( 143) CLC-PROB 43 6.4 0.78
Hawkins et al. (29) CLC 34 11.9 6.0 0.57
Murray et al. ( 147) CLC-PROB 70 15.4 7.4 0.74
Leake (23) ND-PROB 76 17.8 8.8 0.90
Slade et al. (27) IND-PROB 65 16.6 9.6 0.89
Hawkins et al. (29) IND 28 14.0 7 .O 0.73
RE=ST OF CANADA Leake (23) PROB 28 12.4 6.9 0.34
G a h , et al. (25) IND 54 15.5 8.9 0.68
*CLC Collective living Center MD Independent& living PROB Probabiliy sample
Table 1.2 Prevalence of root caries in Canadian older adult population
Prevalence (%) Mean (SD) RF/ Reference *Study Site RDFT? I RDT? I RDFT RDT RDFT
ONTARiO Leake (23) Stratford (F) 48
Woodstock (NF) 67
London CLC 83
East York CLC-iNû 70 33 2.5 0.82 0.69
(2.7) (1.6)
t Loçker et al. ( 164) Ontario's 71 27.6 3.6 0.7 0.8 1
Cornmunities
TLocker et al. ( 165) East York IM> 57 37 2.6 1.3 0.50
(4.0) (2.7)
REST OF CANADA
Leake (23) British Columbia 46 (68)
P.E.I. L .8
' ~ a c Innis et al. ( 160) Nova Scotia 5.7 1.6 0.72
Galan, et al. (25) Manitoba 22 1.3
*F Fiuoridared area NF Non-fluoridated area CLC Collective living center IND Independen ti-v living
t Decayed Slrr$uce(s)
Studies conducted in this cohort after this review continued to report similar numbers of
remaining natural teeth, i.e., 1 1.9- 15.4. The review report4 by Leake (23) showed that the treatment
ratio was between 0.32 and 0.62. Compared to the previous studies described in the review (23), Table
1.1 shows that the treatment ratio in recent studies has increased to between 0.57 and 0.78. The number
of decayeà and filled (DF) teeth per dentate elderly has also increased from 4.4-5.8 previously to 6.0-7.4
in the more recent studies. Therefore, the current cohort of institutionalized elders will be more dentate,
having somewhat more teeth left in the mouth than the previous cohort of elders; however, these retained
natural teeth will be expected to have a higher level of treatment when compared to the older generation
of elderly. For independently living older adults, only a very slight change in coronal dental caries statu
was observed.
The number of remaining teeth had varied between 15.3 and 18.0 previously, compareà to 14.C
17.8 presently. Also, the mean DFT was previously 9.5 with a treatment ratio of 0.8 1, compared to the
present range of 7.0-9.6 for mean DFT and 0.57-0.78 for the treatment ratio in the studies reported afier
the review.
Table 1.2 presents the prevalence of root caries in the Canadian elderly. The proportion with at
least one mot decayed, or filled tooth (RDFT) or surface (RDFS) is still between 46% and 83% (23). The
mean number of teeth or sudaces involved ranged fi-om 2.5-5.7. The treatment ratios were high, ranging
fiom 0.5 to 0.72 in studies presented in Table 1.2.
1.6.22 Periodontal Status
The prevalence of periodontal disease often depended on the criteria for diagnosis of the
condition. In his review, Leake (23) defined periodontal disease when penodontal pockets 2 5mm were
present. Table 1.3 presents an update of his findings. Compared to those in institutions, with a
prevalence of between 24% and 88%, the range for independently living older adults in Ontario was 14%
to 29%. in the more recent studies, those with at least 6mm pockets ranged between 11.9% and 12.4%
among the independently living group of older adults and 12.8 among those in institutions.
1.6.2.4 Burden of Dental Disease on Older Canadians
The impact of dental conditions on the elderly is reported in the literature (2, 4, 7, 8, 10, 11,
12, 16, 52, 120). The following discussion descnbes the impact of dental disease on the quality of life of
elderly Canadians. As seen in Table 1.4, criteria for deterrnining this impact varied. In the East York
study, Leake et al. (142) reported that 23% of older adults had hinctional limitation, i.e., inability to chew
one or more of roast meat, fiesh salad, or a whole fiesh apple. Functional limitation increased with age.
Apart from the study of M u m y et al. (166) that used the OHIP and GOHAi to assess oral health status,
there appears to be a general trend for the prevalence of hctional limitation to be less than the
prevalence of pain.
Table 1.4 Burden of dental diseases on older adults in Ontario
Study
- - - --- --
Proportion reporting.. .
Age (Yrs) *Functional Limitation ?Pain
Leake er al., ( 1 42) 65 - 74 17 23
Slade et al., ( 17) 65+ 50 34
Locker et al., ( 18) 50+ 30 37
Locker & Slade (7) 50+ 44 21
Murray et al., ( 166) 65+ $2 1 2
*Functional Limitation is inability to chew orfinction limitation subscale in Locker & Slade (7) ?Pain or disconfort from the niouth $ Toothache in O W assessrnent $Use medication ro relief pain or discornfort from arortnd the mouth
Murray et al. ( 155) assessed the impact of dental disease on institutionalized oider adults in North
York using the OHiP and GOHAI as oral health statu measures. The mean GOHAI score in the 105
subjects was 0.8 1 (SD = 1.3). More than half (59%) of the residents had a zero GOHAI score, Le., no
negative impact of dental disease on wellbeing. Similarly, OHIP was assessed in 95 subjects. Two-thirds
had a score of zero, and the mean score was 0.80 (SD = 1 S).
Studies reviewed showed that older adults have high dental needs and that dental diseases
negatively impact on the quality of life of these elders. However, such information is not available for
most of Ontario's oldest old, including Durham Region.
The population of Durham is quite different fiom the rest of Ontario. Therefore, prevalence
estimates of the burden of dental diseases obtained fiom North York, the only jurisdiction to have
reported on the oldest old, rnay not be directly applicable to Durham. The uniqueness of the population of
Durham is the access of many of its older adult population to dental insurance since 1974. Many of the
older adults have retired fiom General Motors, a Company that continues to offer dental insurance
coverage to its retirees and their spouses/widows. The impact of dental insurance on oral health status is
based on the extent to which it influences the quaiity of life of these elders. This study will examine the
effect of dental insurance on oral health and will provide dental epiderniological data on institutionalized
eIderly in Durham.
CaAPTER 2
MATERLALS AND METHODS
2.1 Data Collection
This study was cmied out as part of Durham Region's assessrnent of oral health status and dental
treatment needs of older adults resident in the three Regional Homes for the Aged in Durham, Ontario. It
was expected that planning of oral health programs for this cohort would be informed by findings fkom
this study. Consistent with the design of studies on older adults in Ontario (17, 18, 142, 143), this study
was carried out in two phases. The first phase of the study was an interview, followed by a dental
examination among those who gave consent during the first phase. Consent fonns for both the interview
and clinical examinations are presented in Appendices 2A & 2B.
Face-to-face or telephone interviews were carried out using a protocol modified f?om Locker et
a . (18). Information gathered included the resident's social and demographic characteristics,
predisposing oral health beliefs, enabiing oral health resources, oral needs, oral health behaviors, ability to
perform activities of daily living - ADL (Appendix 2C). Trained staff of Durham Region's Dental Health
Division conducted al1 interviews. A resident who, pnor to this study, had k e n legally declared
incompetent and a third-party appointed by law to oversee his or her health-care was declared
incompetent to respond to the interview. Such, cognitively impaired residents resided in separate rooms
in al1 three homes. For these residents, telephone interviews were conducted w ith the residents' substitute
decision-rnaker. Otherwise, face-to-face persona1 interviews were conducted with residents in the
Homes. Participation in the interview was requested fkom al1 of the 788 residents or their substitutes.
Interviewai participants, residents or their substitutes, were asked for consent for subsequent oral
examinations (Appendix 2A & 2B).
The second phase of the study was canied out with the assistance of trained staff of the Dental
Heakh Division in Durham Region, who acted as recorders and interviewers. A clinical protocol,
deveioped and used in the study of older adults in Ontario (167), was rnodified and used to collect
information on dental status and dental treatment needs (Appendix 2D). Examinations were carried out
with the use of disposable gloves and autoclaved dental exarnination instruments. Periodontal assessment
involving probing was not carried out in residents with contraindicating medical conditions. These
contraindicating conditions were history of open-heart surgeqr, organ transplant, rheumatic h a r t disease,
defects and or enlargement of the hart, radiation therapy, or rheumatoid arthntis. Other contraindicating
medical conditions were a history of systemic lupus erythernatosus, or joint replacement surgery in the last 2
years, or infection h m a prosthetic joint, or the need for antibiotics prior to routine dental are . The clinical
exarnination was conducted in each resident's room. Ethical approval was obtained for the second phase
of the study (Appendix 2E).
Al1 interview data were entered using data entry screens created in Eped in EpiInfo Version
6.04b. Data obtained fiom clinical examinations were entered separately, using another data entry screen.
The two files were sorted by record identification numbers and subsequently merged. The merged file
was exported into SAS Version 8 for cleaning and analysis.
2.2 Quality Assurance in Data Collection
Dr. P.A. Main, Director of Dental Health Division in Durham Region, conducted a oneday
training session for al1 interviewers in the Health Unit. Professor J.L.Leake, Head of the Department of
Community Dentistry, University of Toronto, conducted two training sessions for the three dental
assistants and the author of ths paper pnor to the chical exarnination phase of the study. Pnor to this
training, the author conducted studies in a cross-section of al1 ages in another population using similar
criteria ( 168, 169).
Repeat examinations were carried out in four dentate subjects, who had 69 teeth, during clinical
data collection; Professor J.L. Leake was the "gold standard" for the reliability exarninations. The
number of subjects used was not sufficient to estimate Kappa statistic (170). Nevertheless, there was a
78% agreement in recording the level of gingival recession measured in millimeters and 100% agreement
in recording the presence or absence of gingival recession. Inter-examiner agreement in recording CPITN
scores was 92%. For dental caries status, the level of agreement was 80%. Disagreements were found in
classifying a tooth as fil1ed and not decayed when the other examiner recordeci the tooth as absent, and in
the recognition of tooth-colored fillings.
23 Sample Size Estimates and Selection of Participants
The results of Slade et al. (17), Hawkins et al. (28, 29), Locker and Slade (7), Galan et al. (25),
Locker and Payne (165), and MacEntee et al. (171) provided the basis for sarnple size estimates. The
minimum sample required to estimate population parameters within an absolute 10% margin at 95%
significance level was 73 (Table 2.1). Sample sizes were derived with StatCalc in EpiInfo.
Table 2.1 Sample size detexmination using previously reported data
Ref. '%O Working Sample size Prevalence prevalence estimates: * 10% of
Indicator (pl 0') (P) and a = 5%
inability to chew Pain from teeth, face or mouth
Edentulous
Exposed root Root caries Visited dentist within the last year Needed dental extraction Untreated decay Untreaied root decay Untreated coronal decay
Impact domain 1 32.5 30 73 1 7.3 - 43.2 30 73
(Ave. = 27) 2 66 70 73 3 69 4 70
Proxy variables 4 30 30 73 4 25 25 66 5 23 25 66
Critical sample site 73 Ref.
1. Slade et al. (1 7) 2. Galan et al. (25) 3. Hawkins et al. (29) 3. MacEntee et al. (1 71) 5. Hawkins et al. (28)
The prevalence of edentulism and the expected proportion of the study population covered with
dental insurance were used to estimate the sample size needed for the hypothesis that dental insurance
hfluenced oral health status. The difference in the prevahce of edentulism in insured and uninsured
6S+ years old elders in the USA was 8.7%, although the average rate of edentulism in this age cohort was
24.4% (107). In this study, it was assurned that the prevalence of edentulism among insured persons
would be 10% better than the projected average of 70% (Table 2.1) and that uninsured persons would be
5% worse off. Therefore, for sample size calculations, we estimated that 60% and 75% of subjects
respectively in the insured and uninsured groups would be edentulous.
Samples size estimates were drawn with a power (1 - P) of 80% to detect this difference at 95% (1
- a = 0.05) confidence. The sample size required to meet this objective with respect to edentulism using
the StatCalc in EpiMo software was 165 subjects in each group (insured/uninsu.red), i.e., 330 subjects.
Finally, non-response is a major issue in appropnate selection of sarnples among the elderly. ln a
study of independently living older adults in Winnipeg with a mean age of 62.3 years, oniy 2 1% provided
written consent and another 1 1% could not be examined for medical reasons (34). One-third of a veteran
population (mean age = 7 1.8 years) could not be examined because of CO-morbidity (25). Response rates
in studies conducted in Ontario among older adults varied between 2 1% and 66% (1 72).
For the purpose of this study, a non-response rate of 30% was fixed for the primary sample.
Therefore, the estimated primary sample of 788 (population of residents) subjects was expected to yield
552 consents for the interview. We expected that a similar proportion would not respond to clinical
examination, resulting in participation arnong only 386 residents. Since 330 subjects were required for
the estimation of odds ratios, we elected to include al1 residents in the prirnary sample because some of
those who consented at the time of the interview rnight be il1 or absent on the actual day of the
examination, in order words we elected to conduct a census of the residents.
2.4 Study Design
This is a cross-sectional observational study of residents in al1 Regional Homes in Durham
Region. Participation was requested Erom al1 residents, and clinical examination was carried out within
one month of the i n t e ~ e w .
2.5 Data Manipulation
2.51 Measurement of Outcome
To assess oral health in this population, a composite index of oral health was derived. Unlike
previous studies referred to in Section 1.6.2 that used many oral health dornains, the index in this study
was limited to three. Administrators in the Homes had revised the survey instrument in order to reduce
the burden of interview and to enable residents to cope with the interview process. The domains on
which the composite index in this study was derived were oral disability, satisfaction with condition of
the mouth, and oral discornfort.
2.5.1.1 Derivation of The Composite Oral Health Status Outcome Measure
For oral disabitity, the chewing index of Leake (173) was measured. This Gutman-type scale
ranks residents on the ability to chew six selected food items food items (Yes, able = 1, No. not able = 0).
Reproducibility coefficient for the Guttrnan-type chewing index was calculated.
Participants who were able to chew none of the food items were scored zero. Those who could
chew only boiIed vegetables, the least difficult food item, were scored 1. Those who could chew only
boiled vegetables and hamburger were scored 2. A score of 3 was assigned to participants who could
chew both hamburger and boiled vegetables and the next difficult food item - fiesh salad. Those who
could chew finn meat such as steak or chops in addition to the three less difficult food items were scored
4 on the chewing index ability. Participants who were able to chew fkesh apple and al1 preceding 4 items
were scored 5. Finally, those who could chew fiesh apple and al1 preceding 4 food-items as well as fiesh
carrots were assigned a score of 6. Though the scores on the index of chewing ability could potentially
range fiom O to 6, a cut-off of 4 was used to rank participants into those who were competent and
incompetent in chewing. Leake (1 73) had previously reported that a cut-off that used the most difficult of
5 food items resulted in a much higher sensitivity and specificity in diagnosing older adults chewing
ability. Therefore, a participant was deemed orally able if he or she could chew al1 food items before and
including fresh apple or if he or she could chew al1 six-food items that included fiesh carrots. Final
scoring was based on the ability of residents to chew at least the five food items that included fksh apple
(Yes, chews at least five food items that included fiesh apple and therefore healthy = 1. No, unable to
chew al1 five food items that included kesh apple = O). Prior to developing the chewing index in this
study, assessrnent of the scalability of the food items was carried out. Convergent validity of the
dichotomized scores was tested by assessing the association of with participants' dental status.
