Oral health is a contributory factor to general well-being and quality of life. The Canadian Health Measures Survey between March 2007 and February 2009, documented the oral problems that elderly people experience. This age group faces inequity in oral health care (especially in a fee-for-service system) and the aging of the Canadian population will exacerbate the problem of inequity. This article, the first of a 3-part series, discusses the impact of poor oral health on elderly people. The second article will consider inequity in terms of the financial, behavioural and physical barriers within the Canadian health care system, as well as ethical considerations related to this inequity, and the third will provide suggestions to overcome the barriers.
The mouth is the gateway to the body; hence, good oral health is an integral part of general well-being and a contributory factor to quality of life.1 According to Statistics Canada, the life expectancy for Canadian men and women is 79?years and 84?years, respectively.2 Although there is no universal definition of old age, an adult 65?years or older is considered a senior citizen or elderly person in Canada.2 More than 80% of elderly people have chronic health conditions, including arthritis, cataracts, back pain, cardiovascular disorders and diabetes mellitus.3 These conditions typically worsen with advancing age, eventually restricting daily activities, including oral hygiene activities and regular access to dental care.4 As a result, even though utilization of medical services rises with increasing age, the opposite occurs with dental services.5 In particular, elderly people face inequity in oral health care, especially within a fee-for-service system.6-8Although all permanent residents in Canada have prepaid access to a general health care plan administered by a provincial or territorial government,9 the legislation for these plans does not cover dental services.10
This 3-part series of articles addresses the inequities faced by elderly patients in a fee-for-service environment for dental services. This first article of the series describes the oral health status of older Canadians, on the basis of findings from a recent health survey, and notes the implications of oral health for general well-being. The second article will briefly discuss the public and private oral health care plans available in Canada and will explore the inequity in care experienced by elderly people and related ethical considerations. The third article will offer suggestions for reducing this form of inequity and improving access to dental care among elderly people.
Canadian Health Measures Survey
Oral problems commonly observed in elderly people include caries, periodontal diseases, tooth loss, xerostomia, candidiasis and cancer.11,12 The Canadian Health Measures Survey (CHMS), conducted from March 2007 to February 2009 sampled 5,600 Canadians from approximately 97% of the population, excluding people living on Aboriginal reserves or Crown lands, members of the Canadian Forces, residents of institutions and residents in some remote regions.13 Dwellings of known household composition were stratified into 5 age groups: 6–11, 12–19, 20–39, 40–59 and 60–79 years. Very young (<?6 years) and very old (>?80 years) people were excluded. Each participant was interviewed and underwent a physical (including oral) examination. During the interviews, questions about oral health were related to the comfort and appearance of the mouth and teeth, the effects of oral disabilities, oral care habits, visits to dental professionals and dental insurance coverage. The oral examinations were performed by dentists whose examination skills were calibrated to achieve high agreement (Cohen’s kappa coefficient ≥?0.6) with clinical criteria recommended by the World Health Organization. During the examination, the dentist gathered data on occlusion, mucosal lesions, accumulation of debris and calculus, gingivitis, edentulism, prostheses and trauma to the incisors. The prevalence and severity of caries were estimated from the average numbers of decayed?(D), missing?(M) and filled?(F) teeth?(DMFT). Periodontal status was represented by the deepest probing depth on 1 of 10 indicator teeth and mean loss of attachment on 6 sites of indicator teeth. The data collected are suitable for developing policies about oral health needs in Canada but are inadequate for clinical research.
Oral Health Status of Elderly Canadians
The CMHS revealed that almost everyone in the oldest age group (60–79 years) had at least 1 DMFT (excluding wisdom teeth). This age group had the highest mean DMFT (15.7, consisting of D?=?0.4, M?=?5.6 and F?=?9.7) and the highest rate of edentulism (22%).13 Nonetheless, earlier studies in various countries have identified a trend toward the retention of more natural teeth in older age,14,15 and this trend is supported by evidence from Statistics Canada that the rate of edentulism among those older than 65 years declined in Canada from 43% in 1990 to 30% in 2003.16 ?More recently, the CHMS found that over half (58%) of those 60–79 years of age retained more than 21 natural teeth (mean?= 19). Older adults participating in the survey claimed to brush and floss as frequently as the younger participants, yet more than a tenth (11%) had untreated root caries, and nearly one-third (31%) had at least one periodontal pocket of at least 4?mm. Although oral problems were distributed similarly in both the oldest age group and in the 40- to 59-year age group,13 there was a greater need for professionally administered preventive and restorative therapies, particularly to prevent and control caries. This can be explained by accelerating factors such as loss of gingival attachment, dry mouth and reduced dexterity, and possibly because the pathogenesis of dental diseases follows a different pattern with advancing age.
