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Dental treatment workload and cost of newly enrolled personnel in the Canadian Forces [A study of the 2007 and 2008 recruit population] by Constantine Batsos A thesis submitted in conformity with the requirements for the degree of Master in Science in Dental Public Health Graduate Department of Dentistry University of Toronto © Copyright by Constantine Batsos (2010)

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Page 1: Dental treatment workload and cost of newly enrolled ... · Dental treatment workload and cost of newly enrolled personnel in the Canadian Forces [A study of the 2007 and 2008 recruit

Dental treatment workload and cost of newly enrolled personnel

in the Canadian Forces

[A study of the 2007 and 2008 recruit population]

by

Constantine Batsos

A thesis submitted in conformity with the requirements for the degree of Master in Science in Dental Public Health

Graduate Department of Dentistry University of Toronto

© Copyright by Constantine Batsos (2010)

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Dental treatment workload and cost of newly enrolled personnel

in the Canadian Forces

[A study of the 2007 and 2008 recruit population]

Constantine Batsos

Master in Science in Dental Public Health

Graduate Department of Dentistry University of Toronto

2010

Abstract

Aim: To describe and analyze the demographic profile and the dental treatment needs, workload

and costs of the 2007 and 2008 CF recruit population (N=10,641). Method: Treatment

procedures and costs were aggregated and calculated, beginning from the date of a member’s

enrolment, over a period that ranged between 13 to 36 months. Associations between treatment

services and the demographic variables were tested using one-way ANOVA and chi-square tests.

Independent samples T-test was used to compare means. Linear regression models were used to

determine the influence of demographic variables on treatment cost. Results: Treatment needs

and costs varied with recruit age, gender, rank, first language (French/English), birthplace

(Canada/Foreign), tobacco use, province and census tract. The cost of treatment for the entire

population was $13.9M. Mean cost per recruit was $1224 over an average period of 26 months.

Outsource costs ($2.9M) were driven by referrals for restorative, endodontic and oral surgery

procedures.

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Dedication

To Peggy, for her unwavering patience, support and

understanding, and for bringing happiness into my life.

To my Father, Mother and big brother Steve for always being

there.

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Acknowledgments

I owe a great amount of gratitude to my supervisor, the late Dr. David Locker, who left us before

this thesis was completed. David left behind a wealth of insight and thought-provoking literature

that guided me through my work, as it will guide scholars for years and years. Reading his

papers brings a somber smile to my face. I am fortunate to have known him. I miss our

luncheons at the Met.

Equally, I would like to thank Dr. Carlos Quiñonez for taking over as my supervisor in his own

right. His vast knowledge in many areas and distinct approach to instruction challenged me to

think about public health issues and concepts in a different light. I am grateful for his

encouragement and exacting standards in writing this thesis.

I wish to thank Dr. Herenia Lawrence for serving on my thesis advisory committee and

providing me with advice and statistical expertise.

I would also like to thank Dr. Jim Lai and Dr. Peter Cooney for taking time away from their busy

schedules to serve as my internal and external examiners.

Lastly, I would like to acknowledge the support I received from the CFDS:

Col S.A Becker

LCol J.P. Picard

LCol D. Lemon

LCol J.J.A. Ouellet

LCol (Ret’d) G. Levesque

LCol (Ret’d) E. Reid

Maj R.R Groves

Maj T.L. Russu

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Table of Contents

Abstract……………………………………………………………………………………..ii

Dedication ...................................................................................................................................... iii 

Acknowledgments .......................................................................................................................... iv 

Table of Contents ............................................................................................................................ v 

List of Tables ............................................................................................................................... viii 

List of Figures .............................................................................................................................. xiii 

List of Appendices ....................................................................................................................... xiv 

List of Abbreviations .................................................................................................................... xv 

Executive Summary ..................................................................................................................... xvi 

Recommendations ........................................................................................................................ xix 

Preface .......................................................................................................................................... xxi 

1  Overview of the Canadian Forces Dental Services (CFDS) ...................................................... 1 

1.1  CFDS structure and personnel ............................................................................................ 1 

1.2  The Canadian Forces Dental Care Program (CFDCP) ....................................................... 2 

1.3  Military Dental Fitness Classification ................................................................................ 3 

1.4  CF Health and Dental Information Systems ....................................................................... 6 

1.5  Summary ............................................................................................................................. 8 

2  Literature review of Canadian young adult and military recruit dental treatment needs ........... 9 

2.1  Introduction ......................................................................................................................... 9 

2.2  Young adult oral health and the determinants of oral health in Canada ........................... 10 

2.3  CFDS studies on recruits .................................................................................................. 15 

2.4  Dental research on the recruit population of foreign militaries ........................................ 18 

2.4.1  Historical trends in dental caries experience among military recruits .................. 18 

2.4.2  Periodontal health of recruits ................................................................................ 20 

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2.4.3  Recruit dental treatment cost ................................................................................ 21 

2.4.4  Recruit dental treatment workload ........................................................................ 22 

2.4.5  Recruit dental service utilization .......................................................................... 23 

2.5  Summary of expected dental treatment needs in newly enrolled CF members ................ 25 

3  Dental treatment requirements of the 2007 and 2008 recruit population ................................. 26 

3.1  Abstract ............................................................................................................................. 27 

3.2  Introduction ....................................................................................................................... 28 

3.3  Methodology ..................................................................................................................... 29 

3.3.1  Study Design ......................................................................................................... 29 

3.3.2  Measures ............................................................................................................... 31 

3.3.3  Statistical analysis ................................................................................................. 32 

3.4  Results ............................................................................................................................... 32 

3.5  Discussion ......................................................................................................................... 36 

3.6  Conclusion ........................................................................................................................ 45 

4  Is census tract income an indicator of dental treatment needs in a young adult Canadian military population? ................................................................................................................. 47 

4.1  Abstract ............................................................................................................................. 48 

4.2  Introduction ....................................................................................................................... 50 

4.3  Methodology ..................................................................................................................... 51 

4.3.1  Study Design ......................................................................................................... 51 

4.3.2  Measures ............................................................................................................... 54 

4.3.3  Statistical Analysis ................................................................................................ 54 

4.4  Results ............................................................................................................................... 55 

4.5  Discussion ......................................................................................................................... 58 

4.6  Conclusion ........................................................................................................................ 63 

5  The impact of recruit dental treatment workload on Canadian Forces dental detachments .... 65 

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5.1  Abstract ............................................................................................................................. 66 

5.2  Introduction ....................................................................................................................... 67 

5.3  Methodology ..................................................................................................................... 68 

5.3.1  Study Design ......................................................................................................... 68 

5.3.2  Data Analysis ........................................................................................................ 69 

5.4  Results ............................................................................................................................... 70 

5.5  Discussion ......................................................................................................................... 73 

5.6  Conclusion ........................................................................................................................ 80 

6  Conclusion ................................................................................................................................ 82 

7  References ................................................................................................................................ 83 

8  Tables ....................................................................................................................................... 92 

9  Figures .................................................................................................................................... 154 

10 Appendices ............................................................................................................................. 157 

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List of Tables

Table 1 DentIS Tobacco User Status 01 June 2010. ..................................................................... 93 

Table 2. Carries Risk Status 01 June 2010 ................................................................................... 94 

Table 3. CHMS Severity of coronal caries ................................................................................... 95 

Table 4. CHMS Prevalence of periodontal conditions according to CPITN scores ..................... 96 

Table 5. Nutrition Canada Dental Report 1970 – 1972. Mean number of DMF teeth per person 97 

Table 6. 1977 Nutrition Canada Dental Report – (1)Prevalence. Percentage (%) of the population

requiring a dental restoration. (2) Severity. Mean number of dental restorations required by

those requiring a minimum of one restoration. ............................................................................. 98 

Table 7. 1977 Nutrition Canada Dental Report – (1) Prevalence. Percentage (%) of population

requiring a dental extraction. (2) Severity . Mean number of dental extractions required by those

requiring a minimum of one extraction. ...................................................................................... 99 

Table 8. The Dental condition of the Canadian Forces (1967). .................................................. 100 

Table 9. The dental condition of the Canadian Forces recruits (1973). ...................................... 101 

Table 10. Comparison of active and released members. ............................................................ 102 

Table 11. Recruit province of residence at the time of enrolment. ........................................... 103 

Table 12. Prevalence of dental treatment requirement, by treatment category ...................... 104 

Table 13. Multiple linear regression analysis of dental treatment cost. ...................................... 105 

Table 14. Age Group Analysis – Mean Age, Time in Services, Treatment Costs and Prevalence of 

Treatment Requirement ............................................................................................................. 106 

Table 15. Age Group Analysis – Severity of Treatment Requirement ........................................ 107 

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Table 16. NCM and Officer – Mean Age, Time in Services, Treatment Costs and Prevalence of 

Treatment Requirement ............................................................................................................. 108 

Table 17. NCM and Officers – Severity of Treatment Requirement .......................................... 109 

Table 18. NCM Male and NCM Female – Mean Age, Time in Services, Treatment Costs and 

Prevalence of Treatment Requirement ...................................................................................... 110 

Table 19. NCM Male and Female‐ Severity of Treatment Requirement .................................... 111 

Table 20. Officer Males and Officer Females – Mean Age, Time in Services, Treatment Costs and 

Prevalence of Treatment Requirement ...................................................................................... 112 

Table 21. Officer Male and Female‐ Severity of Treatment Requirement ................................. 113 

Table 22. First Language English/French – Mean Age, Time in Services, Treatment Costs and 

Prevalence of Treatment Requirement ...................................................................................... 114 

Table 23. First Language English and French ‐ Severity of Treatment Requirement ................. 115 