For the reasons stated earlier regarding the need to keep the inteniew within a time f b e that
would not burden residents in the Homes, only one question was used to assess oral discornfort. Oral
discomfort was assessed by the presence of pain two weeks prior to the study (Yes, pain present = O, No,
pain absent = 1 ).
The third oral heaIth domain used in constmcting the composite index was oral satisfaction.
Residents were asked if they were satisfied with the condition of their mouth using three items -
satisfaction with ability to chew, satisfaction with the appearance of teeth and gums, and satisfaction with
the ability to speak clearly. Residents were either satisfied (score = 1) or unsatisfied (score = O) with each
of the items. The scores (satisfied = 1, not satisfied = O) from the three items were sumrned for each
participant. Those who were satisfied with al1 three items; i.e., ability to chew, speak clearly and the
appearance of teeth and gums had a score of 3. Others had scores ranging fiom O to 2 depending on the
number of items with which participants were satisfied. Because we had decided to weigh al1 three
dornains equally, participants who had a score of 3 were given a score of 1 on the oral satisfaction domain
while those not satisfied with al1 three items were assigned a score of O.
Although we used 9 items to assess oral health status - 1 for oral discomfort, 3 for oral
satisfaction, and 5 for oral disability - these items are based on three underlying dornains (concepts) of
the unobservable theoret ical constmct (oral health). The GOHAI, though based on three underlying
dimensions (9, 123), used more items. The 12 final items used in the GOHAI was derived fiom pre-
testing of 36 items (122). The final GOHAI index is the simple sum of the 12 items.
The OHIP is the only oral health index that is based on the weighting of item scores (120, 12 1).
However, Allen and Locker (1 74) have recently reported that, compared to simple scoring method, item
weighting did not dramaticaliy improve the performance of the OHIP. Given the precedence of the
GOHAI (123) and the fïndings of Allen and Locker (174) we did not weight items within the three
domains.
Therefore, our final composite oral health score in this study was based on the addition of binary
scores on the three identified domains. These were 1) chewing ability (Yes= 1Mo = O), 2) satisfaction
with the conditions of the mouth (Yes= 1/No = O), and 3) pain present within two weeks pnor to the
intewiew (Yes= Omo = 1).
2.5.1.2 The Global Rating of Oral Health Status
Residents' reported rating of oral health was obtained during the i n t e ~ e w . This global rating of
oral health ("How would you describe your dental health? 1s it excellent, vexy good, good, fair, or poor")
was treated as both an outcome and the criterion (9, 52, 125, 132-136) to assess for the validity of the
composite oral health index. The choice between the composite oral health status index and the global
oral health status rating for the end-outcome in this study was based on examination of the distribution
pattern and the convergent-validity tests described in Section 2.5.4.
Scores on both the composite and global oral health measures were dichotomized for ease of
clinically relevant interpretation of the results of this. Therefore, residents whose oral health was rated as
poor to fair on the global measure (criterion) were ranked as having poor oral health status; otherwise,
residents were ranked as having good oral health status. Using a cut-off of fair on the criterion, an
appropriate cut-off on the composite index that resulted in the best likelihood ratio between the composite
and the dichotomized critenon was selected.
2.5.1.3 The Intermediate Oral Health Status Outcome Measures
intermediate outcornes in this study were dental caries (coronal and root surfaces) status,
periodontal status, degree of gingival recession, and level of unmet treatment needs as measured by
standard dental status indicators (175). Functional impairment - edentulism - was treated as an
intermediate outcome and a potential confounder of oral health status in this study.
2.5.2 Measurement of Exposure
The independent measure of interest in this study was dental insurance status. During the
interview, residents or their substitutes were asked if the resident had dental insurance. Those who had
dental insurance were asked if the coverage provided full or partial benefits and how long they had had
coverage. Those who were not insured were asked if they had had coverage in the past and how long the
coverage had lasted. Three exposure groups were identified: those continuously insured since the 1970s,
those previously insured but whose coverage upon retirement, and those who had never been inswed.
2.5.3 Measurement of other Covariates
Asze Residents' age was either ranked as 80 years and older or younger than 80 years of age. The
reference group in logistic analyses was residents' aged 79 years of age or younger.
Gender: Males were the reference group.
Perceived General Health Status: Participants were asked: Would you describe your general
health as excellent, very good, fair, or poor. Those who perceived being in fair to poor general health
state were treated as the reference group.
Edentdous: During the interview participants were asked how best they would describe the condition
of their mouths - 1 have my own teeth and no dentures, 1 have my own teeth and one or more denture(s)
or bridge@), 1 have no teeth and full upper and lower dentures or plate, 1 have no teeth and no denture.
Those who had no teeth and full upper and lower dentures or plate and those who had neither teeth nor
dentures were classified as being edentulous. Those who had some teeth left - the dentate - were treated
as the reference group in the analyses.
Place of Birth: Participants who were not bom in Canada were classified as being non-lanadian born
and treated as the reference group.
Marital Status: Participants were classified as king cunwitly rnarried or unmarried. Residents' were
defrned as currently unmarri& if he or she was single (never manid), rnarried, but separated, widowed, or
divorced. This group - unmanieci - was treated as the reference group.
Educational Status: Participants were asked to state the highest level of education they had attained.
Those who had no foxmal education were treated as the reference category. Those with sorne secondary
schooi education or pst-secondary education constituted the 0 t h category (Appendix 2H).
Oral Health Beliefs: Oral health beliefs had been obtained using three separate indicators. In al1 cases,
participants' were requested if they strongly disagreed, disagreed, agreed, or strongly agreed with three
statements. Those who strongly disagreed or disagreed were treated as reference for those who had strongly
agreed or agreed.
Occupational Class: Residents' occupation prior to retirement was ranked into two occupational
classes: high - skilled clerical or higher (professionakemi professionai, managerial, or skilled technical,
skilled clerical, skilled clerical, sales, or service), and low - unskilled or not in the labour market (Appendix
2H).
Access to Dental Provider: Participants who had their ovm private dentist, dental hygienist, or denturist
were classified as having access to a dental provider. Those who did not have such access were treated as the
reference group.
Current Smoking Status: Participants' who currently smoked or had quit within the year prior to this
study were classified as cwent smokers. Those who had never smoked or those who smoked but had quit
more than one year before the study were classed as non-cument smokers and treated as the reference group
in analysis.
Performing Activities of Dailv Living: Participants who were able to: a) take care of themselves in the
toilet without assistance, b) eat without assistance, c) dress/undress and select clothes fkom the wardrobe
by themselves, d) bathe without assistance, and e) wak about the home without assistance were classifieci
as being able to perform al1 activities of daily living. Those who could not perform al1 five activities were
treated as the reference category.
Cognitive Impairment: Residents who did not respond to the interview because they were d e h e d as
incompetent were classified as being cognitively impaired and treated as the reference group. The non-
participant who responded for a cognitively impaired resident is referred to as the substitute or substitute
res~ondent .
2.6 Statistical Analysis
2.6.1 Assessrnent of Criterion and Convergent validity of Oral Health Status Measures
inter-item correlation, between the items used to create the composite index of oral health - oral
discornfort, oral disability, and oral satisfaction - was assessed with the Cronbach's Alpha. Criterion
validation was assessed with the correlation of the composite index to the global rneasure (self-perceived
oral health status) as criterion. The composite oral health index and the global measure were compared
for their distributional properties of both indicators and face-validity. Convergent-validity was assessed
by measuring the association of both measures with factors known to be associated with oral health status:
dental status; oral disability; and perceived need for care (38, 52, 120, 122, 176, 177).
Reliability of the information obtained on dental status during interview was assessed with the
likelihood ratio test, the Kappa statistic, sensitivity and specificity tests using information obtained on
dental status fiom clinical examination as "gold standard". We assessed the reliability of oral health
rating of residents by comparing the odds of reporting poor health between resident respondents and
substitute respondents controlling for factors that were verifiable - age and dental status, gender and
dental status, and age and gender - using the Cochran-Mante1 Haenszel's odds ratio (CMH-OR) test. .
The homogeneity of the cornmon M-H OR was tested with the Breslow-Day X2 (178). This statistic, the
Breslow-Day X2, tests the nul1 hypothesis of homogeneity between overall and stratum-specific OR.
2-62 Analyses of the Influence of Dental Insurance on Oral Health Outcornes
Bivariate effects of dental insurance exposure on oral health outcomes were assessed with the
odds ratio (OR), the chi-square (strength of association was assessed with the coefficient of contingency -
CC (1 79), one-way analysis of variance (ANOVA), and Kruskal Wallis tests.
After bivariate analyses, the adjusted effeçt of dental insurance on oral health outcomes was
assessed in 3-way analyses. The trivariate analysis was c e e d out with the CMH-OR test. . The
homogeneity of the common M-H OR was again tested with the Breslow-Day 2 (1 78).
The trivariate analysis was based on factors in a model previously used by Atchison and Gifi
(139) to explain the predictors of self-perceived oral health status. Their mode1 was a follow up to that
developed previously by the WHO (43) and based on a summary of evidence in the literature on the
factors that influence oral health status.
Atchison and Gifi (139) propose that an individual's characteristics, beliefs, and behavior will
predict that individual's oral health status. immutable personal characteristics, such as age, gender,
ethnicity, and health belief system will predispose the individual to il1 or good health. Enabling resources
are a group of characteristics that facilitates a person's ability to use services that could lead to an
improvement in health status. Need factors in the model are used to describe the presence of signs and
symptoms that help cue the individual to the presence of disease. Finally, the individual's health behavior
pattern assesses the attempt the individual makes to promote, maintain, and protect hisher own health.
Given that we expected many residents to be fùnctionally and cognitively impaired, necessitating
that interviews be conducted with substitutes, ADL and cognitive status of the resident were included as
potential confounders for the effect of dental insurance on oral heaith status.
2.7 Study Hypothesis
The nuil hypothesis tested in this study was that no diffaence existed between continuously
insured and uninsured older adults with respect to both intermediate (dental status) and the end-outcome
of oral health (composite or global masures of oral health).
2.8 Inclusion/Exclusion Criteria
The target population is older residents of Durham Region's Regional Homes for the Aged.
Nevertheless, only residents from whom valid informed consents were obtained were included in this
study. As stated in Section 2.1 consenting residents with compromising medical conditions were also
excluded fiom penodontal assessments invo1ving periodontal probing.
2.9 Ethical Approval and Informed Consent
We obtained approval from the Scientific Research and Ethics Review Committee at the Region
(Appendix 2F). Funding and Scientific approval was obtained from the Faculty of Dentistry, University
of Toronto (Appendix 2G). Ethical approval was obtained ti-om the Ethics Review Committee of the
University of Toronto (Appendix 2E). To enable the Durham Region Department of Health to rnake the
results of the interview available for this study, consent was obtained fkom residents or their substitutes at
the time of the interview. lnformed consent was obtained fkom the residents or from a substitute decision-
maker where the resident was legally incompetent in providing an informed consent. A substitute
decision-maker was the Iegal caretaker of the incompetent residents' health care (Appendix 2A & 2B).
During the clinical exarnination, whenever a resident by act or speech refùsed to continue participating in
the study, clinical exarnination was tenninated. Participating residents were not given any advantage over
non-consenting residents for participating in the study. Residents who were judged to be in need of care
were informed at the time of the examination.
CHAPTER 3
RESULTS
3-1 Study Response Rates
The population of the three Homes was 788. Nearly two-thirds (64%) of the residents
participateci in the interview. Of the 504 residents who were i n t e~ewed , 323 (64%) gave consent for
clinical examination. Clinical exarnination was completed in 275 residents, i.e., 85% of the consenting
residents, or 35% of the residents in the Homes. Figure 3.1 presents the participation of residents at the
two study levels. Item response rates varied in the study.
Figure 3.1 Participation of residents of Durham's Regional Homes for the Aged in the study
1 Population of the Homes 1
Did not consent to examination = 181 I
L J
Sample consenting to clinical exarnination
323 (64% of 504 or 41 %
f f \
1 Refused examination, died or in hospital = 48
Not interviewed = 284 (Consent not given for
interview)
Participatecl in Subjects for chical l k - 1 CIinical examination '
275 (85% of 323 or 35% of 788
Subjects for non- clinicai outconres 4
Intervieweci sample 504 (64%)
More than half (56%) of the study population were from Hillsdale Manor. Similarly, the
proportion of Hillsdale Manor residents in the interview was 58%. Most (63%) of those who completed
clinical exarnination were also residents of Hillsdale Manor. One in every five (19%) residents of
Durham's Regional Hornes for the Aged lived in Lakeview Manor but the Manor contributeci 17% and
14% to the interview and examined groups, respectively (Table 3.1).
Nevertheless, participation in the interview was not significantly different between the Homes ~ y '
= 1.12; P = 0.57; and df = 2). Those who participated in both the interview and the clinical examination
were nearly signi ficantl y di fferent between the Homes Ot = 5.5 7; P = 0.06; and d/ = 2), with a tendency
for higher participation among the residents of Hillsdale Manor. The proportion of residents in the three
Homes that participated in the interview and both the interview and the clinical examination were not
significantly different = 2. O.?; P = 0.36; d f = 2).
Table 3.1 Residents' participation in the study
Home Home population Level of participation
I n t e ~ e w Interview & examination
-
Hillsdale Manor 438 55.6 294 58.3 1 74 63.3
Fairview Manor 202 25.7 125 24.8 63 22.9
Lakeview Manor 148 18.8 85 16.9 38 13.8
Total 788 100.0 504 100.0 275 100.0
Forty-eight of those for whom consent was obtained could not be examined for the following
rasons: 44 refbsed clinical exarnination, two were in hospital at the tirne of the examination, and two
others died before the examination.
3.2 Characteristics of Study Participants
The mean age of the population in the three Homes of 8 1.1 years (SD = 10.0) was lower than the
83.1 years (SD = 8.8) observed among those who participated in the interview but age was not
statistically significant between the two groups. Table 3.2 presents the characteristics of study
participants of the 504 participants who participated in the interview. The percentages in the table are
based on valid numbers (N) of observation for each characteristic. As seen in the table, nearly 64% of
interview participants belonged to the 'oldest-old7 cohort, i.e., 80+ years age. h t e ~ e w e d residents were
mostly female (77%) and 54% perceived being in good, very good or excellent general health status. Just
about half (56%) of these elders were edentulous.
