Oral health status of a population ofcommunity-dwelling older Canadians

D. Galan', Michael Brecx-and M. Robin Heath''Faculty of Dentistry, University of Manitoba, Winnipeg, Canada;-Z.M.K., University of Tubingen,Germany: ^Department of Prosthetic Dentistry. The London Hospital Medical College, UK.

A sample oi I7U responsive residents of seniors housing centres in Winnipeg. Canada, werestudied, (>65 years, mean 82 years), with the objectives of relating their dental state lo theirperception of need and uptake of service. Only 6% rated their oral health as poor, 46%reported a dental visit within the previous year and 68% felt they needed dental treatment. Alack of perceived need (88%) was the primary reasons why dental care was not sought morefrequently. Hygiene practices revealed that only 7% brushed <1 time/day, 60% never llossed,14% cleaned their dentures <1 time/day, and 42% slept with their dentures. Dental historiesshowed that examination (94%-), prosthodontic treatment (76%), and restorative services (65%)were the most commonly sought treatments. Perceived dental needs included prosthodontictreatment (39%), periodontal/ prophylactic treatment (10%), restorative treatment (9%) andpain relief (9%). Study subjects had 2.8 decayed teeth, a DMFT of 25.1, and a Root CariesIndex of 38%. CPITN scores of 3 or 4 in at least one sextant were found in 80% of subjects. Ofthe 41% edentulous, all wore complete dentures but 15% of complete upper dentures and 51%of complete lower dentures fitted poorly. Of the partial dentures, 20% fitted poorly. Soft tissueanomalies were seen in 67% of subjects and 47% had TMJ anomalies. Overall. 77% ofedentulous subjects and all dentate subjects required some dental treatment even though 46%had seen a dentist within the preceding year. It is concluded that appropriate management ofsuch people needs further attention.

Key words: tnobile. responsive elderly, Ganada. dental state, perceived needs, serviceutilisation

Gerodontology 1995 12(1):

Introduction

As in most industrial countries, the Canadian populationis ageing with individuals >65 years of age likely tocomprise 3.9 million (12.0%) of the total Canadianpopulation by the year 2001'. In Manitoba, those 65 yearsof age (11.9%) is greater than the rest of Canada (I0.17o),and will continue to increa.se at a higher rate. Projectionsfor the year 2001 suggest that Manitoba's population ofolder adults will number 150,000 and constituteover 13%of the entire population.

Coupled with this increase in ageing, the prevalenceof edentulism in Canada appears to be declining-. This,in conjunction with changes in attitudes towards oralhealth amongst older adults\ should produce an increasedneed and demand for dental services. Oral disorders also

have a significant impact on the social and psychologicalwell-being of the elderly*.

Although interest and a greater understanding ofthe dental needs of older adults has increased amongstthe dental profession in Canada, surveys have shownmuch dental need across the population and that thereis a wide range of oral health status and dentaltreatment need required. There is also a wide rangeof compliance and the best cost/benefit from treatmentwill usually be for more responsive patients.

Aims and Objectives

It therefore appeared valuable to examine a sampleof old but independent people who would respond

©The Gerodontology Association 1995Volume 12. No. I

42 Galan cf <//.

positively to an invitation to bo examined. Theobjectives being to relate their dental state to theirperception of need and uptake of service.

Matenais and Methods

Stud) pmtieipants were all residents ot two independ-ent seniors' housing centres. A census survey formatwas used to recruit participants, with a letter sent toall 800 residents inviting them to participate in thestudy. Only 171 respondents >65 years of ageprovided written eonsent, thus establishing a selectedsample of responsive independent elderly people.

All participants were interviewed using a surveyquestionnaire and examined in a dental surgery in oneeentre and in a temporary surgery with portableequipment in the other. A standardised dentalexamination protocol was used. The surveyquestionnaire contained questions about dental serviceutilisation, dental history, a self-rating of oral healthand oral hygiene practices. Oral examinations wereconducted by the principle investigator (DG) using afront-surface mirror, a #5 caries explorer and aCommunity Periodontal Index of Treatment Needs(CPITN) periodontal probe. No intra-oral radiographswere taken.