Table 24. Birthplace Canada and Foreign – Mean Age, Time in Services, Treatment Costs and 

Prevalence of Treatment Requirement ...................................................................................... 116 

Table 25. Birthplace Canada and Foreign – Severity of Treatment Requirement ..................... 117 

Table 26. Treatment Prevalence (All Members) according to province of residence at the time of 

enrolment ................................................................................................................................... 118 

Table 27. Treatment Severity (All Members) according to province of residence at the time of 

enrolment ................................................................................................................................... 119 

Table 28. Treatment Prevalence (16 yrs – 19yrs) according to province of residence at the time 

of enrolment ............................................................................................................................... 120 

Table 29. Treatment Severity (16 yrs – 19yrs) according to province of residence at the time of 

enrolment ................................................................................................................................... 121 

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Table 30. Treatment Prevalence (20 yrs – 29yrs) according to province of residence at the time 

of enrolment. .............................................................................................................................. 122 

Table 31. Treatment Severity (20 yrs – 29yrs) according to province of residence at the time of 

enrolment ................................................................................................................................... 123 

Table 32. Treatment Prevalence (30 yrs – 39yrs) according to province of residence at the time 

of enrolment ............................................................................................................................... 124 

Table 33. Treatment Severity (30 yrs – 39yrs)  according to province of residence at the time of 

enrolment. .................................................................................................................................. 125 

Table 34. Treatment Prevalence (40 yrs – 59yrs)  according to province of residence at the time 

of enrolment. .............................................................................................................................. 126 

Table 35. Treatment Severity (40 yrs – 59yrs) according to province of residence at the time of 

enrolment. .................................................................................................................................. 127 

Table 36. Tobacco User – Mean Age, Time in Services, Treatment Costs and Prevalence of 

Treatment Requirement ............................................................................................................. 128 

Table 37. Tobacco User – Severity of Treatment Need, measured in mean number of 

procedures among those requiring a minimum of one procedure. ........................................... 129 

Table 38. Periodontal Screening and Recording (PSR) Score Prevalence .................................. 130 

Table 39. PSR Status – Prevalence and Severity of preventive and periodontal treatment 

requirement ................................................................................................................................ 131 

Table 40. Dental Treatment Inequities between Officers and NCMs. ....................................... 132 

Table 41. Demographic comparison of Canadian population and recruit age group ................. 133 

Table 42. Demographic comparison of Canadian population level of education versus recruits

rank classification ....................................................................................................................... 134 

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Table 43. Demographic comparison of Canadian population birthplace and recruit birthplace 135 

Table 44. Demographic comparison of Canadian population most spoken language and recruit

first language as reported at enrolment. ...................................................................................... 136 

Table 45. Comparison of treatment requirements between members living in a census tract and

members not living in a census tract. .......................................................................................... 137 

Table 46. Census tract population descriptive statistics ............................................................. 138 

Table 47. Census tract group descriptive statistics, age, and months of service in relation to

median income Groups ............................................................................................................... 139 

Table 48. Census tract group prevalence of emergency visits .................................................... 140 

Table 49. Census tract group mean treatment cost ..................................................................... 141 

Table 50. Multiple logistic regression - likelihood of dental treatment requirement, by treatment

category, in the combined well below and below groups vs. the above and well above groups. 142 

Table 51. Multiple linear regression analysis of dental treatment cost. ...................................... 143 

Table 52. Census tract group prevalence of treatment requirement, .......................................... 144 

Table 53. Census tract group prevalence of treatment requirement, .......................................... 145 

Table 54. Census tract group severity of treatment requirement, stratified by rank class. ......... 146 

Table 55. Treatment workload by treatment category – number of procedures and cost ........... 147 

Table 56. Detachment workload at 6 month intervals following recruit enrolment. .................. 148 

Table 57. Detachment workload impact – Total procedures and cost ........................................ 149 

Table 58. Detachment workload by treatment category ............................................................. 150 

Table 59. Timeline for treatment delivery, by category (not including diagnostic services, other

than emergency visits), in 6 month intervals following date of enrolment ................................ 151 

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Table 60. Detachment impact of completed tooth extractions ................................................... 152 

Table 61. Detachment impact of completed root canals ............................................................. 153 

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List of Figures

Figure 1. 2007 and 2008 recruit population inclusion criteria .................................................... 155 

Figure 2. Recruit population residing in census tracts ................................................................ 156 

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List of Appendices

Appendix 1. CFDS Dental Detachments .................................................................................... 158 

Appendix 2. CFDS Dental Fitness Classification System .......................................................... 159 

Appendix 3. Dental Fitness Standards ....................................................................................... 160 

Appendix 4. Data Set Variables .................................................................................................. 163 

Appendix 5. CFDCP criteria for third molars, teeth and roots ................................................... 164 

Appendix 6. Example: Recruit dental experience while in training .......................................... 165 

Appendix 7 The Advanced General Dentist Position Paper .................................................... 166 

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List of Abbreviations

AGD – Advanced General Dentist

BMQ – Basic Military Qualification

BOQT – Basic Occupational Qualification Training

CA – Census Agglomeration

CBI – Compensations and Benefits Instructions

CDA - Center for Data Analysis

CF – Canadian Forces

CFB – Canadian Forces Base

CFDCP – Canadian Forces Dental Care Program

CHASS - Computing in the Humanities And Social Sciences

CHMS – Canadian Health Measure Survey

CMA – Census Metropolitan Area

CMP – Chief of Military Personnel

CT – Census Tract

DentIS – Dental Information System

DFC – Dental Fitness Category (fitness classification used by US military services)

DHRIM – Department of Human resources Information Management

DMFT – Decayed, Missing, Filled teeth

DPH – Dental Public Health

NATO – North Atlantic Treaty Organization

NATO STANAG - North Atlantic Treaty Organization Standing Agreement

NCDR – Nutrition Canada Dental Report

NCM – Non Commissioned Member

NCNS – Nutrition Canada National Survey

ODA – Ontario Dental Association

PSR – Periodontal Screening and Record

RCDC – Royal College of Dentists of Canada

RMC – Royal Military College

TSCOHS - Tri-Service Comprehensive Oral Health Survey

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Executive Summary

In Canada, precise normative dental treatment needs data for young adults are not readily

available. Dental public health planners and policy makers, both within and outside the military,

require current knowledge of population oral health treatment needs, in order to ensure that

programs are achieving intended goals and health care providers are being utilized efficiently.

This study comprised a data analysis of the dental treatment that was provided to CF members

enrolled in 2007 and 2008, from the date of their enrolment until 31 January 2010. The principal

strength in using military data is that dental treatment in the Canadian Forces (CF) is provided in

accordance with standardized criteria established in the CF Dental Care Program. As such, it

represents a more reliable picture of actual treatment needs and costs.

The dental treatment needs of the newly enrolled 2007 and 2008 CF population were shown to

vary in accordance with demographic composition. The study population consisted of 10,641

recruits, including 8953 (84.4%) males and 1658 (15.6%) females. There were 8547 (80.3%)

Non Commissioned Members (NCM) and 2094 (19.7%) officers. The mean age of all active

members was 25.1 (range 16.6 to 58.2 years). The mean total treatment cost observed per recruit

was $1224 over an average time period of 26 months. Approximately 44% of new members did

not require any restorations, root canals or dental extractions.

Except for dental extractions, prevalence and severity of treatment requirement (preventive,

restorative, endodontic, periodontal) was found to increase with age. Treatment needs and costs

were higher in NCM recruits versus officer candidates; members who reported French as their

first language versus those who reported English; those who were born outside of Canada versus

those who were born in Canada; and users of tobacco versus non users.

Females generally incurred higher treatment costs and received more treatment as compared to

males. Even though Periodontal Screening Record scores in females were significantly less

severe than males, a greater proportion of females received preventive and periodontal treatment.

Thus, the increased amount of treatment provided to females may be partly explained by a

propensity to be more proactive in seeking dental services.

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Considerable regional differences in treatment needs were noted. Members residing in

Saskatchewan and Newfoundland and Labrador showed the highest treatment needs and costs.

Members from Ontario had lower treatment requirement and incurred the lowest treatment costs.

Individual-level socioeconomic statistics were not studied; however, an analysis of area-based

measures confirmed that the majority of recruits living in census tracts at the time of enrolment,

resided in neighbourhoods with a median income that was 4% higher than the median income of

the census metropolitan area or census agglomeration. Prevalence of treatment requirement,

emergency visits and cost increased as neighbourhood income advantage decreased. It was

demonstrated that census tract median income can act as a risk marker for the dental treatment

needs of Canadian young adults entering the CF. Recruits originating from less urban (non

census areas) showed slightly higher treatment needs compared to recruits living in census tracts.

These findings suggest that, unlike the recruits enrolled in the late 1960’s and early 1970’s, who

were shown to represent the lower socioeconomic scale of the Canadian population, current

recruits appear to be more representative of middle class and upper middle class Canada.

Disparities in treatment requirement and inequalities in access to care between the officers and

NCMs were observed. Despite the higher treatment requirement among NCMs, the wait time

before they receive attention was greater than that of officers. Furthermore, the average officer

received a greater number of preventive treatments and sooner access to preventive care.

Caries risk assessments were not routinely completed and the proportion of the restorative

treatment that was delivered remained relatively constant throughout the 36 month observation

period. This may be an indication of inefficient preventive care and a lack of provider

compliance with protocol.

Dental detachments were unable to handle the dental workload at a uniform level of proficiency,

resulting in excessive outsource treatment costs. Detachments on training bases, which were only

staffed to provide emergency treatment on recruits, were much more adept at handling dental

treatment within the detachment. Large detachments designated as specialty centres were less

capable of delivering care within the detachment. The employment of clinical specialists

(Compensation and Benefits Instructions (CBI) 204.217), particularly the Advanced General

Dentists, was shown to be inconsistent in reducing the need for outside referrals and patient

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travel. These findings suggest that NCM recruits, whose comprehensive treatment is normally

deferred until after training, encounter additional delays prior to receiving necessary dental care.