The proportion of participating residents with positive oral health beliefs was variable. More than
threequarters (78%) agreed or strcngly agreed that; "Going to the dentist regularly will keep me fiom
having trouble with my teeth and gums." Less than half (47%) agreed or strongly agreed to the statement
that, "1 have so rnany other things to worry about that dental health is low on rny list of priorities." About
half (5S?/o) had a fatalistic belief about oral health. These residents agreed or strongly agreed that, "Older
adults get dental probiems no matter what they do."
Given that most participants were fernale, and given the iower participation of women in the labor
force, it is not surprising that nearly half (46%) of the i n t e ~ e w participants were not previously in the
labor market (housewives) or had an unskilled occupation pnor to retirement. O d y 15% of residents
i n t e ~ e w e d were engaged in a skilled technical or higher occupation prior to retirement. More than half
(54%) had skilled clerical, serni-skilled technical or higher occupation at retirement. Many of the
residents (62%) had a regular dental care provider, i.e., a dentist, dental hygienist or denturist. Just more
than a quarter (28%), of the 504 participants had been continuously insured since the 1970s and 7.2% had
lost dental coverage on retirement.
Participants were asked if they had had dental pain within two weeks prior to the interview, and if
they felt the need for dental care. Nearly one in every ten (8%) residents responded in the affirmative to
the question on dental pain, and nearly onequarter (24%) of residents perceived the need for dental care.
Approximately onequarter (24%) of participating residents were curent smokers. One-third of these
residents had visited the dentist within the year preceding the interview and many (40%) visited only
when in (dental) pain.
Table 3.2 Characteristics of interviewed residents
Characteristic of interviewed residents Inteinewed residents Percent *N
Predisposing socio-demographic characteristics 80+years old 63.9 Female 77.2 Perceived being in good - excellent general health state 53.7 Edentulous 56.3
Predisposing health belief Agreeing that:
Going to the dentist regularly will keep fkom having dental problern
O Older adults get dental problerns no matter what they do I have so many other things to wony about that dental health is low on rny list of priorities
Enabling oral health resources Higher than unskilled occupation at retirement
O Has own dentist, hygienist or denturist O Continuously insured
Oral need Oral pain present within two weeks prior to the study Perceived the need for dental care
Oral health behavior r, Current srnoker or quit less than one year ago - Visited the dentist when not in pain r, Visited the dentist within the last year
Others - Performs al1 five activities of daily living 9.5 487 - Not cognitively impaired 47.1 50 1
*N = number of valid responses to this question among the 504 interviewed residents
Table 3.3 Comparison of the charactenstics of residents who participated in both the interview and the clinical examination, and interviewed residents who refûsed M e r participation after the examination
C haracteristic of residents % (n*) Participation Interview & interviewed but interview
exam refiised exam alone Predisposing socio-demographic characteristics
- -
80+ yrs old Fernale
6 Perceived being in good - excellent general health state
0 Edentuious **Canadian born **Cmently married
O *% High school education Predisposing health belief Agreeing that:
Going to the dentist regularly will keep fiom having dental problem Older adults get dental problems no matter what they do
O 1 have so many other t b g s to worry about that dental health is low on my list of pnorities
Enabling oral health resources Skilled occupation and higher at retirement
O Has own dentist, hygienist or denturist Continuously insured
Oral need O Oral pain present within two weeks prior to the
study Perceived need for dental care
Oral health behavior Current smoker or quit less than one year ago Visited the dentist when not in pain Visited the dentist within the last year
Others O Performs al1 five activities of daily living 12.7 (268) 5.5 (219) $ 9.4 (487)
Not cognitively impaired 49.1 (275) 44.7 (226) 47.1 (501)
*n = number of valid responses among 504 residents who participated in interview, 2 75 who participated in both interview and clinical examination, and 229 resident who reficsedfiirther participation aper the interview. tP-value 4 .0001 $ P-value >O.OU1 and (0.01 7 P-value <0.0110.05 &.a = not applicable **Information obtained during clinical examination
More than half (53%) of the residents who participated in the interview were cognitively
impaired. Only about one in every ten (9.5%) could perform al1 activities of daily living, i.e., take care of
himherself in the toilet, eat, dresslundress and select clothes fiom the wardrobe, bathe, and walk about
the home without assistance.
As shown in Figure 3.1, 275 residents participated in both the interview and the clinical
examination. Table 3.3 presents the comparison between those who participated in both the interview and
the clinical examination, and those who refused participation in the clinical examination after the
interview. information on some of the factors was obtained during clinical examination: place of birth,
marital status, and education. Therefore, no comparison could be made on these characteristics between
those who were examined and those who refused clinical exarnination.
There were observable di fferences between interviewed residents and t hose who refused further
participation in the study after the interview. Those who refused to participate in clinical examination
perceived being in poorer general health state when compared to those who participated in both the
interview and the c h i c a i examination. Similarly, those who did not participate beyond the interview
were mostly edentulous, had retired in a lower occupational class, did not perceive a need for dental care,
and were less able to perform al1 five activities of daily living (ADL). Fewer of those who refused
clinical examination, agreed that regular visit to the dentist will keep him or her fiom having dental
problems.
Table 3.4 compares the age distribution of residents who were inteniewed alone, interviewed and
examined, refùsed participation in examination after interview, as well as the target population.
Information on age was only available for 780 of the 788 residents. The mean age of the target
population was 81.9 years. ANOVA test using the EpiTable in Epihfo showed that residents who
participated in the interview were significantly older than the target population, their mean age being 83.1
years. Residents who had participated in both the interview and clinical exarnination were 1.2 years
younger than those who had refùsed M e r participation afier interview were; but, this difference was not
statistically significant. On the other hand, the 1.2 years age difference between residents in the three
Regional Homes and those who participated in the interview though statisticall y signi ficant was not
clinically relevant since they al1 belong to the same demographic age class interval.
Table 3.4 Age distribution of the target population and participants at the two study levels.
Participation Ievel Target
Interview and population Age (Years) interviewed but i n t e ~ e w
(n=496) (n=7 8 O) exarn (n= 275) refùsed exam (n=22 1 )
65 - 74 19.3 75 - 84 35 -3 85 -94 39.3 = > 9 5 2.9 Mean 82.6
Variance 77.2 SD 8.8
*ANOVA test for cornparing the mean age of interviewed & exurnined vs interviewed & not examined TANO KA test for cornparing the mean ages of interviewed vs target population
Table 3.5 Dental status of residents (11499) obtained kom interview
Dental status Frequency (%)
1 have my own teeth, no dentures 17.0
I have my own teeth and one or more denture(s) or bridge(s) 26.7
1 have no teeth, full upper and lower dentures or plate 50.3
1 have no teeth and no dentures 6.0
Table 3.6 Dental status of residents (n=28 2) obtained fiom clinical examination
Dental status Frequency (Y0 )
Dentate both arches 31.2
Dentate maxilla only 2.2
Dentate mandible ody 18.1
Edentulous 48.6
In order to determine the resident's dental status, residents or their substitutes were asked whether
the resident had at least one natural tooth left in the mouth. Table 3.5 presents the result for residents who
participated in the interview. Dental status of six of the residents could not be ascertained at intewiew.
The reliability of the information on dental status was validateci during clinical examination among
residents who consented to clinical examination. It was possible to confirm dental status in 282 residents
because either clinical examination was initiated or it was possible for the examiner to see residents' full
upper and lower dentures (Table 3.6).
Reliability of information obtained during the interview was very hi&; only 17 (6%) of residents
were wrongly classified (Table 3.7). The Kappa statistic, the proportion of agreement beyond chance, for
the reliability of the reporting of edentulism between the interview and the clinical examination was 0.88
(95% Confidence limits: 0.82 - 0.93). Sensitivity and specificity values for the assessment of dental
status on interview were 92.9% and 93.0%, respectively. Given the high reliability between information
on dental status obtained fiom the interview (Table 3.5) and the clinical examination (Table 3.6), the
prevalence of edentulism obtained during the interview was uçed for analyses in this study unless
otherwise stated.
Table 3.7 Reliability of infonnation on resident's dentition status collected duing interview
Dentition status Clinical examination
Gold Standard Edentulous Dentate
Edentulous
Dentate
2 = 216.2 P = ~0.0001 Kappa = 0.88 95% Confidence limits = 0.82 - 0.92 Likelihood ratio = 260.4 P = <0.0001
3 3 Development of a Composite Index of Oral Health Stitus
The perceived rating of residents' oral health status was generally good (39%) or fair (25%).
Very few residents (1%) rated their oral health as excellent. Similarly, residents' rating of general health
status was either good (39%) or fair (28%). Perceived generai health status was rated as excellent in only
2% of residents. More than two of every five residents perceived their oral health (43.9%) or general
health (45.7) status as poor or fair. There was a highly significant positive association between perception
of residents' oral health and general health status (Table 3.8).
Table 3.8 Association between self-perceived general and oral health statu
Self perceived general healtb status AI1
Eicellent Very good Good Fair Poor N (%)
$ = 50.2 P-value = < 0.0001 Coeflcienr of Contingent-v (CC) = 0.32
dl œ YI
5 9) & I
f 3 + 4 Q,
L 2 01 *
As stated previously, the three oral health domains were used to derive a composite masure of
- --
Excellent 1 2 1 1 1 6 (1.2)
Very good 2 16 38 16 6 78 (16.1)
Good 4 26 75 55 28 188 (38.8)
Fair 1 10 50 37 22 120 (24.7)
Poor 1 7 26 26 33 93 (19.2)
oral health status were oral satisfaction, oral disability, and oral discomfort. Oral satisfaction was
AI1 - N 9 61 190 135 90 468 (%) (1.9) ( 12.6) (39.2) (27.8) (18.6) ( 1 00)
assesseci with three items: a) How satisfied are you with the appearance of your teeth and gums? b) How
satisfied are you with your ability to chew? c) How satisfied are you with your ability to speak clearly?
More than half of the residents who participated in the interview reported being satisfied with each of the
three oral satisfaction items. Table 3.9 shows that almost two-thirds (65.2%) reporied being satisfied or
very satisfied with al1 three items. As was seen in Table 3.2, the prevalence of dental pain among
participants was 8.3%.
Table 3.9 Resident's reported satisfaction (%) with three sub-scale items in oral satisfaction domain
ve ry very Domsin of Oral Satisfaction dissatisfied Dissatisfied Satisfied satisfied N
1. Appearance of teeth and gums 9.1 16.0 56.2 18.7 482
2. Ability to chew 9.3 21.2 53.0 16.5 482
3. Ability to speak clearly 8.9 11.6 58.1 21.4 485
Verv satisfied and satisfied with 1 +2+3 65.2 480
Table 3.10 Ability to chewing five selected food items
Are vou ordinarily able to:.. .. Yes (%) Total (N)
1. bite and chew a piece from a whole fresh apple? 46.6 487
2. chew firm meat such as steak or chops? 58.6 488
3. chew fiesh salad? 65.6 49 1
4. chew hamburger? 73.8 488
5. chew boiled vegetables? 79.9 492
When six-food items, i.e., including fiesh carrot, were used to create the index, residents were not
properly arranged on a continuum, resulting in relatively poor scalability. For example, of the 226
residents who were reportedly able to chew h s h carrot, 35 could not chew less difficult food items,
nearly half (14) of whorn could not chew fim meat. More than a third (37%) of those who reported k ing
able to chew the next food item - take a bite off and chew a whole apple - were wrongly classifiecl since
they reporteci being unable to chew less difficult food item.
Residents (54%) were least able to chew a piece of fkesh carrot. Table 3.10 presents the ability of
residents to chew al1 five-food items. A nearly equal proportion of residents (53%) could not bite off and
chew a whole fiesh apple. The Guttman-type chewing index was developed with five of the six food
items; the ability of residents to chew a piece of fresh carrot was excluded.
When five food items - excluding ability to chew fresh carrots - were used, the errors in the
pattern reduced. The triangular response pattern typical of Guttrnan scales that represent perfect
scalability is demonstrated by A, F, J, L, N, and O in Table 3.1 1. The observed and expected (or chance)
reproducibility coefficients when five food items were used were 97.9% and 92.0%, respectively. Table
3.12 shows that 19% of residents could not chew any of the five-food items and 47% were able to chew
al1 five food-items.
The convergent validity of the dichotornized Guttrnan chewing index was tested with the dental
status of residents. More than half (53%) of the participants were unable to chew the most difficult of
five food items. Figure 3.2 shows the that inability to chew al1 five food items increased fiom 36%
among those who iiad al1 their teeth and no dentures to 93% among those who were edentulous but had no
dentures. Three of every five edentulous residents who had dentures were unable to bite off and chew a
whole fiesh apple. The relationship between dental status and ability to chew the most dificult of five
food items was statistically significant (,$ = 33.5; P < 0.0001; CC = 0.26).
Table 3.12 Ranking of residents by the ability to chew five food items
Resident able to chew.. . Cbewing index score Frequency Item Cumulative Percent
O. None O 18.7 18.7
1. Boiled vegetables 1 4.7 23.4
2. Hamburger ( 1 +2) 2
3. Fresh salad (1 +2+3) 3
4. Meat /steak (l+2+3+4) 4
5. Fresh apple (1 +2+3+4+5) 5
A moderate reliability coefficient - Cronbach 's Alpha - of 0.73 (standardized) was obtained for
the raw scores for the three items used to create the composite oral health index. The final scoring for the
derived patient-based composite index of oral health was basd on presencdabsence of dental pain, and
dichotomized scores on oral satisfaction and oral disability (ability to chew), Le., satisfiedhot satisfied in
al1 oral satisfaction subdomains, ablehot able to chew al1 five food items. However, these dichotomized
variables had a lower standardized - Cronbach 's Alpha - inter-item correlation of 0.36 when compared to
the 0.73 obtained for the raw scores
Figure 3.2. Proportion of residents who could not chew al1 five food items related to
Dental Status
No teeth and no dentures
FuU dentures
Own teet h and dentures
Own teeth and no dentures
dental statu
The distributions of the scores derived from these two patient-based oral health status measures -
composite and global - are presented in Table 3.13. Given that one criterion for assessing health
measures is the ability to spread subjects, a major limitations of global measures (135). However,
contrary to the report of Rowan (135), a slightly collapsed (collapsing excellent and very good into one
category) global rating of oral health status appear supenor in spreading responses between categories
with 18.2% reporting poor oral health compared to 4.3% scoring O on the composite measure. This
collapsed global oral health rating would have 18% cornpared to 35% on the composite measure at the
other extreme end of the measures (Table 3.13). There was a hi@y significant association between the
two patient-based measures of oral health status & = 132.2; df = 12; P <0.0001; CC = 0.4 7).
Table 3.13 Cornparison and association between the global rating and the derived composite index of oral health status
Poor Fair Good Very good Excellent N (%)
Convergent-validity of the two patient-based measwes of oral health status was carrieci out by
examining the association and the direction of association between the measures and factors that are
related to oral health. Table 3.14 shows the results of the validity tests. Oral health status, when assesseci
by the global index, was not significantly related to being dentate. On clinical examination, 36% of
subjects with a composite oral health score of zero were dentate. This proportion increased to 63%
among those with a score of 4. Similady, the mean number of sound and filled teeth significantly
increased as the composite score increased, i.e., as participants became more healthy. The mean
increased f?om 8 teeth among those with a composite oral health score of O to a mean of 14 teeth arnong
those with a composite score of 3. The global oral health rating showed no significant association with
the mean number of sound and filled teeth.
