The 2007–09 Canadian Health Measures Survey, in accordance with Statistics Canada, released data regarding the oral health status and treatment needs of elderly Canadians, but did not do so at the provincial level. 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, but they also provide important insight into the oral health-related quality of life of these individuals.
The most interesting finding of this study was regarding the comparison of oral health impacts on pre-seniors and seniors. It was found that pre-seniors living in the community reported more oral health impacts than seniors even though the oral health of pre-seniors was better than that of seniors. This reinforces the notion that individual expectations and experiences can greatly impact ones satisfaction or dissatisfaction with their oral health. For example, one who experiences poor health but has low expectations may not perceive their health to have a significant impact on his/her life. Seniors living within the community may not feel as though oral health has a huge impact on their lives 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. 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. Locker and Gibson’s (2005) study of community living individuals over the age of 50 reported that 16.5% of those who rated their oral health as either excellent, very good, or good were dissatisfied with their oral health. Moreover, 50.8% of participants who rated their oral health as fair or poor reported that they were satisfied with mouth, teeth or gums.
In addition, the frames of reference on which people base their oral health can naturally range depending on a host of variables. While some compare themselves to others who are close in age, others might use their physical or emotional state to assess their oral health. Some people who have, or perceive themselves as having, poor oral health may actually be satisfied with the state of their oral health[12, 24]. Sprangers and Schwartz (1999) explain this phenomenon through the process of response shift. This is when changes in internal standards, values and meanings of health contribute to the acceptance of an individual’s illness or disability. As individuals age, they are more likely to consider minor or even severe oral health problems as insignificant at this point in their lives. The theory of response shift may explain why community dwelling seniors, and the elderly population in general, may report fewer impacts in certain dimensions. As these individuals age, they come to accept that their health is deteriorating and they may consider oral health problems as less significant. Consequently, these oral health problems take a backseat to general health problems. 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 ones cognitive and communicative skills, cause barriers in identifying treatments needs for these residents.
In the study completed by Locker and Quinonez 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. In this national study an older population of community dwellers reported 1.2% more impacts than a younger population of community dwellers. Despite the slight difference in age groups, our results show that among those living within the community, pre-seniors reported a 28.8% prevalence rate of oral impacts, whereas seniors reported a prevalence rate of 22.0%.
Another important finding of our study indicates that approximately one in four pre-seniors and seniors report at least one or more impacts of their oral health on the quality of life ‘fairly’ or ‘very often’. This is slightly higher than a national study of adults aged 55 years and older where the finding was one in five (19.5%). The Yukon, Nunavut and Northwest Territories, which make up 0.3% of the Canadian population, were not included in that study. It is evident that no matter where you live in Canada, people in your community are going to report having oral impacts. But, it is important to note that older samples and edentulous samples will report having more OHRQoL impacts.
Logistic regression models indicate that both socio-demographic factors and self-perceived oral health can have an effect on the prevalence of impacts. The findings that pre-seniors and seniors in rural areas have the poorest OHRQoL suggest that a decreased access to dental care may be affecting their oral health and OHRQoL. Further findings show that elderly residents living in the community visit the dentist significantly less often if they live in rural areas as opposed to urban areas. Results indicate that 75.4% of Nova Scotia residents aged 45 and older who live 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”. 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. The reliance of many seniors on others for help may also limit their ability to receive dental 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.
Although many health economists believe that government funding 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 because it is generally less expensive to prevent disease than cure it. A large percentage of the Nova Scotian elderly population has a high school education or less. This is especially troubling because education is a social determinant of health and education is also highly related to health literacy.
Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”. Health literacy skills are essential in the maintenance of quality of life for the elderly population. It has also been shown to be an important contributor to both general and oral health. As individuals age, health literacy also becomes an important tool to help take or administer medications appropriately.
Although our study, in addition to other similar studies, have identified potential correlates of health literacy, few studies have attempted to recognize educational and learning pathways that increase health literacy skills throughout ones life. The development and maintenance of health literacy skills throughout ones life can be accomplished by the use of adult education, seminars, self-study, internet use, library use, daily reading and engagement in social networks. A study found that practicing literacy at home by methods such as reading books, magazines and newspapers, had a stronger effect on ones health literacy than educational attainment. These practices can be maintained throughout ones life and will maintain and increase ones literacy in a relatively inexpensive manner. In addition, using the internet or computer to learn was found to be one of the strongest predictors of adequate health literacy.
Another issue that must be addressed is the current level of communication between dental care providers and their patients, which is important for the elderly population. Effective communication is critical for dentists and hygienists in improving the oral health literacy of their patients. Several findings suggest that the communication techniques used by dentists may not be effectively accommodating the literacy skills of certain patients. One technique among others that has been proven to be effective in increasing the health literacy of patients is the teach-back method; therefore it is important that a set of communications guidelines for practicing dentists be developed.
While some studies question whether literacy is really a problem in the context of health care, and suggest a need for more Canadian research in this area, education and health literacy can improve access to care for Canadian seniors and the general population by focusing on health, oral health, and quality of life issues. Education that focuses and raises awareness on how oral health enhances self-image and social interactions can also positively affect attitudes towards care.
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. An increase in educational resources and training by dentists and dental hygienists can be essential in developing proper oral health care skills and routines for seniors, LTC nursing staff, and family members. Education is also necessary so that they can provide care in a productive, cost-effective and timely manner.
The binary logistic regression model also indicated that for those living in the community, people with oral pain were 1.87 times more likely to report impacts, and those with fair or poor perceived mouth health were 2.19 times more likely to report impacts. These two 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. Similarly, those with dissatisfaction with the appearance of their teeth and/or dentures were 5.16 times more likely to report impacts ‘fairly often’ or ‘very often’. This readdresses the theme of how a complication with ones teeth and/or dentures can have a significant impact on oral health-related quality of life. Dissatisfaction with the appearance of 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 trouble with teeth, mouth or dentures was one of the highest scoring items on the OHIP-14.
Moreover, LTC residents with a low education level may be a group at risk in terms of greater impacts on their OHRQoL. LTC residents have poorer indicators of socioeconomic status including household income and dental insurance. Since dental coverage is not covered by the Canadian healthcare system, out of pocket costs may deter people from seeking dental care or accepting recommended dental care when visiting the dentist. The Canadian Health Measures Survey reported that as Canadians age they are less likely to have dental insurance. In addition, being born outside of Canada, annual income and level of education are also directly related to having dental insurance. 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. This study confirms these findings in the NS population as 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.
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 15% did not graduate from high school. In addition, 32% of adults aged 55 to 64 years did not have a high school diploma. 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[38, 39]. Regardless of age, people with low education levels have more disabilities and chronic illnesses. People with a higher educational background tend to embrace positive health practices and have access to healthier physical environments.
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 health of Canadians.
In addition to a high school education, LTC residents with fair or poor perceived mouth health were 9.49 times more likely to report impacts. LTC residents have poor oral hygiene and limited access to routine dental care. It has been shown 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. Living in an LTC facility is a barrier to treatment in and of itself. Therefore it is imperative that dental programs be developed in order to increase access to dental care for seniors in LTC, by providing transportation or by bringing oral care providers and dental equipment into the facilities.