Retention of natural teeth among older adults—United States, 2002

Retention of natural teeth among older adults—United States, 2002 – Public Health and Aging

During the past several decades, the percentage of older adults who have retained their natural teeth has increased steadily (I). This trend is expected to continue, resulting in improved oral function and quality of life (2). To estimate the prevalences of tooth retention and total tooth loss in 2002 among adults aged [greater than or equal to] 65 years, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of that analysis, which indicated that in 26 (52%) states, more than half of older adults reported having most (i.e., losing five or fewer) of their natural teeth. However, rates varied substantially among states and by selected characteristics. With tooth retention, older adults remain at risk for dental caries (i.e., tooth decay) and periodontal disease. To help adults maintain healthy teeth for life, community-based strategies should promote healthy behaviors, optimal use of fluoride, timely examinations and clinical services, and increased research into preventing oral diseases and promoting oral health among adults (3,4).

BRFSS is a state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. civilian population aged [greater than or equal to] 18 years, administered in all 50 states, the District of Columbia, and three U.S. territories (Guam, Puerto Rico, and the U.S. Virgin Islands). In 2002, the median response rate was 58.6%. In 1999, oral health questions were added to the core interview of the survey to improve surveillance of oral health among older adults at the state level. In 2002, respondents were asked how many of their permanent teeth were removed because of tooth decay or gum disease. Of the 50,635 survey participants aged [greater than or equal to] 65 years who were asked this question, 48,866 (96%) responded; nonresponders were excluded from this analysis. State-specific estimates were age-adjusted to the 2000 standard U.S. population. A complete adult dentition is made up of 28-32 permanent teeth; those persons who reported losing five or fewer teeth were considered to have most of their teeth.

In 26 states, >50% of older adults reported having most of their teeth (Table 1). Estimates ranged from 27% in West Virginia to 64% in Utah. In three states (California, Colorado, and Utah), >60% had retained most of their teeth, and in five states and territories (Kentucky, Mississippi, West Virginia, Puerto Rico, and the U.S. Virgin Islands), <40% had done so. The prevalence of edentate persons (i.e., those who have lost all their natural teeth) ranged from 13% in Hawaii and California to 42% in Kentucky. In 12 states, 40% reported total tooth loss (Table 1).

Retention of most of their teeth by older adults was less common among those with less than a high school education (31%) than among those with more education (46%-64%), among those with annual household incomes of <$15,000 (30%) than among those with higher incomes (41%-73%), among non-Hispanic blacks (30%) than among non-Hispanic whites (53%) or Hispanics (53%), among persons who smoked every day (31%) and some days (33%) than among persons who had quit smoking (47%) or who had never smoked (59%), among persons with diabetes (42%) than among those without diabetes (53%), and among persons reporting fair or poor general health status (38%) than among those with good to excellent general health status (56%) (Table 2).

Reported by: BF Gooch, DMD, PI Eke, PhD, DM Malvitz, DrPH, Dry of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note: Compared with younger persons, the current cohort of older adults likely experienced higher rates of dental caries and tooth extraction as young adults and are more likely to have lost all their teeth (1,5). However, data from successive national surveys indicate that the percentage of older adults losing all their natural teeth has declined substantially since the 1950s, when the majority of persons aged [greater than or equal to] 65 years were edentate (1). The current cohort of older adults has likely benefited from substantial improvements during the preceding 50 years that have resulted in greater tooth retention (5). These improvements include community water fluoridation and fluoride dentifrice (i.e., toothpaste), advancements in dental technologies and treatment modalities, changing patient and provider attitudes and treatment preferences, improved oral hygiene, and regular use of dental services (1,5).

Throughout the life span, teeth remain at risk for the two most prevalent oral diseases (i.e., dental caries and periodontal disease). Older adults remain at risk for new and recurrent decay that is untreated in approximately 30% of dentate adults (6). They are at increased risk for root caries because of both increased gingival (i.e., gum) recession that exposes root surfaces and increased use of medications that produce xerostomia (i.e., dry mouth) (2). Approximately 50% of persons aged [greater than or equal to] 75 years have root caries affecting at least one tooth (2). Approximately 25% of older adults have loss of tooth-supporting structures because of advanced periodontal disease (2). Without early prevention and control interventions, these progressive conditions can demand extensive treatment to curb infection and restore function.