Table 3.14 Convergent-validity of the composite index of oral health and the global rating of oral health
Oral health stahrs Face-validity testing criteria Offoor 1 /Fair 21Good 3Nery good P-value
- Excellent % Dentate on examination
Global rating 57.7 (52) 52.9 (70) 45.8 (107) 55.3 (47) *0.4720 O Composite index 36.4 (1 1) 44.2 (52) 43.8 (105) 63.1 (103) *O.O 177
Mean number of füled and sound teeth remaining
Global rating 1 1.3 (28) 9.5 (35) 13.4 (48) 13.3 (26) f.0.1117 O Composite index 7.8 (4) 9.3 (22) 10.8 (44) 13.9 (63) 0.0324
% Not perceiving the need for dental care
O Global rating 48.9 (92) 64.5 (12 1) 89.4 (387) 90.6 (85) *<O.OOO 1 Composite index 5.0 (20) 55.9 (106) 82.3 (186) 89.1 (165) *<O.OOO 1
* Chi-square test t ANOVA test
Both measures were significantly associated with the perceived need for dental care.
Nevertheless, the composite index was more responsive to changes in participants' perceived need for
care. The range between the extreme categones of global oral health rating was 41.7%, nearly twice the
propoxtion among those who rated their oral hedth status poorly. For the composite measure, on the
other hand, the range was 84.1% or 17 times the score of those who were scored O on the composite
measure. The composite index of oral health was therefore selected as the end-outcorne for this study.
The cut-off on the composite index that achieved the bighest likelihood ratio with the criterion
was 1. Therefore, participants who had a score of O or 1 were classified as having poor oral health status,
whilst, the others were classifieci as having good oral health status.
Information on many of the items used to develop the composite index of oral health status were
obtained frorn substitutes in cognitively impaired participates. Nevertheless, the odds of poor oral health
were not significantly different between residents who responded to the interview thernselves and those
whose interview was carried out with a substitute (Table 3.15).
Table 3.15 Analysis of the odds of poor composite oral health related to cognitive status of residents controlling for age, gender, and dental status.
Controlling for.. . OR (95% Confidence Interval)
Age Dental status
r 80 years 2 80 years c 80 years < 80 years
Gender
Female Fernale Male
0 Male
Gender
Dentate 0.6 (0.2- 1.6) Edentulous 0.9 (0.5-1.7) Dentate 0.4 (O. 1- 1.4) Edentulous 1.5 (0.6-3.9)
Overall 0.8 (OS- 1.3) Dental stahis
Dentate 0.7 (0.3- 1.5) Edentulous 1 .O (0.5- 1.8) Dentate 0.2 (0.0-2.6) Edentulous 0.7 (0.2-2.6)
Overall 0.8 (0.5-1.2) Age
Female O 28Oyean 0.8 (0.5-1.5) O Female O 18Oyears 1.1 (0.5-2.5)
Male ~ 8 O y e a r s 0.7 (0.2-2.7) Male < 80 years 0.5 (0.1-2.5))
Overall 0.9 (0.6- 1.3) Cnide OR for Oral Health Status * Cognitive Status 0.8 (0.5- 1 -3)
3.4 Bivariate Analysis of the Effect of Mode1 Determinints on Poor Oral Health Status
The prevalence of poor orai health, score O - 1 on the composite index, was 26% compared to
43% when assessed by the global rating (Table 3.13). Thirty-six of the 504 residents interviewed had
dental insurance coverage during some of their working years but coverage had lapsed on retirement.
Prelirninary bivariate analysis showed that these 36 residents were unique in their behavior to other
characteristics. Therefore, they could not be merged with either exposure groups and were too few to
rnake up their own group. Therefore, they were not included in al1 subsequent analysis.
Table 3.16 present the results of the bivariate analysis of the association between composite oral
health and the variables identified in Atchison and Gift's (139) mode1 using the remaining 468
participants with valid responses. Oral pain was excluded from the explanatory mode1 since it was used
to derive the composite index.
The prevalence of poor oral health was significantly higher among participants who perceived a
need for dental advice; more than half of those who perceived the neai for care were classified as having
poor oral health on the composite measure.
The prevalence of poor oral health among those who had at least some high school education was
12%. Although, this prevalence was less than half of the interviewed participants' average of 25.6%, this
did not reach statistical significance. Only 34 participants who participated in the clinical exarnination
had at least some hi& school education. Sirnilarly, the prevalence of poor oral health (19%) was lower
among those who were abIe to perfonn al1 five activities of daily living; but the difference was not
statistically significant. However, the prevalence of poor oral health was significantly lower among those
who perceived being in a good to excellent general health state and those who were dentate (Table 3.16).
The prevalence of poor oral health was not significantly lower 'mong participants who had being
insured continuously since the 1970s. Visiting the dentist within the year prior to the study also did not
influence the prevalence of poor oral health among participants. Access to a regular dental provider (own
dentist, dental hygienist, or dentwist) and visiting the dentist when not in pain were both not significantly
associated with poor oral health status among these participants.
Table 3.16 Poor oral health (composite index) related to participants' characteristics
% Prevalence of poor oral health (Composite index)
Characteristic of resident (in row) Absent (n) Present (n)
Predisposing socio-demograpbic characteristics 80+ yrs old Fernale Perceived being in good - excellent general health state Dentate *Canadian boni *Currently &ed *2 High school education
Predisposing health belief Agreeing that:
Going to the dentist regularly will keep from having dental problem Older adults get dental problems no matter what they do 1 have so many other things to wony about that dental health is low on my list of priorities
Enabling oral health resources Higher than unskilled occupation at retirement Has own dentist, hygienist or denturist
O Continuously insured
Oral need Perceived need for dental care
Oral healtb behavior O Current smoker or quit less than one year ago O Visitedthedentistwhennotinpain
Visited the dentist within the last year
Others Performs al1 £ive activities of daily living
0 Not cognitively impaired
* Information collected during clinical examination t P 5 0.01 (n) Nurnber of observations wirh valid responses
3.4 Cornparison of Residents' Characîeristics By Dental Insurance Exposure Croups
Nearly a third (30.1%) of the 468 participants had had dental insucance plans that paid for some
or ail of their denta1 treatment continuously since the 1970s. Bivariate analyses were carried out to
examine the relationship between dental insurance status and the social, demographic, and other
characteristics of residents. The results of these analyses are presented in Table 3.17.
Continuously insured and uninsured groups differed significantly with respect to some of the oral
health predisposing social and demographic characteristics in the Atchison and Gift's (139) mode1 (Table
3.1 7). Compared to the uninsured, contiriuously insured residents were significantly younger, male,
belonged to a higher occupational rank, perceived themselves as being in good to excellent general health,
and were marrieci at the time of the study.
The mean age of continuously insured residents was 81.4 (SD=9.6) years compared to 84.3
(SD=8.0) years for uninsured residents. The 'oldest-old' constituted 55% of the continuously insured
group compared to 70% for uninsured residents. Significantly, more than four of every five (83%)
uninsured residents were fernale, cornpared to 65% for continuously insured participants. The prevalence
of edentulism was 12% higher arnong participants who had never had dental insurance, but this difference
was not statistically significant. Continuously insured participants were significantly more currently
manied when compared to participants who had never been insured.
Predisposing health beliefs were significantly different between continuously insured and
uninsured participants. While 85% of continuously insured participants agreed to the statement "visits to
the dentist will keep me fiom having dental problem", 10% fewer uninsured participants agreed to the
statement. More (5 1%) of the uninsured participants placed low prionty on dental health compared to
3 8% for the continuously insured group.
Continuously insured participants differed significantly h m their uninsureci counterparts with
respect to enabling oral health resources (Table 3.17). A rnajority (70%) of continuously insured
participants retired in a higher than unskilled occupational class when compared to 47% arnong uninsurd
participants. Nearly two-thirds (73%) of continuously insured residents had access to a regular source of
dental care when compareci to 59% for the uninsured group.
Table 3.17 Characteristics of interviewed residents related to a history of continuous dental insurance exposure
Characteristic of residents Continuously insured
% *No (n) % *Yes (n) *AN (n)
Predisposing socio-demographic chatacteristics O 80+yrsold
Female O Perceived being in good - excellent general health
state Edentulous
0 **Canadian bom O **Currentl y married m **2 High school education
Predisposing heolt h belief Agreeing that:
Going to the dentist regularly will keep fiom having dental problem
0 Older adults get dental problems no matter what they do 1 have so many other things to womy about that dental health is low on my list of priority
Enabling oral health resources 0 Higher than unskilled occupation at ret irement O Has own dentist, hygienist or denturist
Oral need O Oral pain present within two weeks prior to the study o Perceived need for dental care
Oral health bebavior Current smoker or quit less than one year ago
m Visited the dentist when not in pain m Visited the dentist withïn the last year
Others Performs al1 five activities of daily living Not cognitively impaired 50.3 (326) 55.0 (140) 51.7 (466)
n is number of observations rvith valid responses t p c 0.0001 # P > 0.0001 and < 0.001 $ p > 0.001 and50.01 7 P > 0.01 and 5 0.05 ** Information collected during clinical examination
Perceived need for dental advice was not significantly different between the continuously insured
and never insured groups. Onequarter of the participants perceived a need for dental care and less than
10% reportedly had dental pain within two weeks prior to the study.
Whereas smoking behavior was similar amongst the two groups, health behaviors related to the
utilization of dental services differed significantly. More (43%) continuously insured participants had
visited the dentist within the year preceding the study, compared to 28% for uninsured participants.
Fewer (46%) continuously insured participants Msited the dentist only when in pain, compared to 65%
among the uninsured group. However, when dental statu was controlled, the direction was reversed,
compared to the uninsured, continuously insured dentate participants were significantly more likely to
have visited the dentist when not in pain.
No statistically significant differences were observed between exposure groups with respect to
residents' cognitive state; just more t han ha1 f of the participants were cognitive1 y impaired. Nevertheless,
the two groups differed in their ability to cany out al1 activities of daily living. Continuously insured
residents were significantly more likely to have reported being able to perform al1 activities of daily
living.
3.6 The Effect of Dental Insurance on Oral Health Status
3.6.1 Unadjusted Effects
Dental insurance was not significantly related to any oral health outcornes presented in Table
3.18. There was a trend for continuous dental insurance exposure to protect participants fiom being
edentulous. The reporting of edentulism was 9.5% higher among the uninsured and on clinical
examination, the difference between continuously insured and uninsured participants was 13%. In
addition, continuous dental insurance exposure reduced the probability that participants would be satisfied
with the appearance of their teeth and gums. However, this study had only a 48% power to detect a
difference of 9.5% between exposure groups with respect to reporting of edentulism.
Table 3.18 The effect of dental insurance exposure (uninsured as reference group) on oral health related outcornes among residents
Dependent outcome measure of oral healtb Outcome Odds 95% Confidence N present Ratio limits
Oral health related quaiity of life measures
Poor perceived generd health status insured Uninsured
Poor perceived oral health status Insured Uninsured
Poor oral health (Composite measure) 4 Insured
Uninsured Dental pain in the last two weeks
4 Insured Uninsured
Sarisjied with the appearance of teeth and gums Insured Uninsured
Satisfed with the abiliw to chew 0 Insured 4 Uninsured
Satisfied with the ability to speak clearly hsured Uninsured
Functional disa bility measure Able to chew the most diflctrlt offive food items
insured Uninsured
Functional impairment measure Prevalence of edentulism (interview))
Insured Uninsured
Prevalence of edentulisrn (Clinical examination) Insured Uninsured
The odds of king in a poor to fair general health state was not significantly associated with
participants' dental insurance status. Similarly, the odds of having poor oral health status, both on the
composite and global measures, were not significantly associated with exposure to dental insurance in
these participants. The prevalence of poor oral health (global rctting) was 2.5% lower among
continuousl y insured participants when compared to uninsured participants. Ho wever, when assessed
with the composite measure, the prevalence of poor oral health was 2% higher arnong continuously
insured participants when compared to the uninsured. The odds of being satisfied with the ability to
chew, being satisfied with the appearance of teeth and gums, having oral discornfort, or having orai
disability were al1 not significantly associated with participants' dental insurance exposure status.
The lack of association between exposure to dental insurance and the oral health status of
residents may be due to the presence of confounders. To assess for this, trivariate analyses were carried
out. The following section presents the findings for the adjusted effect of dental insurance on oral health
status.
3.6.2 Adjusted Effects of Dental Insurance and other Factors
The adjusted effect of dental insurance exposure on oral health status was tested in trivariate
analyses controlling for factors contained in Atchison and Gift's (139) explanatory model for self-
reported oral health status. The model includes dental insurance as an enabling resource for achieving
positive oral health status. Pain was one of the variables used to derive the composite oral health measure
the end-outcome in this study and was therefore excluded fiom these analyses.
Tables 3.19A & B show that continuous access of participants to dental insurance did not
influence oral health status of participants when row characteristics were controlled in the analyses.
There is a trend for the efl'ect of dental insurance to shift fiom being slightly predictive of poor oral health
status to being protective in trivariate analyses when predisposing health beliefs, oral need, place of birth,
marital status, pattern and the penod of last dental visit were controlled. However, the 95% confidence
interval of the point estimates of al1 adjusted ORS in Tables 3.19A & B included 1, showing that dental
insurance was still not significantly associated with oral health status.
However, given that there are 18 factors examined in Tables 3.19A & B, a more rigorous
guideline would state that the cntical P-values should be adjusted to 0.003 (0.091 8). Overall, ORS were
significantly different fiom stratum specific ORS when three row characteristics were controlled: gender,
marital status, and having access to a regular source of dental care.
