A critical step in meeting the oral health care needs of older adults, whether preventive or restorative, is a dental visit. With this in mind, a useful way to assess some of the anticipated oral health needs of older adults is to examine their patterns of utilization.

Such an assessment requires two inquiries:

– Who is and is not visiting the dentist regularly?

– What factors determine whether an older adult visits a dentist?

In answering these questions, we need to consider further the older adult population. Two important characteristics that affect older adults are edentulism and retirement, and these characteristics are especially relevant for any exploration of utilization. A low utilization rate among edentulous adults has been well-established^5,6 and may affect the maintenance of pros-theses and the early detection of oral cancer.

In addition, the traditional transition into retirement at the age of 65 years, with its loss of private dental insurance benefits and the institution of fixed incomes, might herald a reduced financial capacity for obtaining dental care.^7,8 Despite the reduced capacity to afford dental care, the oral health care needs of retirees and edentulous adults persist,² which creates the potential for an increase in unmet needs and diminished oral health status among members of these groups.

During the next few decades, adults aged 55 years or older can be expected to have substantial oral health care needs owing to the combination of a projected increase in their proportion of the total U.S. population, an increase in the number of retained teeth (decrease in edentulism) and the complexity of their medical histories. Meeting these oral health care needs could be challenging, especially for those with diminished financial capacity after retirement. Consequently, a better understanding of the dental visit patterns of older adults is at the crossroads of oral health care needs and the ability to meet them.

The traditional transition into retirement at the age of 65 years, with its loss of private dental insurance benefits and the institution of fixed incomes, might herald a reduced financial capacity for obtaining dental care.

We conducted an investigation to examine this intersection of oral health care needs and constraints by using the most current nationally representative data to describe the utilization patterns of adults aged 55 years or older, including the reasons reported for visiting or not visiting a dentist. The investigation also accounted for edentulism in all analyses, and explored cost as a potentially relevant factor in visit patterns for this age group. Findings will be useful for anticipating visit patterns, as well as for developing and targeting interventions to improve visit patterns as one means of addressing the oral health care needs of older Americans.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The source of the data for this investigation was the 1999 public-use version of the National Health Interview Survey, or NHIS. The NHIS is a large health survey administered by the National Center for Health Statistics, Hyattsville, Md., and is the main source of health, illness and disability information for the civilian, noninstitutionalized population of the United States. The NHIS has been collecting data continuously since its inception in 1957. The 1999 NHIS included several core questionnaires and a number of questions that are included periodically in separate survey sections. For this investigation, we used questionnaire items from the Health Care Access and Utilization portion of the Adult Core Questionnaire.

The 1999 NHIS used a complex, multistage probability sampling design to select survey participants. African-Americans and Hispanics were oversampled to increase analytical precision for these two racial/ethnic groups. The final interviewed sample consisted of 37,573 households, containing 97,059 family members from 38,171 families. The final response rate for the Adult Core Questionnaire was 69.6 percent. A detailed description of the 1999 NHIS has been published elsewhere.⁹

Outcome variables. This investigation consisted of three outcome variables. The first was a general dental visit variable, the second involved the main reasons for the last dental visit, and the third variable involved the main reasons for not visiting a dentist in the previous year. The dental visit variable was derived from a questionnaire item that asked, "About how long has it been since you last saw or talked to a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists."

We derived the "reason for the last dental visit" variable from an item that asked, "What was the main reason that you last went to the dentist?" Response categories for this questionnaire item included patient-initiated checkup, examination or tooth cleaning; dentist-initiated checkup, examination or tooth cleaning; something wrong, bothering them or hurting; treatment or condition found during an earlier dental visit; and other undefined reasons. For simplicity of interpretation, we combined the "patient-initiated" and "dentist-initiated checkup, examination or tooth cleaning" categories into a single "checkup or cleaning" category. We also combined the "treatment or condition found during an earlier dental visit" and "other undefined reasons" categories into a single "treatment or other reason" category.

We derived the "reason for no dental visit" variable from a questionnaire item that asked, "What are the reasons that you have not visited a dentist in over 12 months?" Respondents selected from a list of possible reasons, including the following:

– fear of dentist;

– nervous about dentistry;

– fear of needles;

– cost;

– do not know a dentist;

– dentist is too far away;

– transportation issues;

– no dental problems;

– no teeth;

– did not think it was important;

– did not think about it;

– other undefined reasons.