Among those 60 to 79 years of age, more than a tenth (13%) avoided dentists, and even more (16%) declined treatment because of the cost. Thirteen per cent of this age group, and nearly a quarter (23%) of those without natural teeth reported that they avoided certain foods because of oral problems, while about one-tenth (7%) of the participants reported persistent pain.13 Although such complaints were not highly prevalent, these responses could be an underestimation of the true prevalence, as older people tend not to report oral pain, possibly because of increased tolerance of noxious stimuli17 or misattribution of pain to old age.18 Denture stomatitis was observed in 20% of edentulous mouths.13 Contrary to the common belief that loss of teeth ends the need for dental visits,19 a substantial proportion of the edentulous participants (41%) needed treatment for soft-tissue abnormalities.14
Consequences of Poor Oral Health
Poor oral health can adversely affect quality of life20 by imposing a physiological burden, particularly among elderly people. For example, hyposalivation, which is common in old age, arises from hypofunction of the salivary glands, the manifestations of systemic diseases such as diabetes and the adverse effects of medications or radiotherapy for cancer. Polypharmacy is common in older adults, and multiple medications can interact to induce dry mouth. Nearly one-third (29%) of adults 65 years or older living independently in Ontario reported xerostomia.21 Loss of the natural cleansing effect of saliva increases the oral bacterial load, which predisposes a frail person to dental problems and other systemic conditions, such as aspiration pneumonia,22 coronary artery disease and cerebral infarction.23 Moreover, people with subjective xerostomia and tooth loss may have reduced masticatory ability24; food avoidance from fibre, protein, vitamins25,26 and minerals27; and impairment of speech.28?Malnutrition may reduce immunity against infection29 and has been associated with cardiovascular disease,30 poor cognitive performance31 and periodontal disease in older adults.32In turn, periodontal disease increases the risk of root caries33 and further tooth loss. Indeed, this vicious cycle of poor dentition, malnutrition and increased comorbidities (including dental comorbidities) can escalate to inflate medical expenses across the population, with far-reaching consequences for society in general.
Mandatory retirement has been abolished in many provinces in Canada and may be removed at the federal level.34 As such, a large proportion of those over 65 years of age may wish to remain in the workforce.35However, poor oral health can create psychological and social constraints, by undermining general appearance and limiting a person’s confidence in social interactions36 and his or her ability to secure or retain a job.19 Furthermore, older adults with poor oral health tend to lead an inactive lifestyle.37 More specifically, the CHMS showed that approximately 40% of those 60–79 years of age reported an average of 3.5?hours lost from work or normal activities per year because of dental sick days.13 Unexpected absence from work38 due to acute oral discomfort or pain could create financial and socio-economic strains at the individual, corporate and social levels.
Furthermore, many systemic diseases exhibit oral manifestations, and oral cancer is among the top 10 most common cancers worldwide.39 About 3,400 new cases of oral cancer were diagnosed in 2009 in Canada alone, and the incidence increases after age 40.40 Thus, oral care should remain an important part of health screening for the older population.
The CHMS provides an incomplete picture of oral health in older Canadians. It did not survey people 80?years of age or older, although this age group now makes up about 4% of the Canadian population.41 It also excluded institutional residents, who are generally more frail , are unable to execute an optimal standard of oral hygiene, receive less dental care, and have poor oral health and greater treatment needs.42,43 In one study, 58% of elderly Canadian nursing home residents were in need of dental treatment; and two-thirds (67%) of the need was attributed to caries and periodontal problems.44 Although dental services were made available to residents of the facilities, the incidence of tooth loss and edentulism increased over the subsequent 5-year period.45
Utilization of dental services in Canada has risen modestly, from 44% to 68%, since 1970.13,46 Over the same period, dental expenditures per capita have increased approximately fourfold,47 which indicates that either dental services have become more costly or individual patients are utilizing more services. Data from the CHMS indicate that income is a strong determinant of health status and access to care.13 The inequitable situation is even more palpable for elderly people, especially if they have lost insurance coverage after retirement and have become more frail . The next ?article in this 3-part series will discuss the barriers to oral health care faced by the elderly population in Canada and the ethical considerations associated with inequities in oral care.