Table 3.19A The odds of continuous dental insurance exposure on poor oral health status controlling for the effect of factors in the Atchison and Gifi's (1 39) mode1
Adjusted OR (95% Confidence laterval)
Characteristic of resident in rows.. .* Present *n Absent *n All *n
Predisposing socio-demographic characteristics
a 80+ yrs old 1.39 (0.77-2.5 1) 288 0.66 (0.3 1-1.4 1) 150 1 .O4 (0.65- 1.65) 438
Female 0.86 (0.50-1.48) 346 3.35 (1.16-9.66) 98 t 1.16 (0.73-1.86) 444
0 Perceived being in good - excellent general healtli state 0.83 (0.40-1.7 1) 243 1 .25 (0.67-2.3 1) 197 1 .O4 (0.66-1 -67) 440 Dentate 0.72 (0.33- 1 -56) 188 1.50 (0.84-2.68) 254 1.14 (0.72-1.80) 442
a *Currently married
*2i High school education 1.50 (O. 18-1 2.15) 34 0.96 (0.46- 1 -99) 182 1 .O0 (0.50-2.00) 2 16
Predisposing health belief
Agreeirtg t hat : Going to the dentist regularly will keep from having dental problem 0.84 (0.47-1 SO) 286 1.10 (0.34-3.60) 79 0.89 (0.53-1.49) 365
a Older adults get dental problenis no matter what they do 1 .OS (0.54-2.14) 196 0.65 (0.29- 1.49) 160 0.87 (0.5 1 - 1.47) 356
1 have so many other things to worry about that
- -. dental health is low on my list of priority 1.23 (0.59-2.90) 17 1 0.7 1 (0.33-1 -52) 183 0.94 (0.55-1.59) 354 _ - -* -- -_- -
Cnide OR (95% Confidence Interval) for the effect of dental insurance on poor oral health 1 .O9 (0.69-1.7 1) 444
* Injormation collected during cliniwl e.rurriincrtion Probabiliiy ofBreslmv-Da)? Chisquare t P 2 0.01 and ~ U . 0 5
# P = 0.0125
Table 3.198 The odds of continuous dental insurance exposure on poor oral health status controlling for the effect of factors in the Atchison and Gift's (1 39) rnodel
Adjusted OR (95% Confidence Intentai) Characteristic of resident in rows.. .. Present *n Absent *n Al1 *n
Enabling oral health resources
Higher than unskilled occupation at retireinent
Has own dentist, hygienist or denturist
Oral need
Perceived need for dental care
Oral health bebavior
a Current smoker or quit less than oiie year ago
Visited the dentist when not in pain
Visited the dentist within the last year
Others
Performs al1 five aciivities of daily living
a Not cogiitively impaired
1.25 (0.38-3.27)
0.43 (O. 1 8- 1 -06)
0.57 (0.26-1.26)
Crude OR (95% Confidence Interval) for the effect of dental insurance on poor oral health 1 .O9 (0.69-1.71) 444
Among male participants, there was a trend towards (P-value = 0.022) access to dental insurance
iiicreasing the odds of being in a poor oral health state by 3.35 times. Recognizing that these are trends
only, one notes that being married reduced the odds of k i n g in a poor oral health state by nearly four
times (OR = 0.27). Apart fkom the fact that overall odds ratio showed a trend (P-value = 0.012) towards
being different fiom straturn specific ORS, the direction of the mata ORS were reversed among those with
the opposite characteristic.
Sirnilarly, there was trend (P-value = 0.039) towards a protective effect of dental insurance on
poor oral health status was observed among participants who had their own dentist, dental therapist, or
denturist. However, this trend was reversed, among those who had no access to their own dental care
provider.
Table 3.20 Consistency of trends towards a m o d i m g effect of access to regular source of care on the effect of dental insurance on oral health status
OR (95% Confidence interval) n Has own provider n Has no provider n Al1
Gender Female 185 0.56 (0.27-1.18) 104 1.96 (0.73- 1.18) 293 *0.86 (0.48-1 -53) Male 57 2.28 (0.60-8.69) 30 5.71 (0.88-36.89) 87 3.1 1 (1.06-9.14)
Marital Unmarried 77 1-50 (0.46-4.89) 55 2.36 (0.6 1-9.08) 132 1.8 1 (0.75-4.4 1 ) stahis Marrïed 42 0.15 (0.03-0.83) 13 0.95 (0.12-7.27) 55 0.3 1 (0.09- 1.08)
Probability of Bresfow-Day 2 = 0.0149
Table 3.21 shows the results of fùrther examination of gender, marital status, and having own
dental care provider on the effect of dental insurance on oral health status. The modi*ng effect of access
to a regular dental care provider remained when the analysis was restricted to females. However, even
with access to a regular dental care provider, dental insurance increased the odds of poor oral health
among men. For men, the ORS are in the same direction. Among those without access the odds poor
health was 5.7 1 , more than twice the OR (2.28) among those who had access to their own dental provider.
The possible protective effect of dental insurance among currently married participants was
stronger among those who had their own dental provider (OR = 0.15) compared to 0.95 among those who
did not have their own dental care provider. Table 3.20 shows that the trend the effect of dental insurance
to be different among males and females as well as between m M e d and unmarried participants were
sustained among those with and without their own source of dental care. Nevertheless, it should be noted
that, except among males and those who were &ed, the modification of effect were still not significant
even at the 5% level of significance. Therefore, we can only say that there were trends pointing to the
modimng effects of gender, marital status, and having access to own dental provider on the effect of
dental insurance on oral health status in this group of participants.
3.7 The Effect of Dental Insurance on Edentulism and Other Clinical Outcornes
3.7.1 Bivanate Analysis of the Effect of Model Determinants oa Edentulism
Table 3.21 shows the bivariate relationship between edentulism and determinants in the model.
Age was dichotomized into 579 years and 80+ years. ANOVA test showed that residents' age was very
highly correlated to dental status (F-ratio = 16.2; P-value < 0.001). Of the 499 residents (Table 3.3 , 30
(6%) had no teeth and no dentures.
The prevalence of edentulism was significantly lower among participants who had at least some
high school education, those who agreed that visiting the dentist would keep him or her fkom having
dental problems, and those who did not agree that older adults would have dental problems no matter
what they did. Those who had retired from a skilled occupation were also significantly less likely to be
edentulous.
Participants' dental insurance status was not significantly related to the prevalence of edentulism.
However, factors that are related to visiting the dentist significantly influenced the prevalence of
edentulism in these participants. The prevalence of edentulism was significantly lower among those who
had access to a regular source of dental care, those who visited when there was no pain, and those who
had visited the dentist during the year prior to this study. The prevalence of edentulism was higher
among current smokers.
Table 3.2 1 Prevalence of edentulism related to participants' characteristics
% Prevalence of edentulism Characteristic of residents (in row) *Absent (n) *Present (n)
Predisposing socit+demographic characteristics
80+ yrs old Female Perceived being in good - excellent general health state **Canadian boni ** Cwently rnarried **> High school education
Predisposing health belief Agreeing that:
Going to the dentist regularly will keep fiom having dental problem Older aduIts get dental problems no matter what they do 1 have so many other things to womy about that dental health is low on my list of pnorities
Enabling oral health resources Higher than unskilled occupation at retirement Has own dentist, hygienist or denturist Continuously insured
Oral need Perceived need for dental care
Oral health behavior Current smoker or quit less than one year ago Visited the dentist when not in pain Visited the dentist within the last year
Others Perfoms al1 five activities of daily living
49.3 (294) 62.5 (200)
58.7 (172)
50.2 (253) 49.0 (249) 51.1 (141)
50.5 (109)
69.0 (LOO) 31.6 (136) 31.1 (135)
37.2 (43) Not cognitively impaired 55.6 (239) 59.6 (223)
* n is number of observations with valid responses f P c 0.0001 3 P > 0.0001 and 5 0.001 5 P > 0.001 and 5 0.01 7 P 2 0.01 and 5 0.05 ** Information collected during clinical examination
The prevalence of edentulism was significantly higher among participants who could not perform
al1 activities of daily living.
3.7.2 Adjusted Effects of Dental Insurance and other Factors
Tables 3.22 A & B present the results of the adjusted effect of dental insurance on edentulism.
Again, the cntical P-value for the tests carrieci out should be adjusted to 0.003 (0.05/17). At this fevel of
probability and controlling for row charactenstics, the effect of dental insurance on edentulism remained
not significant. There was a trend towards a protective effect of dental insurance on edentulism when
residents7 ranking of dental health on the list of pnorities and cognitive status of residents were
controlled. The trend towards dental insurance having a preventive effect on edentulism was stronger
among those who disagreed that dental health was low on the list of their pnorities and those who were
cognitively competent .
in one of the 17 analyses in Tables 3.22A & B, agreeing that older adults would always have
dental probtems no rnatter what they did, the overall OR was significantly different from the straturn-
specific ORS. The probability of the Breslow-Day x2 was than 0.0357. Continuous access to dental
insurance trended to reduce the odds of edentulism only arnong females and among participants who
disagreed that; older adults would always have dental problems no matter what they did.
As observed for oral health status, there was a heterogeneous effect of dental insurance on
edentulism among participants' when access to a regular source of care was controlled. Whereas
continuous access to dental insurance significantly protected participants who had access to th& own
dentist Erom being edentulous, its effect is reversed arnong those who did not have access to a regular
source of dental care - dentist, dental hygienist, or dentwist. In this latter group, being continuously
i n s u d significantly increased the odds of edentulism.
Table 3.22A The odds of continuous dental insurance exposure on edentulism controlling for the effect of factors in the Atchison and Gifi's ( 139) mode1
Adjusted OR (95% Confidence Interval) Controlling row characteristic of residents.... Present *n Absent *n Al1 *n Predisposing socio-demographic characteristics
80t yrs old
Female
O Perceiveci being in good - excellent gerieral health state 0.90 (0.5 1 - 1.57) 249 0.57 (0.32-1.01) 208 0.72 (0.48-1.08) 457 Tanadian born 0.97 (0.5 1 - 1.85) 16 1 0.40 (O. 13- 1.19) 66 0.77 (0.44- 1.33) 227
a *> High school education 0.60 (O. 14-2.60) 34 0.83 (0.45-1.54) 183 0.79 (0.45- 1.40) 2 17
Predisposing health belief
Agreeing that: Goingtothedentist regwlarlywill keepfrom having dental problem 0.74 (0.46- 1.2 1 ) 294 0.70(0.23-2.18) 82 0.74(0.47-1.15) 376
Older adults get dental problems no matter what they do 1 . 1 5 (0.60-2.20) 200 0.42 (0.22-0.83) 167 t0.70 (0.45-1.1 1) 367
a 1 have so many other things to wony about that dental health is low on my list of priority 0.75 (0.37- 1.5 1) 172 0.59 (0.33-1 -07) 193 0.65 (0.42- 1.03) 365
Cnide OR (95% Confidence Interval) for the effececi of dental insurance on edentulism 0.68 (0.46-1 -01) 463
Table 3.22B The odds of continuous dental insurance exposure on edentulisin controlling for the effect of factors in the Atchison and Gifi's
Adjusted OR (95% Confidence Interval)
Characteristic of resident in rows.. .. Present *n Absent *n Al1 *n
Enabling oral health resources
Higher than unskilled occupation at retirement
Has own dentist, hygienist or deiitiirist
Oral need
Perceived need for dental care
Oral hcalth behavior
Current smoker or quit less than one year ago
rn Visited the dentist when not in pain
a Visited the dentist within the last year
Others
rn Performs al1 five activities of daily living
Not cognitively impaired
Crude OR (95% Confidence Interval) for the effect of dental insurance on tdentulisrn 0.68 (0.46-1 .O 1) 463
3.73 The Effect of Dental Insurance on other Clinical Outcornes
Continuously insured dentate residents had a mean of 5.4 filled teeth cornpared to 3.6 for
uninsured residents. The mean number of remaining teeth among dentate residents was 13.3. Table 3.23
shows that, apart tiom the mean number of filled teeth, there were no differences between insured and
uninsured dentate residents with respect to other clinical dental outcornes, i.e., mean number of teeth
present, sound teeth, sound abutment teeth. decayed teeth or root, and decayed and filled teeth (DIT).
The 10% difference in edentulism between continuously insured and uninsured residents was no longer
significant in this group. There was a strong tendency for the insured edentulous not to have dentures.
Though not statistically significant, the rnean of 14.1 teeth among insured residents was 1.4 teeth
more than that found in uninsured residents. There was aIso a tendency for insured residents to have
fewer decayed teeth. Compareci to 0.9 mean decayed roots arnong insured residents, uninsureci residents
had 1 -4. The mean number of teeth with coronal decay among insured residents was 50% less than the
mean of 0.9 observed among uninsured residents. The mean number of teeth with prhary decay arnong
uninsured residents was 1 S. This was 0.6 higher than that observed in insured residents. Comparing the
odds of not having dentures when a resident was edentulous showed that the continuously insured
demonstrated a strong tendency to be more than twice (OR = 2.2) as likely not to have dentures when
they were edentulous. This effect was only observed among those who were unable to carry out al1
activities of daily living.
The worst periodontal score is presented for 1 16 residents in whom periodontal probing for
pocket assessment was carried out. The occurrence of periodontal pocket as the worst score was not
related to previous dental insurance exposure, although the occurrence of pockets was higher (31%)
among currently insured residents when cornpared to uninsured residents (18%).
The prevalence of lesions of the oral mucosa is also presented in Table 3.23. Nearly equal
proportions of currently insured and uninsured residents (90 % and 89 % respectively) had no lesions of
the oral mucosa. Sirnilarly, those with lesions that required no treatment were 8.6% and 8.5%,
respectively. The proportion of uninsured residents with lesions of the oral mucosa that required treatment
was 2.3%, compared to 1.2 % for continuously insured residents.
Table 3.23 Dental status related to residents' previous exposure to dental insurance
Dental insurance status: Insured Never Currently Al1 P-value
Clinical outcome measure % Edentulous - interview (N)
% Edentulous without dentures (N)
% With lesions of the oral mucosa
1. None
2. Present no treatment needed
3. Present treatment needed
N
Dental stutus of dentate residents O Mean (SD) number of teeth remaining
O Mean number of teeth with decay (SD)
1. Coronal decay (SD) 2. Root decay (SD)
3. Prirnary decay (SD)
4. Seconrtiiry decay (SD)
Mean number of filled teeth (SD)
O Mean number of decayed & filled teeth
- DFT (SD) Periohntal Health (R3
O Periodontal status (% of subjects with
worst CPITN score as ..)
1. Healthy
2. Bleeding
3. Caiculus
4. '4-5' mm pocket 5. Pockets 6 mm or more
*P-value from Chi-square test tP-value fiont ANOVA tesi SKmskal- Wallis Test
Table 3.24 Exposure to dental insurance related to clinical oral health status outcomes
Outcome Relative Odds Ratio 95% Confideiice Power to
Dependent outcome measures N present (%) % Difference* (tOR) Interval detect TOR - --
Periodontal statu~ No attaclrrrtent Ioss
lnsured 62 24.2 50 0.6 0.3 - 1.2 26% Uriinsured 77 36.4
No periodoritul pocker (CPI TN 3 or 4) Insured 56 67.9 2 1 0.5 0.2 - 1.1 37% Uninsured 71 81.9
Dental Caries Status $Dentu1 caries absent
Insured 62 64.5 Uninsured 77 54.6
Roof caries absent lnsured 62 75.8 Uninsured 77 61.0
Dentition Status More than 19 teeth reniaining
Insured 62 30.6 Uninsured 77 19.5
v o r e thari 19 sound teeth rentainirig Insured 62 24.2 Uninsurcd 77 14.3
Denture Status Edentulotcs havittg no dentures
Insured 72 15.3 -99 2.2 0.9 - 5.0 27% Uninsured 195 7.7
* (% outcome present in irisured - outcorne prescrit in iininsitred) / % oictconie pment in insiired x 100 tPoint estimate of OR SBoth coron01 and root caries absent YSortnd teeth = teeth with no decuy +/illed teeth with no decav + sound abutnient teeth
CHAPTER 4
DISCUSSION
4.1 Summary of Study Findings
The pwposes of this study were to describe the oral health status and then examine the
relationship between dental insurance and oral health among older adults in Durham Region, Ontario,
Canada. This stud y examineci oral health status using pat ient-based psyc hosocial measures derived fiom
three oral health dornains (composite measure) and the global rating of oral health. Clinical biophysical
rneasures of dental status were regarded as intennediate outcomes to oral health in this study. The clinical
fmdings in this study are contained in a report entitled: "Oral Health Status of Institutionalized Older
Adults in Durham Renion - An Outline Report" submitted previously to the Durham Region (1 80).
