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Oral Health-Related Quality of Life in an Aging Canadian Population
by
Robert Kotzer
A thesis submitted in conformity with the requirements for the degree of Masters of Science
Graduate Department of Dentistry University of Toronto
© Copyright by Robert Kotzer, 2011
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Oral health-related quality of life in an aging Canadian population
Robert Kotzer
Masters of Science
Graduate Department of Dentistry
University of Toronto
2011
Abstract
The purpose of the study is to describe the impact of oral health-related quality of life
(OHRQoL) on the lives of pre-seniors and seniors living in Nova Scotia, Canada. This cross-
sectional study involved 1461 participants, grouped by age (pre-seniors [45-64] and seniors
[65+]) and residential status (long-term care facility [LTC] or community). OHRQoL was
measured using the 14-item Oral Health Impact Profile questionnaire. Approximately one in four
pre-seniors and seniors reported at least one OHRQoL impact ‗fairly/very often‘. Of those
residing in the community, pre-seniors (28.8%) reported significantly more impacts than seniors
(22.0%). Logistic regression revealed that for the community dwelling sample, those who were
dissatisfied with their teeth or dentures were 5.16 times more likely to report an impact
‗fairly/very often‘, which was the strongest indicator. Among the LTC sample, those who have
poor perceived mouth health were 9.87 times more likely to report an impact.
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Acknowledgments
First and foremost I would like to thank my thesis supervisor and mentor Dr. Herenia
Lawrence for providing me with the opportunity to obtain my Master of Science degree. Without
her none of this would have been possible. I was extremely lucky to have such a wonderful
supervisor who provided me with guidance, knowledge and support over the past two years.
Throughout the construction of my dissertation, Dr. Lawrence was always available and spent
hours helping me analyze data and assemble my thesis. Dr. Lawrence was always by my side
offering encouragement whether it was during my thesis defense or while I was presenting at the
CAPHD conference here in Toronto, or at the IADR conference in Barcelona, Spain. Her
guidance has truly been invaluable to me.
I would also like to thank my committee members Dr. Jokstad and Dr. Lai for taking the
time to offer their wisdom and expertise during committee meetings. My examination committee
members Dr. Glogauer and Dr. Wyatt also provided me with helpful advice. I am also thankful to
Dr. Fenton for chairing my thesis examination.
Furthermore, I would like to express my appreciation to the members of the TOHAP
team and founders of this research: Dr. Matthews, Dr. Clovis and Dr. Brillant. Their enthusiasm,
kindness and endless help over the past two years have made it feel as though they were working
with me here in Toronto, not in Nova Scotia.
Finally, I would like to thank my family, who I dedicate my thesis to. My parents, Judy
and Brian, my grandfather Andrew Raab, and Michael, Jennifer, Jonas, Alivia and Gracie have
always been there for me offering love, support and encouragement throughout my life. I would
also like to thank Lexi for everything she has done for me and for accompanying me to
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Barcelona to present my research. Everyone knows I could not have accomplished this without
her.
I extend my gratitude to other faculty members such as Dr. Quinonez and Dr. Locker, as
well as my friends and colleagues who I had the opportunity to spend time with in the Lab.
Funding for this research was provided by the Canadian Institutes of Health Research -
Institute of Musculoskeletal Health and Arthritis, Health Canada (Office of the Chief Dental
Officer) and the Nova Scotia Health Research Foundation (ROP-86224).
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Table of Contents
Abstract ….. .................................................................................................................................... ii
Acknowledgements ....................................................................................................................... iii
Table of Contents ........................................................................................................................... v
List of Tables ............................................................................................................................... vii
List of Appendices ...................................................................................................................... viii
Chapter 1: Introduction and Study Overview .......................................................................... 1
Section 1: Background and Literature Review .............................................................. 2
Section 1.1 History on the Subject of Oral Health-Realted Quality of Life .............. 2
Section 1.2 Seniors and the Aging Population ........................................................... 4
Section 1.3 Oral Health Impact Profile (OHIP) ......................................................... 7
Section 1.4 Oral Health-Related Quality of Life and the Elderly ............................ 10
Chapter 2: Aim of the Study ...................................................................................................... 13
Section 2: Objectives and Hypotheses ........................................................................ 13
Section 2.1 Objectives .............................................................................................. 13
Section 2.2 Hypotheses ............................................................................................ 13
Chapter 3: Research Methodology ............................................................................................ 14
Section 3: Study Design ............................................................................................... 14
Section 3.1 Sample Size Determination ................................................................... 14
Section 3.2 Sampling Frame and Sample Selection ................................................. 15
Section 3.3 Measurements ........................................................................................ 17
Section 3.4 Clinical Examination ............................................................................. 17
Section 3.5 Procedure ............................................................................................... 18
Section 3.6 Data Analysis ........................................................................................ 20
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Chapter 4: Study Results ............................................................................................................ 23
Chapter 5: Discussion ................................................................................................................. 27
Chapter 6: Study Limitations .................................................................................................... 42
Chapter 7: Conclusions .............................................................................................................. 43
References ..................................................................................................................................... 44
Tables ….. ..................................................................................................................................... 52
Appendices ................................................................................................................................... 68
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List of Tables
Table 1 – Characteristics of study participants aged 45 years and older living in the
community or long-term care in Nova Scotia, Canada ............................................... 52
Table 2 – Self-percieved oral health of adults aged 45 years and older living in Nova Scotia,
Canada ......................................................................................................................... 54
Table 3 – Clinically-determined oral health status characteristics of adults aged 45 and older
in Nova Scotia, Canada ............................................................................................... 55
Table 4 – Percent of elderly Nova Scotia residents making 1 or more visits to the dentist ......... 57
Table 5 – Distribution of responses to individual OHIP-14 items and mean item scores ........... 58
Table 6 – Prevalence, extent and severity by OHIP-14 subscale and total score ........................ 59
Table 7 – Prevalence, extent and severity of impacts by OHIP-14 subscale grouped by pre-
seniors and seniors ........................................................................................................ 60
Table 8 – Prevalence, extent and severity of impacts by OHIP-14 subscale grouped by
community and LTC .................................................................................................... 61
Table 9 – Bivariate analysis for prevalence of impacts (‗fairly often‘ or ‗very often‘) for
community residents ..................................................................................................... 62
Table 10 – Bivariate analysis for prevalence of impacts (‗fairly often‘ or ‗very often‘) for
LTC residents ............................................................................................................... 64
Table 11 – Logisitc regression model for prevalence of impacts (‗fairly often‘ or ‗very often‘)
for community residents ............................................................................................. 66
Table 12 – Logisitc regression model for prevalence of impacts (‗fairly often‘ or ‗very often‘)
for LTC residents ....................................................................................................... 67
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List of Appendices
Appendix A – OHIP-14 items grouped according to dimension .................................................. 68
Appendix B – Location of community sites sampled in Nova Soctia, Canada ............................ 69
Appendix C – Location of LTC sites sampled in Nova Soctia, Canada ....................................... 70
Appendix D – Study questionnaire .............................................................................................. 71
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Chapter 1
Introduction and Study Overview
Compared to previous decades, the elderly population today is much more predominant in
Canada and continues to rapidly increase due to longer life expectancy and the effects of the
baby boom generation [1-3]. As these individuals (born between 1947 and 1966) begin to turn 65
years of age (in 2012), the number of seniors in Canada is estimated to jump from 4.2 million to
9.8 million from 2005 to 2036 [4]. In Nova Scotia, the seniors‘ population in 2033 is estimated to
be 257,874, an increase of 86.3% from 2007 [2]. Currently, Nova Scotia represents the oldest
provincial population in Canada, as 15.4% of the population is older than 65 years of age [2].
Due to the aging of the population and increased purchasing power of today‘s elderly,
more people are taking advantage of the advancements in dental healthcare, leading to a decrease
in rates of edentulism [5-8]. As a result of living longer and retaining more of their natural teeth,
more oral problems arise and the treatment decisions of these patients becomes much more
complex [5,9]. It is therefore imperative that information regarding the current oral health status,
treatment needs, as well as the oral health-related quality of life (OHRQoL) of aging Canadians
is collected in order to guide oral health policy. This study examines the differences in oral
health-related quality of life between people aged 45 years and older living in the community
and in long-term care (LTC) facilities in Nova Scotia. It also addresses the differences in oral
health-related quality of life between pre-seniors and seniors within the community and LTC
residences. Discussions regarding the disparities among these populations along with possible
solutions to these problems are also explored.
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1 Background and Literature Review
1.1 History on the Subject of Oral Health-Related Quality of Life
The concept of oral health-related quality of life is one that is very abstract and
multidimensional, which in turn makes it very difficult to describe [10]. Oral health and quality
of life are dimensions that are continuously evolving, and due to their subjectivity, may vary
according to different cultural, social, political or practical settings [10]. The development of
patient based measures of health outcomes sparked a change in the belief of what constitutes
health, and the strategies to generate health. This sparked a shift from accepting the medical
model of health to what is known as the socioenvironmental model of health [11]. The medical
model is a reductionist theory, which views health and illness as biological, which can be
improved through technology and medicine. This view isolates the oral cavity from both the
body and the person as if it is an autonomous anatomical structure [10]. The socioenvironmental
model is an approach that focuses on health promotion, disease prevention and social and
psychological well being rather than merely curing disease [12]. One‘s physical and social
environment is therefore a major determinant of oral health [10]. With regards to oral health, it is
important to focus on how conditions or disorders threaten health, well-being and quality of life
[10]. This shift in philosophy sparked the discovery of the concept of oral health-related quality
of life and its importance in relation to oral health.
The Canadian Dental Association defines oral health as ―a state of the oral and related
tissues and structures that contributes positively to physical, mental and social well being and
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enjoyment of life‘s possibilities, by allowing the individual to speak, eat and socialize
unhindered by pain, discomfort and embarrassment‖ [13]. Therefore, it is important to note that
oral health has both physiological and psychosocial significance. In the field of dentistry, the
term ‗oral health-related quality of life‘ is commonly used to describe the impact that one‘s oral
health can have on their everyday life experiences [14, 15]. Quality of life is a dynamic and
subjective concept that has biological and psychosocial implications which is also influenced by
one‘s personal and socio-cultural environment [14, 16, 17]. Quality of life is influenced by the
ability of an individual to feel as though they are able to partake in activities that meet their
needs and expectations [14]. These activities are affected by factors such as one‘s environment,
economic status, responsibilities [14], biological constitution [18, 19] and time [16, 20] to
complete these activities. Therefore, generally when an individual has good oral health, they feel
as though they can meet their needs and expectations and in return enhance their oral health-
related quality of life. In contrast, when an individual is deprived of high quality oral health, they
unfortunately may feel as though they cannot meet their needs and expectations and suffer from
poor oral health-related quality of life. But, it is important to note that the concept of oral health
only has meaning at a personal level [10]. While health problems and conditions can have an
impact on one‘s oral health-related quality of life, it is not a causal relationship. Many people
assume that having poor oral health will result in poor oral health-related quality of life. This
assumption is false, as many people with chronic disorders (poor health) rate their quality of life
higher than those who are healthy. It has also been found that studies regarding elderly people
show that when talking about quality of life, they will mention health as a factor but do not
consider it to be the most important determinant of quality of life [10].
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The shift towards the importance of measuring one‘s oral health-related quality of life
reflects the reality that modern dentistry is not just aiming to prolong life and eliminate oral
disease, but ultimately is attempting to make life better [21, 22]. Measures of oral health-related
quality of life have made it much easier to gain insight on subjectively perceived aspects of oral
health such as functional, psychological and social impacts of oral diseases [10].
1.2 Seniors and the Aging Population
At the turn of this century approximately one in twenty-five Americans reached the age
of 65, whereas in 1990, one in eight Americans were at least 65 years of age. By 2030, the
population of older adults in America will double and make up approximately 20% of the
American population. Although the population of all older adults is rapidly increasing, the fastest
growing age group are those aged 85 and older, who are expected to triple in size by the year
2030 [23, 24, 25]. As mentioned earlier, the Canadian elderly population is growing in a similar
fashion as the number of seniors in Canada is estimated to jump from 4.2 million to 9.8 million
from the year 2005 to 2036 [4]. Longer life expectancy has resulted in an increase in chronic
conditions, which in turn often translates into functional disability and the need for assistance
[23]. The majority of older people report two or more chronic conditions, and older women are
more likely to experience multiple chronic conditions than men. Men who reach 65 years of age
can expect to live for at least fifteen more years, with 13 of those years being in good health and
independence. Women on the other hand can expect to live for 20 more years with 16 of those
years in good health and independence [23].
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This issue of longevity and disability raises a number of important research questions.
Firstly, does an increase in longevity of life result in a greater burden of disability, or will
lifestyle changes in accordance with advances in medical care and technology cause a decrease
in disability? Recent research has shown that aging does not necessarily lead to an increase in
disability [23, 26]. Between the years 1982 and 1989, there was a 14.7% increase in older adults,
but fewer people were institutionalized in 1989. After adjusting for the growth in people aged 85
and older, the decline in disability rate was approximately 7%. The number of people who had
disabilities, which included those who had difficulty eating and bathing, were studied. Disability
was defined as ―an inability to perform an activity without help or use of equipment, due to
health or age‖ [23, 26]. In a follow up study, it was found that once people became disabled there
were drastic changes in services used by these people [23, 26]. National long-term care surveys
were examined, and showed increases in the use of certain equipment such as raised toilets
(148% increase) and shower seats (65.9% increase), but personal assistance was down 9% [23,
26].