- Naito M, Yuasa H, Nomura?Y, Nakayama?T, Hamajima?N, Hanada?N. Oral health status and health-related quality of life: a systematic review. J?Oral Sci. 2006;48(1):1-7.
- Statistics Canada. 2010. Population Projections for Canada, Provinces and Territories - 2009 to 2036. Statistics Canada, catalogue no. 91-520-XWE [accessed 18 Jul 2012]. Available: http://www.statcan.gc.ca/pub/91-520-x/91-520-x2010001-eng.htm.
- Gilmour H, Park J. Dependency, chronic conditions and pain in seniors. Health Rep. 2006;16?Suppl:21-31.
- Komulainen K, Yl?stalo P, Syrj?l??AM, Ruoppi?P, Knuuttila?M, Sulkava?R, et al. Associations of instrumental activities of daily living and handgrip strength with oral self-care among home-dwelling elderly 75+. Gerodontology. 2012;29(2):e135-42. Epub 2012 Jan?12.
- Grignon M, Hurley J, Wang?L, Allin?S. Inequity in a market-based health system: Evidence from Canada's dental sector. Health Policy. 2010;98(1):81-90. Epub 2010 Jun?23.
- Millar WJ, Locker?D. Dental insurance and use of dental services. Health Rep. 1999;11(1):55-67.
- Leake JL. Why do we need an oral health care policy in Canada? J?Can Dent Assoc. 2006;72(4):317.
- Qui?onez C, Grootendorst P. Equity in dental care among Canadian households. Int J Equity Health. 2011;10(1):14.
- Health Canada. 2011. Canada’s Health Care System [accessed 2011 Sep?4]. Available: tỷ lệ kèo bóng đáhttp://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php#a8.
- Hurley J, Guindon GE. 2008. Centre for Health Economics and Policy Analysis (CHEPA) Working Paper Series – Paper 08-04 – Private Health Insurance in Canada. Available: http://www.chepa.org/research-products/working-papers/08-04.
- Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2005;33(2):81-92.
- Gonsalves WC, Wrightson AS, Henry?RG. Common oral conditions in older persons. Am Fam Physician. 2008;78(7):845-52.
- Health Canada. Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey 2007-2009 (Technical Report) [accessed Apr 2012]. Available: http://www.fptdwg.ca/English/e-documents.html.
- Douglass JM. Mobile dental vans: planning considerations and productivity. J?Public Health Dent. 2005;65(2):110-3.
- Mojon P, Thomason JM, Walls AW. The impact of falling rates of edentulism. Int J Prosthodont. 2004;17(4):434-40.
- Millar WJ, Locker?D. Edentulism and denture use. Health Rep. 2005;17(1): 55-8.
- Gibson SJ, Helme RD. Cognitive factors and the experience of pain and suffering in older persons. Pain. 2000;85(3):375-83.
- Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med. 2001;17(3):417-31.
- Bedos C, Levine A, Brodeur?JM. How people on social assistance perceive, experience, and improve oral health. J?Dent Res. 2009;88(7):653-7.
- De Marchi RJ, Leal AF, Padilha?DM, Brondani?MA. Vulnerability and the psychosocial aspects of tooth loss in old age: a Southern Brazilian study. J?Cross Cult Gerontol. 2012;27(3):236-58.
- Locker D. Xerostomia in older adults: a longitudinal study. Gerodontology. 1995;12(1):18-25.
- Azarpazhooh A, Leake?JL. Systematic review of the association between respiratory diseases and oral health. J?Periodontol. 2006;77(9):1465-82.
- Beck JD, Offenbacher S. The association between periodontal diseases and cardiovascular diseases: a state-of-the-science review. Ann Periodontol. 2001;6(1):9-15.
- Okada K, Enoki H, Izawa?S, Iguchi?A, Kuzuya?M. Association between masticatory performance and anthropometric measurements and nutritional status in the elderly. Geriatr Gerontol Int. 2010;10(1):56-63.
- Nowjack-Raymer RE, Sheiham A. Numbers of natural teeth, diet, and nutritional status in US adults. J?Dent Res. 2007;86(12):1171-5.
- Quandt SA, Chen H, Bell?RA, Savoca?MR, Anderson?AM, Leng?X, et al. Food avoidance and food modification practices of older rural adults: association with oral health status and implications for service provision. Gerontologist. 2010;50(1):100-11.