Less than half (44%) of participants perceived themselves as having fair to poor oral health status.
Fewer participants (26%) were similarly rat& by the composite measure of oral health status. Validity
tests showed that the composite measure was a better index of oral health status among these participants.
The composite measure was therefore selected as the final patient based end-outcome measure of oral
health status in this study.
One in every ten participants (10.6%) had a lesion of the oral mucosa; however, treatment was
only needed in 20% of the cases. Reported edentulism among participants was 57.8%. Of the 504
residents interviewe4 6% reported having neither dentures nor their own teeth. The mean number of
teeth remaining in the mouth of dentate residents was 13.3. The mean number of decayed and filled teeth
(DFT) was 5.7. The treatment ratio FT/DFT was 0.8.
Nearly a-third (30%) of the participants had had dental insurance coverage continuously since the
No significant difference in the prevalence of poor oral health was observed between
continuously insured and uninsured participants. The absolute difference between continuously insured
and uninsureâ participants was 2.0%. We observed that there was a trend for edentulism to be lower
among continuousl y insured (5 1 96) residents when compared to their uninsured counterparts (6 1 %).
Similar, non-signi ficant trend showed clinically relevant ciifferences in biop hysical measures of oral
health status between continuously insured and uninsured residents (Tables 3.18, 3.23 & 3.24). An
absolute 36% difference in the proportion of uninsured =d continuously insureci residents who had more
than 19 remaining teeth was observed. When only sound teeth were considered, i.e., teeth with no decay
or filled teeth with no decay or sound abutment, then the difference rose to 41% between the groups.
There was a tendency for root caries to be more prevalent among the uninsured group. There was also a
tendency for loss of periodontal attachment and periodontal pockets to be more prevalent arnong
continuously insured participants.
The tendency for continuously insured residents to be dentate when compared to uninsured
participants was not observed in trivariate analyses when each of the row characteristics in the Atchison
and Gift (139) mode1 was controlled. However, there was a trend towards a protective effect of dental
insurance on edentulism when cognitive status of participants and the ranking placed by residents on their
dental health were controlled. The effect of dental insurance on participants appeared to differ depending
on whether they had access to a regular source of dental care or not; i.e., there was heterogeneity of effeçt
among participants with and without their own dental care provider. Whereas, dental insurance was
protective of edentulism among those who had their own dental care provider, it increased the odds of
edentulism among those who did not have a personal dental care provider. Being continuously insured
tended to increase the odds of being edentulous among male subjects. However, it appeared to prevent
edentulism among current 1 y marrieci participant S.
We observed no significant relationship between dental insurance and the composite masure of
oral health status during bivariate and trivariate analyses. A trend towards heterogeneity of effect was
observed among participants who had or did not have their own private dentai care provider. Being
continuously insured prevented a participant fkom being in a poor oral health state if the participant had
his or her own dental care provider; but increased the odds of being in a poor oral health state if the
participant had no private dental care provider.
Similarly, the effect of dental insurance on oral health status was modified by residents' marital
status and gender. Continuous access to dental insurance appeared to protect females and married
participants fiorn being in a poor oral h d t h state. On the other hand, dental insurance increased the odds
of poor oral health among males and unmanid participants. This trend persistai even when the analyses
of the effect of dental insurance on oral health status contingent on access to care was stratifiai by gender
and marital status. Similarly, the modifjring effect of gender and marital status persisted (Table 3.20).
4.2 Threats to External Validity
Although a standard design of carrying out the interview, followed by clinical examination, was
used in this study (17, 18, 142, 143), there are threats to the validity of this study that must be
acknowledged. Given the relatively few residents in Durham Region's Regional Homes for the aged, a
census of residents was targeted. Participation rates reduced fiom 64% for the interview to 35% for both
the interview and the clinical examination. This is common in studies conducted in this cohort (1 72).
However, the response bias did not seriously affect the estimates derived fiom probability sample surveys
in East York and Ottawa-Carleton Regions in Ontario. Locker (181) has since suggested appropriate
methods for weighting results obtained fiom such studies. Weights cannot be applied in this study since
we conducted a census rather than a probability sarnple survey.
Our study participants were somewhat different fkom to the source population. The age of
interviewa! participants was signi ficantl y di fferent fiom the age of al1 residents of Durham's Regional
Homes for the Aged; our participants were older by nearly 2 years. Nevertheless, both groups belonged
to the same dernographic age bracket, 80+ years old. For participants who completed both the interview
and the clinical examination and those who refused participation afier the interview stage, no difference
was observed in their ages. It was not possible to compare residents on other characteristics since we did
not obtained ethical approval to use residents' records.
Those who declined to participate in the study after the interview were somewhat diffcrent fiom
residents who participated fùlly in the study, i.e., both the interview and the examination. Those who
refused clinical examination perceived being in poorer general health state, were less able to c m y out al1
five activities of daily Iiving, retired in a lower occupational class, and were more edentulous. Perceived
need for dental care was less common among the study dropouts who, also, more commonly agreed that
going to the dentist regularly would keep him or her fiom having dental problem.
Findings fiorn the interview can be generalized to al1 residents in Durham's Regional Homes for
the Aged since the 2-year age difference between interviewed residents and al1 residents is not clinically
relevant; the mean ages of the two groups were 83.1 years and 81.9 years, respectively. However,
findings fiom clinical examinations are based on relatively more ambulant and dentate group who also
perceiveci a need for dental care. Therefore, inference based on clinical findings rnay not be generalizable
to al1 residents in the Homes.
4 3 Threats to Interna1 Validity
A major limitation in this study is the multiple statistical tests carried out. This multiple testing
tends to lead to false positive findings as the effective ievel of significance rises by the number of
statistical tests carried. The use of an alpha level of 5% may therefore yield some false positive results
since this level of significance would only have been established if our findings were associated with a
significance level of 0.003. This was not present for most of our statistical tests. Notwithstanding the
consemative nature of the Bonferoni's adjustment (182), most ORS were not significant even at the 5%
level of significance.
The cross-sectional nature of this study limits the ability to draw a causal link between exposure
and outcomes. This study design cannot demonstrate a temporal link between cause and effect. The
Hill's criteria (183) and the definition of causation by Elwood (1 84) - "a factor is a cause of an event if its
operation increases the frequency of the event" - are al1 philosophidly based on consensus of consistent
associations.
Because this shidy was cross-sectional, there were possibilities for errors in the assessrnent of the
outcornes and exposure in this study. For exarnple, we could not determine those who became edentulous
during the exposure period since many residents rnight have been edentulous before dental insurance
coverage began in 1974 when the average participant in this study was aged 57 years. In Canada, 49.5%
of male and 55.7% of fernale 60+ years old were already edentulous in 1977. For 50-59 year olds, the
prevalence of edentulism was 30.4% and 35.4%, respectively (1 85). Participants were asked: "How old
were you when you last had a tooth out?" - Appendix 2C. However, inconsistencies in responses and
high non-responses made the item unusable. For example, while some reported age, other reported how
long they had had dental extraction, reported on the year of last extraction, and many others did not
respond to the question.
We obtained a history of dental insurance exposure but did not separately validate this
information. There is a possibility that some of the participants, who were mostly female, did not know if
they were continuously covered; residents could only have used dental services if they were fully aware
of the fui1 extent of their coverage. Similarly, substitute respondents may not be aware of current
insurance coverage status of the residents for whom they act as substitute decision-makers. Thus,
misclassification by exposure as well of under-reporting of exposure could have occurred among
participants, especially those who had retired fiom companies other than General Motors where the dental
plan for retirees was not known a priori. Both misclassification and under-reporting of exposure have a
tendency to produce a nul1 effect for the relationship between dental insurance exposures for any
outcome.
in the case of cognitively impaired participants, we carried out telephone interviews with
substitute decision-makers. Responses fkorn respondents differ f?om that of their substitute (186);
different modes of data collection are documented as potential sources of bias (1 84). We obtaineù a high
reliability for the assessrnent of dental status by substitute respondents, but we did not validate any other
infonnation provided by substitutes, especially those relating to health beliefs and behavior.
Administrators in the Homes reviewed and subsequently limited the survey instnunent (Appendix
2C) to ailow for a maximum interview period of about 30 minutes. This was because of the h i 1 nature of
residents and the need to ensure that residents were not burdened by the interview. Given the h i 1 nature
of participants, the derived composite measure was limited to three domains of oral health that was
ultimately based on 9 items. This less comprehensive outcome measure may limit the ability to fully
measrue oral health in this study. As presented in section 1.6.1, the concept of oral health encompasses
more than the three domains usai in this shidy. Notwithstanding, t h , a high correlation was obtained
with an acceptable criterion - the global rating of oral health (9, 53, 123-127). The GOHAI that is based
on 12 items obtained a correlation of 0.47 with the sarne global oral health rating. We obtained a
correlation of 0.46 between the composite measure of oral health used in this study and the global oral
health rating. Further, a high face-validity was obtained for our composite measure of oral health statu.
Responses to items used to denve the composite oral health index were obtained fiom substitutes
in about half of the participants. Nevertheless, classification of residents as being in a poor oral health
state was not significantly higher among participants whose i n t e ~ e w s were conducted with substitutes.
Another potential source of bias in this study was that oral health status was measured in a cross-
sectional rnanner. This suggests that the effect of dental insurance on oral health status is cumulative.
This may not be a valid assumption, since other prevailing conditions can impact on oral health status.
Dolan er al. (133) observed changes in oral health scores among participants in a three-year study.
Significant associations were observed between broader measures of psychological well-being and life
satisfaction in older adults and oral health related dysfunction, pain, and disability in a 7-year follow-up
shidy. Those who rated their oral health poorly had lower morale, more life stress, and were less satisfied
with their lives than subjects who rated their oral health favorably (1 87). Therefore, the net change in oral
health status in this cohort might have been influenced by life circumstances that were not controlled in
this study.
4.4 Oral Health Status (biopbysical measures) Compared to other Ontario Studies
The prevalence of edentulism in this study (57.8%) is within reported rates in Ontario. However,
this was lower than the estimated working average of 70% (Table 2.1). Leake (23) observed that the
prevalence of edentulism varieci between 6 1% and 76% in older adults aged 80-84 years old in Ontario in
studies conducted up until 1988. Hawkins et al (29), in a study of 1,375 85+ years old adults in North
York between 1982 and 1992, reported a prevalence of edentulism of 65.8%.
Viewed fiom a cohort perspective (Figure 1. IO), this group of 82.6 years olds was born in 191 7.
The reported rate is consistent with a declining prevalence of edentulism. However, a cross-sectional
swvey of collective living centers (CLCs) in North York reported a lower prevalence of 3 1.7 % arnong
those 85+ years old (1 47). This latter study obtained participation fiom 13 of the 2 1 CLCs in North York,
but only 200 people participated. Thus, this may be a biased group of older adults, as Figure 1.10 also
shows that the decline in the cohort rate of edentulism in this group is very high relative to previous
obsexvations fkom other studies.
There were about 13 teeth rernaining, on average, arnong dentate residents. This is comparable to
the average of between 12.1 and 14.6 teeth reported firom other studies conducted in Ontario (23). There
were five more teeth to every two older aduIts in this study compared to those in the study of Hawkins et
al. (29). There were, however, 2.0 fewer teeth remaining in the mouths of dentate older adults in this
study, compared to those in Munay et al's (147) study.
The mean DFT in residents of CLCs in Ontario ranged Fom 4.4 to 5.8, while the treatment ratio
(FT/DFT) varied between 0.32 and 0.62 (23). Other studies, presented in Table 1.1, reported a mean of
between 6.0 and 7.4 and a treatment ratio of 0.57 to 0.78 (23, 29, 143, 147). The mean DFT of 5.7 and
FT/DFT of 0.8 fïndings in this study are in the upper end of cwrent range in the province (Table 1.1).
Compared to older adults in North York institutions between 1982 and 1992, those in Durham Homes for
the Aged in 2000 had more teeth remaining, a lower number of DFT, and a higher treatment ratio.
Nearly a third (32.4%) had 21 tooth with root decay (RDT). The mean (SD) root decayed teeth
(RDT) was 1.2. The prevalence of RDT or root decayed tooth surfaces (RDTS) reported in independently
living (7, 144), or a combination of independently living and collective living center (23) residents, in
previous studies in Ontario was between 28% and 37%. However, the studies involved a relatively
younger cohort of elders. In East York, the mean RDT reported in Leake's (23) review was 0.82.
The prevalence of periodontal disûise as assessed by the CPITN is different fiom that reported in
previous studies. Compared to adults in CLCs in North York, the prevalence of calculus is higher in this
study while pockets 26 mm were fewer. ]
4.5 The Effect of Dental Insurance on Oral HeaIth Status
Apart fiom oral ne&, being continuously insured was significantly associated with many of the
other variables in the mode1 (Table 3.17). Given the design of this study we are unable to determine
whether dental insurance resulted fkom or is a result of any of these factors. Al1 enabling resources -
having higher than unskilled occupation at retirement and access to a usual source of dental care - were
related to being continuously insured. This is not surprising, since most of the participants were female
and invariably housewives. Occupation is ofien employment related and those in higher occupational
classes have a higher rate of dental insurance coverage (35, 39, 40, 4 1,48). This study observed that the
use of dental service within the year preceding the study and visiting the dentist when not in pain were
more common among continuously insured participants.
Edentulism was treated as an intermediate oral health outcome in this study. This study reported
a tendency for uninsured residents to be more edentulous (61%) when compared to their continuously
insured counterparts (51%). However, this study lacked statistical power to demonstrate significant
difference between continuously insured and uninsured residents (Table 3.24). The higher prevalence of
edentulism of 9.5% among uninsured older adults is similar to the 8.7% reported arnong 65-1- years old
Americans (108). The low absolute difference between continuously insured residents and uninsured
participants in this study, as in the American Behavioral Risk Surveillance System - BRSS (log), might
be due to misclassification since both studies related current dental insurance status to reported
edentulism.
The causes of edentulism are multi-factorial. Slade et al. (72) had reported that baseline predictor
of tooth loss was the number missing teeth among 60+ years old Australians. Eklund and Burt (71), on
the other hand, had reported that the initial numbers of missing teeth was an important factor in
edentulism. Social, cultural and historical factors also affect tooth loss (68). Thus, the dental experience
of older adults who were partidly dentate in the early 1970s might have been predetennined by their
previous history of dental extraction.
Compared to the mid 2 0 ~ century, the practice of dentistry had gone through significant
advances. Cment cohort of older adults belongs to a different era in the history of dentistry when
prevention was not the modus operandi (20). Older adults were reportedly l a s convinced of the eficacy
of prevention (1 88). The benefits of dental insurance, if any, might not be uniform across these elders
since those who loose rnany teeth earlier on in life may rapidly become edentulous (68, 71, 72). Being
dentate, arnong other factors, also positively influences the attitude of the elderly to oral health issues
(189). The operation of these socid, cultural and historical factors might not be random between
exposure goups and are liable to reduce the difference in the rate of edentuiism between insured and
uninsured participants.