Not only is the North American elderly population growing, it is also becoming much
more racially and ethnically diverse than in the past. Due to the heterogeneous nature of the
elderly population, the lifelong patterns of oral health, general health, and healthcare are very
different. Economic, psychological and social factors will have an effect on an individual‘s
quality of life. Although the weight of these factors in assessing one‘s quality of life will change
throughout the course of an individual‘s life, certain conditions and events that a young
population may take for granted, may be more impacting on the quality of life of an elderly
population [14-17]. For example, a young person may take for granted the ease in driving or
6
taking public transportation to visit the dentist, while an elderly person may have difficulty
traveling to the dentist without a driver‘s license or having limited mobility.
The increase in life expectancy over the past decade has resulted in a gain of 25 years of
total life expectancy in the industrialized world, equaling the gain obtained from the last 5,000
years [27]. The increase in life expectancy over the last century has been termed the ―Longevity
Revolution‖, and is a result mainly of progression in public health along with economic well-
being. In addition, there has been a decrease in maternal, infant and child mortality rates [27].
The recent study of how the restoration and maintenance of biological systems increases life
expectancy has been termed the ―Longevity Revolution II‖. This theory suggests that
maintaining one‘s endocrine, immune and central nervous system has positive effects on diseases
caused by old age, and thus extending life. Furthermore, some suggest that a ―Longevity
Revolution III‖ may be apparent in the near future. This theory proposes that if the ability to
manipulate genes related to the length of life is achieved, life expectancy can be greatly
enhanced [27].
Increases in life expectancy raise the debate to whether aging is a normal or a disease
process. The first theory suggests that aging is a process that is a programmed part of life that is
both inherent and developmental in nature. The second theory suggests that aging occurs due to
random environmental or wear and tear factors [27]. Regardless of which theory is more
accurate, research shows that living a productive life is good for the individual and society. Ever
since the Social Security law was passed, research has shown that working later into life will
increase life expectancy. Since then, the life expectancy of men has risen from under 60 years of
age to over 70. For women, life expectancy has risen from 63 to almost 80 years of age over the
7
last 50 years. Therefore, the new benchmark for determining retirement should be functional
status rather than chronological age [27].
1.3 Oral Health Impact Profile (OHIP)
The Oral Health Impact Profile (OHIP) is a measure of oral health-related quality of life,
which according to Slade, ―measures people‘s perception of the social impact of oral disorders
on their well-being‖ [28]. The impact of the OHIP was initially intended to compliment
traditional indicators of clinical disease by offering information about the burden of illness
within a population [29]. In addition, rather than measuring impacts related to specific oral
conditions, the OHIP measures impacts that are related to oral conditions in general [29].
The questions contained in the OHIP were formulated in order to represent Locker‘s
theoretical model of oral health [30]. Locker‘s model is based on the concept that impacts of
disease are sorted into a hierarchy, and was used to define the seven dimensions contained in the
OHIP. The seven dimensions are: functional limitation, physical pain, psychological discomfort,
physical disability, psychological disability, social disability and handicap [29].
The 49 self-report questions contained in the OHIP were developed through the process
of interviews on a convenience sample of 64 dental patients in Adelaide, Australia. Each patient
was asked open-ended questions in order to ascertain statements concerning impacts of oral
conditions [31]. A total of 535 statements were derived from the interview process, which were
arranged into 46 unique statements that incorporated the seven conceptual dimensions. Three
statements were then added for use in the handicap dimension to complete the 49 total statements
that were then rephrased as questions [31]. Each question is answered in terms of a five-point
8
Likert scale of how frequently the respondent experiences each problem within a given reference
period [29].
Reliability of the OHIP was assessed in an Australian study of 122 randomly selected
people aged 60 years and older. For the first study, Chronbach‘s alpha coefficients for internal
reliability ranged from 0.70 to 0.83 for six of the subscales, but only 0.37 for the social disability
subscale. Intra-class correlation coefficients of test-retest reliability ranged from 0.42 to 0.77 for
six of the subscales and 0.08 for social disability [31].
In addition to reliability, construct validity was evaluated through a number of cross-
sectional comparisons of OHIP responses and similar self-reported measures. For example, in the
Australian study of 122 elderly patients, those who perceived a need for dental treatment scored
higher on each OHIP subscale than those who did not perceive a need for dental treatment [31].
In general, findings from the OHIP have indicated that those who have poor clinical oral
health status including missing teeth, retained root fragments, untreated dental decay, periodontal
pockets and periodontal recession have higher OHIP scores. In addition, those who are socially
or economically disadvantaged, infrequent visitors to the dentist or HIV patients also score
higher on the OHIP [32].
In order to generate more findings, the OHIP-14 was constructed; a shorter and simpler
version of the OHIP [28]. The OHIP-14 contains 14 questions and eliminated items that applied
only to those who wear dentures, as well as items which had a non-response rate (left blank or
marked ―I don‘t know‖) of 5% or more. After the 14 questions were identified using a controlled
regression procedure, the OHIP-14 was investigated and found to be both reliable and valid,
9
having an internal reliability coefficient (α) of 0.88 [28]. The short version contains two
questions for each of the seven dimensions [28].
There have been several other measures and scales developed in order to assess oral
health-related quality of life. This includes but is not limited to: the Social Impacts of Dental
Disease, Dental Impact Profile, Oral Impacts on Daily Performance, Oral Health-Related Quality
of Life Measure, Oral Health Quality of Life Inventory, Child Oral Health Quality of Life
Questionnaire and the General (Geriatric) Oral Health Assessment Index (GOHAI) [15, 30]. The
measures that have been developed include many differences and similarities. Generally, they are
all self-report measures but differ in terms of their length, content, response formats, sub-scale
structure, and method of obtaining OHRQoL scores [33]. The GOHAI is another measure that is
used to assess the OHRQoL of an elderly population, most of whom live in a long-term care
setting [33, 34]. The GOHAI is a 12-item measure developed for use with the elderly, but has
also been used with younger populations. The GOHAI and the OHIP-14 both consist of a single
index score using Likert-type frequency responses, and incorporate different dimensions of oral
health. The measures differ in terms of item content and time reference, where the GOHAI uses a
3-month reference and the OHIP-14 uses a 1-year reference. The GOHAI is generally more
accurate in terms of detecting impacts in the form of pain and dysfunction, while the OHIP-14 is
better at detecting psychosocial impacts [33]. Despite differences in content, the internal
consistency reliability and validity assessments suggest that one measure is not distinctly better
than the other [33].
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1.4 Oral Health-Related Quality of Life and the Elderly
In recent studies, Locker and Gibson (2005) examined subjectively perceived and
professionally measured health status and satisfaction, and found that they may not be correlated
[21]. In the first of two studies, Locker and Gibson (2005) collected data through personal
interviews on people aged 50 years and older. The majority of these individuals lived within a
geriatric care setting. Furthermore, many of them had multiple chronic medical conditions and
other various disabilities. The second study was performed on those over the age of 50, who
were independent community living individuals with significantly better health than those in the
first study. The questions asked during these studies were concerned with the participant‘s self-
perceived oral health, in addition to their overall health and well-being. As well, satisfaction and
dissatisfaction with their oral health was assessed on the level of ability to chew, speak clearly
and appearance [21]. Results indicated that in both studies there was a significant association
between self-rated oral health and satisfaction or dissatisfaction with oral health status. In the
first study, 83.3% of people who rated their oral health as poor were dissatisfied. In comparison,
those who rated their oral health as excellent were only 4.5% dissatisfied. In the second study,
the statistics were 61.3% and 6.9% respectively [21]. Interestingly, in both studies cross
tabulations using dichotomized variables proved otherwise. In the first study, 8.2% of those who
rated their oral health as either excellent, very good, or good had reported to be dissatisfied with
their oral health. Moreover, 55.1% of participants who rated their oral health as fair or poor
reported being satisfied. In the second study, the corresponding percentages were 16.5% and
50.8% respectively [21].
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When examining the oral health-related quality of life of the elderly population, it is
important to note that they are not a homogenous group. The elderly population can be separated
into pre-seniors aged 45-64, and seniors aged 65 and older. In addition, they differ in terms of
living conditions whether they reside in a long-term care facility, or are community dwelling.
Whether an individual lives in the community or long-term care facility usually depends on their
level of independence. It has been documented in many Canadian studies that the overall oral
health status of long-term care residents is poor [1]. Most long-term care residents are in need of
some form of dental care, but it is difficult for them to access care because most dental care
professionals do not feel comfortable providing treatment that is unconventional or outside the
context of traditional dental surgery [35].
Factors that can affect access to care in a community dwelling population include:
financial access, mobility, transportation and advocacy [1]. These factors are causing Canadian
seniors to visit the dentist less frequently. Canadian studies have indicated that 89% of
community dwelling seniors aged 65 and older visit a physician, but only 38% of seniors visit
the dentist [1]. While elderly Canadians are less likely to visit a dentist, when they decide to
receive oral treatment, they are more likely to undergo treatment that they consider to enhance
their self image and social interactions, rather than treatments that improve physical function
[14]. This may be due to the fact that elderly people tend to maintain patterns and tendencies of
oral healthcare that they established during their earlier stages of life [14].
The treatment decisions of older adults may also be affected by cost and the magnitude of
the procedure. For example, one of the more common oral problems for older adults is tooth
wear. Tooth wear is a problem that can occur in people of all ages, but since it is part of the
12
normal human aging process, it was found that people aged 65 years and older have three times
more tooth wear that those aged 26 to 35 years old [36]. The different types of tooth wear
include attrition (tooth against tooth wear), abrasion (tooth wears against other surfaces) and
erosion caused by acids [36]. Bartlett (2007) mentions how a recent study has shown that within
two years, 50 percent of direct or indirect composites that are used to treat wear have failed [36].
Elderly patients are then faced with the difficult decision of whether or not they should undergo
the costly restoration procedure if it may not last throughout the remainder of their life. If
untreated, this oral disease could take a toll on the patient and affect their oral health-related
quality of life.
It is evident that there is previous research on oral health-related quality of life, but little
regarding the elderly population in Canada. A major problem with the Canadian health care
system is that oral healthcare is generally absent from discussions regarding health care reform.
Prior to collecting data for the present study, Canada was one of the few developed countries
without a national oral health strategy, and lacked provincial and national databases concerning
Canadians oral health status and treatment needs. This study will attempt to provide data
regarding the oral health-related quality of life as well as the oral-health status of the elderly
population in Nova Scotia, Canada, and hopefully will be a step towards implementing a
complete nationwide database.
13
Chapter 2
Aim of the Study
2 Objectives and Hypotheses
2.1 Objectives
I. To describe the oral health-related quality of life of a representative sample of adults aged
45 years and older living in Nova Scotia, Canada, and how their oral health impacts their
daily lives.
II. To identify correlates of oral health-related quality of life among community dwelling and
long-term care residents aged 45 and older living in Nova Scotia, Canada.
2.2 Hypotheses
I. LTC residents will report more oral health-related quality of life (OHRQoL) impacts ‗fairly
often‘ or ‗very often‘ than community dwellers and therefore score higher on prevalence,
extent and severity.
II. LTC residing seniors will report more OHRQoL impacts than LTC residing pre-seniors.
III. Community dwelling seniors will report more OHRQoL impacts than community dwelling
pre-seniors.
IV. Individuals with poor oral health status, socio-demographic characteristics and self
perceived oral health status will report more OHRQoL impacts ‗fairly often‘ or ‗very often‘
on the OHIP-14.
14
Chapter 3
Research Methodology
3 Study Design
This cross-sectional study involved 1476 participants, but the analysis below contains
1461 participants because fifteen people failed to complete the interview. This study is part of a
larger study called The Oral Health of our Aging Population (TOHAP) study conducted in the
province of Nova Scotia, Canada. The primary objective of this cross-sectional provincial study
(TOHAP) was to understand how the oral health and expectations of the baby boomer (45yr-
64yr) generation differ from those preceding them (65yr+) for the purpose of planning and
creating policy. The participants were grouped by age (pre-seniors [aged 45yr-64yr] and seniors
[65yr+]) [2, 4], geographic location (urban or rural) and residential status (long-term care facility
[LTC] or community dwelling). A pilot study was conducted prior to this study to test the survey
instruments. The pilot study included 146 participants in dependent and independent living
situations, as well as in rural and urban areas [37]. Funding for this research was provided by the
Canadian Institutes of Health Research – Institute of Musculoskeletal Health and Arthritis,
Health Canada (Office of the Chief Dental Officer) and the Nova Scotia Health Research
Foundation (ROP-86224).
3.1 Sample Size Determination
According to the 2006 census for Nova Scotia, there were 231,941 people aged 45-64
years of age and 133,571 people aged 65 years or older [38]. Of the adults aged 60 years or
15
older, approximately 90% lived in accommodations that were either owned or rented within the
community, 5% lived in LTC facilities, and the remaining 5% of the population lived in public
senior rental housing programs [2, 4]. The Nova Scotia census reported 5827 beds in licensed
LTC facilities. A sample size calculation based on known population prevalence rates
determined the minimal sample size required was 382 pre-seniors, 382 seniors and 359 LTC
residents [38]. This was adjusted to allow for a 10% cancellation rate of appointments.