The wide variation in rates of tooth loss and retention among states and by selected characteristics suggests that many older adults have not benefited fully from improvements in the prevention and control of oral diseases. Differences in tooth retention by education, income, and race/ethnicity reflect disparities in unmet dental needs (e.g., untreated caries and advanced periodontal diseases) among persons with limited education and income and among non-Hispanic blacks (2). The findings in this report indicate that Hispanics and non-Hispanic whites reported similar rates of tooth retention; however, other surveys have indicated that Mexican-Americans had higher rates of untreated caries than non-Hispanic whites (2). These associations might reflect differences in health literacy and behaviors, attitudes toward oral health and dental care, and access to and use of dental services and types of treatment received (1,27). The lower prevalence of tooth retention among smokers might be related directly to the adverse effects of cigarette smoking (7), which accounts for approximately half of all cases of periodontal disease in the United States (8).

Self-ratings of health have been associated with functional ability (9). These associations suggest that older persons who report poorer general health are at increased risk for limited dexterity, mobility, and tolerance of stress; such factors can compromise abilities to maintain oral hygiene, visit a dental office, or tolerate treatment. The results of this study suggest that many aging adults who are in poorer general health have retained most of their natural teeth. These persons likely will need caregiver assistance and innovative strategies to maintain daily self-care, obtain regular oral assessments, and receive primary and secondary prevention services.

The findings in this report are subject to at least four limitations. First, the sample is drawn from the noninstitutionalized population and excludes persons residing elsewhere (e.g., nursing homes or long-term care facilities). Second, persons without residential telephone service (e.g., persons with lower incomes or households using cellular phones) are excluded. Third, results are self-reported data and have not been validated; however, a strong agreement between self-reported and clinically assessed number of teeth has been documented (10). Finally, measures of oral health status are limited to tooth loss.

In the United States, older adults usually pay for dental services themselves without the benefit of insurance (2). Medicare does not cover routine services, and Medicaid provides only limited coverage in certain states; the majority of elderly persons lose their dental insurance when they retire (2). Community water fluoridation remains the most effective and cost-effective method for caries prevention (3); current dental recommendations provide additional guidance on best practices in fluoride use, such as brushing teeth twice daily with fluoride toothpaste (3). Expansion of community-based programs could help increasing numbers of dentate older adults manage their oral health needs. Programs that have focused historically on younger populations might promote oral health in older adults by 1) increasing public and professional awareness of common oral conditions, risk factors, and healthy behaviors; 2) expanding partnerships, especially with organizations focused on aging issues; 3) monitoring oral health status of older adults; 4) ensuring access to clinical services; and 5) increasing support for prevention research and involvement of oral health professionals in tobacco-control activities (3,4,7).

TABLE 1. Age-adjusted * percentage of persons aged [greater than or

equal to] 65 years who reported loss of all or retention of most

([dagger]) of their natural teeth, by state/area–Behavioral Risk

Factor Surveillance System, United States, 2002

Lost all natural teeth%

State/Area % (95% CI ([section]))

Alabama 29.9 ([+ or -] 3.7)

Alaska 26.3 ([+ or -] 7.1)

Arizona 20.4 ([+ or -] 4.1)

Arkansas 30.1 ([+ or -] 3.1)

California 13.3 ([+ or -] 2.7)

Colorado 19.2 ([+ or -] 4.7)

Connecticut 16.0 ([+ or -] 2.5)

Delaware 25.8 ([+ or -] 3.7)

District of Columbia 16.7 ([+ or -] 4.3)

Florida 21.3 ([+ or -] 2.3)

Georgia 32.6 ([+ or -] 3.7)

Hawaii 13.1 ([+ or -] 2.9)

Idaho 22.5 ([+ or -] 2.7)

Illinois 24.0 ([+ or -] 4.3)

Indiana 24.7 ([+ or -] 2.7)

Iowa 21.3 ([+ or -] 2.9)

Kansas 22.8 ([+ or -] 2.9)

Kentucky 42.3 ([+ or -] 3.3)

Louisiana 33.8 ([+ or -] 3.5)

Maine 30.4 ([+ or -] 4.7)

Maryland 19.3 ([+ or -] 3.7)

Massachusetts 22.9 ([+ or -] 2.7)