The effectiveness of a dental plan is contingent on the comprehensiveness of the benefit provided
to the insured. In Canada, there has been a considerable increase to coverage since the early 1970s when
the plan was initiated (4 1,85, 185); however, plan benefits are highly variable. This study provided some
evidence that having dental insurance was only effective in preventing edentulism if the participant had
access to a regular source of dental care. Without access to a private regular dental care provider, dental
insurance appears to Iead to sporadic care that preferentially led to dental extractions and resulting in poor
oral health status among participants.
An unexpected finding, which is also contrary to the RAND study (45), was the tendency for
continuously insured residents to have poorer periodontal status. The difference between the proportions
of contuiuously insured and uninsured residents who had attachment loss was 50% in the continuously
insured group. The continuously insured group was worse-off. However, insured participants were better
off on dental caries status measures and the number of remaining teeth.
An incidental finding in this study is the odds of not having dentures when a resident is
edentulous. Continuously insured edentulous residents were nearly twice as likely not to have dentures.
However, most of those who had no dentures and no teeth were significantly less likely to be able to
perforrn al1 activities of daily living, despite being relatively young. Therefore, despite having dental
insurance, once a resident becomes limited in the ability to perform the activities of daily living, they
appear to become unable to receive or tolerate the care they need. This fïnding lends support to the
fmdings of others who report that disability in the elderly is an important barrier in accessing care (48,
75).
Trivariate analysis still failed to show a signifiant effect of dental insurance on patient based
measures of oral health status. The null effect of dental insurance on oral health status rnay be viewed
from rnany perspectives, other than the intemal validity issues discussed earlier. The first perspective is
in the context of the measurernent of oral health. Locker and Miller (1 25) have arguecl that subjective
indicators of oral health may either be Iirnited in scope or that disease and h a h h may exist as different
discrete human experiences, with dental status measures identifjnng disease and subjective measures
identifjmg the individual's health state. In a separate evaluation of subjective measures, Kressin (123)
reported that the GOHAI and OKRQoL measured different aspects of general health and wellbeing.
Dolan et al. ( 136) have previously reported that their subjective measure of oral health, "Dental Health
index", was jointly and significantly related to mental health measures, but were split when the
comparing with physical health (role limitation and personal function) index.
Therefore, the null effect in this study might have arisen because of the iirnited scope of
subjective measures and the ability of the measures used in this study to capture the areas of oral health
where dental insurance might have had an impact. However, we observed no effect on these non-
subjective (clinical) measures because of lack of statistical power.
This study evaluated the prevalence of pain over a two-week period but disability due to puor-
fitting dentures for example was not included in the limited composite index used in this study. Indeed,
the use of equal domain weights may not be valid since areas of impact rnay not be tmly equal. Lester, et
al. (190) obsbwed that oral health impact differs between groups; therefore assigning weights in
composite indices should be done with caution. McGrath and Bedi (1 l), as well as Kressin et al. (9),
have also reported that impact ranking differed between social class, gender, income and the area of oral
health in which impact is highest. Thus, while the influences of some dornains are over-sampled, other
critical areas may be under-represented. However, previous measurement techniques were also based on
the addition of un-weighted dornain scores (53, 120- 122).
Except for the relationship between clinical outcornes and edentulism, previous attempts to
examine the relationships between clinical and subjective measures of health have often observed only a
weak association between the two measures (8, 122, 123, 125, 132, 138, 190). in this study, the
difference in level of edentulism only became nearly significant among those who participated in the
clinical examination where the difference in prevalence between the insured and uninsured was 14%.
Thus, whereas dental insurance may influence some dental morbidity-based measures, it lacked effect on
patient-based measures or the difference between insured and uninsured residents in these participants is
too small.
Another useful perspective to interpret the nul1 effect is the possible dilution effect, due
potentially to insured residents who had no teeth and no dentures and who were lirnited in their activity of
daily living. Convergent validation with the measure of disability - ability to chew the most difficult of
the five food items - was highly related to dental status @igue 3.2). Those without teeth and dentures
were the most disabled group. They were also the group less likely to be able to perfonn al1 five activities
of daily living. Therefore, in the functionally compromised elderly, other non-economic barriers may
prevent the elderly from receiving the care they need promptly. McGrath and Bedi (1 1) have reported that
eating was the most important way oral health influenced the quality of life of older adults 65+ years old
in Britain. Age, social class or gender did not influence the significance of chewing on quality of life.
Leake (23) had previously revealed a high correlation between the chewing index and edentulism.
This finding may be viewed within the context of fmdings reported Erom previous studies that
examined the influence of dental insurance on subjective measures of oral health. Atchison and Gifi
(139) failed to consistently demonstrate a direct effect of dental insurance on oral health in a diverse
sample of older adults aged 65-74 years old. An independent effect for dental insurance on oral health
(global rating) was only observed among a sample of San Antonio Caucasians drawn ftom Texas.
Similady, Locker and Slade (138) reported a direct effect of dental insurance on OHIP scores with the
uninsured having higher (worse health) OHIP scores. Dental insurance accounted for 14% in the
variation of OHIP scores. The explanatory model's coefficient of detennination was 0.32. The study
sarnple consisteci of Ontarians, a predominantly Caucasian population, aged Sot years old. The average
age of participants in this study was 82 years. Both groups of researchers, Locker and Slade ( 138) and
Atchison and Gifi (139) observed that age was a predictor of oral health status. The average age of
participants in this study was higher than that in the previous studies. Nevertheless, we observed that the
effect of dental insurance on oral health and edentulism was modifieci by whether a participant had access
to a regular source of dental care or not. Possibly, those who had no regular source of care had a
tendency to receive intermittent care that might have resulted in their tendency to being more edentulous
(Table 3.18) and subsequently being in poor oral health. The increase in odds of poor oral health arnong
edentulous participants was statisticaliy significant at the 1% alpha level.
The nul1 effect may be because other factors that prevent continuous access to care in the very old
may eliminate the previous benefits the insured had over the uninsured. This study observed that
edentulous participants without dentures were unable to perform the activities of daily living. A
significant disproportion of insured participants belonged to this group.
At the inception of the Swedish Dental Plan, Barenthin (90) reporteci that dental insurance most
certaidy increased the use of dental services by the edentulous elderly. That an insured edentulous
elderly was not likely to have dentures lends support to this view. This study shows that this contact
independently influenced tooth survival. Tooth survival is necessary for reducing oral disability, a
component of the measure of oral health in this study. Nevertheless, even when insured, the elderly who
are functionally impaired need to break other bamiers to maintain this contact. There is a need for dental
services within the Homes for the Aged to cater especially to those who are unable to carry out al1
activities of daily living, i.e., the functionally limited.
Finally, older adults were exposed to dental insurance for 20+ years. However, the assessrnent of
oral health was assessed in a cross-section of tirne. It is unlikely that this assessment adequately
represents the impact of dental insurance over the entire period of exposure. This study did not assess a
change in oral health status over the period of exposure. Furthemore, oral health status changes over
time (133, 191, 192).
4.6 Need for Future Research
At the 59" Council Meeting of the National Advisory Council on Aging (NACA) held on
September 7, 2000, the fust recornmendation was (193) as follows. "That publicly fiindeci services be
extended to comprise al1 services necessary to restore and preserve health and fimctional capacity,
including home care, prescription dnigs, care provided in long-tenn care facitities, dental care and
vision, hearing and other assistive technology" (ernphasis mine). This study did not observe significant
differences in the oral health outcomes between the continuously insured and the never-inswed residents.
We also observed that among the dentate, dental insurance reduced the odds of poor global oral health.
However, we are not in a position to support the nul1 hypothesis proposeci earlier. The effect of losing
coverage at retirement was not evaluated in this study. To address the limitations in this study, especially
as it relates to a lunited participation level, and other interval validity issues identified (especially
i den t iwg the t h e participants become edentulous), a region-wide prospective study with opportunity
for nested case-control sub-studies study should be carried out. The question intended to assess when
respondents became edentulous must be reworded and adequate cues provided to aid responses. The
longitudinal component of this design will enable the measurement of the transition in oral health status
and isolate the temporal association between exposure and outcorne. It wili also be possible to study the
effect of loss of coverage.
To the extent that policies must be formulated that are intended to address health outcomes in the
impaired elderly, the validity of information on patient rated health masures obtained f?om proxy
respondents should be investigated. Future studies should include sufficient participants to enable
stratification by cognitive status of residents or matching by cognitive statu. Altematively, masurement
techniques in oral health should be refmed to produce robust instruments that are applicable for use in the
nursing home setting.
4.7 Conclusion
Findings fiom this study provide insufficient evidence to reject the hypothesis that dental
insurance exposure did not influence oral health stahis in institutionalized older adult residents in
Durham's Regional Homes for the Aged when assessed by the composite and the global measures.
Rather, we observed a tendency for the effect of dental insurance on oral health to be Muenced by
whether a resident had access to a regular source of dental care or not. Whereas being continuously
insured was protective of poor oral health if a resident had had access to dental insurance continuoudy, it
tended to increase the odds of poor oral health if the resident did not have a regular source of dental care.
This suggests that the effectiveness of dentai insurance in improving oral health status, edentulism and
patient-based measures of oral health status, might be dependent on a concomitant the e1ders' access to a
regular source of dental care. Clinically relevant differences - periodontal status (absence of attachent
loss and absence of periodontal pockets - CPïïN 3 or 4), dental status (absence of dental caries, absence
of root caries), dentition status (having more than 19 teeth rernaining in the mouth), and denture statu5
(being edentulous and having no dentures) - were observed between continuously insured and uninsureci
participants in this study. Given the interna1 and external validity issues identified, it is suggested that a
region-wide nested case-control study be initiated to address the question of the impact of dental
insurance on institutionalized elderly.
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APPErnIX 2 COVER LETTER FOR INFORMED CONSENT
DURHAM HEALTH REGION & FACULTY OF DENTiSTRY UNIVERSITY OF TORONTO 124 EDWARD STREET TORONTO, M5G 1G6
Resident/Substitution Decision Maker
SURVEY OF ORAL HEALTH STATUS OF OLDER ADULTS IN DURHAM, ONTARIO
The Durham Health Region in collaboration with the Faculty of Dentistry, University of Toronto, is conducting a study to assess the oral health status of older adults living in Durham Homes for the Aged. The information fiom the examination with be put together to provide a picture of the oral health status of seniors in Durham Region. Participants will receive a dental examination. The examination is a routine inspection and will not cause any h m . it will be conducted using sterilized dental mouth rnirrors and dental probes but no X-rays.
We will provide advice on any problem that we find. Apart fiom the advice, no direct benefit will be derîved fiom this study.
We want you to participate in our study. Please read the attachd letter of consent. If you agree to participate, please sign one of the two copies of the letter and return to the undersigned. Please keep the other copy for your records
Yours truly,
Dr. Pat. Main DireCror, Dental Services Durham Health Region
APPENDIX 2A INFORMED CONSENT (SUBSTITUTE DECISION-MAKER)
DURHAM HEALTH REGION & FACULTY OF DENTISTRY UNIVERSITY OF TORONTO 124 EDWARD STREET TORONTO, M5G 1G6
Resident SURVEY OF ORAL HEALTH STATUS OF OLDER ADULTS IN DURFIAM, ONTARIO
1 understand that 1 may be exarnined as par? of a study of the oral health status of older adults living in Durham Homes for the Aged. The examination is a routine inspection and will not cause me any h m or injury. The clinical examination will be carried out using standard dental instruments but no X-rays.
1 understand that 1 not be given any dental treatment but will receive advice about my dental health. Apart fiom this advice 1 will receive no direct benefit from the study. 1 can refuse or tenninate the examination at any stage. 1 may also withdraw my consent at any time. If 1 refuse participation or withdraw my consent, 1 have been assured that, 1 will still be eligible to al1 services norrnaIly provided by the Region.
1 have been assured that al1 information about my general health and dental health will remain confidential and that my name will not appear in any paper or report.
1 hereby give my consent to participate in the study.
Name & Signature:
Examiner's Narne & Signature:
Witness' Narne & Signature:
Date:
APPENDIX 2B INFORMED CONSENT (RESIDENT)
DURHAM HEALTH REGION & FACULTY OF DENTISTRY UNIVERSITY OF TORONTO 124 EDWARD STREET TORONTO, MSG IG6
Substitute Decision Maker, SURVEY OF ORAL HEALTH STANS OF OLDER ADULTS IN DURHAM, ONTARIO
1 understand (Name), for whom 1 am the substitute decision-maker, may be examined as part of a study of the oral health status of older adults living in Durham Homes for the Aged. The examination is a routine inspection and will not cause her/him any harm or injury. The clinical examination will be camed out using standard dental instniments but no X-rays.
1 understand that she/he will not be given any dental treatment but 1 will receive advice about her/his dental health. Apart fiom this advice shehe will receive no direct benefit fiom the study. 1 have been infonned that shehe can refuse or terminate the examination at any stage. I may also withdraw th s consent at any tirne. If 1 refuse participation or withdraw consent, 1 have been assured that, she/he will stitl be eligible to al1 services normally provided by the Region.
1 have been assured that al1 infoxmation about her/his general health and dental health will rernain confidential and that her/his name will not appear in any paper or report.
1 hereby give my consent for (Name) to participate in the study.