3.2 Sampling Frame and Sample Selection
A multi-stage cluster sampling technique was used in order to gain a sample of residents
living in long-term care facilities. All private and government owned LTC facilities with at least
20 beds per facility were included in the sampling frame. A total of 102 LTC facilities were used
to determine the sampling frame. The LTC samples were proportionate to size (small, medium or
large) as well as location (rural or urban). A small facility had 20-34 beds, a medium sized
facility had 35-101 beds and a large facility had greater than 102 beds. Statistics Canada‘s rural
and small town (RST) definition was used to assign facilities to urban or rural stratums [39]. A
contact person (usually the director of care/nursing, recreation coordinator or administrator) at
each facility recruited residents to partake in the study. The study was completed in 31 LTC
facilities across 21 communities in Nova Scotia, Canada (refer to Appendix B). Fifteen of the
LTC facilities were located in rural areas (14 medium sized and 1 large sized); whereas sixteen
of the facilities were located in urban areas (3 small sized, 9 medium sized and 4 large sized).
Four private facilities and 28 public facilities were sampled.
16
There are three kinds of publicly funded LTC facilities that are all licensed and approved
by the Department of Health [40]. Nursing Homes (homes for the aged) meet the needs of people
who require a high level of personal care and professional nursing care. These facilities are
licensed and inspected by the Department of Health. Residential Care Facilities are homes for
people in need of supervision and limited help with personal care. These facilities are also
licensed and inspected by the Department of Health. Community Based Options provide a
similar level of care that residential care facilities offer but only accommodate a maximum of
three people in each home. These facilities are unlicensed, but are inspected and approved by the
Department of Health [40]. No Community Based Options were included in this study because
they did not meet the requirement of accommodating at least 20 beds. This study also did not
distinguish between Residential Care Facilities and Nursing Homes.
A care coordinator from the Department of Health provides assessments for individuals
in order to determine what level of care they need. They also collect information that begins the
financial assessment process in order to provide individuals with financial assistance. The
provincial government and LTC residents jointly pay for long-term care. The provincial
government pays for health-care costs for residents care, transportation for dialysis and for inter-
facility transfers and for specialized equipment loans. LTC residents pay for accommodation
charges (including salaries, benefits and operational costs of LTC employees) and personal
expenses (including dental services and transportation) [40].
Community sites were selected based on proximity to previously selected LTC facilities
(refer to Appendix C). In total, 22 Nova Scotian communities were chosen.
17
3.3 Measurements
Oral health-related quality of life was measured using the 14-item Oral Health Impact
Profile questionnaire (OHIP-14) [28]. This questionnaire was administered through a random
digit dialing telephone survey, completed by a Toronto-based telephone marketing company (for
those living independently in the community), or a face-to-face interview (for those in LTC). For
each of the 14 items contained in the OHIP-14, study members were asked how often they had
experienced the problem in the past year. Responses were coded as ‗very often‘ (scoring 4),
‗fairly often‘ (scoring 3), ‗occasionally‘ (scoring 2), ‗hardly ever‘ (scoring 1) or ‗never‘ (scoring
0). This self-report questionnaire contains seven domains including: functional limitation,
physical pain, psychological discomfort, physical disability, psychological disability, social
disability and handicap. Please refer to Appendix A for the complete list of OHIP-14 items.
Included with the OHIP-14, additional questions were derived from the 2007-09
Canadian Health Measures Survey [41]. These questions included: demographic information
(age, sex, education, etc.), oral health questions (personal oral care habits and oral health care
services utilization), general health questions, medication use, labour force activity (income and
employment status) and questions regarding smoking and alcohol exposure. The entire
questionnaire was translated into French. The average duration of the interview was 26.3±6.5
minutes (range 11.3 – 50.9.).
3.4 Clinical Examination
Comprehensive intra-oral examinations were performed after the interview by one of six
dentists, whose methods were calibrated according to the standards of the World Health
18
Organization [42]. A second calibration session was completed after 300 subjects had partaken in
the study. No radiographs were taken during the clinical examination. When available, standard
dental operatories were used. When they were not available, clinical examinations were
conducted in various rooms within LTC facilities. The equipment used for these clinical
examinations included: a portable Adec chair, an Aspetico light and a Mountain Equipment
Co-op headlamp. Ethics approval was received from the Health Sciences Research Ethics
Board at Dalhousie University and from the District Health Authorities. The clinical exam
included oral health questions, which touched on subjects such as untreated dental conditions.
The average duration of the clinical exam was 14.6±5.7 minutes (range 2.9 – 40.6). Per day, 20-
24 community dwelling participants and 14-18 LTC participants were booked for clinical
examinations. The clinical examination also looked at dentate status, prosthetic status and
quality, jaw function, mucosal status, orthodontic status, gingival status, periodontal assessment,
tooth status, history of traumatic injury and urgent clinical treatment needs.
3.5 Procedure
A call list was assembled for each community, targeting pre-seniors and seniors living
within a 20km radius of the community. From each call list, numbers were chosen randomly and
called until contact with the individual was made, or three calls were made without contact. Only
those who were able to provide informed consent to complete the telephone survey and the
clinical exam were included in the study. Informed consent by the participant was accepted in
writing or verbally.
19
Once informed consent was obtained for community dwellers, an interview was done
over the phone in either French or English. Interview data received over the telephone was
immediately entered into an electronic database. The same telephone interviewers were used
throughout the entire data collection period. Appointments for the clinical exams were then
scheduled using an online appointment system and were conducted at hospitals, local private
dental offices, long-term care facilities and public health offices. Approximately one-third of
daily appointments were double booked to compensate for those who did not show up to their
appointment.
In LTC facilities, a trained research assistant conducted interviews in person and
recorded the data on paper after the participant provided informed consent. The interview data
were later transferred into the password-protected database. In the LTC facilities, an onsite
clinical exam was performed immediately following the interview. As an incentive to complete
the study, all participants were placed in contention to win one of two $250 prizes by means of a
lottery (upon completion of the study). The presence of a free dental examination was also a
good incentive for participants to partake in the study. Data were collected in two different
collection periods. The first collection period took place from October to November of 2008, and
the second from April to October of 2009. Further details related to the methodology of this
study can be found in a separate publication by Matthews, Brillant, Clovis, McNally, Filiaggi,
Kotzer and Lawrence, titled: ―Assessing the oral health of an aging population: methods,
challenges and predictors of survey participation‖ [43].
20
3.6 Data Analysis
Socio-demographic characteristics and selected clinical oral health outcomes of
community dwelling and LTC residents were summarized using descriptive statistics. Similarly,
responses to individual OHIP-14 items were summarized according to place of residence. OHIP-
14 overall scores were computed in three ways: (i) a total OHIP-14 score was calculated by
summing responses over all 14 items, with possible scores ranging from 0 to 56 which indicates
the severity of OHRQoL impacts; (ii) the prevalence of people reporting one or more items
‗fairly often‘ or ‗very often‘; (iii) the extent, which is the number of items reported ‗fairly often‘
or ‗very often‘ ranging from 0 to 14 [44]. Descriptive and inferential statistics were computed
using SPSS 17. The non-parametric Mann-Whiney U test was used to compare the mean extent
and severity of oral health impacts between pre-seniors and seniors living in the community or in
LTC residences. A chi-square analysis for categorical variables and logistic regression (using a
stepwise and forward technique based on the Wald statistic) were used to identify factors related
to prevalence of oral impacts for community dwelling and LTC residents. Statistical tests were
two-tailed and interpreted at the 5% significance level. The variables that were inserted into the
multivariate analysis and are thus being controlled for include: age, community type (rural vs.
urban), sex, having a high school education, perceived general health, perceived quality of life,
perceived mouth health, satisfaction with one‘s teeth or dentures, frequency of dental visits,
having dental insurance, smoking, household income, oral pain, dentate status and country of
birth. These were also the variables included in the bivariate analysis. The variables listed above
were chosen in order to adjust for co-variates, and were done so with logical reasoning. First,
socio-demographic variables were chosen so that certain at risk populations could be recognized.
21
Age, community type, sex, education, income, dental insurance and country of birth fell into this
category. Next, lifestyle factors were included into the analysis such as smoking frequency and
frequency of dental visits. Finally, self-perceived and satisfaction variables that are known to
directly or indirectly impact oral health and oral health-related quality of life, such as: oral pain,
perceived general health, perceived mouth health, satisfaction with teeth or dentures and
perceived quality of life, were included in the analysis.
Clinically-determined oral health status characteristics were not included in the logistic
regression analysis because the focus was on determining possible socio-demographic predictors
of OHRQoL. The measures of severity and extent of OHRQoL impacts were not used as
outcomes in multivariate analyses due to their skewed distribution with excess zeros.
The variables used in the data analysis were dichotomized based on logical cut off points in
terms of data distribution (skewed distributions), recommendations from dentists and hygienists
and standards used in other studies. Annual household income was dichotomized into greater
than or equal to $30,000 per year and less than $30,000 per year based on Statistics Canada‘s
Low Income Cutt-offs (LICO) and Low Income Measures (LIM). LICOs are income thresholds
determined by analyzing family expenditure data, whereas LIMs are relative measures of low
incomes set at 50% of adjusted median family income [45]. According to Statistics Canada, the
before tax LICO for a family of two people in 2008, ranges from $19,000 (living in a rural area)
to $23,769 (living in an urban area). Comparable numbers for a family of five people are
$32,278 to $40,239. The before tax LIM (which is not dependent on location) for two people in
2007, ranges from $25,449 (with no children) to $41,809 (with three children) [45]. The
LICO/LIM for pre-seniors will be higher than seniors as they are more likely to have children
22
living at home and living spouses. Based on this information, a conservative measure of $30,000
was used to dichotomize the annual household income variable. Other dichotomizations such as,
brushing and flossing were suggested by dentists and dental hygienists involved in this study due
to the recommended number of times per day an individual should brush (twice per day) and
floss (once per day). Frequency of dental visits (less than once per year vs. greater than once per
year) was also a recommended frequency. Perceived general health, mouth health and quality of
life were dichotomized into excellent, very good and good vs. fair or poor. This dichotomization
seemed like a logical distinction based on the skewed distribution, as most people rate their
health and quality of life in a favorable matter. Smoking frequency was dichotomized into daily
smoking (generally having a severe effect on an individual‘s health) and occasionally or never
(generally having a minimal detrimental effect on an individual‘s health).
23
Chapter 4
Study Results
LTC residents were over-sampled and represented 22.6% of the study population (Table
1). Since there is such a small portion of Nova Scotia residents who live in LTC facilities
(approximately 5%) [2], LTC residents were over-sampled in this study in order to gain enough
power to identify an effect during statistical analyses. Among the LTC sample, 399 participants
were recruited. Of the 399 participants, 64 people (16%) did not qualify or cancelled, 330 people
completed both the interview and clinical examination and 5 people completed the clinical exam
but were not interviewed due to hearing problems. Among the community sample 11,603 phone
numbers were called. Sixty-one percent of the phone numbers called made contact, and of those
contacted 16% completed the interview. Forty-nine percent of these people were ineligible due to
age, 20% declined to participate in the study, 10% said they were physically unable to participate
and 5% asked to be called back [43]. The cooperation rate (number of people who completed
divided by the number of eligible people who were contacted) for the interview was 35% for
community dwellers and the response rate (number of people who completed divided by the
estimated number of eligible cases in the sample) was 21% [43]. The cooperation and response
rates were calculated using the definitions from the American Association for Public Opinion
Research (AAPOR 2009) [46]. Sixty-six percent (738) of those interviewed completed the
clinical exam. Nine percent cancelled and 25% failed to show up. The cooperation rate for the
clinical exam was 23% for community dwellers and the response rate was 13.5%. In addition, 19
people volunteered to have a clinical exam, and 18 of those people completed he phone interview
[43].
24
LTC residents were significantly more likely to be aged 65 and older, be female, have a
high school education or less, a household income of less than $30,000/yr, visit a dental
professional less than once per year, be edentulous, brush their teeth less than twice per day
(dentate only), floss their teeth less than once per day (dentate only) and were less likely to have
dental insurance or be daily smokers. In addition, LTC residents were significantly more likely to
perceive their general health, quality of life and mouth health as fair or poor but have less oral
pain than their community-dwelling counterparts (Table 2). In terms of clinically-determined
oral health status, LTC residents were significantly more likely to have one or more decayed
teeth, have higher coronal and root caries scores on average, have 1+ sites with periodontal
attachment loss of 4mm or more, higher mean scores for periodontal attachment loss, pocket
depth and gingival index, more sites with gingival index score greater than or equal to 2, as well
as higher scores for debris and calculus (Table 3). Only 24.7% of LTC seniors visit the dentist
one or more times per year, compared to 64.6% of community dwelling seniors. Moreover, only
24.2% of LTC pre-seniors visit the dentist one or more times per year, compared to 74.4% of
community dwelling pre-seniors (Table 4).
The most commonly reported oral health quality of life impacts were within the
dimensions ‗physical pain‘ and ‗psychological discomfort‘ (Table 5). It was found that 12.2% of
LTC residents found it uncomfortable to eat any foods ‗fairly often‘ or ‗very often‘ compared to
7.7% in the community. Nearly 12% of LTC residents reported being self-conscious ‗fairly/very
often‘ compared to 8.2% in the community, while 9.7% of LTC residents reported being
embarrassed by their teeth, mouth or dentures ‗fairly/very often‘ compared to 4% in the
community. In addition, 6.1% of LTC residents compared to 2% of community dwellers reported
impacts ‗fairly/very often‘ with regards to difficulty pronouncing words.