World Health Organisation standards were usedto assess all teeth for the presence of decay by bothvisual and tactile criteria. A Root Caries Index (RCI)value was also determmed following the formulaestablished by Katz^-^

Plaque level was measured using the VisiblePlaque Index (VPI)-, and periodontal health evaluatedby means of the Gingival Bleeding Index (GBI)"* andCPITN^"'. VPI and GBI measurements were pooledand divided into six categories (0-19% level. 20-39%level, 40-55% level. 60-79% level, 80-99%^ or 100%-level), with the number of individuals within eachcategory expressed as a percentage of the sampleinvestigated. A Calculus Index, supplementing theCPITN. determined calculus quantity {slight - onlysupragingival calculus; moderate - supra- andsubgingival calculus; or heavy - supra- andsubgingival calculus joining teeth or present onocclusal tooth surfaces) and calculus location(localised - <3 sextants; generalised - >3 sextants).Gingival recession, measured on the vestibular andlingual surfaces of each tooth from the gingival crestto the cemento-enamel junction, was categorised as1-3 mm, 4-6 mm or 7 mm with a tooth placed in theappropriate category based upon the worst measuredfinding. Tooth mobility was classified as Class 1 (> 1mm horizontal mobility, but < 2 mm). Class 2 (2 mmhorizontal mobility), or Class 3 (> 2 mm horizontal

mobility or apical depression or both). Teeth withoutiiuihility were not categorised.

Prevalence of edentulism, presence and type ofdentures, and fit of these prostheses were documented.Dentures were assessed for defects and denture basequality aeeording to defined parameters". Dentureretention and stability were judged as good, averageor poor according to established criteria'". Occlusionwas noted as satisfactory or unsatisfactory usingpreviously described criteria".

Soft tissues of the intra- and extra oral structures wereexamined for the presence of anomalies. Examinationincluded a digital palpation of sub- mandibular, sublingualand cervical lymph nodes, an assessment of the lips,maxillary and mandibular sulci. retromolar areas,maxillary and mandibular alveolar mucosa, the palate,fioor of the mouth and tongue. Visual inspection for thepresence of moist oral tissues was conducted and subjectswere asked about chronic symptoms of a dry mouth.Anomalies present in any of these structures wererecorded. Temporo-mandibular joints (TMJ) were assessedusing a digital, auditory and observational technique. Painduring palpation, lateral deviations, opening limitationsand audible clicks or crepitus sounds were documented.

Based upon these clinical findings, dentaltreatment needs were subdivided into categories: notreatment, emergency treatment, prophylaxis only,periodontal treatment, restorative treatment,extractions, other oral surgery, fixed or removableprosthetics, endodontic therapy, or other treatment(oral pathology consultation, TMJ therapy, etc.).

Results

Anamnestic data

The 170 older adults examined had a mean age of81.8 ± 6.3 years {range 65-97 years) with a sexdistribution of 77% female and 23% male. For bothmales and females, 66% of the subjects werebetween 80-89 years and 3.57o <70 years. Most studysubjects lived alone {11%) and were long timeWinnipeg residents (mean 56.1 ± 25.7 years).Educationally. 60% had a high school education and17% some post-secondary education. Over 2/3 ofthese subjects (72%) had an annual income $20,000CDN or less and were receiving income supplements,however they felt their income either very well (29%)or adequately (65%) met their needs.

Dental attendance

All individuals had been to a dentist at some point intheir lives, the mean time since the last visit was 4.8± 7.3 years (range 0.5-48 years). Dental visit

Gerodontology

Oral heallli status ol older Canadians 43

UpperMolar

UpperBicuspid

UpperAnterior

LowerMolar

Lower

Bicuspid

LowerAnterior

Figure /. Caries prevalence: ihc nutnher oJ iccih tn lhe sample aj IVl denlale .subjects affected by caries by lucalion in the nioiiih.

frequency depended upon dentition status; 46% ofthose dentate reported a visit within the previous year,while less frequent visits of >6 years (by 27% of thesample) was normal for edentulous subjects. Why carewas not sought more frequently was primarily due toa lack of perceived need (88%). and rarely due to fear(3.8%). cost of dental care (2.6%) or accessibilityproblems (1.9%). When asked, only 34% said theavailability of free dental care would increase theirdental visitation.

Self-rated oral health and hygiene

Most self-rated their oral health as either good (52%)or average (42%). Dental histories showed thatexaminations (9490), prosthodontic treatment (76%)and restorative services (65%) were the mostcommonly sought treatments. Amongst the 68% thatexpressed a perceived dental need, the most commonwere prosthodontic treatment (39%). periodontal/prophylaxis treatment (10%), restorative treatment(9%) and pain relief (9.4%); 18% felt that no treat-ment was required.