As of April 2010, the Canadian Forces Dental Services (CFDS) employed 651 personnel,

including 103 military dentists, 36 military dental specialists and 44 civilian dentists, and were

responsible for the provision of comprehensive dental treatment to 75,000 CF members. That is,

approximately one dentist for every 420 patients. CFDS personnel annual salaries add up to more

than $55M. From April 2007 to March 2010, the CFDS paid more than $27.4M to civilian dental

practices for the provision of treatment on CF personnel, including more than $2.9M for our

study population. Thirty-eight cents out of every dollar of non-diagnostic and non-preventive

treatment services, performed on recruits, was outsourced to civilian dentists in private practice.

If this trend continues, the CFDS may soon provide the majority of the cost of diagnostic and

hygiene services while general and specialist dentists in private practice provide the greater share

of the cost of the treatment workload.

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Recommendations

The protocol based delivery of dental treatment in the CF can assist the Canadian public health

system with regards to population health planning and research. Treatment statistics that are

routinely collected on new CF members were shown to compliment national and regional oral

health surveys by imparting tangible and confirmatory evidence to their findings. With some

adjustments and standardization for variables such as, age and gender, CF recruit dental

treatment data can become more generalizable and may serve as a predictor of young adult dental

treatment needs. Further exploration is recommended in order to fully assess the contribution

that can be afforded through the use of military dental data and research in understanding and

relieving the burden of illness for all Canadians. Future directions include, but are not limited to,

the study of demographic and regional determinants of population dental treatment needs, dental

treatment requirements and costs in the CF population over time, and the CFDS model of dental

care delivery as compared to the public and private sectors.

The CFDCP is overdue for a review. One of the areas that will require revisions is the

integration of population risk assessment metrics, such as caries risk, periodontal disease risk,

oral cancer risk and tobacco user status into the current fitness classification system. By doing so,

the program will represent a more valid assessment of the oral health status and preparedness of

CF personnel, and will allow resources to be more effectively targeted. Provider adherence to

these population risk protocols will facilitate the use of preventive procedures and may provide

some relief to the CFDS burdened recall system by assigning an 18 month and 24 month recall to

low risk patients. Dental hygiene appointments can nonetheless be prescribed in shorter time

intervals as necessitated by a patient’s needs. Furthermore, quality assurance criteria must also be

integrated into the CFDCP and monitored routinely, in order to ensure that structural, process

and outcome components are being carried out efficiently and consistently in all 26 detachments.

Similarly, the CF Health Information System (CFHIS) and Dental Information System (DentIS)

must be overhauled and aligned to function in accordance with a modernized CFDCP. The

collection of population health risk measures and outsource treatment data should be included in

DentIS. Additionally, dental health planners should be able to extract aggregate information

captured in the CFHIS, such as forensic dental chart data and treatment plan time units, in order

to assess population oral health status and treatment workload.

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Disparities in access to care in newly enrolled members should be addressed. A horizontally

equitable model, such as the approach used in the British army whereby all recruits access

routine dental care during training, is suggested. Incorporating synchronized block appointment

scheduling during BMQ training would establish dental readiness on new members at the earliest

point in their military career, decreasing the number of future emergencies and the likelihood of

deterioration of existing dental pathology. Ultimately this would also decrease the necessity of

more significant and costly definitive care and time away from the workplace. Secondly, it

would focus sufficient and appropriately skilled dental resources to two dental detachments (St

Jean, Borden), thereby increasing efficiency and cost-effectiveness. Thirdly, it would eliminate

inequalities in access to care between officers and NCMs. Fourthly, it would champion oral

health promotion and oral health behaviors on an equal degree of importance with dress and

deportment, physical fitness, general hygiene and other military attributes strongly emphasized

during BMQ, which could in turn lead to dental care cost savings over a member’s career.

The significant amount of outsourced dental treatment in the recruit population, and in the CF

population as a whole, stands out as a notable concern because of the implications on cost-

control and quality of patient care. The CFDS must study the treatment needs of distinct

demographic groups that exist on CF bases and examine whether dental detachments are

employing an appropriate compliment of primary care providers and auxiliary staff to meet

patient needs, in a cost-effective manner. In addition, further investigation is warranted to

determine the efficiency and effectiveness of the current employment of dentists and clinical

specialists (CBI 204.217), and to explore alternatives that will mitigate their non-clinical

responsibilities so that they may be more gainfully employed in the clinic.

In 1974, the CFDS had an establishment of four dental public health (DPH) specialists. At one

time, DPH specialists were employed at recruit training bases CFB St Jean and CFB Cornwallis.

However after the cutbacks in the 1990’s, the CFDS divested all but one established positions for

a DPH specialist. The Royal College of Dentists of Canada recognizes DPH specialists for

having a broad knowledge and skills in: oral epidemiology; oral health interventions; health

status monitoring; DPH program planning, implementation and evaluation; oral health

promotion; and health program management and financing of dental care. It is strongly

recommended that the CFDS reestablish a minimum of two DPH positions.

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Preface

In 2006, following Canada’s expanded operational role in Afghanistan and the election of the

Conservative government, came the impetus to increase regular force strength of the Canadian

Forces (CF) to at least 75,000 personnel (1). At the time, the regular force strength stood at

roughly 61,000 members while the regular force intake between 2002 and 2005 averaged

approximately 4,300 new personnel per year. The revived state of force expansion has resulted

in an intensified strategic intake plan that targets approximately 8,000 new personnel annually

(2). The sudden rise in the number of new members requiring training and support has placed

greater demands on all CMP (Chief Military Personnel) resources, including the CFDS

(Canadian Forces Dental Services).

Dental treatment needs of a population will vary in accordance with demographic composition.

Understanding variations in dental service utilization by demographic and other variables

provide a basis for predicting how dental services may be used (3). The demographic

composition of new CF members is quickly transforming in response to changes in recruitment

and retention policies, the appeal of improved service benefits, the state of the economy and

national unemployment levels. An analysis of the demographic shift that is currently taking place

in the CF will facilitate evidence-based planning so that the CFDS can fulfill its mandate.

Historically, the dental condition of recruits on enrolment has presented a heavy treatment

commitment on the CFDS (4, 5). Newly enrolled personnel have displayed high levels of dental

disease requiring a substantial amount of treatment. In the U.S., recent studies reported that

42% of incoming army recruits had at least one dental condition that rendered them non-

deployable (6), and that oral surgery accounted for the greatest proportion (32%) of recruit

treatment costs (7). In the United Kingdom, it has been reported that the dental health of the

British army has been in decline for the past 10 years and that one of the major factors

contributing to the decline was the increasing number of recruits who enlist with outstanding

dental needs (8).

There has been an absence of recent research data examining the dental treatment needs and

costs involved in enabling the operational dental readiness of newly enrolled CF personnel. This

thesis presents a compilation of research and information concerning the dental treatment

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requirements of Non Commissioned Member recruits and Officer candidates who enrolled in the

Canadian Forces in 2007 and 2008. Statistical analysis of these data are meant to fill gaps in

knowledge regarding the treatment needs of newly enrolled personnel in the Canadian Forces,

and hence, will be of especial value in determining the resources and professional activity

necessary to meet treatment requirements.

In addition, current normative dental treatment needs statistics pertinent to the young adult of

recruit age are not available in Canada. A national study to collect such data would be very

expensive due to the distribution of the population and the difficulty involved in standardizing

treatment providers in different regions of the country. Since the provision of treatment in the CF

is guided by the Canadian Forces Dental Care Program (CFDCP), this study will increase our

knowledge of dental treatment needs and costs of a national population sample, transitioning

from a civilian to a military environment, in accordance with established criteria. Newly

enrolled CF members are mostly male, and arguably representative of healthy, employable,

young adult Canadians.

The body of the thesis is divided into 5 chapters. The first chapter is intended to be an overview

of the operations of the CFDS. For those who are unfamiliar with military dental services, this

chapter puts into context the mission and objectives of the dental services, and provides a

rationale into the delivery of dental treatment and the collection and monitoring of military oral

health data.

Chapter 2 reviews current and historical literature concerning the oral health status of newly

enrolled members in the CF and in foreign military services. Recent Canadian oral health data

will also be reviewed. The general scope of this chapter is to describe and compare the oral

health status of new military members as they transition from civilian to a military life, and the

oral health status of the Canadian population that is of similar age.

Chapter 3 (Manuscript 1) is a descriptive analysis of the demographic and dental treatment

provided to members that enrolled in the CF in 2007 and 2008. This manuscript will describe the

treatment needs of a national and divers sample of young adult Canadians and assess regional

differences in treatment needs, based on the member’s home province at the time of enrolment.

The generalizability of the recruit population to the Canadian population at large will also be

considered.

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Chapter 4 (Manuscript 2) is an analytical study that explores the association between census tract

income data and the dental treatment requirements of the young adult military population. This

manuscript will examine the validity of using neighbourhood area-based measures to determine

population dental treatment requirement. Information such as this could potentially assist

population oral health planning and surveillance activities.

Chapter 5 (Manuscript 3) is a descriptive study that will examine the footprint that is being

created by new recruits from the time they enter the CF up until they are rendered dentally fit.

Uncovering the dental detachments that are most affected by incoming recruits will enable dental

resources to be predictably managed so that optimal and timely care can be provided.

Additionally, this manuscript will assess the proportion and type of treatment that is being

outsourced. The findings will inform human resource planning so that the CFDS can ensure an

ideal mix of primary providers and auxiliary personnel to look after the needs of CF members.