25
The mean OHIP-14 score was 5.57 (SD = 7.57) for community dwellers and 5.57 (SD =
9.58) for LTC residents. In addition, a statistically significant difference was reported in terms
of the mean number of items reported ‗fairly/very often‘ between community and LTC residents.
Community residents mean OHIP-14 score was 0.63 (SD = 1.59) and LTC residents mean
score was 0.89 (SD = 2.24). Furthermore, 25.8% of the community dwellers and 24.8% of LTC
residents reported one or more OHIP problems ‗fairly/very often‘ (Table 6). A larger percentage
of LTC residents reported one or more impacts ‗fairly/very often‘ in the functional limitation,
physical pain, psychological disability and handicap dimensions.
Further analysis of prevalence, extent and severity were carried out by comparing pre-
seniors and seniors in both LTC and community settings. In Table 7, pre-seniors were compared
with seniors both in the community and LTC. It was found that in the community, pre-seniors
scored significantly higher than seniors on prevalence (p-value = 0.009), extent (p-value = 0.007)
and severity (p-value = <0.001). In the LTC residences, seniors scored higher than pre-seniors
for prevalence, extent and severity but there was not a statistically significant difference in the
OHIP-14 scores. In Table 8, pre-seniors from the community were compared with pre-seniors in
LTC, and seniors from the community were compared with seniors from LTC. Pre-seniors in the
community scored higher on prevalence, extent and severity than pre-seniors in LTC residences,
but severity was the only significant difference (p-value = 0.033). Furthermore, seniors in LTC
residences scored higher than seniors in the community for prevalence, extent and severity, but
the differences were not statistically significant.
A bivariate analysis was conducted for prevalence of impacts for both community and
LTC residents. Community residents who reported one or more impacts ‗fairly often‘ or ‗very
26
often‘ were more likely to be pre-seniors, live in a rural area, be female, have a high school
education or less, make less than $30,000 per year, visit the dentist less than once per year,
smoke daily, have oral pain, perceive their general health, mouth health and quality of life to be
fair or poor and be dissatisfied with their teeth or dentures (Table 9). LTC residents who reported
one or more impacts ‗fairly often‘ or ‗very often‘ were more likely to have a high school
education or less, have oral pain, perceive their general health, mouth health and quality of life to
be fair or poor and be dissatisfied with their teeth or dentures (Table 10).
Logistic regression models controlling for all the factors (significant and non-significant)
at the bivariate level of analysis were used to predict the prevalence of impacts ‗fairly often‘ or
‗very often‘ for community and LTC residents, separately. For the community dwelling sample,
individuals living in rural areas and those born outside of Canada were approximately 2.0 times
more likely to report an impact ‗fairly/very often‘ (Table 11). Having oral pain, poor perceived
mouth health and dissatisfaction with teeth or dentures also caused community residents to report
impacts. Among the LTC sample, those having a high school education or less were 2.6 times
more likely to report an impact ‗fairly often‘ or ‗very often‘ (Table 12). Those with poor
perceived mouth health were nearly 10 times more likely to report impacts ‗fairly often‘ or ‗very
often‘.
27
Chapter 5
Discussion
The 2007-2009 Canadian Health Measures Survey [47], in accordance with Statistics
Canada, released data regarding the oral health status and treatment needs of Canadians, but did
not do so at the provincial level, nor did it include residents living in LTC facilities [47]. The
TOHAP study is the first to focus on the oral health of older adults living in the province of
Nova Scotia. The findings of this study are not only important in assembling a complete picture
of the oral health of Canadians; it also provides important insight into the oral health-related
quality of life of these individuals.
Hypothesis I stated that LTC residents would report more impacts ‗fairly often‘ or ‗very
often‘ than community dwellers, and therefore score higher on prevalence, extent and severity.
Upon analyzing prevalence, extent and severity scores, LTC residents scored significantly higher
than community dwellers in terms of the mean number of items reported ‗fairly often‘ of ‗very
often‘ on the OHIP-14. Although LTC residents total extent score was significantly higher than
community dwellers, there were no significant differences regarding prevalence and severity
scores. Upon analyzing the distribution of responses on the OHIP-14, a larger percentage of LTC
residents compared to community dwellers scored ‗fairly often‘ or ‗very often‘ on 13 out of the
14 questions.
Long-term care residents are more likely to have poorer indicators of socioeconomic
status, clinicaly-determined oral health outcomes and self-perceived oral health status compared
to community dwellers. Having more oral health problems (higher DMFT and Root Caries Index
28
scores) and being unable to afford or access treatment (lower annual household income and less
likely to have dental insurance) can have an effect on one‘s OHRQoL and in turn explain why
LTC residents may report impacts ‗fairly/very often‘ on the OHIP-14. Only 56.2% of LTC
residents brush their teeth two or more times per day and only 16.8% floss one or more times per
day.
Results show that 18% of community dwellers never visited a dental professional or
visited one only in case of emergency, in contrast to 73% of LTC residents. Table 4 indicates
that for community dwelling pre-seniors, 74.4% visit a dentist one or more times per year,
compared to 64.6% of seniors. A major concern is apparent for those who reside in LTC
facilities, as only 24.2% of pre-seniors and 24.7% of seniors visit a dentist one or more times per
year. In order to increase the oral health-related quality of life of LTC residents, the availability
and accessibility of oral healthcare services in LTC facilities must be greatly improved.
It is evident that as Nova Scotians age, they visit the dentist less regularly. Results of a
national study also show that as Canadians age, they visit the dentist less regularly, as 48.8% of
pre-seniors and 34.3% of seniors visit the dentist one or more times per year [48]. As Canadians
age, they utilize dental services less often but utilize a physician more often, as 78.6% of pre-
seniors and 87.5% of seniors visit a physician one or more times per year. The comparison of the
factors influencing utilization of dental and medical services indicate that high income and
education are positively associated with visiting the dentist, but are not associated with visiting a
physician. In contrast, those with poor general health utilized a physician the most, although this
group utilized a dentist the least. What is particularly telling is that for dental care, socio-
29
economic factors are what predict utilization of services to the extent that visiting a dentist is
opposite to the expected needs of the individual [47, 48].
According to Table 5, elderly adults and specifically LTC residents, find it uncomfortable
to eat foods but have less pain in their mouth than community dwellers. A large percentage of
LTC residents wear a removable prosthesis (dentures), which may lend evidence to why this
group has less oral pain than community dwellers and why they find it uncomfortable eating. In
LTC facilities, 41% of residents are edentulous compared to 8.1% in the community. The
adjustment period to eating with new dentures can be very difficult for elderly people, especially
if the dentures are loose fitting or uncomfortable. This also supports the notion that better
availability and accessibility of oral healthcare services in LTC facilities must be improved in
order to maintain residents‘ dentures.
A lesser issue that can cause difficulty eating is changes related to the natural aging
process. The ageing process even in healthy dentate adults induces changes in oral physiology
and can have an effect on masticatory ability [49, 50]. The effects of aging on the masticatory
apparatus are most prominent in teeth and muscle activity [50]. Aging stimulates changes in
dental arch anatomy, and the constant chewing of hard or tough food can cause occlusal
abrasion, which flattens the crown of the tooth [50]. In addition, with increased age, one‘s
voluntary masticatory muscles change, leading to a reduced bite force [50]. These age related
changes can cause difficulty eating and may lend evidence to the fact that elderly people find it
difficult to eat many foods and that 12.2% of LTC residents find it uncomfortable to eat any
foods ‗fairly/very often‘ compared to 7.7% in the community. This information is important and
can be used to help LTC facilities make better choices when selecting food for their residents.
30
Chewing behavior also changes with age and foods that are difficult to chew such as meat and
dry bread become much more difficult for seniors to eat [50]. Determining an appropriate,
acceptable and easy to eat nutritional diet is the first step in improving the health and the quality
of life of LTC residents.
An important finding of this study indicates that approximately one in four pre-seniors
and seniors report at least one or more impacts of their oral health on their quality of life ‗fairly
often‘ or ‗very often‘. This is slightly higher than a national study of adults aged 55 years and
older where the prevalence rate was one in five (19.5%) [51]. The Yukon, Nunavut and
Northwest Territories which make up 0.3% of the Canadian population were not included in the
aforementioned study [51]. When the extent scores were compared, the findings from this study
were higher than those from the national study in which the mean number of impacts reported
was 0.63 for the community residents and 0.89 for the LTC residents, compared to a extent score
of 0.49 for the population aged 55 years and older in the national study [51]. These scores are
quite low, as on average pre-seniors and seniors in Nova Scotia report less than one impact
‗fairly‘ or ‗very often‘ on the OHIP-14. Finally, when the severity scores were compared, the
mean OHIP-14 score was 5.57 for both the community and LTC residents in this study,
compared to 4.9 in the national study [51]. This is also quite low, as pre-seniors and seniors in
Nova Scotia are on average scoring 5.57 out of 56 on the OHIP-14, keeping in mind that zero is
the lowest and four is the highest score for any given question.
LTC residents scored higher than community dwellers in terms of prevalence, extent and
severity of impacts in almost all dimensions, and the scores are comparable to other similar
studies in Canada and other countries. A Canadian study of 3019 adults aged 18 and older,
31
reported that 18.6% of dentate individuals aged 18 years and older and 30.7% (approximately
one in three) of edentulous individuals had impacts ‗fairly often‘ or ‗very often‘ [51].
Furthermore, it was found that the prevalence of impacts for Atlantic Canada was 16.1% (the
lowest in Canada) and 23.3% in the Prairies (highest in Canada) [51]. In two national studies, the
1998 Adult Dental Health Survey in the United Kingdom reported 15.9% of people having
impacts and the 1999 National Dental Telephone Interview Survey in Australia reported 18.2%
of people in Australia having impacts. The Australian study included edentulous individuals, and
approximately one in four people reported impacts ‗fairly often‘ or ‗very often‘ [51]. In another
study located in New Zealand, approximately one in four (23.4%) individuals aged 32 years old
have impacts ‗fairly often‘ or ‗very often‘ [44]. It was also found that ‗physical disability‘,
‗physical pain‘ and ‗psychological discomfort‘ were the dimensions with the most commonly
reported impacts [44].
There are several conclusions we can draw from these studies in comparison with the data
obtained from the elderly Nova Scotian community. It is evident that reporting oral health
impacts on quality of life is common in many parts of the world. But, it is important to note that
generally older samples and edentulous samples will report having more impacts ‗fairly often‘ or
‗very often‘. Most notably, data reported that approximately one in six adults aged 18 and older
in Atlantic Canada had impacts, compared to one in four adults aged 45 years and older in Nova
Scotian elderly [51].
Hypothesis II was satisfied as seniors in LTC facilities reported more oral health impacts
than pre-seniors living in LTC facilities. Contrary to expectation, as reported in Hypothesis III,
the reverse was true for those living in the community.
32
In the study completed by Locker and Quinonez (2009), telephone numbers for
households (therefore those living in the community) were randomly sampled in a Canadian
population. They found that those between the ages of 35-54 reported an 18.3% prevalence rate
of oral impacts, and those aged greater than or equal to 55 years reported a 19.5% prevalence
rate [51]. In this national study, an older population of community dwellers reported more
impacts than a younger population of community dwellers.
As mentioned earlier in the Locker and Gibson (2005) study of community living
individuals over the age of 50, it was reported that 16.5% of those who rated their oral health as
either excellent, very good, or good had reported to be dissatisfied with their oral health.
Moreover, 50.8% of participants who rated their oral health as fair or poor reported being
satisfied [21]. Individual expectations and experiences can greatly impact one‘s satisfaction or
dissatisfaction with their oral health [21]. For example, one who experiences poor health but has
low expectations may not perceive their health to have a significant impact on their life. Seniors
living within the community may not feel as though oral health has a huge impact on their life
and may be more satisfied with the quality of their oral health compared to their general health,
causing them to report less impacts ‗fairly often‘ or ‗very often‘. In contrast, one who has
excellent oral health but extremely high expectations might report being dissatisfied due to a
minor oral health related problem [21]. Community dwelling pre-seniors who are generally in
good health may become irritated by small oral health problems, and frustrated that dental visits
can be expensive and cut into work hours. In addition, frames of reference in which subjects base
their oral health can range. While some compare themselves to others who are close in age,
others can use physical or emotional state to assess their oral health. Some people who have or
perceive themselves as having poor oral health are actually satisfied with their state of oral health
33
[21, 52]. Sprangers and Schwartz (1999) explain this phenomenon through the process of
response shift. This is when changes in one‘s internal standards, values and meanings attribute to
assisting an individual in accepting their illnesses or disabilities [52]. As they age, they begin to
attribute small or large oral health diseases as being insignificant to them at this point in their life
[21]. The theory of response shift may explain why community dwelling seniors, and the elderly
population in general, may report fewer impacts in certain dimensions [52]. As these individuals
age, they come to accept that their health is deteriorating and may consider oral health problems
to be less significant at this point in their lives [21]. Oral health problems also tend to take a
backseat to general health problems that may be more serious or life threatening to an older
individual. A study completed in Ontario involving 61 residents in three long-term care facilities
suggests that general health issues often overshadowed and minimized oral health issues in long-
term care facilities. Chronic illnesses such as Alzheimer‘s and Parkinson‘s disease, which
interfere with one‘s communication skills, cause barriers in identifying treatments needs for
these residents [53].
After extensive research into this matter it is not surprising to learn that a younger
population of community dwellers reported more impacts than an older population of community
dwellers. In addition, pre-seniors with poor oral health who are living in the community are
younger and less likely to retire. Therefore, community dwelling pre-seniors with poor oral
health and oral health-related quality of life are less likely to move to LTC facilities than seniors.