Respondents were allowed to give more than one reason.

We combined similar responses into a smaller number of categories, including fear (from "fear of dentist," "nervous about dentistry," "fear of needles"), cost, access problems (from "do not know a dentist," "dentist too far away," "transportation issues"), no dental problem, no teeth, not believing dental treatment was important (from "did not think it was important," "did not think about it") and other undefined reasons.

For simplicity of presentation and interpretation, we considered the following three categories to indicate that the respondent did not recognize a need to visit the dentist: having no dental problem, having no teeth and not believing it was important. We considered the remaining categories (fear, cost, access problems and other undefined reasons) to reflect a belief that the respondent recognized a need to visit the dentist.

Descriptor variables. The descriptor variables included age (55 through 64 years, 65 through 74 years, 75 years or older), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, Hispanic), poverty status (200 percent of the federal poverty level, or FPL, or higher; 100 to 199 percent of the FPL; less than 100 percent of the FPL; unknown poverty status), geographic region (Northeast, Midwest, South, West), private dental insurance status and dentition status (dentate, edentulous).

Analysis. We used the SUDAAN statistical software program¹⁰ to produce bivariate and multivariate estimates and confidence intervals, because SUDAAN accounted for the complex sampling design of the 1999 NHIS when it calculated standard errors. We used full sample weights during the analysis so that estimates would be representative of the civilian, noninstitutionalized population of the United States. We assessed the statistical significance of each analysis against an value of 0.5.

We stratified all analyses according to dentition status, because presence or absence of teeth is such a strong predictor of whether an individual visits the dentist. We excluded from the analysis those respondents with an unknown dental visit history (n = 233), dentition status (n = 55) and private dental insurance status (n = 322), because of the small sample sizes for these groups. We included respondents with an unknown poverty status in the poverty status variable because this category included about 11 percent of the total sample, and we did not want to eliminate that many respondents from the analysis. The final sample was composed of 9,272 respondents, representing 52.8 million adults aged 55 years or older in the United States. The results that follow are statistically weighted to represent these 52.8 million adults.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
According to the 1999 NHIS data, 28.6 million dentate adults (70.9 percent) aged 55 years or older had a dental visit in the previous year, and 36.4 million (90.1 percent) had a dental visit within the previous five years. By contrast, only 2.5 million edentulous adults (19.8 percent) aged 55 years or older had a dental visit in the previous year, and only 5.1 million (40.7 percent) had a dental visit within the previous five years (Figure 1).

View larger version (34K): [in this window] [in a new window]   Figure 1. Time since last dental visit among adults aged 55 years or older, by dentition status.

View this table: [in this window] [in a new window]   TABLE 1 WEIGHTED PREVALENCE OF A REPORTED DENTAL VISIT IN THE PREVIOUS YEAR AMONG U.S. ADULTS AGED 55 YEARS OR OLDER, 1999 (n = 9,272).*

View this table: [in this window] [in a new window]   TABLE 2 ADJUSTED ODDS RATIO ASSOCIATIONS FOR A REPORTED DENTAL VISIT IN THE PREVIOUS YEAR AMONG U.S. ADULTS AGED 55 YEARS OR OLDER, 1999 (n = 9,272).*

Main reasons for last dental visit. Figure 2 lists the main reasons reported by adults for their last dental visit, stratified by dentition status. Among dentate adults, the vast majority reported that their last dental visit was for a checkup, examination or cleaning. More than 20 percent reported that their last visit was because something was wrong, bothering them or hurting, whereas the remaining 6 percent said that their last dental visit was for treatment or for a condition found during a previous visit, or because of some other undefined reason. Among edentulous adults, we found a more equal distribution of reasons reported for the last dental visit than we found among dentate adults. Although checkup, examination or tooth cleaning remained the most common reason, the proportion of edentulous adults who gave the two alternative reasons was substantially higher than the proportion among the dentate group.