It is hoped that the knowledge gained from this thesis will assist the CFDS to improve the

delivery of dental services and the oral health of CF members, and provide valuable insight into

the dental treatment needs of the young adult Canadian population.

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“The concept of need is at the core of health care planning. Panning health

services is, in turn, rooted in the ethical imperative to use resources

appropriately.”

Aubrey Sheiham and Georgios Tsakos (99; p.59)

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1 Overview of the Canadian Forces Dental Services (CFDS)

1.1 CFDS structure and personnel

The Canadian Forces (CF) comprise the singular unified armed forces of Canada and include an

Air, Maritime and Land Force Command. In 2009, the CF consisted of approximately 68,000

Regular Force personnel and 20,000 Reserve Force Personnel (9). Members serve on Canadian

military bases, NATO bases outside of Canada, navy vessels and on operational deployments

and attachments around the world.

The CFDS are responsible for the provision of comprehensive dental treatment services to the

Regular Force members and Reserve Force members on extended full time duty (approximately

7000 personnel). Additionally, the CFDS provides emergency treatment to non full duty

Reserve Force members. Dental treatment is delivered through 24 in garrison dental

detachments in Canada and two in Europe. The dental detachments are listed at Appendix 1, as

well as their designation as a specialty centre, mid-size clinic with an Advanced General Dentist

(AGD) specialist, or dental detachment with general dentistry. Dental detachment operations

and treatment delivery is comparable to a prepaid managed healthcare staff model, whereby all

clinics are owned by the Department of National Defence and dentists, dental hygienists, dental

assistants and auxiliary staff are salaried employees of the organization.

As of April 2010, the CFDS employed 651 personnel. The health care staff consisted of 139

military general and specialist dental officers, 175 dental technician assistants and 19 dental

technician hygienists, 44 civilian general dentists, 137 civilian dental assistants, 65 civilian

dental hygienists and 72 clerical staff on a full or part-time basis. The CFDS employed 36

military dental specialists under salary (CBI 204.217). The set establishment included 5

periodontists, 5 oral surgeons, 4 prosthodontists, 14 AGD specialists. Additionally, the CFDS

employed 7 AGDs and 3 prosthodontists and 2 periodontists in the ranks of Lieutenant Colonel

and Colonel who did not count against the set establishment. Despite employing 651 personnel

and being responsible for the provision of comprehensive dental services to approximately

75,000 CF regular and reserve force members, the CFDS establishment currently includes only

one position for a dental public health (DPH) specialist. Population oral health planning is

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largely carried-out by general dentists and dental clinical specialists who have not had the benefit

of any formal training or possess the core competencies of a DPH specialist in Canada, as

defined by the Royal College of Dentists of Canada (RCDC) (82).

Clinical specialists in the CFDS have benefited from subsidized dental training and are

remunerated with a specialty pay allowance. Nonetheless, a substantial amount of specialty

dental treatment is referred to civilian dental practices on a fee-for-service basis. In recent years,

the CFDS has struggled to keep up with basic dental treatment needs and has also had to

outsource a significant portion of the basic dental treatment workload. Medavie Blue Cross is

the dental third party provider for the CF. From April 2007 to Mar 2010, the CFDS paid more

than $27.4M to civilian dental practices for the provision of dental treatment to military

personnel (11).

Currently, the CFDS are in the middle stages of implementing Operation RESTORE, the planned

initiative to increase the establishment of dental personnel, from 528 to 684, as a measure to

address the rising dental treatment workload, which is being experienced in nearly all CF dental

detachments (12). Op RESTORE is based on the commonly used population ratio planning

method that expresses the supply of human resources in terms of number of patients per health

care worker. In particular, Op RESTORE compares dental provider/population ratios in recent

years to those of the early 1990’s (12). Although this methodology is simple and requires

minimal data and analysis, it does not address the dynamics and determinants of health service

utilization, nor does it address demographic and treatment need differences that are known to

exist between CF bases and wings. In addition, population ratio approaches do not consider the

effect of technology, the changing patterns of disease and the role and efficiency of primary and

auxiliary healthcare workers (13).

1.2 The Canadian Forces Dental Care Program (CFDCP)

The mission statement defines the purpose of an organization. The mission of the CFDS as

stated on the National Defence website:

“To enable the CF to fulfill its operational role, the CFDS will provide high quality,

operationally focused dental care, at home and abroad, which establishes and sustains a

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high state of readiness and is both consistent with the scope of dentistry available to the

Canadian population and appropriate to the needs of the member (14).

The CFDS mandate calls for a functional level of dental fitness that ensures soldiers, sailors,

airmen and airwomen are always dentally ready to be deployed anywhere in the world for

military operations. At the individual level, members must be free of pain and discomfort; have a

functional occlusion allowing for communication, mastication and ingestion of a balanced

adequately nourishing diet; and possess a degree of oro-facial aesthetics sufficient for normal life

in society (12). The CFDCP defines the dental fitness classification system and dental fitness

goals of the CFDS. The CFDCP also sets the standards of knowledge and practice by defining

the normative needs of CF members in a logic system that specifies the decision conditions

which justify diagnosis and treatment. Providers are trained to deliver treatment in accordance

with the CFDCP’s detailed guidelines. Criteria are described for all dental disciplines, dental

conditions and treatment categories. As such, the care provided by military dental providers

maintains a consistent level and the relative performance of all 26 CFDS dental detachments is

comparable. Not only does this arrangement enable comparative assessments between CFDS

clinics and providers, it arguably also enables the consistency of research into the CFDS

programs and population treatment needs.

The CFDCP is not a recent document. It was originally developed in 1983 and implemented in

1985. Revisions and modifications to the program were made in 1992 and 1999, which now form

the basis of the latest version of the document. Where the CFDCP falls short is that it does not

include a detailed population monitoring and evaluation component. Its main method of

monitoring program success is the goal attainment of 90% dental fitness across the CF, a

measure which the CFDS has fallen well short of over the past decade. To be sure, the CFDCP

is in need of a review in order to become better aligned with modern dental information systems

that systematically collect, analyze and report on program structural, process and population

health measures.

1.3 Military Dental Fitness Classification

Military dental services use dental fitness classification to determine the deployability status of

members and to predict which patients are most likely to experience a dental emergency within a

12 month period. The principle objective is to measure population oral health status and

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establish a metric for unit and forces-wide dental readiness, which can be communicated to

commanders. Dentally fit personnel have been shown to experience fewer dental emergencies

while on deployment. Chisick and King reviewed the literature on dental casualties and

concluded that dental emergencies ranged from as low as 65.8 to as high as 259 per 1000 soldiers

per year (15). In their review of the literature pertaining to dental casualty rates, Mahoney and

Coombs found studies to be fairly consistent “in that a well-prepared dentally fit force can expect

150-200 dental casualties per 1000 soldiers per year. If the force were less prepared, as in the

case of a reserve callout, this figure would be likely to increase; in the extreme case of an ill-

prepared force or a force assisting in humanitarian aid, the emergency rate could be five times

that figure” (16). Dental emergencies, in an active theatre of operations, put many lives at risk

when the dental casualty must be transported to a dental facility. Furthermore, in today’s highly

technological force that depends on each soldier’s unique experience and knowledge in team

tactics, a unit’s effectiveness could be seriously compromised if members were to be evacuated

for dental reasons (17).

Most NATO nations classify dental fitness into four categories in accordance with NATO

Standard Agreement (STANAG) 2466, which was published in 1998. Category 1 implies

complete dental fitness. Category 2 means dental treatment is required but the condition is not

expected to cause a problem within the next year. Category 3 signifies that treatment is required

and that the condition is expected to cause a problem within the next year. In category 4, dental

fitness is undetermined because a dental examination is overdue. Personnel in dental fitness

categories 1 and 2 are considered deployable. The NATO definitions, and in particular the

definition for what conditions constitute category 2 and 3, are not entirely precise and can be

subject to varied interpretation. Some nations, including Canada, apply policies and rules to

categorize certain conditions while other nations leave the interpretation up to the clinicians. As

a result, this lack of consistency makes research and fitness level comparisons between national

militaries highly unreliable.

The CF classifies its military personnel into four dental fitness categories (Appendix 2) based on

the NATO STANAG 2466. The CFDS has an established goal of 90% dental fitness (class 1 and

class 2 combined). Since 1996 the CFDS has failed to reach this goal, averaging between 74%

and 83% dental fitness. The majority of members that were unfit consisted of class 4

“undetermined”, thus in actuality, if the undetermined were examined, the true fitness levels

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would likely be better than what performance measures indicate. Staffing issues are largely to

blame for the continuing shortfall in the dental fitness attainment goal. It is also important to

note that dental fitness of students/recruits is not included with that of the regular force. The

dental fitness of recruits is normally between 45% and 55% at any given time. As of 13

September 2010, it was 53.4% (18).

When put in practice the required fitness level for class 2 in the CF is much higher than what is

expected under the NATO STANAG 2466. Dental Fitness standards for class 1 and 2 in the

CFDCP are far more rigorous (Appendix 3). Strict adherence to these specific guidelines is the

main reason why there are typically a low number of emergency dental procedures observed

among deployed CF members as compared to military members of other nations (19). It is also

worth noting that the risk of deploying a class 3 or class 4 members is extremely low. All

members are required to have a dental screening within the six month period prior to

deployment. The CFDS prioritizes dental resources to CF bases of deploying units in order to

ensure the dental fitness of members being deployed.

Despite being a good triage tool, dental fitness classification has been shown to be a poor

predictor of dental emergencies in individuals. For this reason, an Australian study is currently

underway to establish a predictive risk-based dental classification system (20). A considerable

portion of dental emergencies, even in class 1 and 2 personnel, are impossible to predict.