Evaluation of oral and denture hygiene practicesrevealed that 60% never tlossed. and 6.8% brushedtheir teeth and 14%- cleaned their dentures less thanonce a day. Dentures were mostly cleaned by acombined brushing and soaking method (70%). Thirtypercent of those <75 years used mouthwashes daily,while mouthwash was never used by 34% of those>75 years.

Dental state

Forty percent ofthe sample were edentulous (females43%', males 33%), with most of the edentulous foreither sex aged between 80-89 years. Mean numberof years of maxillary edentulism was 32.5 ± 17.0 yeat sand 33.0 ± 6.9 years in the mandible (range for both:

2 to 73 years). One third of all subjects (females =males) had teeth only in the mandible. The rest ofthedebtate sample with at least one tooth in both archesincluded six females >90 years of age.

For the 101 dentate subjects, the mean number ofremaining teeth was 15.5 ± 8.1 (Table 1). Tooth losswas mainly due to dental caries {11%). while only20% was due to periodontal disease. The DMFT valueof 25.1 ± 5.1 was high because of the large numberof missing teeth, with mandibular posterior teeth andall the maxillar>' teeth more likely to be missing.

Dental pathology

Coronal caries, root caries or both were present in76% of dentate subjects, with 41% having onlycoronal caries and 22% with only root caries. Themean number of decayed crowns and decayed rootsper subject was 1.5 ± 1.7 and 1.3 ± 2.0 respectively(Table 1). Most of these lesions (80%) occurred onteeth that had been previously restored. Caries wasslightly more prevalent in anterior teeth (Figure 1)

Table 1. Dentition status and caries scores for 101 dentateindividuals

Mean number of Teeth ±SD per subject

Total number of teeth 15.maxillary areh 6.mandihular arch 9

Decayed teeth 2decayed crowns 1decayed roots 1

Missing teeth 16Filled teeth 6Decayed and filled iceth 8Decayed, missing & filled teeth DMFT)25Reeurrent decay 1Root caries index (RCl) 38

5±8.14+5.3.3±3.7.8±3.O.5±1.7.3±2.0.3±8.O.I±5.1.9±8.I.1±5.1.I±1.6

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44 GaUiM ,7 .;/,

100

Upper

Molar

UpperBicuspid

Upper

Anterior

LowerMolar

Lower

Bicuspid

LowerAnterior

Figure 2. Restorations: the number of restored teeth in the sample of 10J dentate .subjects by type of restoration and by location inthe mouth.

Table 2. Percentages of 100 dentate individuals* accordingto the various pooled scores of either the Visible PlaqueIndex (VPI) or the Gingival Bleeding Index (GRT).

VPI or GBl Dentate Individuals Dentate IndividualsIndex Levels with VPI with GBI

0-19%20-39%40-59%60-79%80-99%

11.0%12.0%30.9%22.0%

5.0%

49.0%'22.0%12.0%4.0%'0.0%

One individual did not have a periodontal assessmentdue to a medical condition which prevented periodontaltissue manipulation without prior prophylactic antibioticcoverage.

and in those utider 80 years because more teethwere retained. RCI value for subjects with gingivalrecession was 38% (females 33%, males 447o). Themean number of filled teeth was 6.1 ± 5 . 1 , withcoronal portions of the maxillary and mandibularmolars, and mandibular bicuspids more likely to betilled (Figure 2).

VPI analyses revealed that 58% of teeth in dentatesubjects were covered with plaque, with 19% havinga VPI of 100% (Table 2). For GBI. 31% of teeth bledand 13% had a GBI of 100%. The Calculus Indexrevealed light and localised calculus deposit in 53%of the sample, while another 7.7% had no deposits.Gingival recessioti of 1-3 mm was present on 7.3teeth/individual and 4-6 mm of recession on a further1.9 teeth. Class I tooth mobility was identified on 1.9teeth/subject. Periodontal pocket depths of 377sextants (1577 teeth) revealed that most CPITNreadings for all sextants were betweeti I and 3(aggregate score Code 1-3 = 72%). However. 80.0%'

of all subjects and 56% of all sextants had at leastone tooth with shallow pockets (code 3) or deeppockets (code 4) (Table 3). Only 9.2% of subjectsand 2.0% of sextants were disease-free (code 0).