- Sahyoun NR, Lin CL, Krall E. Nutritional status of the older adult is associated with dentition status. J?Am Diet Assoc. 2003;103(1):61-6.
- Boehm TK, Scannapieco FA. The epidemiology, consequences and management of periodontal disease in older adults. J?Am Dent Assoc. 2007;138 Suppl:26S-33S.
- Wardwell L, Chapman-Novakofski?K, Herrel?S, Woods?J. Nutrient intake and immune function of elderly subjects. J?Am Diet Assoc. 2008;108(12):2005-12.
- Nagura J, Iso H, Watanabe?Y, Maruyama?K, Date?C, Toyoshima?H, et al. Fruit, vegetable and bean intake and mortality from cardiovascular disease among Japanese men and women: the JACC Study. Br J Nutr. 2009;102(2):285-92.
- Vogel T, Dali-Youcef N, Kaltenbach?G, Andrès?E. Homocysteine, vitamin B12, folate and cognitive functions: a systematic and critical review of the literature. Int J Clin Pract. 2009;63(7):1061-7.
- Yu YH, Kuo HK, Lai YL. The association between serum folate levels and periodontal disease in older adults: data from the National Health and Nutrition Examination Survey 2001/02. J?Am Geriatr Soc. 2007;55(1):108-13.
- Sugihara N, Maki Y, Okawa?Y, Hosaka?M, Matsukubo?T, Takaesu?Y. Factors associated with root surface caries in elderly. Bull Tokyo Dent Coll. 2010;51(1):23-30.
- Canada’s Economic Action Plan. Eliminating the mandatory retirement age [accessed Apr 2012]. Available: tỷ lệ kèo bóng đáhttp://actionplan.gc.ca/en/initiative/eliminating-mandatory-retirement-age.
- Canadian Imperial Bank of Commerce. CIBC Poll: More than three-quarters of British Columbians plan to continue working in retirement. Canada NewsWire 5 Oct 2011 [accessed Apr 2012]. Available: http://www.theglobeandmail.com/globe-investor/news-sources/?date=20111025&archive=cnw&slug=C6245.
- Donnelly LR, MacEntee MI. Social interactions, body image and oral health among institutionalised frail elders: an unexplored relationship. Gerodontology. 2012;29(2):e28-33.
- Swoboda J, Kiyak HA, Persson?RE, Persson ?R, Yamaguchi?DK, MacEntee?MI, et al. Predictors of oral health quality of life in older adults. Spec Care Dentist. 2006;26(4):137-44.
- Gift HC, Reisine ST, Larach?DC. The social impact of dental problems and visits. Am J Public Health. 1992;82(12):1663-8.
- Parkin DM, Bray?F, Ferlay?J, Pisani?P. Global cancer statistics, 2002. CA Cancer J Clin. 2005;55(2):74-108.
- Health Canada. Oral Cancer. 2009 [accessed Apr 2012]. Available: http://www.hc-sc.gc.ca/hl-vs/oral-bucco/disease-maladie/cancer-eng.php.
- Statistics Canada. Population by sex and age group [accessed Apr 2012]. Available: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo10a-eng.htm.
- Hawkins RJ, Main PA, Locker?D. Oral health status and treatment needs of Canadian adults aged 85 years and over. Spec Care Dentist. 1998;18(4):164-9.
- Matthews DC, Clovis JB, Brillant MG, Filiaggi MJ, McNally ME, Kotzer RD, et al. Oral health status of long-term care residents-a vulnerable population. J Can Dent Assoc. 2012;78:c3.
- Wyatt CCL, So FHC, Williams M, Mithani A, Zed C, Yen E. The development, implementation, utilisation, and outcome of a comprehensive dental program for older adults residing in long-term care facilities. J Can Dent Assoc. 2006;72: 419a–419h.
- Wyatt CC. A 5-year follow-up of older adults residing in long-term care facilities: utilisation of a comprehensive dental programme. Gerodontology. 2009;26(4):282-90.
- Bureau of Nutritional Sciences, Nutrition Canada. Ottawa. 1977. Nutrition Canada Dental Report: A Report from Nutrition Canada by the Bureau of Nutritional Sciences, Food Directorate Health Protection Branch, Department of National Health and Welfare.
- Baldota KK, Leake JL. A macroeconomic review of dentistry in Canada in the 1990s. J Can Dent Assoc. 2004;70(9):604-9.