Restored teeth can fracture and acute pulpitis, aphthous ulcerations and pericornitis may occur

without warning. Simecek et al found that 58.4% to 70.3% of dental emergencies were non-

preventable and that only 11% of all dental emergencies occurred in class 3 personnel (21).

Assessing risk is challenging for all population health planners; in the military, risk assessment

becomes that much more significant. When options are limited, commanding officers of

deploying units need accurate probability information in order to gauge whether they can

manage the risk of deploying class 3 personnel. For obvious reasons, the risk of deploying a

class 3 member will have different implications on a submarine versus a domestic operation in a

non-remote area in Canada.

In 2002, the UK Defense Dental Agency replaced the dental fitness categories in NATO

STANAG 2466 with a dental risk category system that classifies a member as either low,

medium or high risk of experiencing symptoms related to a dental pathological condition over

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the next year (22). This was done partly because, over time, the dental fitness category 2 was

designated only to members requiring elective procedures, rather than those with minor

pathological conditions. This resulted in a higher proportion of military members being deemed

unfit for deployment, much to the dissatisfaction of unit commanders. A 90% performance

target in the low and medium risk was set under the new system. This target was surpassed in

ensuing years, but this did not mean that the overall oral health of the military was improved; it

just made it more helpful for commanders to gauge the dental risk for deployment. It is still

uncertain whether the predictive value of risk is improved under the new system, but an early

study found the results to be poor (22).

1.4 CF Health and Dental Information Systems

The CFDS utilizes two separate electronic databases to track and capture patient fitness and

treatment information. The Dental Information System (DentIS) stores dental fitness

classification, Periodontal Screening Record (PSR), smoking status, caries risk and oral cancer

risk data and provides an accurate account of the dental treatment a member has received in

CFDS clinics during his/her career. Procedure codes and associated fees recorded in DentIS are

identical to codes and fees that were utilized by the Ontario Dental Association, in 2006. This

feature enables the comparison of dental treatment delivery and associated costs with those of the

civilian population. Population health status and treatment provision reports can be generated

from DentIS.

Since 2001, despite having the ability to capture significant population health metrics such as

tobacco use, caries risk, periodontal risk and oral cancer risk, the CFDS have shown poor

consistency in collecting this information. Table 1 and 2 shows a snapshot taken of tobacco user

and caries risk data on June 01, 2010. The status of more than half of the military population is

unknown. Furthermore, DentIS is only capable of tracking the periodontal disease risk and oral

cancer risk status of patients at the individual level and not at the population level. The lack of

adherence to the collection of this information implies that population health metrics can not be

used to help improve overall health and enhance the delivery of dental care. For one, these

measures can serve as a tool to augment clinical judgment and enable providers to use clinical

based protocols described in the CFDCP. Secondly, these health measures can be used to

enhance the dental classification system’s ability to attribute risk. Lastly, proper adherence to

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these population risk protocols may provide some relief to the CFDS’s aggressive and thus

burdened recall system. For example, a member who is not a tobacco user and who is at low risk

for caries, periodontal disease and oral cancer can be assigned an 18 month or 24 month recall

period, whereas a member who is of moderate or high risk for any of the categories may not be

assigned a recall period of greater than 12 months. Since most CF personnel fit into the former

group resources can be prioritized to higher risk individuals. Research findings on US Navy and

Marine recruits showed that “subjects identified as being high caries risk demonstrated

significantly higher restoration replacement rates than did low caries risk subjects” (23). In 2006,

Byrappagari et al showed that a strong association exists between dental fitness categories and

caries and tobacco risk in US Army active duty soldiers (24). Population health strategies are

also fully compatible with the common risk factor approach since the solutions to chronic disease

conditions have shared solutions (25). High risk patients will benefit from the knowledge of

knowing their disease potential and this may empower them to improve their oral health and

general health.

Another area where DentIS falls short is that it does not store a record of dental treatment that is

outsourced to civilian dental practices. As the amount of treatment that is outsourced has been

increasing in recent years, this information becomes increasingly important. Human resource

planning and staffing decisions to address resource deficiencies can potentially be insufficiently

informed. Matching the appropriate mix of skilled dental providers and auxiliary staff requires a

thorough understanding of population dental treatment needs. Outsourced treatment can be

requested through the Federal Health Claims Processing System, but this necessitates additional

requisitions and measures for data integration.

The CF Health Information System (CFHIS) database maintains the electronic health records of

CF members. The dental components of the CFHIS include treatment records, diagnosis,

treatment planning, dental charting and procedure codes. A detailed schematic dental chart is

produced on every new member enrolled in the CF. Colours on the chart are used to represent

different types of restorations and decayed tooth surfaces. This chart is updated automatically as

treatment procedures are completed and entered. The patient colour chart and drop box for

recording diagnosis, present good opportunities to assess, in real time, the oral health status of

serving members and newly enrolled members. Moreover, the treatment planning section which

links procedures to time units can potentially be utilized to predict treatment workload.

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Unfortunately, in terms of population health planning the CFHIS is of little use as none of the

data that are collected and stored can be extracted for analysis, at the present time.

1.5 Summary

The CFDS employs 651 personnel and is responsible for the comprehensive dental treatment

needs of more than 75,000 Regular and Reserve Force personnel. The mandate of the CFDS is to

ensure a high state of dental readiness and to provide quality oral health care that is appropriate

to the needs of CF members. Dental fitness standards are based on STANAG 2466 and goals are

defined by the CFDCP. In recent years dental fitness levels for the CF have dropped below 75%.

In order to address the treatment deficit, the CFDS is currently in the process of increasing the

establishment of dental personnel. Concerns have been raised regarding the validity of the

fitness classification system as a predictor of dental emergencies and dental readiness such that a

review of the CFDCP is required to modernize standards and incorporate population risk

assessment metrics and quality assessment criteria into the program. Similarly, DentIS and

CFHIS need to be overhauled in order to collect and report on population health metrics,

outsourced treatment data and epidemiological statistics. To be sure, dental public health

planners in the military require current and pertinent data to accurately assess population oral

health status and program effectiveness.

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2 Literature review of Canadian young adult and military recruit dental treatment needs

2.1 Introduction

Dental public health planners and policy makers, both within and outside the military, require

knowledge of the major determinants of population oral health and treatment requirements, in

order to ensure that programs and funding are reaching those that are in need of treatment.

Nevertheless, there is a scarcity of Canadian normative dental treatment needs data for young

adults; the little data that are amassed have many limitations. Ideally, information on dental

treatment needs, on a national level, would have to be collected through a survey specifically

designed for such a purpose or systems that capture dental treatment data according to a

standardized set of criteria. Provincial, territorial and federal health departments do collect dental

treatment statistics for the general population, but it is often in a form that makes its use

problematic. Some provinces, such as Quebec, may collect treatment statistics as part of

conducting their children’s oral health program; however, these data are mainly used for

financial expenditure monitoring. Other regional public dental insurance programs provide only

limited treatment coverage for adults who are eligible for social assistance benefits. Private

dental insurance providers may keep track of dental treatment information, however, the

treatment that is provided to, or purchased by, a client who is covered by a plan may differ from

that which is provided to, selected or requested by a client that must pay all treatment expenses

out-of-pocket. In addition, treatment plan recommendations will vary from one dental provider

to another, as a result of deferring levels of training, skill and experience. Because of the

potential confounding created by the variation in the access and provision of dental care, neither

public nor privately funded treatment data would be an accurate and reliable representation of the

dental treatment requirements of the average young adult Canadian. A significant advantage in

using military data is that dental treatment in the CF is provided in accordance with standardized

criteria established in the CFDCP. As such, it represents a clearer picture of actual treatment

needs and costs. Although military data has its own limitations, such as sex distribution, it is

more readily available, and at no extra cost.

Historically, military oral health studies and surveys on recruit populations have presented

unique opportunities to reveal insight into the oral health status and dental treatment

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requirements of a national young adult segment of the population. Research findings may be

partly or completely generalizable on a national scale, with limitations. For instance in Israel,

since military service is compulsory with the entire 18 year old male and female cohort being

recruited every year, findings should be representative on a national scale. In Greece and

Turkey, where military service is compulsory for men, research findings would be generalizable

for the male population of those countries. On the other hand, in countries such as the USA,

Australia and Canada, where military service is voluntary, research findings will not be as

generlizable. The demographic composition of new members enrolled in volunteer military

services is influenced by recruitment and retention policies, the appeal of service benefits, the

state of local and the national economies and unemployment levels (26). An appropriate

description that characterizes newly enrolled members in the CF is: a healthy, employable young

adult population, with a significant male bias, and from a diverse socioeconomic and

geographical background.

Since the early 1970s, there has been an absence of published research involving the oral health

status and treatment requirement of newly enrolled and regular force CF members. However, the

dental services of other national militaries around the world have proactively produced a

considerable research base that may provide some indication as to what dental research findings

may be expected in the CF. Similarly, in this respect, civilian Canadian dental research may also

provide some clarity. This chapter will review current and historical dental research regarding

the oral health status and determinants of oral health of the young adult Canadian population.

This chapter will also examine research regarding dental treatment requirements and dental

service utilization of military recruits in the CF and in foreign militaries.

2.2 Young adult oral health and the determinants of oral health in Canada

Oral health surveys provide valuable insight on the oral health status of a population.