Denture state

Eighty percent of edentulous or partially dentateindividuals wore complete or partial dentures and,throughout their life-time, have had an average of 3.8±4.3 setsof dentures. All edentulous subjects wore acomplete upper denture (CUD) and all but 2 indi-viduals wore a complete lower denture (CLD). Meandenture age was 11.6 ± 9.9 years, with 73% of thesedentures being made by a dentist. Poor retention andstability was presetit in 15%' of CUDs, 51% of CLDsand 20% of partial upper and lower dentures (Table4). Denture occlusion was generally satisfactoryfor most dentures but 32% had defects, primarilymissing or worn teeth, and 20% had denture materialdeficiencies, primarily crazing or porosities (6.0%)and temporary or deficient relines (14%). Poordenture hygiene was present in 79% of dentures.Finally, 42% of the sample wore their dentures whenthey slept, which in addition to poor denture hygiene,probably influenced the presence of pathologicallesions on the denture bearing tissues.

Oral pathology

Soft tissue anomalies were noted in 67% of thesubjects (59% rnale, 70% female). Alveolar bone(41%) and alveolar mucosal (40%) atiomalies werethe most common, particularly hyperplastic ridges,denture stomatitis and severe alveolar bone resorption.With the exception of the denture bearing tissues, theother soft tissues were essentially within nortiiallimits in their appearance. TMJ anotiialies were

Gerodontology

hcallh status oi older Canadians 45

Tahle 3. Pcriodonlnl pocket depths (CPITN) Un I(H) ik-nUik- iiuiividiuils' and 377 roolh sextants

No. of SextantsCode 0Code ICode 2Code 3Code 4

No. of Subjects100

No. of Subjects100

Sextant IMaxillaryRight

513.9

17.65.9

43.129.4

CodeO1.8

Sextant IIMaxillaryCentred13-23

6513.830.84.6

33.816.9

Mean 1

Code 11.8

Perce

Sextant III

Maxillary

Left24-28

449.1

20.50.0

43.227.3

ut of Sextants

Sc\t(Uit IVMauilihularLeft38-33

5815.527.617.232.86.9

Sextant VMainlihularCentral33-43

942.14 3

48.929.8149

Number of sextants in each code

Code 21.5

Code 32,1

Code 41.6

Sextant VIMandihuUirRight44-48

6510.824.6

7,738.518.5

Percent dentate individuals with their highest score in each code

CodeO2.0

Code 13.0

Code 215.0

Code 336.0

Code 444,0

CompositeScorePercent

7<119.2

20.914136.919.0

Code 0 = periodontium clinically healthyCode 1 = no pockets, no calculus, no overhangs on fillings, but gingival bleeding occurs upon gentle probingCode 2 = no pockets, but supra- or subgingival calculus or othel retentions arc presentCode 3 = pathological pockets 4 or 5 mm deepCode 4 = pathological pockets 6 mm or deeper

'One individual was not examined due to a medical condition which prevented periodontal tissue manipulation withoutprior prophylactic antibiotic coverage.

Table 4. Denture status assement for the quality of denture fit and the presence of ID labels for 170 complete dentureprostheses and 59 partial denture prostheses

% Complete maxillaiydentures (N= 103)

RetentionGood 40.8Average 44.6Poor 14.6

StabilityGood 39.8Average 48.5Poor 11 7

'•/f Complete nuuulibuhirdentures (N=67)

25.423.950.7

25.423.950.7

'/c Partial iihixitlan'dentures (N=25)

RetentionGoodAveragePoor

StabilityGoodAveragePoor

60.020.020.0

64.016.020.0

% Partial mandibulardentures (N=34)

52.923.523.5

52.923.523.5

present in 47% of subjects (33% male, 50% female).Joint sounds were present in 35% of the subjects (12%>crepitus, 23% clicking), with 22% revealing limitedjaw movement.

Treatment needs

Overall, all dentate subjects and 89% of edentuloussubjects required dental treatment (Table 5).Emergency treatment for the management of oralinfections or biopsies was needed by 15% of dentatesubjects and 52% of those edentulous. Amongst thedentate group, prophylaxis or periodontal treatment

(as defined by CPITN measurements) was needed for95% of subjects, with restorative treatment for 79%.For edentulous subjects, 77% needed prosthodonticCtire, primarily relines or repairs of existing dentures;few new prostheses were required. No treatment wasneeded for 10% of subjects (all edentulous).