Michigan 18.8 ([+ or -] 2.9)

Minnesota 14.8 ([+ or -] 2.5)

Mississippi 35.1 ([+ or -] 3.7)

Missouri 26.4 ([+ or -] 3.3)

Montana 20.9 ([+ or -] 3.5)

Nebraska 25.5 ([+ or -] 2.7)

Nevada 20.5 ([+ or -] 4.9)

New Hampshire 21.8 ([+ or -] 3.2)

New Jersey 20.1 ([+ or -] 4.7)

New Mexico 25.2 ([+ or -] 3.1)

New York 18.7 ([+ or -] 3.1)

North Carolina 33.3 ([+ or -] 4.1)

North Dakota 23.2 ([+ or -] 3.5)

Ohio 23.6 ([+ or -] 3.5)

Oklahoma 33.2 ([+ or -] 2.5)

Oregon 18.9 ([+ or -] 3.3)

Pennsylvania 25.8 ([+ or -] 1.9)

Rhode Island 22.5 ([+ or -] 3.3)

South Carolina 24.4 ([+ or -] 3.9)

South Dakota 24.7 ([+ or -] 2.7)

Tennessee 36.0 ([+ or -] 4.1)

Texas 20.4 ([+ or -] 2.7)

Utah 14.7 ([+ or -] 3.3)

Vermont 21.7 ([+ or -] 3.1)

Virginia 21.3 ([+ or -] 3.3)

Washington 16.8 ([+ or -] 2.9)

West Virginia 41.9 ([+ or -] 3.7)

Wisconsin 20.6 ([+ or -] 3.2)

Wyoming 25.7 ([+ or -] 3.5)

GuamT 14.9 ([+ or -] 18.0)

Puerto Rico 31.7 ([+ or -] 3.9)

U.S. Virgin Islands 20.8 ([+ or -] 6.5)

Have most% natural

teeth

State/Area % (95% CI)

Alabama 41.2 ([+ or -] 4.1)

Alaska 40.1 ([+ or -] 8.3)

Arizona 56.6 ([+ or -] 4.5)

Arkansas 40.8 ([+ or -] 3.5)

California 60.5 ([+ or -] 4.5)

Colorado 60.5 ([+ or -] 4.4)

Connecticut 58.3 ([+ or -] 3.4)

Delaware 46.7 ([+ or -] 4.3)

District of Columbia 48.3 ([+ or -] 5.8)

Florida 53.6 ([+ or -] 2.8)

Georgia 43.2 ([+ or -] 4.0)

Hawaii 59.8 ([+ or -] 3.6)

Idaho 54.1 ([+ or -] 3.5)

Illinois 51.4 ([+ or -] 4.8)

Indiana 44.7 ([+ or -] 3.2)

Iowa 50.2 ([+ or -] 3.9)

Kansas 52.7 ([+ or -] 3.6)

Kentucky 35.6 ([+ or -] 3.4)

Louisiana 46.0 ([+ or -] 3.5)

Maine 43.8 ([+ or -] 5.1)

Maryland 52.0 ([+ or -] 4.6)

Massachusetts 48.0 ([+ or -] 3.2)

Michigan 53.8 ([+ or -] 3.5)

Minnesota 59.4 ([+ or -] 3.5)

Mississippi 34.4 ([+ or -] 3.6)

Missouri 44.6 ([+ or -] 4.1)

Montana 52.9 ([+ or -] 4.5)

Nebraska 50.9 ([+ or -] 3.2)

Nevada 51.9 ([+ or -] 5.8)

New Hampshire 53.8 ([+ or -] 3.7)

New Jersey 45.1 ([+ or -] 5.2)

New Mexico 51.4 ([+ or -] 3.6)

New York 50.9 ([+ or -] 3.9)

North Carolina 41.2 ([+ or -] 3.8)

North Dakota 46.8 ([+ or -] 4.4)

Ohio 48.1 ([+ or -] 4.3)

Oklahoma 42.4 ([+ or -] 2.6)

Oregon 54.8 ([+ or -] 4.3)

Pennsylvania 43.1 ([+ or -] 2.3)

Rhode Island 48.1 ([+ or -] 3.9)

South Carolina 46.3 ([+ or -] 4.3)

South Dakota 48.9 ([+ or -] 3.1)