Information from the 2007-2009 Canadian Health Measures Survey (CHMS) (27) identified

which segments of the Canadian population could be expected to have the highest dental

treatment needs. For instance, lower income individuals, persons without insurance, individuals

born outside Canada and households with less than a degree or diploma, tended to have higher

DMFT values, a greater number of decayed teeth and higher incidence of self reported oral

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health impacts. It is therefore reasonable to assume that the aforementioned groups would also

have higher dental treatment requirements. In addition, among all the stratified age groups of the

CHMS, the 20 to 39 year age group had the highest prevalence of self-reported poor oral health;

the highest prevalence of persons reporting the avoidance of foods because of problems with

their mouth; the highest prevalence of persons reporting persistent pain in their mouth; the lowest

percent of individuals reporting visiting a dentist within the last year for any reason; the lowest

percent of persons reporting visiting the dentist at least once per year; the highest percent of

individuals avoiding visiting a dental professional because of costs; and the highest percent of

individuals declining recommended dental work because of costs. In addition, with the

exception of the elderly, the 20 to 39 year age group had the highest prevalence of uninsured

individuals. Consequently, the 20 to 39 year age group, which also makes up the majority of

new members enrolling into the CF, could be expected to be among the age groups with the

highest dental treatment needs in Canada.

The epidemiological findings on caries severity, described by the CHMS (27), which are

pertinent to the newly enrolled population in the CF, are described in Table 3. Following the 20

to 39 year age group, there is a fairly large proportion of CF recruits aged 16 to 19 years. There

is also a much smaller proportion of newly enrolled members 40 to 59 years of age. As would be

expected, the CHMS reported that DMFT scores increased with age. The age group with the

highest mean number of decayed teeth was the 20 to 39 year age group. Adult females showed a

higher number of mean missing and filled teeth and a lower number of mean decayed teeth

suggesting that they had a higher tendency to utilize dental services and may thus have fewer

restorative treatment requirements than males. Adults born outside of Canada displayed a

slightly higher average number of decayed teeth, while adults residing in a household where the

highest education level was less than a degree/diploma had more than double the average number

of decayed teeth in comparison to those residing in a household where the highest education

level was a degree/diploma. With regards to newly enrolled military members, these findings

suggest that new members who were in their twenties and thirties at enrolment, who were born

outside Canada and who have less than a high school education, will likely have higher

restorative treatment needs. Nevertheless, it is important to note that the examiners of the CHMS

did not utilize radiographs in their assessments. Becker et al compared the DMFT index with a

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modified DMFT index with radiographs and found that without radiographs there was a 44%

probability that DMFT scores would be underestimated (28).

The CHMS also reported epidemiological results on the prevalence of periodontal conditions

according to CPITN scores. Findings pertinent to the newly enrolled population in the CF are

described in Table 4 (27). These findings suggest that new members who are male, older, born

outside Canada and who have less than a high school education will probably have higher

periodontal treatment requirements. Nonetheless, because the CHMS protocol only captured

recordings on 10 index teeth, the findings “may over- or under-represent the severity of the

disease in an individual participant” (27). Partial recordings on 10 index teeth have been shown

to underestimate the prevalence of subjects with at least one 6 mm periodontal pocket (29). A

1994 regional oral health survey that examined 2110 Quebec adults aged 35 to 44, reported that

21.4% of individuals had at least one tooth with a periodontal pocket ≥ 6mm, and that men were

1.9 times more likely to have a pocket ≥ 6mm than women (30). The findings of the regional

study were much worse than what was reported in the CHMS, and may be explained by regional

differences, differences in methodology for collecting data, or a possible improvement in

periodontal health since 1994.

The dental examiners of the CHMS recorded information on the treatment needs of Canadians

who participated in the survey. This was carried out according to a hierarchy of need

methodology consistent with a 1978 ADA (American Dental Association) publication (31) and a

work conducted by Otchere et al. (32) on an elderly population in Ontario. In the CHMS findings

it was reported that nearly two thirds, 66.8% of Canadians age 20 to 39 years, had no treatment

needs identified at examination (27). Furthermore, the hierarchy of treatment needs was reported

as follows: 1.8% had at least one urgent need, 11.5% had surgical needs, 1.8% had endodontic

needs and 14.1% had restorative needs (27). In their breakdown of the treatment needs of

various age groups, many estimates were not provided because of extremely high sampling

variability or low sample size. Another noteworthy consideration is that the CHMS examiners

did not have access to dental radiographs. Without dental radiographs interproximal carious

lesions are less likely to be diagnosed (33) and certainly periapical lesions and pathology

associated with impacted teeth would be almost impossible to detect. Thus, the treatment

requirement findings provided by the CHMS are most reliable for comparison with other

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population surveys using the same methodology, and likely represent an underestimation of

need.

Prior to the 2007-2009 CHMS the only complete national examination survey of all ages was

conducted between 1970 and 1972 as part of the Nutrition Canada National Survey (NCNS)

(34). According to the findings of the Nutrition Canada Dental Report (NCDR), 96.1% of adult

Canadians had experienced coronal caries and the mean DMFT was 17.5. In the early 1970’s, the

prevalence and severity of dental caries in young adults was higher than it is today (Table 5).

More importantly, the mean number of reported decayed teeth is much lower in the CHMS in

comparison to the Nutrition Canada Survey. These findings suggest that the dental treatment

needs were more severe in the past. As the population aged the number of decayed teeth

decreased in part because the number of missing teeth increased. As such, the requirement for

prosthodontic treatment was much more prevalent in the young adult population of the 1970’s.

Although national surveys are good sources of dental epidemiological information, national level

data will not be as representative of some regions, especially in a country that is as large and

diverse as Canada. In a review of North American dental data, in 1994, Burt found

“considerable geographic variations in caries experience in the general populations of the United

States and Canada; the highest prevalence and severity [was] found in Quebec” (35). In a

separate study Brodeur and colleagues noted that Quebec had a higher prevalence of edentulous

people and a much higher average number of missing teeth among its population (36). Regional

variations in oral health status may be partly explained by dental service utilization, access to

care and dental insurance coverage. Millar and Locker reported that income and insurance are

important determinants of dental service utilization and that the lowest rates of insurance

coverage were in Quebec and Newfoundland (37). More recently, in an analysis of 2003

Statistics Canada Canadian Community Health Survey data, Bhatti et al. found that the

“probability of receiving any dental care over the course of a year was lowest in Newfoundland,

Quebec, Saskatchewan, and New Brunswick, and highest in Ontario, Manitoba, and British

Columbia” (38; p57c). The authors also noted that the probability of receiving dental services

varied by region and suggested that the observed differences may be attributed to the supply of

dentists. Provinces with the lowest dentist-to-population ratios, in 2002, were Newfoundland,

Saskatchewan and New Brunswick; whereas, the highest ratios were found in Ontario and British

Columbia (38).

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Considerable geographic variation was described in the NCDR with regards to the prevalence

and severity of treatment requirement for dental restoration (Table 6) and tooth extraction (Table

7). Due to insufficient examiner calibration and small sizes of certain age/sex groups “extreme

caution should be exercised in interpreting the results [...], particularly in the less populous

provinces” (34). Despite the limitations of the data it is evident in Table 6 that the requirement

for restorations peaked between the age of 20 and 40 years, and that needs were greatest in

Newfoundland and lowest in Ontario. In terms of the prevalence and severity for dental

extraction requirement (Table 7), there is much variability between jurisdictions; no clear general

trend emerges from the analysis of the data. Nationally, prevalence of tooth extraction for

females appeared to peak at the age of 19. For males, there was a peak at the age of 19 followed

by another peak between 50 and 59 years of age.

Since 2006 the CF have streamlined their recruitment policies and have made it easier for new

immigrants to join the military (39). Culture and ethnicity are well recognized determinants of

dental service utilization and oral health (3). Locker and Matear reported that 73% of Canadian

born adolescents presented for regular preventive dental visits compared with 43% of those who

had immigrated (40). Moreover, in a group of 13 to14 year-olds, 3.5% of those born in Canada

needed restorations compared with 13.6% of those born outside Canada (15). More recently, the

findings of the CHMS were also in agreement, demonstrating that adults born outside of Canada

had a higher prevalence of decayed and untreated teeth (Table 3) (40). Cultural differences may

also explain significant differences in oral health status measures between English and French

speaking Quebec residents. Brodeur et al reported that in Quebec adults, aged 35 to 44 years,

Anglophones had an average of 5.9 missing teeth while Francophones had an average of 8.5

missing teeth (36). Over the last 10 years, Canada has been receiving an average of 250,000 new

immigrants per year, the majority of whom originate from south-east Asian countries (41). It is

reasonable to assume that differences in oral health status and treatment needs will also be

reflected between Canadian and foreign born newly enrolled members. Similarly, differences

may also be found between English and French speaking members enrolling in the CF.

Socioeconomic status, as measured by education, income, occupation and place of residence, has

been shown to be an important determinant of dental service utilization and treatment

requirement (3). Lower income groups, are less likely to have dental insurance, use dental

services less frequently, and when they do, it is more likely to be for emergencies rather than

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preventive services (27,37). In their summary of recent research evidence, Locker and Matear

reported that for Ontario adolescents between 18 and 19 years of age, 85% of those from

advantaged households (high income with dental insurance) versus 53% from disadvantaged

households (low income without dental insurance) had seen a dentist in the previous year (40).

In addition, more than one third (37%) of adolescents from disadvantaged households only

visited a dentist when having pain or other trouble, compared with 7% from advantaged

backgrounds (40). Studies in Canada have shown that lower education status is associated with

less frequent visits to the dental clinic (27, 37), and with poorer oral health (42.43).

Individual level socioeconomic data is not normally collected on newly enrolled personnel.

Nevertheless, there has been a growing interest in the influence of neighbourhood socioeconomic

position and characteristics on oral health. Evidence suggests that area level measures of socio-

economic characteristics are better predictors of health than individual level socio-economic

characteristics, and provide additional explanatory power to models of health inequalities (44).