This study provides very useful information pertaining to the difference between pre-
seniors and seniors living in Nova Scota, Canada. It is apparent that the baby boomer generation
is considerably different than those preceding them. Although this study looked at the difference
34
between pre-seniors and seniors, the comparison goes beyond that and includes a generational
gap. People born in different generations have different outlooks on life and the circumstances of
each generation are quite different. It is important to note that even though a comparison between
today‘s pre-seniors and seniors is important and useful, seniors today are vastly different from
seniors 20 years ago, and are likely to be different from seniors in the future. Therefore we must
continue to study different elderly populations in the past and future and take into account the
history, environment, circumstances and conditions of these populations.
Hypothesis IV stated that individuals with poor oral health status, socio-demographic
characteristics and poor perceived oral health status will report more impacts on the OHIP-14.
The bivariate analysis indicates that community residents that live in rural areas, have a high
school education or less, make less than $30,000 per year, visit the dentist less than once per
year, have oral pain, smoke daily, perceive their general health, mouth health and quality of life
to be fair or poor and be dissatisfied with their teeth or dentures are significantly more likely to
have one or more impacts ‗fairly often‘ or ‗very often‘. LTC residents who have oral pain,
perceive their general health, mouth health and quality of life to be fair or poor and be
dissatisfied with their teeth or dentures reported one or more impacts ‗fairly often‘ or ‗very
often‘.
The binary logistic regression model indicated that for those living in the community, the
strongest predictor of prevalence of impacts ‗fairly often‘ or ‗very often‘ was for those having
dissatisfaction with the appearance of their teeth and/or dentures. These people were 5.16 times
more likely to report impacts ‗fairly often‘ or ‗very often‘. This was the most significant value in
the model and readdresses the theme of how a complication with one‘s teeth and/or dentures can
35
have a significant impact on one‘s oral health-related quality of life. Dissatisfaction with the
appearance of one‘s teeth and/or dentures is directly related to variables on the OHIP-14 such as
being self conscious and embarrassed. Being self conscious because of troubles with one‘s teeth,
mouth or dentures was one of the highest scoring items on the OHIP-14. Having oral pain (1.87
times more likely to report impacts), and those with poor perceived mouth health (2.19 times
more likely to report impacts) were also strong predictors of prevalence of impacts. These
variables are closely related to the outcome of oral health-related quality of life and it is therefore
not surprising to find them in this model.
Logistic regression models also indicate that both socio-demographic factors and self-
perceived oral health can have an effect on the prevalence of impacts. Findings indicate that pre-
seniors and seniors in rural areas have the poorest OHRQoL, suggesting that a decreased access
to dental care may be affecting their oral health and OHRQoL. This variable was also the second
most significant variable in the model. Further findings show that elderly residents living in the
community visit the dentist significantly less often if they live in a rural area as opposed to an
urban area. Results indicate that 75.4% of Nova Scotia residents aged 45 and older who live
independently in an urban area visit the dentist one or more times per year, whereas only 62.4%
of rural residents visit the dentist one or more times per year. According to the literature, ―in
dentistry, a functional definition of an elderly adult is based on his or her ability to travel to seek
services‖ [5]. Many elderly patients who live in rural areas may have access to fewer dental
clinics, or there may be barriers limiting their access to care. Barriers include lack of public
transportation, cost of transportation and treatment, or mobility issues [54]. The reliance of many
seniors on others for help may also limit their ability to receive dental care [54].
36
Although many health economists believe that government funds may be insufficient to
meet the increasing dental needs of the baby boom population, education is a relatively
inexpensive, yet effective dental health care initiative. Education can improve access to care for
Canadian elderly by focusing on quality of life issues. Education that focuses and raises
awareness on how oral health enhances self-image and social interactions can positively affect
attitudes towards care. Furthermore, funding for retired employees must be developed by union
negotiators, working Canadians must plan for retirement by saving money for dental care, and
family members and caregivers must be educated in the importance of dental care for the elderly
[55].
In addition, it was found that those who were born outside of Canada living within the
community have greater oral health impacts, implying that oral health literacy, understanding the
Canadian health-care system and acculturation may be limiting their access to dental care. It is
important to note that those who are born outside of Canada will have come from different
countries around the world, all of which have different oral health profiles. Some countries will
have better oral healthcare than others, resulting in their citizens having better oral health.
Although many people may be coming to Canada with excellent oral health, it can still be
difficult for them to navigate through an entirely different healthcare system, resulting in
difficulties accessing dental care. Support from friends, family, community members and dental
professionals are important in order to help this population access dental care [54]. It is important
that people who are familiar with the dental and healthcare system in Canada and speak the
native language of these seniors, provide help in order that they are able to receive adequate care.
In addition, an increase in educational resources and training by dental hygienists can be
essential in developing proper oral health-care skills and routines for seniors, their nursing staff,
37
and family members [54]. Education is also necessary so that they can provide care in a
productive, cost effective and timely manner [55]. Television programs, magazine articles,
newsletters and other social media outlets can be useful mediums in raising awareness for the
importance of oral healthcare if provided in multiple languages [54].
Moreover, LTC residents with a low education level may be a group at risk in terms of
greater impacts on their OHRQoL, as LTC residents are 2.6 times more likely to report impacts
‗fairly often‘ or ‗very often‘. LTC residents have poorer indicators of socioeconomic status
including household income and dental insurance. Due to the majority of dental coverage not
being covered by Medicare, out of pocket costs may deter people from seeking dental care, in
addition to accepting recommended dental care when visiting the dentist [47]. It is no
coincidence that 79% of LTC residents have less than or equal to a high school education, 82.7%
do not have dental insurance and 90.3% have an annual household income of less than $30,000.
The Canadian Health Measures Survey reported that as individuals age they are less likely to
have dental insurance. In addition, country of birth, annual income and level of education are
also directly related to having dental insurance [47]. A 2006 study using Canadian health survey
data from 2003, found that the probability of receiving any dental care throughout the course of a
year increases dramatically with dental insurance, household income and level of education [56].
Reported in the 2006 census, only 24% of adults aged 25-64 had a high school diploma
as their highest level of educational attainment, while 32% of adults aged 55 to 64 years did not
have a high school diploma [57]. Educational attainment is recognized as one of the key
components of socioeconomic status, and while income and education are highly correlated,
education is an independent predictor of health status and visiting the dentist [48, 58]. Regardless
38
of age, people with low education levels have more disabilities and chronic illnesses [58]. People
with a higher educational background tend to embrace positive health practices and have access
to healthier physical environments [58].
It is clear that public health initiatives need to focus on Canadians with low levels of
education. Even though access to education and literacy levels are for the most part managed
outside of the health sector, they have a direct effect on health status. Therefore, multi-sectoral
strategies must be implemented in order to improve the oral health of Canadians [58].
The strongest predictor of prevalence of impacts ‗fairly often‘ or ‗very often‘ for LTC
residents was having poor perceived mouth health. Those with poor perceived mouth health were
9.87 times more likely to report impacts. It is no coincidence that residents of long-term care
facilities perceive their oral health as being poor. LTC residents have poor oral hygiene and
limited access to routine dental care, in most cases limited to emergency treatment [35, 59]. A
study examining 39 LTC hospitals in British Columbia concludes that residents of LTC facilities
have inadequate daily oral hygiene and high sugar intake [60]. This leads to high levels of caries
bacteria and a tendency for xerostomia. The elderly living in long-term care residents are at a
high risk of dental diseases, although they unfortunately experience greater barriers to receiving
dental care compared to those living within the community [61]. Barriers to care include cost,
transportation, fear and a lack of perceived need for dental treatment. It is proven that once a
comprehensive dental program is implemented into LTC facilities, residents who receive dental
care show improvements in caries rates, periodontal health, and other clinical oral disorders [35].
Living in an LTC facility is a barrier to treatment in of itself. Therefore it is imperative that
dental programs be set up in order to help LTC seniors access dental care. This includes
39
implementing oral healthcare policies, improving geriatric dental training for caregivers and
nursing staff, attaining adequate space to set up dental equipment and transportation of residents
to outside dental care [54].
A study completed in Ontario involving 61 residents in three long-term care facilities also
suggests that access to a dentist is a major issue in LTC facilities, as there is usually no dentist
accessible on-site [53]. Due to the reality that salaried dentists and hygienists are not reasonable
for most LTC facilities, a solution may be for multiple LTC facilities to pool financial resources
together to share dental services [53].
In addition, it is extremely important to screen residents for dental diseases and monitor
their oral health status upon arrival to a facility. The presence of oral diseases is an accumulation
from many years prior to one‘s entry into a long-term care facility, and these problems will
generally become worse over time [62]. Interviewing and discussing the oral health status of
each individual in an LTC facility can be extremely beneficial. Upon completing a study
involving quantitative analyses, it is important to discuss the difference between quantitative and
qualitative analysis. Qualitative analysis involves collecting, organizing and interpreting textual
materials from data analysis, interviews, direct observations or document analysis [63]. Many
researchers, including MacEntee, used a qualitative case research approach to analyze how oral
health programs affect LTC residents [64]. MacEntee collected data from open-ended interviews
and found a clearer understanding of human behavior that could not be found by quantitative
analysis alone [64]. Finkleman and collaborators used qualitative and quantitative analyses to
study the oral health of LTC residents [53]. Diversity in data analysis can help provide a wider
understanding of oral health in LTC facilities [65]. Finkleman et al. found there to be just as
40
much variation in terms of oral health provision between residents within LTC facilities as there
are between the actual facilities themselves [53]. Although using a combination of quantitative
and qualitative analyses could have benefitted the present study, due to the large sample size it
was not a plausible option. Nevertheless, it should be noted that the OHIP-14 was constructed
through an interview process by asking open-ended questions in order to ascertain statements
concerning impacts of oral conditions (31).
It was difficult enough to persuade participants to complete the interview over the phone.
Of the 11,603 phone numbers who were called, 16% completed the interview. This number
would have most likely been lower had the interview involved a longer more thorough
discussion process. In total, 1141 community dwelling participants took part in the study. Of the
1141 participants, 747 completed the interview and clinical examination, 384 completed only the
interview and 10 people completed only the clinical examination (43). It was found that
participants who worked full or part time were less likely to complete both the interview and
clinical exam compared to those who did not work. Those who visited the dentist less than once
per year and those with less than a high school education were also less likely to complete both
the interview and clinical examination (43).
Moreover, the implications of poor oral health goes beyond the mouth, as oral health-
related quality of life is an important issue for the elderly population living in LTC facilities [60].
An individual‘s health and illnesses can have a profound effect on their quality of life through
their perceptions of physical health, psychological state, level of independence, social
relationships and environmental relationships [53]. It is therefore important to integrate dental
41
services into long-term care programs with an idea of how these perceptions can affect oral
health and oral health-related quality of life.
42
Chapter 6
Study Limitations
This study has several limitations that should be pointed out. In many cases studies do not
include participants with diseases such as alzheimer‘s and dementia, but due to the large
proportion of seniors and pre-seniors who have these diseases, this population should have been
included in the analysis. These diseases cause memory loss and can have an effect on one‘s
OHRQoL, in addition to the way in which an individual perceives his/her oral and general
health. Another limitation might be the difference between completing the questionnaire over the
phone via a telephone marketing company, rather than in person via a trained researcher. The
people who complete the survey over the phone may be a different type of person. Generally,
people who are extremely busy will not take the time to complete the survey over the phone, let
alone travel to a clinic to be examined. These people who complete the survey may have more
time on their hands, or they may have poor oral health and are willing to complete the survey in
order to get a free clinical examination. In addition, people who are answering questions in
person may answer them differently due to embarrassment, or may be unwilling to tell the truth
on certain matters due to the sensitive nature of many of the questions. This is known as
measurement bias, because all subjects in LTC facilities were given face-to-face interviews,
whereas community residents were given interviews over the phone.
43
Chapter 7
Conclusions
This study has provided valuable information regarding the oral health-related quality of
life of pre-seniors and seniors living in Nova Scotia, Canada. It was found that LTC residents are
more likely to have poorer indicators of socio-demographic characteristics, clinical oral health
outcomes and self-perceived oral health status compared to community dwellers. Having more
oral health problems can have an effect on one‘s OHRQoL and in turn, explain why LTC
residents may report impacts ‗fairly/very often‘ on the OHIP-14. One in four pre-seniors and
seniors living in the community and LTC facilities reported one or more impacts ‗fairly/very
often‘, however, pre-seniors in the community experienced greater prevalence, extent and
severity of oral impacts than seniors. These findings suggest that as people age, oral health
problems may take a backseat in relation to general health problems. The study findings also
indicate that the strongest predictors for prevalence of impacts ‗fairly often‘ or ‗very often‘ for
community dwelling pre-seniors and seniors are having dissatisfaction with one‘s teeth or
dentures, poor perceived mouth health, having oral pain and living in rural areas. In addition,
those who were born outside of Canada but now living within the community have greater oral
health impacts. The strongest predictor for prevalence of impacts ‗fairly often‘ or ‗very often‘ for
LTC residents was having poor perceived mouth health, while LTC residents with a low
education level may be a group at risk in terms of greater impacts on their OHRQoL.