Reasons for no dental visit in the pre vious year. Figure 3 shows the reasons for not having had a dental visit in the previous year among adults aged 55 years or older, stratified by dentition status. Of the 11.7 million dentate adults without a dental visit, almost 8.6 million did not recognize a need to visit the dentist, in that they gave "no problems" and "not believing it was important" as the main reasons. The remaining 3.15 million suggested that they recognized a need to visit the dentist, in that they gave fear, cost, access problems and other undefined reasons as the explanations for not having visited a dentist.

View larger version (41K): [in this window] [in a new window]   Figure 3. Reasons for not having had a dental visit in the previous year among adults aged 55 years or older, by dentition status.

Figure 4 presents the percentage of adults aged 55 years or older who reported that cost was a reason for not visiting the dentist in the previous year, stratified by dentition status and age. For both dentate and edentulous adults, the percentage who reported that cost was a reason for no dental visit decreased as age increased.

View larger version (30K): [in this window] [in a new window]   Figure 4. Prevalence of cost reported as a reason for not having had a dental visit, by dentition status and age.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

We also would expect the increase in utilization to affect the nature of dental practice, because higher utilization should be associated with greater demand for diagnostic services, general restorative procedures, endodontic therapy, fixed and removable prosthetics, and other restorative care.¹² In addition, dentists increasingly would be expected to consider the complicated medical, dental and pharmacological histories associated with older adults. As a result, oral health care practitioners would be required to have greater knowledge of these complex histories, and exercise due care in developing appropriate treatment plans when these challenges present themselves.^5,13,14

Our findings showed that utilization was associated with a number of demographic and SES variables. Among dentate adults, women, certain racial/ethnic groups, respondents with higher SES and those with private dental insurance were more likely to have had a dental visit in the previous year than were their counterparts. Among edentulous adults, those with higher SES and those with private dental insurance were more likely to have had a dental visit in the previous year than were their counterparts.

Our findings are consistent with those from the 1989 NHIS¹¹ and with those from other national investigations,¹⁵ and highlighted the disparities in health care–seeking behaviors of some population subgroups. Our investigation also showed that approximately 72 percent of dentate adults aged 55 years or older said that their last dental visit was diagnostic or preventive in nature. Again, these findings are consistent with those reported by other national surveys.^15–17

Perceptions of dentate and edentulous adults. According to our findings, dentate adults aged 55 years or older were more likely to have perceived a need for preventive care in the form of a checkup or cleaning, and were more likely to have acted on that perception than were edentulous adults. By contrast, edentulous adults were more likely to have reported a dental visit because of a problem than were dentate adults. Although our findings suggested that preventive health care–seeking behaviors were more likely to be associated with dentate adults than with edentulous adults, our investigation was unable to assess whether this was a cause-and-effect relationship. In other words, we were unable to identify whether adults with poor preventive health care–seeking behaviors were more likely to become edentulous as a result, or whether adults who lost all of their teeth were more likely to change their perceptions about prevention as a result. Future studies should be designed to detect the direction of this cause-and-effect pathway.

For decades, the dental profession has recognized the importance of regular checkups and professionally delivered preventive services. Our findings suggest that the vast majority of dentate adults aged 55 years or older also recognize the importance of regular checkups and preventive services. By contrast, only 44 percent of edentulous adults aged 55 years or older reported that their last dental visit was diagnostic or preventive. Edentulous adults clearly need diagnostic and preventive services, including assessment of the fit and function of removable prostheses, evaluation of soft-tissue health and identification of oral pathology. Our data suggest that edentulous adults either are ignoring these needs or are unaware of them. These scenarios are not likely to lead to optimal oral health.

Our investigation also showed that there were relatively high proportions of dentate and edentulous adults who did not recognize a need for a dental visit. Among dentate adults, approximately 73 percent of those who did not visit the dentist did not recognize a need for a visit, and among edentulous adults, approximately 94 percent did not recognize a need. We should point out that the vast majority of adults aged 55 years or older who had not visited a dentist in the previous year reported that they had not done so because they thought there was no reason to do so, either because they perceived that they had no oral health problems or had no teeth.

Health education campaigns. If the dental profession believes that regular dental visits are crucial to the promotion and maintenance of oral health, then either the profession is failing to deliver this message to all segments of the population, or segments of the population are not appreciating the messages they are receiving. Either way, the profession needs to improve its health education campaigns, both inside and outside the dental office.