In a 1996 study, Locker and Ford found that the mean household income of the area in which

subjects resided had an effect on oral health and health related behaviours that was independent

of their individual household socio-economic status (45). Several recent studies have also

concluded that the contextual effects of neighbourhoods are significant contributors to

population oral health, perhaps even more than individual based explanations (46-49). In

Canada, it has been demonstrated that census tracts are good proxies for natural neighbourhood

boundaries in studies of neighbourhood effects on health (50). Hence, in the absence of

individual level socioeconomic data on new members, census tract data from home residence at

the time of enrollment may be utilized to predict dental treatment requirement. Moreover,

neighbourhood socioeconomic advantage would be expected to be inversely related to dental

treatment needs.

2.3 CFDS studies on recruits

The dental treatment requirements of newly enrolled members create a significant burden on the

military dental services. The CFDS have conducted two studies that have examined the oral

health status and treatment needs of recruits. The first and most in-depth study, of new enrollees

was conducted in 1967 (4). The sample population included 2400 male NCM recruits, 160

female NCM recruits and 492 male officer candidates, with 99% of the sample between 17 and

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24 years of age. All members involved in the survey also filled out a questionnaire that was

designed to obtain socioeconomic background and dental behavioural information. Only 6.7%

of NCM male recruits, 10% of NCM female recruits and 16.8% of officer candidates were

considered dentally fit at the time of the clinical examination. The remainder were either in need

of urgent care, or care at the earliest opportunity. The DMFT, DMFS and clinical chair time

required to bring the newly enrolled members to a suitable level of dental fitness are shown in

Table 8. The DMFT and DMFS scores were collected through clinical examination with the use

of radiographs and the treatment times were calculated based on treatment plans developed by

examining dental officers. The female NCM recruits demonstrated the highest DMFT and DMFS

scores but also the highest mean scores for filled surfaces and required the least amount of

clinical chair time to be rendered fit, suggesting that females sought dental treatment more

regularly than the males. The male NCM recruits had the highest mean scores for decayed teeth

and required the greatest amount of treatment time. None of the 2400 male recruit sample with a

mean educational level of 9.6 years schooling had visited the dentist in the previous 12 months

while only 3.1% of officer candidates with a mean educational level of 12.1 years had visited the

dentist in the same period of time. The report concluded that the study sample represented a

population of Canadian young adults in the lower socioeconomic scale. This was due to the fact

that the job classification of the fathers of 77.5% of the recruits and 72.6% of the officer

candidates fell below the average Canadian wage described in the 1961 Canadian census returns.

In 1973, the CFDS conducted their second and last epidemiological study of the dental condition

of the CF members (5). The objective of the report was to determine the DMF index and the

treatment needs of recruits. The researchers also investigated differences between male and

female recruits and differences between French language recruits who were processed in

Canadian Forces Base (CFB) St Jean and English language recruits who were processed in CFB

Cornwallis. A sample study population of 533 male recruits (mean age 19.3 years) and 137

female recruits (mean age 20.5 years) were enrolled into the study. The DMFT, DMFS and

clinical chair time required to bring the newly enrolled members to a suitable level of dental

fitness are reported in Table 9. The report concluded that recruits from CFB St Jean (French

speaking) had a higher DMFT score than recruits from CFB Cornwallis (English Speaking), that

female recruits had a higher treatment level index (FT/DMFT) than male recruits and that CFB

Cornwallis recruits had a much higher treatment level index than CFB St Jean recruits. A further

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observation was the high score of missing teeth and low number of fillings of the St Jean recruits

when compared to that of CFB Cornwallis, suggesting that there was a greater tendency to

extract teeth rather than to restore teeth in the St Jean sample. Both the 1967 and the 1973

studies stated that recruits were “from among the lower socioeconomic strata of Canadian

Society and […] have little appreciation of the need for dental care” p.22 (5).

Since the Nutrition Canada study and the 1973 CFDS report were conducted at roughly similar

times, the comparison of results is possible. Nationally, in the Nutrition Canada Survey, the

mean DMFT scores for 19 year old males and females were reported as 12.4 and 13.2

respectively (Table 3) (34). The Nutrition Canada DMFT scores are much lower than the DMFT

scores reported in the 1973 CFDS study on military recruits. Furthermore, conversely to the

CFDS study, the Nutrition Canada survey showed a greater number of filled teeth and a lower

number of decayed teeth. As stated previously, Nutrition Canada examiners did not have the

benefit of patient radiographs, as was the case of the CFDS examiners, which may have resulted

in an underestimation of diagnosis of decayed teeth. Nevertheless, it appears that the dental

treatment needs of a CF recruit at that time were greater than the average Canadian of similar

age. Comparing military dental research findings to the finding of the Nutrition Canada Survey is

a good example of how the dental health status and treatment needs of a military recruit

population is not necessarily generalizable to the national population.

A notable observation between the 1967 CFDS survey and the 1973 CFDS study was that the

oral health of recruits had improved over the six year period and that the mean DMFT of recruits

was found to have increased. The overall treatment time required to bring recruits to a level of

dental readiness was found to have decreased. This was because fewer teeth were being

extracted and more teeth were being restored, thus reducing the requirement for prosthesis. This

observation underlines the influence of shifting military recruit demographics, disease patterns

and technological treatment advancements, on treatment workload. Moreover, this observation

underlines how simply using provider to population ratios, as a method of dental healthcare

human resource planning, is inadequate and can lead to an over or underestimation in health

care workers.

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2.4 Dental research on the recruit population of foreign militaries

In the absence of current CF dental research data, foreign military dental research papers may

provide some insight on current recruit disease rates and treatment workload. Particularly, the

US Army Dental Corps, Navy Dental Corps and Air Force Dental Service publish a steady

stream of dental literature. The standards and procedures practiced by the US military dental

services are consistent with those practiced by the CFDS, and therefore findings should be

comparable.

2.4.1 Historical trends in dental caries experience among military recruits

Studies on military recruits have been influential on community water fluoridation policies on

and off military bases. In the past, various national armed forces have studied the effect of

fluoride by analyzing the oral condition of new recruits when they first join in the military. The

military enrolls new members from a country’s entire geographic region which enables the

evaluation of the oral health status of recruits originating from fluoridated versus non fluoridated

areas. One of the earliest military studies on the effects of fluoridated water was conducted in

the early 1940’s by Deatherage (51). Deatherage investigated the caries experience of 2026

white service men recruits living in 91 Illinois communities whose public water supplies

contained varying concentrations of fluoride. What he uncovered was that recruits living in

fluoride-free areas (0.0-0.1ppm) had a higher caries experience than recruits who lived in

suboptimal fluoridated areas (0.5-0.9ppm), and who in turn had a higher caries experience than

recruits who lived in optimal water fluoridated areas (1.0ppm and over). It was also noted that

fluoridated communities produced fewer recruits that were rejected for military service on

account of their dentition, and fewer recruits that required the fabrication of dental prosthesis

(51).

The Deatherage findings came at a very pivotal time in American military history. Prior to the

American entrance into World War II, in 1942, the US military maintained rigid dental standards

for enlistment. However, as the need for servicemen and women increased the standards were

relaxed. The explanation for the change was, “we are going to fight’em not bite’em” (52).

Following the war the dental standards remained low, but despite the increase in dental treatment

requirement, the number of dental care providers remained unchanged. Adding to the workload

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was the fact that US military dental clinics were also responsible for serving the family members

of personnel and retired personnel.

By 1958 a survey of US Army recruits showed that, on average, every recruit had 7.2 decayed

teeth, required 12.9 carious surfaces to be restored and 1.5 teeth to be extracted (52). The dental

condition of Canadian recruits was not much better. Faced with the increasing workload, the US

began adding fluoride to the drinking water of their military bases, both at home and abroad in

the 1950’s. The Canadian Forces followed the American decision around the same time. Water

fluoridation on military bases was appropriate because most military members and their families

lived in communities and housing that were located on-base. Hence, the impetus to fluoridate

the water of Canadian and American military bases stemmed from the mounting dental

workload, scarcity of dental providers and the results of long term and cross-sectional

fluoridation studies, which supported the efficacy of fluoride in reducing dental decay. The same

justifications that spurred civilian municipalities to adopt community water fluoridation policies.

Nevertheless, starting in the 1980’s military studies in the United Kingdom (53) started showing

that differences in caries experience in recruits residing in fluoridated areas versus those residing

in non-fluoridated areas were no longer as significant as were reported in the past. Studies in

1996 and 2007 on Australian recruits (54, 55) also drew similar conclusions. The authors

explained that the decrease in severity of the disease was probably due to an increase in fluoride

exposure through other sources.

In most western countries, there has been a significant reduction in dental caries over the past 30

years (3). Military epidemiological surveys have also shown changes in the pattern of DMFT

scores. In a comparison of similar aged cohorts over the last 30 years in the Australian military

services, Hopcraft and Morgan found the following DMFT history (54):

In 1966, DMFT ranged from 18.5 to 21.8 for subjects aged 17-29 years;

In 1984, DMFT ranged from 10.9 to 15.3, for subjects aged 15 -29 years;

In 1988, DMFT ranged from 4.3 to 8.9, for subjects aged 15 – 29 years;

In 1996, mean DMFT was 3.59 in subjects aged 17 to 20 years, and 4.62 in subjects aged 21 to 25 years; and

In 2002, mean DMFT was 2.43 in subjects aged 17 to 20 years, and 3.44 in subjects aged 21 to 25 years (56).

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The findings show a continued decline in the severity of dental caries experience in young adult

military members.