Discussion

The self- selection of these subjects, by their positiveresponse to the invitation to participate, provides asample older independent people who represent an

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Table 5. C'linifiillv ilotiiial hv;;lnk-

No IrealmcnlF.niergency irealnieniProphylaxis onlyPeriodonlal treatmentExtractionsOther oral surgeryRestorative trcatmenlEndodontic treatmentFixed prosthodonticsRenunahle prosthodonticsOther

Edentate Subjects (n = 69)

No treatmentEmergency treatmentOther oral surgeryRemovable prosthodonticsOther

0%14.9%2.0%

93.1%28.7%

4.0%79.2%

4.0%8.9%

56.4%4.1%

10.1%52.2%32.3%76.8%

5.S%

interesting sector of the population. They were al!residents in senior's housing centres and thusindependent, not negative towards dental care andmobile enough to get to a dental otTice despite themean age of 82 years. A number of factors will haveaffected these subjects decision tojoin this study butfor most of them a positive attitude to dentistry isassumed, indeed only 4% expressed any fear ofdentistr>'. For eftective dental care, patient respon-siveness is essential and it is therefore appropriate toconsider the dental state of such a sample separatelyfrom those whose compliance is likely to be poorer.

Anamnestic data of this study sample indicatedthe relative homogeneity ofthe subjeets. Most wereof a similar age. independent, had an equivalent levelof education, received a low annual income, livedalone, and were long-time Winnipeg residents oftenspending much of their adult life in the samecommunity.

Almost half of the seniors in the present studyvisited a dentist in the past year, while 60% had seena dentist within the previous 2 years. Other Canadianstudies report a similar number of dental visits (52-70%) within the past 1-2 years"''"'"'\ while earlierstudies show a lower visitation rate (30%)'^ -'.Differences in these utili.sation rates may relate to thenumber of edentulous subjects being assessed.Dentition status has been found to be a principaldeterminant of dental service utilisation with dentateindividuals visiting the dentist at a rate 3 to 5 timeshigher than edentulous individuals-'**. Otherdetermining factors include low perceived dental needand increased age, being dentate and male, and beingdentate with a low incomc"'•'^ Some of these

relalitmships were also idenlilled in the present study.Both Leake et (z/." and Slade et tv/."'mentioned

that elderly persons voiced support for free nationaldental insurance coverage and the availability of freedental check-ups. Although subjects in the presentstudy were not asked about these specific items, whenasked if the availability of free dental care wouldincrease their utilisation only 34% respondedpositively. This llnding is lower than that found inAlberta where 45% of those eligible for thegovernment-sponsored premium-free comprehensivedental care utilised these services".

Reasons why dental eare was not sought morefrequently are generally complex and involve manyfactors: differences between perceived and real need,lack of mobility and accessibility to eare. fear ofdentistry and high cost-\ In the present study, lack ofperceived need was the principle reason (88%) whydental care was not sought more frequently. Fearseemed to have little intluence on non-attendance. Ageneral trend also suggests that younger, moreindependent older people have a higher rate of dentalvisits because they are better educated, and place agreater value on oral health and preventive dental care,while those JS5+ years tend lo have a lower level ofeducation and hence fail to recognise the need forroutine dental care'"'"--\ Lewis and Thompson-^^however found that in 1991-92, only 60% of those70-74 years utilised the Alberta Universal Dental Planfor the elderly in the previous 5+years and just under50% of the 80-84 year olds had done so in theprevious 8+ years. These finding suggest that manyelderly do use dental services once dental access hasbeen achieved (with subsidised dental eare costs).However, the caries prevalenee in this study suggeststhat the common perceptions of "How often" is notoften enough.

Generally, the percentage of total edentulism inolder populations has often been used as an indicatorof dental health'"*, and in Canada this percentage isdeclining'-^ Amongst independently-living elderly,edentulism has been reported in 24-55% of thepopulation-"-''^'-'-^--^^ The only exception was the72% edentulism level found in a Quebec study-*̂ -̂ '.In the present study sample, the 41 % edentulism levelwas within previously reported levels.

While Canadian edentuiism rates are Jeclining,those that are edentulous often have problems withexisting prostheses. Canadian studies havedemonstrated that between 31 and 80% of edentuloussubjects have inadequate denture prostheses'^-'*-'''"'-'.In the present study, 51% of complete lower dentureswere poorly fitting which is consistent with theseearlier studies. By contrast, only 15% of completeupper dentures and 20% of partial dentures were

Gerodontology

Oral hcullh status of older Canadians 47

inadequate. Whether prostheses age or quiility ofptosthcses influenced this difference is unkn<iwn.