Cost as a reason for not visiting a dentist. It is not surprising that cost was listed as a major reason for not visiting the dentist in the previous year among those who recognized a need to visit the dentist, regardless of dentition status. We expected this finding, given the well-established relationship between utilization and the ability to pay for care and the relative lack of oral health safety-net programs for older Americans in the United States. On the one hand, we found it comforting that only 1.6 million dentate and 325,000 edentulous adults reported that cost was the reason for not having visited the dentist; however, it is likely that these numbers would increase if the adults who failed to recognize a need for a dental visit changed their perceptions.

Future studies should assess the true relationship between retirement and health care utilization in longitudinal investigations.

Future studies should assess to what extent cost was a specific barrier to receiving care, and to what extent utilization might increase for these adults with the availability of financial assistance. In addition, future studies should determine how the dental profession and society might address an increased demand for services among people who might have limited financial resources. These new studies would provide important insights into the various types of assistance and insurance programs that might be designed and implemented to benefit older adults.

Although respondents who recognized a need for dental care frequently reported that cost was a reason for not having visited a dentist in the previous year, cost appeared to have little to do with retirement. Adults in the age 65-through-74-years category and 75-years-or-older category were less likely to report cost as a reason than were adults aged 55 through 64 years. This finding was surprising, because we hypothesized that retirement, with its associated loss of private dental insurance and institution of fixed incomes, combined with a constant or increasing need for health care, would result in cost being a more prominent reason for not having had a dental visit with increasing age.

Perhaps our failure to find an increase in reports of cost as a reason for no dental visits represented a cohort effect (that is, characteristics related to the period during which a group was born)—one problem associated with analyzing age using cross-sectional data. Or perhaps our failure to find an increase across age groups meant that cost became less of an issue over time. Whatever the explanation, future studies should assess the true relationship between retirement and health care utilization in longitudinal investigations.

Study limitations. Our investigation was subject to two limitations. The first limitation was that the information regarding dental visits was self-reported and, as such, was subject to reporting biases. For example, a recent investigation¹⁸ showed that self-reported dental visit estimates varied substantially across national surveys, depending on the wording of the question and how the survey was administered.

The second limitation related to the 1999 NHIS investigators’ decision to use "reason for last dental visit" as a representation of the reasons why adults visit the dentist in general. Although this representation was probably accurate among those who visited the dentist once or twice in the previous year, it might have been inaccurate among those who visited multiple times or who visited for the completion of complex treatment plans. There might have been little relationship between the reasons for the initial visit and the last visit when complex, multivisit treatment plans were involved. The 1989 NHIS¹¹ showed that multiple visits were fairly common; about 29 percent of dentate adults aged 35 years or older had three or more dental visits in the previous year, and 38 percent of edentulous adults aged 35 years or older had three or more visits.

Despite these limitations, our investigation had some important strong points. Findings were representative of the U.S. population, including the nation’s many diverse demographic and SES subgroups. In addition, our investigation—which controlled for confounding—provided multivariate results for dental visit rates. Finally, our investigation stratified results by dentition status, which correctly accounted for the interaction between the descriptor variables, dentition status and dental visits.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
It is encouraging that the number and percentage of adults aged 55 years or older who visit the dentist continue to grow. Among the adults in this study who visited the dentist in the previous year, the overwhelming majority said they visited for a diagnostic or preventive procedure, and most of these visits were patient-initiated. Taken together, these results suggest that most U.S. adults aged 55 years or older appreciate the importance of regular dental visits. Among the adults who had not visited a dentist in the previous year, the majority did not recognize a need to do so.

These findings suggest that some adults need to gain a greater appreciation for regular utilization of health care services; however, the resulting increase in demand must be weighed against available resources. Finally, our findings showed that, at all levels of utilization, disparities still exist for specific demographic and SES subgroups.

View larger version (90K): [in this window] [in a new window]   Dr. Macek is an assistant professor, Department of Health Promotion and Policy, Baltimore College of Dental Surgery Dental School, University of Maryland, 666 W. Baltimore St., Room 3-E-02, Baltimore, Md. 21201-1586, e-mail "mdm002@dental. umaryland.edu". Address reprint requests to Dr. Macek.