44
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52
Tables
Table 1. Characteristics of study participants aged 45 years and older living in the
community or long-term care in Nova Scotia, Canada
Characteristic
% (N)
Total
100 (1461)
Community
77.4 (1131)
LTC
22.6 (330)
Age (yrs)
45 – 64
65 and over
45.3 (662)
54.7 (799)
55.6 (629)
44.4 (502)
10 (33)
90 (297)
Sex
Male
Female
34.5 (504)
65.5 (957)
37.1 (420)
62.9 (711)
25.5 (84)
74.5 (246)
Education Level
More than high school
High school or less
49.3 (718)
50.7 (738)
57.6 (649)
42.4 (478)
21.0 (69)
79.0 (260)
Community Type
Urban
Rural
59.1 (864)
40.9 (597)
59.2 (669)
40.8 (462)
59.1 (195)
40.9 (135)
Annual Household Income
More than $30,000
Less than $30,000
57.6 (643)
42.4 (474)
72.0 (618)
28.0 (240)
9.7 (25)
90.3 (234)
Dental Insurance
Yes
No
43.5 (621)
56.5 (806)
50.7 (568)
49.3 (553)
17.3 (53)
82.7 (253)
Country of Birth
Canada
Other
90.3 (1316)
9.7 (141)
90.3 (1018)
9.7 (109)
90.3 (298)
9.7 (32)
Frequency of Dental Visits
1+ times per year
< 1 times per year
59.9 (862)
40.1 (578)
70.1 (782)
29.9 (334)
24.7 (80)
75.3 (244)
Dentate status
Dentate
Edentulous
81.8 (878)
18.2 (195)
91.9 (684)
8.1 (60)
59.0 (194)
41.0 (135)
Brushing Frequency (dentate only)
2+ times per day
< 2 times per day
74.2 (650)
25.8 (226)
79.3 (541)
20.7 (141)
56.2 (109)
43.8 (85)
Flossing Frequency (dentate only)
1+ times per day
< 1 times per day
35.2 (299)
64.8 (551)
40.3 (268)
59.7 (397)
16.8 (31)
83.2 (154)
53
Smoking Frequency
Occasionally or not at all
Daily
88.4 (1288)
11.6 (169)
87.3 (985)
12.7 (143)
92.1 (303)
7.9 (26)
N.B. Bolded percentages are significant when p ≤0.05 using the Chi-square test.
54
Table 2. Self-perceived oral health status of adults aged 45 and older in Nova Scotia,
Canada
Characteristic
% (N)
Total
100 (1461)
Community
77.4 (1131)
LTC
22.6 (330)
Perceived General Health
Excellent/ very good/ good
Fair or poor
80.0 (1167)
20.0 (292)
84.1 (950)
15.9 (180)
66.0 (217)
34.0 (112)
Perceived Quality of Life
Excellent/ very good/ good
Fair or poor
89.8 (1305)
10.2 (149)
92.8 (1049)
7.2 (81)
79.0 (256)
21.0 (68)
Perceived Mouth Health
Excellent/ very good/ good
Fair or poor
79.9 (1161)
20.1 (292)
81.1 (916)
18.9 (213)
75.6 (245)
24.4 (79)
Oral Pain
No oral pain
Mouth, dental, jaw or other pain
69.0 (743)
31.0 (334)
66.0 (493)
34.0 (254)
75.8 (250)
24.2 (80)
Satisfaction with Teeth/Dentures
Very satisfied/ satisfied/ neither
satisfied or dissatisfied
Dissatisfied or very dissatisfied
85.4 (1235)
14.6 (211)
85.4 (1235)
14.6 (211)
84.9 (269)
15.1 (48)
N.B. Bolded percentages are significant when p ≤0.05 using the Chi-square test.
55
Table 3. Clinically-determined oral health status characteristics of adults aged 45 and older in Nova Scotia, Canada
Characteristic
% (N) Mean (SD)
Range (N)
Total
100 (1461)
Community
77.4 (1131)
LTC
22.6 (330)
Community
77.4 (1131)
LTC
22.6 (330)
% with DT = 0
% with 1+ DT
79.9 (860)
20.1 (217)
84.1 (628)
15.9 (119)
70.3 (232)
29.7 (98)
DMFT 22.11 (6.40)
0 – 28 (1461)
21.68 (6.64)
0 – 28 (1131)
23.58 (5.28)
6 – 28 (330)
Root Caries Index = (DFR / Number
of tooth roots) * 100 (dentate only)
13.54 (20.86)
0 – 100 (881)
10.80 (17.02)
0 – 100 (687)
23.24 (28.84)
0 – 100 (194)
% with RCI = 0
% with 1+ RCI
43.1 (378)
56.9 (500)
45.2 (309)
54.8 (375)
35.6 (69)
64.4 (125)
Attachment loss (mm)
Mean ± SD (n) [dentate only]
% with 1+ sites with AL of 4+mm
3.09 ± 1.54 (789)
58.8 (462)
56.4 (347)
67.3 (115)
2.86 ± 1.34 (618)
3.95 ± 1.86 (171)
Probing depth (mm)
Mean ± SD (n)
% with 1+ sites with PD of 4+mm
2.29 ± 0.04 (789)
32.6 (257)
31.6 (195)
36.3 (62)
2.23 ± 1.06 (618)
2.50 ± 1.26 (171)
Gingival Index (GI)
Mean ± SD (n)
% with GI ≥ 2 at 1+ sites
2.29 ± 0.04 (861)
49.8 (429)
45.7 (310)
65.4 (119)
0.97 ± 0.69 (678)
1.51 ± 0.76 (182)
56
Debris Index (DI)
Mean ± SD (n)
0.87 ± 0.02 (873)
0.73 ± 0.49 (683)
1.38 ± 0.64 (190)
Calculus Index (CI)
Mean ± SD (n)
0.77 ± 0.02 (873)
0.68 ± 0.67 (683)
1.10 ± 0.82 (190)
DT = sum of the number of decayed permanent teeth.
DMFT = sum of the number of decayed, missing or filled permanent teeth as a result of dental caries.
DFR = sum of the number of decayed tooth roots.
N.B. Bolded percentages are significant when p ≤0.05 using the Chi-square test.
N.B. Bolded means are significant when p ≤0.05 using the Independent Samples T-test.
57
Table 4. Percent of elderly Nova Scotia residents making 1 or more visits to the dentist
Total % (n) Community % (n) LTC % (n)
Age (years) ≥ 1 time
per year
< 1 time
per year
≥ 1 time
per year
< 1 time
per year
≥ 1 time
per year
< 1 time
per year
45- 64 71.9 (471) 28.1 (184) 74.4 (463) 25.6 (159) 24.2 (8) 75.8 (25)
65+ 49.8 (391) 50.2 (394) 64.6 (319) 35.4 (175) 24.7 (72) 75.3 (219)
N.B. Bolded percentages are significant when p ≤0.05 using the Chi-square test.
58
Table 5. Distribution of responses to individual OHIP-14 items and mean item scores (n = 1461)
Dimension and description of item Distribution of responses %
Mean (SD) ―Because of trouble with your teeth, mouth or
dentures during the last year, …‖
Never (0)/
Hardly Ever (1) Occasionally (2)
Fairly Often (3)/
Very Often (4)
Comm. LTC Comm. LTC Comm. LTC Community LTC
Functional limitation
have you had trouble pronouncing any words? 92.9 86.7 5.2 7.3 2.0 6.1 0.09 (0.35) 0.19 (0.53)
have you felt that your sense of taste has worsened? 88.5 88.8 7.5 5.9 4.0 5.3 0.16 (0.46) 0.17 (0.49)
Physical pain
have you had painful aching in your mouth? 79.7 83.6 15.2 11.8 5.2 4.5 0.25 (0.54) 0.21 (0.51)
have you found it uncomfortable to eat any foods? 74.8 73.3 17.5 14.6 7.7 12.2 0.33 (0.61) 0.39 (0.69)
Psychological discomfort
have you been self-conscious? 78.7 74.5 13.1 14.0 8.2 11.6 0.29 (0.61) 0.37 (0.68)
have you felt tense? 80.2 84.4 12.4 8.0 7.4 7.6 0.27 (0.59) 0.23 (0.58)
Physical disability
has your diet been unsatisfactory? 86.3 84.5 7.8 7.9 5.9 7.6 0.20 (0.53) 0.23 (0.58)
have you had to interrupt meals? 91.0 88.8 6.0 6.7 2.9 4.6 0.12 (0.41) 0.16 (0.47)
Psychological disability
have you found it difficult to relax? 85.4 88.4 9.6 6.4 5.1 5.2 0.20 (0.51) 0.17 (0.49)
have you been a bit embarrassed? 83.8 82.4 12.2 7.9 4.0 9.7 0.20 (0.49) 0.27 (0.63)
Social disability
have you been a bit irritable with other people? 86.1 89.1 10.6 7.3 3.3 3.6 0.17 (0.46) 0.15 (0.45)
have you had difficulty doing your usual jobs? 93.8 93.9 3.9 3.1 2.3 3.1 0.09 (0.35) 0.09 (0.38)
Handicap
have you felt that life in general was less
satisfying? 89.7 87.2 6.6 6.7 3.7 6.1 0.14 (0.44) 0.19 (0.53)
have you been totally unable to function? 96.1 95.1 2.6 2.4 1.3 2.4 0.05 (0.28) 0.07 (0.34)
59
Table 6. Prevalence, extent and severity of impacts by OHIP-14 subscale and total score
Dimension
Prevalence: % reporting
1+ impacts fairly/very
often (no.)
Extent: mean no. of
items reported
fairly/very often (SD)
Severity: mean OHIP-14
score (SD)
Community LTC Community LTC Community LTC
Functional limitation 5.4 (61) 9.4 (31) 0.06 (0.26) 0.11 (0.37) 0.56 (1.20) 0.69 (1.48)
Physical pain 9.6 (109) 13.9 (46) 0.13 (0.42) 0.17 (0.44) 1.25 (1.81) 1.17 (1.85)
Psychological discomfort 12.0 (136) 13.6 (45) 0.15 (0.45) 0.19 (0.51) 1.16 (1.86) 1.14 (2.03)
Physical disability 7.6 (86) 7.9 (26) 0.09 (0.33) 0.12 (0.44) 0.69 (1.40) 0.76 (1.78)
Psychological disability 7.3 (82) 11.5 (38) 0.09 (0.34) 0.15 (0.44) 0.85 (1.59) 0.85 (1.81)
Social disability 4.7 (53) 4.2 (14) 0.06 (0.27) 0.07 (0.33) 0.59 (1.32) 0.46 (1.32)
Handicap 4.1 (46) 6.7 (22) 0.05 (0.26) 0.09 (0.34) 0.47 (1.19) 0.51 (1.43)
Total OHIP-14 score
25.8 (291)
24.8 (82)
0.63 (1.59)
0.89 (2.24)
5.57 (7.57)
5.57 (9.58)
N.B. Bolded percentages are significant when p ≤0.05 using the Chi-square test.
N.B. Bolded means are significant when p ≤0.05 using the Independent Samples T-test.
60
Table 7. Prevalence, extent and severity of impacts by OHIP-14 subscale grouped by pre-seniors and seniors
Community LTC
Pre-seniors
(n=629) Seniors (n=501)
P-value Pre-seniors (n=33)
Seniors (n=297)
P-value
Prevalence: % reporting
1+ impacts fairly/very
often (no.) 28.8 (181) 22.0 (110) 0.009
* 21.2 (7) 25.3 (75) 0.610*
Extent: mean no. of items
reported fairly/very often
(SD)
0.73 (1.73) 0.49 (1.40) 0.007**
0.45 (1.33) 0.94 (2.32) 0.456**
Severity: mean OHIP-14
score (SD)
6.22 (8.0) 4.75 (6.92) <0.001**
4.30 (7.29) 5.71 (9.80) 0.867**
*P-value obtained from the Chi-squared test.
**P-value obtained from the Mann-Whitney U test
61
Table 8. Prevalence, extent and severity of impacts by OHIP-14 subscale grouped by community and LTC
Pre-seniors Seniors
Community
(n=629) LTC
(n=33)
P-value Community (n=501)
LTC (n=297)
P-value
Prevalence: % reporting
1+ impacts fairly/very
often (no.) 28.8 (181) 21.2 (7) 0.348
* 22.0 (110) 25.3 (75) 0.286*
Extent: mean no. of items
reported fairly/very often
(SD)
0.73 (1.73) 0.45 (1.33) 0.292**
0.49 (1.40) 0.94 (2.32) 0.124**
Severity: mean OHIP-14
score (SD)
6.22 (8.0) 4.30 (7.29) 0.033**
4.75 (6.92) 5.71 (9.80) 0.129**
*P-value obtained from the Chi-squared test.