The number of teeth reiiiaiiiing (15.5) in thedeiiiate sample was also consistent with otherindependently-living Canadian elderly populations{12.1-18.0)--''-* "••-'•-". The only exceptions are studiesby Kandelman ct (//.'- and Galan et cil.^" where < 10teeth remained, Kandelman ct al.^- thought that thelow number of remaining teeth was related to the moredependant type of elderly person tbey examined, whileGalan es al.^'' felt that a decreased access to dentalcare, previous earies experienee. poor oral hygienehabits and a high prevalence of periodontal diseasewere cotitribuling factors.

Soft tissue anomalies (67%) were within butnear tbe upper range of other Canadian studies(13-797P)-^'-' |(V "̂.̂ «.3|'.-*-.-̂ -'. AS in those other studies,most of the anomalies described were denture-related,ranging up to 90% of all anomalies identified'^Common lesions included hypeiplastic ridges, denturestomatitis and severe alveolar bone resorption,primarily caused by inadequately fitting dentures,poor denture hygiene and continuous use of dentures,which have also been previously reported"'*^.

Reasons for the frequent occurrence of TVIJproblems in the present study could not be determined,although subject age and the prevalence of arthriticconditions may be influencing factors. In a study thatevaluated TMJ problems in Inuit elders'", the frequentoccurrence ofmandibular deviations and joint clickingrelated to the level of total edentulism or only partialdentitions without adequate prosthetic replacements,and to the dried and frozen meat consumed in theirdiet. Reports of TMJ pain (6%) in this sample weresimilar to the 57( found by Leake et al.^^ and Slade etal.^*\ but understandably lower than the 8% found inCanadian Inuit elders-''.

When assessing treatment needs, 90% ofedentulous and all the dentate subjects in the presentinvestigation required dental treatment, which is ratherhigher than other studies (67-81%)^'-''^-^". In thepresent investigation, dentate subjects requiredtreatment mainly due to the high levels of periodontaldisease. The greater need for periodontal servicescoincides with the fmdings of Thompson and Lewis"

where periodontal treatment provision increaseddramatically from 1978-79 (3% of lotal services) to1991-92 (22% of total services) as more teeth werebeing retained. For edentulous subjects, removableprosthodontic treatment (11%) was the mainrequiretnent. Although the requirements were greaterthan three other studies (45-70%)'-"-", anotherinvestigation of Winnipeg seniors" found similarlevels (75%) of prosthodontic treatment need. Thedenture treatments required in the present study wereunderstandable due to the age of the dentures beingused. Dentures of a similar or greater age seen bySimard et ai^^ influenced the high demand forprosthodontic treatments (70%) in that study. Therelationship between denturist-made dentures and thehigh need for prosthodontic treatment requires furtherinvestigation.

Overall, it is surprising that high rates of dentaltreatment need exist alongside high rates of dentalcare utilisation. This finding has also been found byothers'*"'^"'"". Results from the present study alsosuggest that dental visits may have consisted ofexarninations only, with no follow-up visits to havedental treatment provided. It would be prudent toinvestigate why subjects had visited the dentist in theprevious year and what type of treatment was received.

Conclusions

Many of the older adults in this sample appeared tovalue their dental health to the extent that they soughtregular dental care.. However, the oral health indicesindicated that there was significant dental disease andtreatment need arnongst this sample of older adults.Overal, 77% of edentulous sujects and all dentatesubjects required some dental treatment. Despite this,88%' were not concious of any need for treatmenteven though half had attended a dentist within thepreceding year.

It is concluded that appropriate management of suchpeople needs further careful consideration. Healthpromtion and prevention strategies should be devisedand implemented to redueed the ineremental diseasewhich contributes to the poor overall dental health.

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Address for correspondence: Dr. D. Galan, Faculty of Dentistry, University of Maniboa, 780 Bannatyne Avenye, Winni-

peg. Manitoba, Canada R3E 0W2

Acknowledgements: This study was funded by the Manitoba Medical Service Foundation. The authors wish to thank

Mary Cheang, Biostatistics Consulting Unit, Faculty of Medicine, University of Manitoba for assistance with the statisti-

cal analyses.

Gerodontology