Tennessee 41.6 ([+ or -] 4.2)

Texas 57.5 ([+ or -] 3.6)

Utah 63.8 ([+ or -] 4.6)

Vermont 51.4 ([+ or -] 3.8)

Virginia 54.7 ([+ or -] 4.5)

Washington 55.8 ([+ or -] 3.9)

West Virginia 26.6 ([+ or -] 3.3)

Wisconsin 54.2 ([+ or -] 3.9)

Wyoming 48.3 ([+ or -] 4.1)

GuamT 45.8 ([+ or -] 17.9)

Puerto Rico 29.3 ([+ or -] 3.7)

U.S. Virgin Islands 33.3 ([+ or -] 7.2)

* Age adjusted to the 2000 standard U.S. population.

([dagger]) Loss of five teeth or fewer.

([section]) Confidence interval.

([paragraph]) Estimates are highly variable.

TABLE 2. Percentage of persons aged [greater than or equal to] 65 years

who reported having most * of their natural teeth, by selected

characteristics–Behavioral Risk Factor Surveillance System, United

States, 2002

Have most natural

teeth

(95% CI

Characteristic No. % ([dagger]))

Sex

Male 17,255 50.6 ([+ or -] 1.3)

Female 31,611 50.9 ([+ or -] 1.1)

Education level

<High school 10,406 30.5 ([+ or -] 2.2)

High school 17,462 45.6 ([+ or -] 1.3)

Some college/College graduate 20,806 63.7 ([+ or -] 1.2)

Annual household income

<$15,000 8,501 30.4 ([+ or -] 2.1)

$15,000-$24,999 11,130 41.4 ([+ or -] 1.6)

$25,000-$34,999 6,713 52.6 ([+ or -] 2.0)

$35,000-$49,999 5,211 60.3 ([+ or -] 2.3)

[greater than or equal to] $50,000 5,612 72.8 ([+ or -] 2.1)

Race/Ethnicity

White, non-Hispanic 41,240 52.7 ([+ or -] 0.8)

Black, non-hispanic 2,520 30.4 ([+ or -] 3.3)

Multiracial, non-Hispanic 610 38.9 ([+ or -] 6.8)

Hispanic 2,268 53.0 ([+ or -] 5.0)

Other races 1,615 46.4 ([+ or -] 7.5)

Cigarette smoking status

Current, every day 4,149 30.6 ([+ or -] 3.1)

Current, some day 986 33.0 ([+ or -] 4.9)

Former 18,879 46.5 ([+ or -] 1.2)

Never 24,626 58.5 ([+ or -] 1.1)

General health rating

Excellent, very good, or good 33,542 56.4 ([+ or -] 1.0)

Fair or poor 15,075 37.7 ([+ or -] 1.5)

Diabetes

Yes 7,651 41.6 ([+ or -] 2.3)

No 40,895 52.6 ([+ or -] 0.9)

* Loss of five teeth or fewer.

([dagger]) Confidence interval.

References

(1.) Burr BA, Eklund SA. Dentistry, dental practice, and the community, 5th ed. Philadelphia, Pennsylvania: WB Saunders Co., 1999.

(2.) U.S. Department of Health and Human Services. Oral Health in America: a Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000.

(3.) CDC. Recommendations for using fluoride to prevent and control dental caries in die United States. MMWR 2001;50(No. RR 14).

(4). Truman BI, Gooch BE Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prey Med 2002;23(suppl 1):35-43.

(5.) Eklund SA. Changing treatment patterns. J Am Dent Assoc 1999;130:1707 12.

(6.) U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health (2 vols.). Washington, DC: U.S. Department of Health and Human Services, 2000.

(7.) CDC. Total tooth loss among persons aged [greater than or equal to] 65 years–selected states, 1995-1997. MMWR 1999;48:206 10.

(8.) Tomar SL, Asma S. Smoking-attributable periodontitis in the [IS: findings from NHANES III. J Periodontol 2000;71:743 51.

(9.) Idler EL, Kasl SV. Self-ratings of health–do they also predict change in functional ability? J Gerontol B Psychol Sci Soc Sci 1995;50:S344-S353.

(10.) Douglass CW, Berlin J, Tennstedt S. The validity of self-reported oral health status in the elderly. J Public Health Dent 1991;51:220-2.

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