**P-value obtained from the Mann-Whitney U test.
62
Table 9. Bivariate analysis for prevalence of impacts (‘fairly often’ or ‘very often’) for
community residents
Characteristic % (N)
No Impacts 1+ Impacts P- value
Age (yrs)
45 – 64
65 and over
71.2 (448)
78.0 (391)
28.8 (181)
22.0 (110)
0.009
Community Type
Urban
Rural
79.2 (529)
67.1 (310)
20.8 (139)
32.9 (152)
< 0.001
Sex
Male
Female
78.3 (328)
71.9 (511)
21.7 (91)
28.1 (200)
0.017
Education Level
More than high school
High school or less
78.3 (508)
68.6 (328)
21.7 (141)
31.4 (150)
< 0.001
Annual Household Income
More than $30,000
Less than $30,000
77.0 (476)
64.2 (154)
23.0 (142)
35.8 (86)
< 0.001
Dental Insurance
Yes
No
75.9 (431)
73.1 (404)
24.1 (137)
26.9 (149)
0.278
Country of Birth
Canada
Other
74.8 (761)
70.6 (77)
25.2 (256)
29.4 (32)
0.341
Frequency of Dental Visits
1+ times per year
< 1 time per year
77.7 (608)
65.6 (219)
22.3 (174)
34.4 (115)
< 0.001
Dentate Status
Dentate
Edentulous
76.3 (524)
68.3 (41)
23.7 (163)
31.7 (19)
0.169
Smoking Frequency
Occasionally or not at all
Daily
75.8 (747)
64.3 (92)
24.2 (238)
35.7 (51)
0.003
Oral Pain
No
Yes
82.8 (408)
61.8 (157)
17.2 (85)
38.2 (97)
< 0.001
Perceived General Health
Excellent/ very good/ good
Fair or poor
77.9 (740)
55.0 (99)
22.1 (210)
45.0 (81)
< 0.001
63
Perceived Mouth Health
Excellent/ very good/ good
Fair or poor
79.7 (730)
50.7 (108)
20.3 (186)
49.3 (105)
< 0.001
Satisfaction with teeth or dentures
Satisfied
Dissatisfied
79.5 (768)
42.9 (70)
20.5 (198)
57.1 (93)
< 0.001
Perceived Quality of Life
Excellent/ very good/ good
Fair or poor
76.5 (803)
44.4 (36)
23.5 (246)
55.6 (45)
< 0.001
64
Table 10. Bivariate analysis for prevalence of impacts (‘fairly often’ or ‘very often’) for
LTC residents
Characteristic % (N)
No Impacts 1+ Impacts P- value
Age (yrs)
45 – 64
65 and over
78.8 (26)
74.7 (222)
21.2 (7)
25.3 (75)
0.610
Community Type
Urban
Rural
76.9 (150)
72.6 (98)
23.1 (45)
27.4 (37)
0.371
Sex
Male
Female
73.8 (62)
75.6 (186)
26.2 (22)
24.4 (60)
0.742
Education Level
More than high school
High school or less
84.1 (58)
72.7 (189)
15.9 (11)
27.3 (71)
0.052
Annual Household Income
More than $30,000
Less than $30,000
88.0 (22)
71.8 (168)
12.0 (3)
28.2 (66)
0.081
Dental Insurance
Yes
No
79.2 (42)
73.5 (186)
20.8 (11)
26.5 (67)
0.384
Country of Birth
Canada
Other
74.8 (223)
78.1 (25)
25.2 (75)
21.9 (7)
0.682
Frequency of Dental Visits
1+ times per year
< 1 time per year
76.3 (61)
74.6 (182)
23.8 (19)
25.4 (62)
0.766
Dentate Status
Dentate
Edentulous
75.3 (146)
75.0 (102)
24.7 (48)
25.0 (34)
0.957
Smoking Frequency
Occasionally or not at all
Daily
76.2 (231)
61.5 (16)
23.8 (72)
38.5 (10)
0.096
Oral Pain
No
Yes
79.6 (199)
61.3 (49)
20.4 (51)
38.8 (31)
0.001
Perceived General Health
Excellent/ very good/ good
Fair or poor
81.1 (176)
64.3 (72)
18.9 (41)
35.7 (40)
0.001
65
Perceived Mouth Health
Excellent/ very good/ good
Fair or poor
85.7 (210)
40.5 (32)
14.3 (35)
59.5 (47)
< 0.001
Satisfaction with teeth or dentures
Satisfied
Dissatisfied
81.0 (218)
56.3 (27)
19.0 (51)
43.8 (21)
< 0.001
Perceived Quality of Life
Excellent/ very good/ good
Fair or poor
80.5 (206)
54.4 (37)
19.5 (50)
45.6 (31)
< 0.001
66
Table 11. Logistic regression model for prevalence of impacts (‘fairly often’ or ‘very often’)
for community residents (n = 565)
Adjusted
Odds Ratio
95% CI for Odds
Ratio
P-value
Living in a rural area 2.07 1.35 – 3.17 0.001
Having oral pain 1.87 1.21 – 2.88 0.005
Born outside of Canada 1.97 1.01 – 3.85 0.048
Poor perceived mouth health 2.19 1.30 – 3.71 0.003
Dissatisfaction with teeth or dentures 5.16 2.87 – 9.27 <0.001
CI = Confidence Interval
67
Table 12. Logistic regression model for prevalence of impacts (‘fairly often’ or ‘very often’)
for LTC residents (n = 229)
Adjusted
Odds Ratio
95% CI for Odds
Ratio
P-value
High school education or less 2.61 1.01 – 6.73 0.047
Poor perceived mouth health 9.87 4.93 – 19.75 <0.001
CI = Confidence Interval
68
Appendices
Appendix A: OHIP-14 items grouped according to dimension
Dimension
Description of item
Functional limitation
1. ―How often, in the past year, have you had trouble pronouncing any words because of
problems with your teeth, mouth or dentures?‖
2. ―How often, in the past year, have you felt that your sense of taste has worsened because
of problems with your teeth, mouth or dentures?‖
Physical pain
3. ―How often, in the past year, have you had painful aching in your mouth?‖
4. ―How often, in the past year, have you found it uncomfortable to eat any foods because of
problems with your teeth, mouth or dentures?‖
Psychological discomfort
5. ―How often, in the past year, have you been self conscious because of your teeth, mouth
or dentures?‖
6. ―How often, in the past year, have you felt tense because of your teeth, mouth or
dentures?‖
Physical disability
7. ―How often, in the past year, has your diet been unsatisfactory because of problems with
your teeth, mouth or dentures?‖
8. ―How often, in the past year, have you had to interrupt meals because of problems with
your teeth, mouth or dentures?‖
Psychological disability
9. ―How often, in the past year, have your found it difficult to relax because of problems
with your teeth, mouth or dentures?‖
10. ―How often, in the past year, have you been embarrassed because of problems with your
teeth, mouth or dentures?‖
Social disability
11. ―How often, in the past year, have you been irritable with other people because of
problems with your teeth, mouth or dentures?‖
12. ―How often, in the past year, have you had difficulty doing your usual jobs because of
problems with your teeth, mouth or dentures?‖
Handicap
13. ―How often, in the past year, have you felt that life in general was less satisfying
because of problems with your teeth, mouth or dentures?‖
14. ―How often, in the past year, have you been totally unable to function because of
problems with your teeth, mouth or dentures?‖
69
Appendix B: Location of LTC sites sampled in Nova Soctia, Canada
70
Appendix C: Location of community sites sampled in Nova Soctia, Canada
71
Appendix D: Study questionnaire
Dalhousie Oral Health Study
Patient ID code ____________________ Date of Interview ____________________ Interviewer Code ________________ Name of LTC Facility _______________________________ Living situation (circle one): LTC Independent Assisted
Q1 TOHAP_AWC_Q01 Before we begin, can you please provide your year of birth [OPEN]
19 _ _
Q2 If refuse to answer Q1 ask [CLOSED] Is it between
1 1944-1965 2 <1944
Q3 4 Do not ask respondent [OPEN] SEX_Q01 Sex
1 Male 2 Female
Q4 MSWC_Q02 What is your current marital status? [OPEN]
1 Married 2 Living common-law 3 Widowed 4 Separated 5 Divorced 6 Single, never married
25 Refuse to Answer
Q5 TOHAP_ED_Q01-04 What is the highest level of education that you have completed? [OPEN]
1 Lower than Grade 8 2 Grade 9 - 10 3 Grade 11 - 13 4 Completed High School 5 Post-secondary Technical School
72
6 Some college or university 7 Completed college diploma 8 Completed university degree 9 Completed post-graduate degree (M.A., Ph.D.)
25 Refuse to Answer
SOCIODEMOGRAPHIC CHARACTERISTICS
Q6 SDC_Q11 In what country were you born? [OPEN]
1 Canada 12 Netherlands/Holland 2 China 13 Philippines 3 France 14 Poland 4 Germany 15 Portugal 5 Greece 16 United Kingdom 6 Guyana 17 United States 7 Hong Kong 18 Vietnam 8 Hungary 19 Sri Lanka 9 India 20 Other
10 Italy 24 Don't Know 11 Jamaica 25 Refused
Q6.a
SDC_S11_OTHER Other: Please specify
_______________________________________________________________________________
Q7 SDC_Q32 What language do you speak most often at home? [OPEN]
1 English 14 Punjabi 2 French 15 Spanish 3 Arabic 16 Tagalog (Pilipino) 4 Chinese (Mandarin & Cantonese) 17 Ukrainian 5 Cree 18 Vietnamese 6 German 19 Dutch 7 Greek 20 Hindi 8 Hungarian 21 Russian 9 Italian 22 Tamil
10 Korean 23 Other 11 Persian (Farsi) 24 Don't Know 12 Polish 25 Refuse to Answer 13 Portuguese
Q7.a SDC_S32 _OTHER
Other: Please specify
________________________________________________________________________________
73
Q8 TOHAP What languages can you read? [OPEN] INTERVIEWER: Mark all that apply.
1 English 14 Punjabi 2 French 15 Spanish 3 Arabic 16 Tagalog (Pilipino) 4 Chinese (Mandarin & Cantonese) 17 Ukrainian 5 Cree 18 Vietnamese 6 German 19 Dutch 7 Greek 20 Hindi 8 Hungarian 21 Russian 9 Italian 22 Tamil
10 Korean 23 Other 11 Persian (Farsi) 24 Don't Know 12 Polish 25 Refuse to Answer 13 Portuguese
Q8.a TOHAP_OTHER
If other: Please Specify ________________________________________________________________________________
GENERAL HEALTH
This survey deals with various aspects of your health. By health, we mean not only the absence of disease or injury but also physical, mental and social well-being.
Q9 GEN_Q11 In general, would you say your health is: [CLOSED] INTERVIEWER: Read categories to respondent.
1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor
25 Refuse to Answer
Q10 GEN_Q19 Would you rate your quality of life as: [CLOSED]
1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor
25 Refuse to Answer
Q11 GEN_Q13 How satisfied are you with your life in general? [CLOSED] INTERVIEWER: Read categories to respondent.
74
1 Very Satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very Dissatisfied
25 Refuse to Answer
Q12 GEN_Q20 Do you have a regular medical doctor? [OPEN]
1 Yes 2 No
25 Refuse to Answer
ORAL HEALTH
Next, some questions about the health of your mouth, including your teeth or dentures, tongue, gums, lips and jaw joints.
Q13 OHM_Q11 In general, would you say the health of your mouth is: [CLOSED] INTERVIEWER: Read categories to respondent.
1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor
25 Refuse to Answer
Q14 OHM_Q12 How satisfied are you with the appearance of your teeth and/or dentures? [CLOSED]
1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very Dissatisfied
25 Refuse to Answer
Q15 OHIP/SOHAP 8. How often, in the past year, have you had trouble pronouncing any words because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q16 OHIP/SOHAP 9. How often, in the past year, have you felt that your sense of taste has worsened because of problems with your teeth, mouth or dentures? [CLOSED]
75
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q17 4.1.1 OHIP/SOHAP 10. How often, in the past year, have you had painful aching in your mouth? [CLOSED]
1 Very Often 2 Fairly Often
3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q18 OHIP/SOHAP 11. How often, in the past year, have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q19 OHIP/SOHAP 12. How often, in the past year, have you been self conscious because of your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q20 OHIP/SOHAP 13. How often, in the past year, have you felt tense because of your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q21 OHIP/SOHAP 14. How often, in the past year, has your diet been unsatisfactory because of problems with your teeth, mouth or dentures? [CLOSED]
76
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q22 OHIP/SOHAP 15. How often, in the past year, have you had to interrupt meals because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q23 OHIP/SOHAP 16. How often, in the past year, have you found it difficult to relax because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q24 OHIP/SOHAP 17. How often, in the past year, have you been embarrassed because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q25 OHIP/SOHAP 18. How often, in the past year, have you been irritable with other people because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q26 OHIP/SOHAP 19. How often, in the past year, have you had difficulty doing your usual jobs because of problems with your teeth, mouth or dentures? [CLOSED]
77
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q27 OHIP/SOHAP 20. How often, in the past year, have you felt that life in general was less satisfying because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q28 OHIP/SOHAP 21. How often, in the past year, have you been totally unable to function because of problems with your teeth, mouth or dentures? [CLOSED]
1 Very Often 2 Fairly Often 3 Occasionally 4 Hardly Ever 5 Never
24 Don't Know 25 Refuse to Answer
Q29 TOHAP _OHM_N31 Now a few questions about your regular dental care habits. How often do you usually brush your teeth and/or clean your dentures? [OPEN]
1 Per day 2 Per week 3 Per month 4 Per Year 5 Never
24 Don't Know 25 Refuse to Answer
Q29.a TOHAP _OHM_Q31 Enter amount of times only: ________
Q30 OHM_N32 How often do you usually floss your teeth? [OPEN]
1 Per Day 2 Per week 3 Per month 4 Per Year 5 Never 6 Full set of dentures
24 Don't Know 25 Refuse to Answer
78
Q30.a OHM_Q32 Enter amount of times only: ________
Q31 SOHAP_29. Right now, whom do you attend routinely for your dental care? [CLOSED] [Select all that apply.] ?
1 Dentist
2 Dental hygienist
3 Denturist
4 Physician
5 Nobody
6 Other
24 Don't Know
25 Refused
Q32 OHM_Q33 How often do you usually see a dental professional? [CLOSED] INTERVIEWER: Read categories to respondent.