Narne & Signature:
Examiner's Name & Signature:
Witness' Narne & Signature:
Date
APPENDIX 2C INTERVIEW SCaEDULE
DURHAM HEALTH REGION
Office use only
Name of Home: Identification No: Date
1. 1s Respondent the Resident: Yes No Substitute Decision-Maker (State relationship to
resident) 2. Name of Resident:
3. Sex: 1 = Male 2 = Female
4. Occupation before retirement:
5. How would you descnbe your dental health? 1s it: READ ALTERNATIVES
1 = Excellent 2 = Very good 3 = Good 4 = Fair 5 = Poor 8 = Don't Know 9 = No response
6. Which of the following best describes the condition of your mouth? 1 = 1 have rny own teeth and no dentures 2 = I have my own teeth and one or more denture(s) or bridge(s) 3 = 1 have no teeth and full upper & lower dentures or plate 4 = 1 have no teeth and no dentures
7. How old were you when you last had a tooth out? Years: 999 = Don't know
8. Are you ordinarily able to: ClRCLE APPROPRLATE RESPONSES
No=O
chew a piece of ffesh cmot O chew boiled vegetables O chew fiesh salad O chew firmmeatsuchassteakorchops O bite and chew a piece from a whole k s h apple O chew hamburger O
Don't Yes = 1 h o w = 8
1 8 1 8 1 8 1 8 1 8 1 8
9. Do you need advice or dental care now? O=No 1 = Yes
10. In the past two weeks, have you had any dental pain? O =No 1 = Y e s
11. How satisfied are you with: READ ALTERNATIVES
V ~ V Very dis- Satisfied Satisfied Dissatis fied satisfied
O The appearance of your teeth and gurns? 1 2 3 4 Your ability to chew? 1 2 3 4
O Your ability to speak clearly? 1 2 3 4
12. 1s there a dentiddental hygienist or denturist you usually see when you want dental treatment or advice? Dentisvdental hygienist? O=No 1 = Yes
Denturist? O=No 1 = Yes
13. Do you see a dentisvdentai hygienist or denturist: For checkup? 1 Only when 1 have pain or other trouble? 2 For checkups and when 1 have pain or other trouble? 3
1 4. Are you currentl y having a course of dental treatment or waiting to see a dentiddental hygienist? No O Currently having a course treatment 1
Yes, waiting to see a dentist provider 2
15. How long has it been suice you last saw a dentist dentwist or other dental care provider? Within the 1 s t two weeks 1 Two weeks to five months 2 Six months to eleven months 3
Ifresponses are scored I - 3 above, then Go to Question 16
One to two years Three to five years More than six years Never obtained care Don't know
Ifresponses are scored 4 - 8 above. then Go to Question 17
Was it here at the home with "Golden Care"? O = N o 1 = Yes 8 = DonTt know Go to Question 18
What was the main reason you didn't visit a dentist in the last year? Any other reasons? CODE ALL THAT APPLY 0 1 = Cannot afford cost 02 = Don't want to spend money on dental care 03 = AfraicUdislike dentists or dental hygienists 04 = Too busy 05 = Nothing wrong 06 = Problem not senous enough, decided to wai-t 07 = Expected problem to go away 1 1 = Don't know a dentist 12 = Dental office too far away 13 = Physical problems prevent me from going 14 = Can't sit in dental chair or tolerate long visits 15 = Medical problems/too il1 1 6 = Have no teethldentures 17 = Other (Specifi: 1 88 = DonTt know
Main reason Others (CODE ALL THAT APPLY)
18. Do you (or your spouse) now have any kind of govenunent or pnvate dental insurance plan that pays for part or al1 of your regular dental care?
O =No 1 = Yes, part Go ro Question 19 2 = Yes, al1 Go ro Question 20 8 = Don't know If responses are scored as either O or 8. then Go to Question 22
19. If YES - PART, about what percentage of your regular dental care costs are covered?
Y0 888 = Don't know
20. How long have you (or your spouse) had dental insurance? 1 = since the 1970s 2 = since the 1980s 3 = since the 1990s
2 1. Do you remember when you (or your spouse) fust had dental insurance? 19 Go to Question 25 Year
22. If No, did you (or your spouse) once have a dental plan that paid for part or al1 your dental care? 0 = 1 1 = Yes, ail 2 = Yes, part 8 = Don't know If response is O or 8, then Go to Question 25
23. Which of the following best describes the total perioà you were covered? 1 = Five to 10 years 2 = 10 to 15 years 3 = More tlian 15 years 8 = Don't remember
24. Did your insurance stop when you retired? O=No 1 = Yes 8 = Don't know
25. Are you able to brush your teeth yourself? O = No Go to Question 27 1 = Yes
26. How often do you brush your teeth? 1 = Never 2 = Once a month 3 = A few times a month 4 =Once a week 5 = A few times a week 6 = Once a day 7 = Twice or more a day 8 = Don't know Go ro Question 29 from here
27. Does a caregiver/member of your family brush your teeth? O=No Go to Question 29 1 = Yes
28. How often does a caregiver or member of your family brush your teeth? 1 = Never 2 = Once a month 3 = A few times a month 4 =Once a week 5 = A few times a week 6 = Once a day 7 = Twice or more a day 8 = Don't know
QUESTIONS O N ATTITUDES I will now go to questions about what you feel about your mouth and what you consider important in caring for your mouth.
29. Going to the dentist regularly will keep me from having trouble with my teeth and gums. 1 = Strongly agree 2 = Agree 3 = Disagree 4 = Strongly disagree
30. Older adults get dental problems no rnatter what they do. 1 = Strongly agree 2 = Agree 3 = Disagree 4 = Strongly disagree
3 1. 1 have so many other things to wony about that dental health is low on my list of priorities. 1 = Strongly agree 2 = Agree 3 = Disagree 4 = Strongly disag-ee
32. It is natural to get gum disease as you get older 1 = Strongly agree 2 = Agree 3 = Disagree 4 = Strongly disagree
QUESTIONS O N GENERAL REALTH Finally, 1 will like to h o w about your general health and whether you smoke or take alcoholic drinks.
33. Would you describe your general health as: 1 = Excellent 2 = Very good 3 = Good 4 = Fair 5 = Poor 8 = Don't Know 9 = No response
34. Do you smoke, or did you ever smoke cigarettes? O=No G o tu Question 37 1 = Yes
35. Which of the following closely describes you? 1 = Smoke more than a pack per &y 2 = Smoke one pack per day 3 = Smoke half of a pack per day 4 = Smoke less than half a pack per day
If response is score either as 1, or 2, or 3, or 4 Go to Question 3 7
5 = Quit less than six months ago 6 = Quit six to 12 months ago 7 = Quit one to five years ago 8 = Quit six years or more ago
36. When you smoked, how many cigarettes did you smoke per day?
Enter nurnber of cigarettes
37. Do you or did you use any of the other types of tobacco? No, never = O In the ~ a s t = 1 chewing tobacco c igars
Yes = 2
pipes snuff
38. With regard to alcoholic drinks, which of the following statements applies to you? 1 = 1 have never dnink before 2 = 1 used to drink alcohol but have not had any alcoholic drink in the past 12 months 3 = 1 drink alcohol less than once a month 4 = 1 drink alcohol at least once in a month 5 = 1 drink alcohol at least once in two weeks
for af f responses scored as 1,2.3,4 or 5. Go to Question 40
6 = 1 drink alcohol daily
39. If you drink alcohol daily, thinking of the PAST SEVEN DAYS: How many alcoholic drinks did you have?
Enter number
40. Do you have any health problems that make it difficult for you to: No = O
Get to the dentist's office Sit or tolerate dental treatrnent Brush or floss your teeth Clean your teeth
124
Yes = 1
PLEASE OBSERVE AM) OR ASK AT TEE NURSE'S DESK TO FILL THE FOLLOWING
No = O a = Are you able to take care of yoursei f in the
toilet without assistance? b = Are you able to eat without assistance? c = Are you able to dresdundress and select
dresses fiom the wardrobe by yourself? d = Are you able to bathe without assistance? e = Are you able to walk about the home without
assistance?
Yes = 1
1 sincerely thank you for your assistance.
APPENDIX 2D CLINICAL PROTOCOL
ADULT DENTAL HEALTH ASSESSMENT FORM
Heaith Unit
Name las t tust tnrml
Address RoomfApt
I Postal Code 1 1 h l , Residence Type 1 1 1 - 1 1 1 1 - 1 1 1 1 Health Card Number 1 1 1 1 1 1 1 1 1
Understands English 0 First Language Et hnicity
Sex Education O=Male l=Female €il Marital Status Cl
Occupation Bofore Retirement 0
ORAL CLINICAL ASSESSrMENT
2. Disorders of TMJ, Mucosa, Teeth, and Bone O = Absent 1 = Present, no treatment recommended 2 = Present, treatment recommended
ORAL MUCOSA
3. Dentition Person is: 0
O = Dentate both arches 1 = Dentate Maxllla only 2 = Dentate Mandible only 3 = Edentulous
TEETH
Prosthetic Status: Maxilla 0 5. Are the dentures clean?
Has Has Has Has Has Has Has
worn 7 = Has 8 = Has
O = No; 1 = Yes; 9 = not applicable Mandi ble no denturetbridge f ixed bridge(s)
0 partial denture, not worn
P artial denture, worn ull denture, not worn
full denture, worn fixed bridge(s) and Partial denture, not
fixed bridge(s and Partial denture, worn d imphnt(s) an prosthesis
U P P E R L O W E R 17/16 26/27 36/37 31 46/47
6. Medical History
O = None of note; 1 = Present DO NO1 PROBE!
7. RECESSION RECESSION
8. CPlTN CWTN
U P P E R 18 17 16 1s 14 13 12 11 21 22 23 24 25 26 27 28
L O W E R 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 36
CARlES
TREATMENT
7. Recession O mm - 7 mm or more 8 = No probing 9 = Missing ToothtRoot tip
I
9.
10.
8. Periodontal Status 9 = Missin Sextant 8 = NO pr%ing 4 = pocket s 5 mm 3 = pockot 4 - 5 mm 2 r calculua 1 = ingiva bleeds O = fesithy ginpiva
,
CARIES
TREATMENT
9.
1 o.
11. Prosthetic Needs
---
Mandible u
none denture Mentlfiition/cleaning re l inehpr i r arthl relinelrepiir Pull denhira new artial denture new Pull dentura new fixed bridga fixed bridge and denture implants with prostheses
9. Dental Caries O = sound 1 = decayed, coronal decay 2 = deayed, root surface decay 3 = dacayad, toronal & root surface 4 = filled, no other decay 5 = filled, coronal decay 6 = filled, root surfa- decay 7 t filled, coronal & root surface decry 8 r sound ibutment tooth or crown 9 t parnanent teeth missing any reason
10. Treatment O = None Restorations 1 = 1 surface 2 = 2 surfaces 3 = 3 surfaces 4 = 4 surfaces or crown Extraction for 5 = carier 6 = periodontal 7 t dentures 8 P other r8ason 9 = other trertrnent (specify)
12. Summary of Treatment Needs O = NO i = Yes - Periodontal Il n Restorative F=i Prosthetic Surgical Urgent u O = Noria 1 = lesion l ikev to q u s e pain within 1 month 2 = Existing pain or infection
APPENDIX 2E ETHICAL APPROVAL FROM THE UNIVERSITY OF TORONTO
University of Toronto
OF FICE OF RESEARCH SERVICES
PROTOCOL REFERENCE #5983 May 3,2000
Dr. James L. Leake Faculty o f Dentistry 124 Edward St. , #5 15 University o f Toronto
Dear Dr. Leakz:
Re: Your reseuch protocol entitledt "Oral Health Statu of Institutionalized Oldrtr Xdults in Durham, Ontario and die EKect of Insurance" Dr. J. L. Leaks (supewisor). Dr. -4. Adegbernbo (mdent)
We are writing to advise you that a Rsview Corni t tee composed of Drs. D. Mock. S. iLlayhaI1 and Prof. D. Craig has gantzd approval to the above-named research s u d > - .
The approved consent fonns are attached. Subjects shouId receive a copy of their consent fom.
During the course of the research, any sipificant deviations from the approved protocol (fhat is, any deviation which would lead to an increase in risk or a decrease in benefit to h u m m subjects) and/or any unanticipated developrnents within the research should be brought to the attention of the Off~ce of Research Services.
Best wishss for the successful completion of your project.
Yours sincerely'
Susan Pilon Ethics Review Officer
SPImr Enclosure
cc: Dr. A. Adegbembo, Dr. J. Heersche
Simcœ Hall, 27 King's College Circie, R o o r n ZOA. Toronto Ontvio L W S LAI Telephone 416/ 978-5585 Fsx 41 6/ 946-5763 emsil [email protected]
The Regional Municipmlity oi Durham
West Otlice 125 Cameruai Avenue Ajax. Ontano caMaa LIS 2Hj (905) 683-568C Fax: (905) 683467 6
APPENDK 2F APPROVAL FROM DURHAM REGION
Direcor, Dental Health Services 126 Commercial Avenue Ajax L l S 2H5
Dear Dr Main,
RE: Suwey of the Impact of Dental Insurance on Oral Health Status of Older AduIts in Durham, Ontario.
Head Office (9051 723-8521 1 -%GO-&% 1-2749
The Resezch and Ethics Review Comrnittet, Durham Heslth Depanment has rcviewed the proposai for the above study.
The interviews to be conducted by your staff are par. of a needs assessrnent progarn of the Health Department and as such rcquirc no additional approvai. At the time of the interviews, dental staffwill obtain an informed consent, as outlined in the Propasai.
There arc rwo addirional areas, which 1 have claritied with y o . ~ that require edition. The first is the confùsion betwetn OR and RR. Secondly, 1 am concenied about your interviews procetdins should there be an outbreak in any of the Harnes. You have assured me that should an outbrcak occur your staff wouid stop their interviews
The Health Depanment is plcascd to approvc the midy.
ïhank you for subrnittins your reseuch proposal for review.
D Reynolds Associate Medical Oficer of H d t h ..
FUNDING GM) SCIENTIFK APPROVAL FROM THE FACULTY OF DENTISTRY, UNlVERSITY OF TORONTO
Faculty of Dentistry
a-5 University of Toronto ?-*- Dr. Johan N.M. Heersche Assoctate Dean (Reseanh) Director. Dental Research inst~tute Phone: (47 6 ) 979-4927 ~ 4 4 4 4 Email: johan.heerçche@ulorant~ ca
Ref. ff 991004
Dr. J.L. Lealce Facu! ty O f Dcn tistxy Cnixrersity ~I'Toronit)
Desr Jim.
I am happy to let you know that your revised research proposa1 cntided "Oral Hedth Status ot' Insritutionaiized Oldcr Adulrç in Durham. Ontario. and the Effcct of Dental Insurïncc" wtis approved for hnding at the amount requested (S926.00). Plexc m g e with Ms. Mnrgarct Mwin for the releve of hnds. Tnese hnds should bc spcni within one yesr of this date: excepional reasons would have to be provided within thc next 6 months to havc the Chair of the Research Cornminec approve the allocation of' unspent funds bcyond one year.
k'ou are reminded that in accordance with the FacuIty -aide!incs. you m u s submit a progess rcpon or its quivalent (Le. published papers) ro the Resexch Comminee within two years. Anachcd is a Progess R q o r t cover pacc that we would ask you.to cornpletc at that time.
Good luck with the project!
Enci. cc: Ms. Margaret Manin
' 1 Johan N.M. Hersche Associate Dean ( Research) Director, Dental Resarch 1 ns i ru~c
1 Doctor Physiçian Reg. Nurse Teacher etc
5 Clerk Receptionist Typist Adjustor Bookkeeper Data Clerk Lab Assistant Hair Stylist
APPENDIX 2H LIST OF OCCUPATIONAL AND EDUCATLNAL CODES
Professional/Semi professional Managerial Ski lled, Technical Skilled, Clerical, Sales, Service Semi Skilled Uns ki t led Not in the Labour Marke? (Unemployed)
3 b 3 4 Supervisor IB-h4 System Engîneer Secretary Manager Word Processor Operator Nursing Aide Administrator Cornputer Operator Sales Agent etc. S ystems Analyst Sales Clerk
etc etc
6 7 General Helper H o m d e r Cashier Housewife Factory Worker Student Construction Work Unemployed Laundry Worker etc Waiter Waitress etc.
Machine Operator etc
LIST OF EDUCATIONAL CODES
Category
P r i m or less -No formal schooling, Some primary school, Primary school
Secon* - Some secondary or high schod, Completed secondary or
high school
Post-secondary - Sorne or completed community college, technical coliege,
CEGEP, nwsing program or University
Code
1
2