1 More than once a year for check-ups or treatment? 2 About once a year for check-ups or treatment? 3 Less than once a year for check-ups or treatment? 4 Only for emergency care? 5 Never?
24 Don't Know
25 Refuse to Answer
Q33 OHM_Q34 When was the last time you saw a dental professional? [OPEN]
1 Less than 1 year ago
2 1 year to less than 2 years ago
3 2 years to less than 3 years ago
4 3 years to less than 4 years ago
5 4 years to less than 5 years ago
6 5 or more years ago
24 Don't Know
25 Refuse to Answer
Q34 TOHAP In the past 12 months, have you avoided having professional treatment for some or all of your dental/oral problems? [OPEN]
1 Yes 2 No (GO TO Q36)
24 Don’t Know (GO TO Q36) 25 Refuse to Answer (GO TO Q36)
Q35 SOHAP 28 Why have you avoided professional treatment? [OPEN] [Select all that apply]
1 Cannot get an appointment 9 Too busy
2 Do not have dental insurance 10 Don't want to upset my mouth
3 Cannot afford it 11 Cannot be bothered
4 Cannot get to the dentist 12 Too sick to go
5 Previous treatment hasn't helped 13 Not important
6 Treatment is too painful 14 Other
79
7 Too afraid 24 Don’t know
8 Too far to travel 25 Refuse
Q35.a Other reasons (please specify): ___________________________________________________________________________________________
Q36 OHM_Q43 Do you have insurance or a government program that covers all or part of your dental expenses? [OPEN]
1 Yes (GO TO Q37) 2 No (GO TO Q38)
24 Don’t Know (GO TO Q38)
25 Refuse to Answer (GO TO Q38)
Q37 OHM_Q44 What is the name of your insurance program? Is it: [CLOSED] INTERVIEWER: Read categories to respondent. Mark all that apply.
1 an employer-sponsored plan? 2 a provincial program for children or seniors? 3 a private plan? 4 a government program for social service (welfare) clients? 5 a government program for First Nations and Inuit?
25 Refuse to Answer
Q38 How much did you spend on dental care last year? [OPEN]
24 Don’t Know
25 Refuse to Answer
Q38.a Enter Amount Here: ___________________
CHRONIC CONDITIONS
Now I’d like to ask about certain chronic health conditions which you may have. We are interested in “long-term conditions” which are expected to last or have already lasted 6 months or more and
that have been diagnosed by a health professional.
4.2 Q39
CCC_Q22 Do you have arthritis or rheumatism? (Rheumatism or Rheumatic disorder is a non-specific term for medical problems affecting the heart, bones, joints, kidney, skin and lung. Arthritis is a group of conditions involving damage to the joints of the body.) [OPEN]
1 Yes 2 No
24 Don't Know 25 Refuse to answer
Q40 4.2.1 CCC_Q51 Have you ever been diagnosed with diabetes? [OPEN] 1 Yes 2 No (GO TO Q43)
24 Don't Know (GO TO Q43) 25 Refuse to answer (GO TO Q43)
80
Q41 CCC_Q52 Were you diagnosed with: [CLOSED]
1 Type 1 diabetes (insulin dependent)?
2 Type 2 diabetes (non-insulin dependent)? 3 Gestational diabetes (diabetes only when you were pregnant)? (GO TO Q43)
25 Refuse to Answer
Q42 CCC_Q53 How old were you when this was first diagnosed? [OPEN]
______
Q43 CCC_Q61 Do you have heart disease? [OPEN]
1 Yes 2 No
24 Don't Know 25 Refuse to answer
Q44 CCC_Q63 Have you ever been told by a health professional that you have had a heart attack? [OPEN]
1 Yes 2 No
24 Don't Know
25 Refuse to Answer
Q45 CCC_Q72 Have you ever been diagnosed with cancer? [OPEN]
1 Yes 2 No (GO TO Q49)
24 Don't Know (GO TO Q49) 25 Refuse to answer (GO TO Q49)
Q46 CCC_Q71 Do you currently have cancer? [OPEN]
1 Yes (If Q3 =MALE GO TO 48, If Q3 =FEMALE GO TO Q47) 2 No (If Q3 =MALE GO TO Q48, If Q3 =FEMALE GO TO Q47)
24 Don't Know (If Q3=MALE GO TO Q48, If Q3 =FEMALE GO TO Q47) 25 Refuse to Answer (If Q3 =MALE GO TO Q48, If Q3 =FEMALE GO TO Q47)
Q47 CCC_Q74 What type of cancer did/do you have? (FEMALE) [OPEN]
1 Breast 2 Colorectal 3 Skin - Melanoma 4 Skin - Non-melanoma 5 Other - Specify
25 Refuse to Answer
Q47.a CCC_S74_OTHER
Other (please specify): _______________________________________________________________________________________________
Q48 CCC_Q75 What type of cancer did/do you have? (MALE) [OPEN]
81
1 Prostate 2 Colorectal 3 Skin - Melanoma 4 Skin - Non-melanoma 5 Other - Specify
25 Refuse to Answer
Q48.a CCC_S75_OTHER
Other (please specify: ________________________________________________________________________________
Q49 TOHAP_CCC_Q81 Have you ever had a stroke or are you currently suffering from a stroke? [OPEN]
1 Yes 2 No
24 Don't Know 25 Refuse to Answer
MEDICATION USE
Now I’d like to ask a few questions about your use of medications.
Q50 MED_Q100A In the past month, did you take any prescription medications? Prescribed medications could include such things as insulin, nicotine patches and birth control (pills, patches or injections). [OPEN]
1 Yes 2 No (GO TO Q52)
24 Don't Know (GO TO Q52) 25 Refuse to answer (GO TO Q52)
Q51 TOHAP_MED_Q100B How many different prescribed medications did you take? [OPEN]
Don't Know (GO TO Q56)
Refuse to Answer (GO TO Q56)
Q51.a TOHAP_MED_Q100B Enter number of medications taken ____________
Telephone Interviewer: If Q51.a = 1 or more, ask “It would be very helpful if you could bring a list of the names of your prescribed medications with you to your dental exam. “
LTC Interviewer: If Q51.a = 1 or more, ask if they have brought a list of their prescribed medications with them,
- if yes, pass the list along to the dental assistant for entry into the database. - If no, ask if they can remember their medications (name, strength and dose if known), write these
down on a note and pass the list along to the dental assistant for entry into the database.
82
SUN EXPOSURE
The next two questions are about your exposure to the sun. For the next questions, think about a typical weekend or day off from work or school in the summer months.
Q52 SEB_Q12 About how much time each day do you spend in the sun between 11 am and 4 pm? [OPEN]
1 None (GO TO Q54) 2 Less than 30 minutes (GO TO Q54) 3 30 to 59 minutes 4 1 hour to less than 2 hours 5 2 hours to less than 3 hours 6 3 hours to less than 4 hours 7 4 hours to less than 5 hours 8 5 hours
24 Don't Know (GO TO Q54) 25 Refuse to Answer (GO TO Q54)
Q53 SEB_Q13 In the summer months, on a typical weekend or day off, when you are in the sun for 30 minutes or more, how often do you use sunscreen? [CLOSED]
1 Always 2 Often 3 Sometimes 4 Rarely 5 Never
24 Don't Know 25 Refuse to Answer
SMOKING
Now, I am going to ask you about cigarette smoking. By cigarettes, we mean both ready-made cigarettes and ones you roll yourself, excluding cigars, cigarillos, marijuana or pipes.
Q54 SMK_Q12 At the present time, do you smoke cigarettes daily, occasionally or not at all? [CLOSED]
1 Daily 2 Occasionally (GO TO Q56) 3 Not at all (GO TO Q57)
24 Don’t Know (GO TO Q61) 25 Refuse to Answer (GO TO Q61)
Q55 SMK_Q31 How many cigarettes do you smoke each day now? [OPEN]
25 Refuse to Answer (GO TO Q59, THEN Q61)
4.3 Q55.a
Enter Amount _____ (GO TO Q59, THEN Q61)
Q56 SMK_Q41 On the days that you smoke, how many cigarettes do you usually smoke? [OPEN]
83
25 Refuse to Answer
Q56.a Enter Amount _____
Q57 SMK_Q51 Have you ever smoked cigarettes daily? [OPEN]
1 Yes 2 No (If Q54=NOT AT ALL GO TO Q58, Otherwise GO TO Q61)
24 Don’t Know (GO TO Q61) 25 Refuse to Answer (GO TO Q61)
Q58 TOHAP Have you ever smoked cigarettes occasionally? [OPEN] (ASK ONLY IF Q54=NOT AT ALL)
1 Yes 2 No (GO TO Q61)
24 Don’t Know (GO TO Q61) 25 Refuse to Answer (GO TO Q61)
Q59 TOHAP_SMK_Q52 At what age did you begin to smoke cigarettes? [OPEN]
25 Refuse to Answer
Q59.a Enter Age _____
Q60 TOHAP_SMK_Q54 At what age did you stop smoking cigarettes? [OPEN] (ASK ONLY IF Q54=NOT AT ALL)
25 Refuse to Answer
Q60.a Enter Age _____
Q61 SMK_Q60 In the past month, have you smoked cigars or a pipe or used snuff or chewing tobacco? [OPEN]
1 Yes 2 No
24 Don't Know 25 Refuse to Answer
ALCOHOL
Q62 ALC_Q17 Have you ever had a drink of alcohol? [OPEN]
1 Yes 2 No (GO TO Q66)
24 Don’t Know (GO TO Q66) 25 Refuse to Answer (GO TO Q66)
84
Q63 ALC_Q11 During the past 12 months, have you had a drink of beer, wine, liquor or any other alcoholic beverage? [OPEN]
1 Yes 2 No (GO TO Q65)
24 Don't Know (GO TO Q65) 25 Refuse to Answer (GO TO Q65)
Q64 ALC_Q12 During the past 12 months, how often did you drink alcoholic beverages [OPEN]
1 Less than once a month 2 Once a month 3 2 to 3 times a month 4 Once a week 5 2 to 3 times a week 6 4 to 6 times a week 7 Every day
24 Don't Know 25 Refuse to Answer
Q65 ALC_Q18 Did you ever regularly drink more than 12 drinks a week? [OPEN]
1 Yes 2 No
24 Don't Know 25 Refuse to Answer
LABOUR FORCE ACTIVITY
Q66 4.3.1 TOHAP Are you currently employed? [OPEN & CLOSED – YES/NO REQUIRES PROMPTING]
1 Yes – Full Time (GO TO Q68)
2 Yes – Part Time (GO TO Q68)
3 No – Retired
4 No – Unemployed
5 Permanently Unable To Work (GO TO Q68)
24 Don't Know (GO TO Q68)
25 Refuse (GO TO Q68)
Q67 TOHAP Have you performed any sort of work over the past 12 months? (part-time jobs, seasonal work, contract work, self employment, baby-sitting and any other paid work, regardless of the number of hours worked) [OPEN]
1 Yes 2 No
24 Don't Know 25 Refuse to Answer
85
INCOME
Although many health expenses are covered by [provincial/territorial] health insurance, there is still a relationship between health and income. Please be assured that, like all other information
you have provided, these answers will be kept strictly confidential.
Q68 INC_Q11 Thinking about the total income for all household members, from which of the following sources did your household receive any income in the past 12 months? INTERVIEWER: Read categories to respondent. Mark all that apply. [CLOSED]
1 Wages and salaries 2 Income from self-employment 3 Dividends and interest (e.g., on bonds, savings) 4 Employment insurance 5 Worker’s compensation 6 Benefits from Canada or Quebec Pension Plan 7 Retirement pensions, superannuation and annuities 8 Old Age Security and Guaranteed Income Supplement 9 Child Tax Benefit
10 Provincial or municipal social assistance or welfare 11 Child support 12 Alimony 13 Other (e.g., rental income, scholarships) 14 None (GO TO END) 24 Don't Know (GO TO END) 25 Refuse to Answer (GO TO END)
4.3.1.1 If more than one source, go to Q69 otherwise go to Q70
Q69 INC_Q12 What was the main source of income? [OPEN BUT PROMPT IF NEED BE]
1 Wages and salaries 2 Income from self-employment 3 Dividends and interest (e.g., on bonds, savings) 4 Employment insurance 5 Worker’s compensation 6 Benefits from Canada or Quebec Pension Plan 7 Retirement pensions, superannuation and annuities 8 Old Age Security and Guaranteed Income Supplement 9 Child Tax Benefit
10 Provincial or municipal social assistance or welfare 11 Child support 12 Alimony 13 Other (e.g., rental income, scholarships) 24 Don't Know 25 Refuse to Answer
86
Q71 TOHAP_INC_Q22-28 Was the total household income from all sources: INTERVIEWER: Read categories to respondent. [CLOSED]
1 Less than $10,000 2 $10,000 to less than $20,000 3 $20,000 to less than $30,000 4 $30,000 to less than $40,000 5 $40,000 to less than $50,000 6 $50,000 to less than $60,000 7 $60,000 to less than $80,000 8 $80,000 to less than $100,000 9 $100,000 or more
24 Don't Know 25 Refuse to Answer
Q70 TOHAP_INC_Q38 Was your total personal income: INTERVIEWER: Read categories to respondent. [CLOSED]
1 Less than $50,000 6 $50,000 to less than $60,000 7 $60,000 to less than $80,000 8 $80,000 to less than $100,000 9 $100,000 or more
24 Don't Know 25 Refuse to Answer