Scandinavian countries have also documented consistent decreases in caries severity among

military recruits. In Finland, military service is compulsory for young men. Oral health surveys

conducted on recruits, of approximately 20 years of age, showed mean DMFT scores of 15.8 in

1976, 14.5 in 1981, 12.2 in 1986 and 7.3 in 1991 (57). Oral health surveys of 18 to 25 year old

male Danish recruits reported mean DMFT scores of 16.2 in 1972, 11.8 in 1982, and 6.2 in 1993

(58). Carious lesions are also not progressing as quickly as in the past. A 2001 Danish study,

conducted by Hintze, that investigated the rate of caries progression on recruits concluded that

the “development of new approximal lesions and the progression of enamel caries was a slow

process during the late teens” (59). Hintze found the median caries incidence transition rate from

sound to enamel caries to be 2.4 surfaces per 100 years, and from enamel to the outer half of

dentine to be 9.2 surfaces per 100 years (59).

Without a doubt, military oral health surveys demonstrate that caries severity is decreasing. This

indicates that the dental treatment requirement and time required to render newly enrolled CF

members dentally fit should also have decreased since the 1970’s. The slow progression of

caries also suggests that military dentists can take a more preventive approach and to consider

monitoring dentin lesions rather than immediately opting to restore teeth with dental fillings,

especially in an environment where periodic dental examination is compulsory. In 1999, Cook

suggested that “a risk assessment protocol for treating dental caries can reduce operative dental

treatment recommended at the initial examination and decrease the need for restorative care

during a military career” (60). The delivery of evidence based patient care will help alleviate

unnecessary workload, and at the same time, ensure that high risk groups receive the attention

they require.

2.4.2 Periodontal health of recruits

Periodontal Disease is the second most common oral pathology after dental caries, and increases

in prevalence with increasing age (3). The association between smoking and periodontitis has

also been recognized in the dental literature, although the causal chain is still a subject of

research (3). In 2003, it was reported that the prevalence of current smokers among Canadian

male and females, aged 18 to 34, was 33% and 28% respectively (61). Military research from

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Israel, Spain and the US showed that in recruit populations, the reported use of tobacco was high

(31 to 51 % smoker prevalence) and was associated with higher periodontal screening record

scores (PSR) and inferior periodontal health (62-64). In a 2008 study, that examined the

periodontal health of 20 and 21 year old Israeli adults prior to release from compulsory duty,

Vered and colleagues observed that the periodontal health among males and members with less

than 12 years of schooling was statistically worse than that of females and members with 12 or

more years of schooling (62).

In a study of US Army personnel the prevalence of periodontitis (PSR score of 3 or 4) was

found to be 7.7% in 18 to 24 year olds, 15% in 25 to 34 year olds, and more than 40% in those

aged 35 and older (65). Diefenderfer and colleagues assessed the prevalence and severity of

periodontal disease among 1107 US Navy recruits with an average of 20.1 years of age (64). At

their initial examination, 98% of recruits exhibited some level of periodontal disease, 25.3% of

recruits had a score of PSR 3 and 3.3% had a score of PSR 4. Over a mean time frame of 3.4

years, it was observed that recruits with more than one sextant PSR 4 averaged 1,93 visits

annually for periodontal and prophylaxis therapy, while all others averaged less than one visit

annually. The authors noted that only individuals with destructive periodontal disease are

required to receive treatment in the US Navy and that it remains uncertain whether an increased

frequency of therapy among all members would improve oral health. When dental resources are

scarce in the military, it becomes increasingly difficult to ensure that all members receive

periodontal therapy. Care is normally prioritized to patients who need it most. Since periodontal

disease increases in severity with age, usually young recruits become a low priority. Over time,

this may lead to the deterioration in the periodontal health status of recruits. Ideally, to maintain

periodontal health in all members, preventive dentistry services and periodontal therapy should

be provided early in a career and repeated at intervals specific to a member’s needs (64).

2.4.3 Recruit dental treatment cost

In 1994, the US military dental services conducted the Tri-Service Comprehensive Oral Health

Survey (TSCOHS) of Army, Navy, Marine and Air Force personnel. The TSCOHS investigated

oral health status, dental treatment needs, dental readiness and dental utilization information on a

random sample of 2711 recruits and 15,924 active service personnel (66). Chisick and

Piotrowski estimated the dental treatment cost for recruit and active duty personnel (7).

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Examiners documented treatment needs with the use of radiographs. Costs were based on 1995

US general dentist fees. The total estimated cost for unmet dental treatment need were $1004 per

recruit and $1118 per active duty member. Converted to 2010 costs using the US Department of

Labor’s Consumer Price Index Calculator (67), the estimated cost per recruit and active duty

member was $1436.00 US and $1599 US respectively. The results of the study showed that

recruits had higher mean costs for oral surgical, endodontic and restorative care, whereas the

active duty personnel had higher mean costs for prosthetic and periodontal care. Oral surgery

accounted for the largest proportion (32%) of recruit treatment cost. Oral surgery procedures in

the recruit population largely consist of the extraction of unerupted or partially erupted third

molars. This is not surprising when one takes into account that the average recruit is

approximately 21 years of age. In 1996, Murray and colleagues investigated the reasons for

tooth extraction in general dental practices in Ontario over a one week period (68). Pericoronitis

associated with third molars and impacted teeth accounted for more than 51% of all extractions

in the 13 to 19 year age group, and over 33% of extractions in the 20 to 39 year age group. Pain

from third molars was also identified as the second most common dental emergency, after caries,

at three medical support facilities supporting Operation Enduring Freedom, in Iraq (69, 70). For

this reason, the military dental services are recommended to take a more aggressive stance

regarding the extraction of partially erupted and unerupted third molars (71).

2.4.4 Recruit dental treatment workload

Although oral surgical procedures account for the largest proportion of costs, it is restorative

treatment that accounts for more than two thirds of dental procedures required to convert Dental

Fitness Category (DFC) 3 recruits to DFC 2 (72). Findings from a US Navy study demonstrated

that 30% of posterior restorations on recruits require replacement at the initial examination or

within the first years of military service (23). Significantly more resin based composite

restorations required replacement in comparison to amalgam restorations. Simecek et al also

observed that the ratio for amalgam to resin based restorations decreased from 10:1, in the cohort

reporting for duty in 1997, to 3:1 in the cohort reporting for duty after September 2002. The

shifting trend in the preference of restorative materials delivered in private practices in North

America may signify a greater requirement for restorative treatment on recruits in future years.

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A cohort of Royal Air Force recruits, in 1988, that was followed over 5 years, required an

average of four restorations (73). Additionally, 13.6% of recruits received endodontic therapy

and 9.6 % were provided with crowns. More recently, a survey of dental treatment delivered to

1959 New Zealand recruits who enrolled in 2005 and 2006 showed that, excluding diagnostic

services, 58% of the treatments provided were amalgam or composite restorations, 25% were

preventive and hygiene services, 10% were extractions, and 10 % were made up of a diverse

range of procedures (74).

The 2000 Tri-Service Center for Oral Health studies reported that 42% of US Army recruits had

at least one dental condition that rendered them non-deployable (6). More than 15% of recruits

who were deemed non-deployable had greater than four teeth in dental fitness category 3

(DFC3). In 2002, Chaffin tracked scheduled appointment for DFC3 patients and calculated the

amount of treatment time that was required to render a recruit dentally fit (75). It was estimated

that on average 2.2 hours of clinical treatment time was required. A 2004 survey of dental

treatment needs of British Army recruits found that 22% of recruits enlisted with no outstanding

treatment needs, and 67% necessitated less than 2 hours of treatment time to be rendered dentally

fit for deployment (8).

In 2001, Chisick used regression modeling techniques to predict differences in dental treatment

workload with changing recruit demographics (76). Compared to the 18-19 year old white males

(controls), mean treatment times were lower for female recruits, non-Army recruits, recruits with

more than a high school education and recruits who had seen the dentist in the past year. Mean

treatment times were higher for minority recruits, older recruits and for recruits with less than

high school education.

2.4.5 Recruit dental service utilization

A survey questionnaire that was distributed to recruits prior to examination in the TSCOHS

revealed that 61% of the recruits perceived a need for dental care, including a statistically

significant higher perceived need among female recruits (26). Additionally, it was shown that

38% of recruits had not seen a dentist in the past year, while 30% had not visited the dentist in

over three years (26). This finding substantiates the belief that recruits carry a backlog of

treatment requirement with them when they join the military. Once a recruit decides to join the

military it is understandable that they would forgo paying for dental care because free dental care

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becomes a service benefit upon enrolment. The researchers also found that 18 -19 year old

recruits had higher utilization rates, prior to joining the military, than older recruits. This was

probably because younger recruits were more likely to have lived with their parents. Recruits

living in their parents’ home have less financial burdens or have dental insurance coverage under

a parent’s employment plan.

A study conducted on 21 year old members upon release from the Israeli military following

compulsory service between 1994 and 1997, demonstrated an average DMFT score of 8.49 (77).

As it is in Canada, national health insurance in Israel does not include dental coverage, but dental

care for serving members is free. Hence, since the study was conducted on recruits exiting the

military after two or three years of service, the oral health status would be expected to be better

than the average citizens’. However, the average person was shown to have 2.25 decayed teeth.

The Israeli dental services are available to provide comprehensive care, but personnel attendance

for members on compulsory service is voluntary. Interestingly, although females had a slightly

higher DMFT score as compared to males, the mean decayed score was significantly higher in

males while the mean filled score was significantly lower. This observation suggests that

females were more proactive in seeking dental care. Additionally, level of education was also a

marker of dental service utilization. Those with less than 11 years of schooling had statistically

significant higher mean decayed scores and lower mean filled scores, than those with 12 or more

years of schooling. It is very telling that despite access to free dental care while in service,

gender and education can still play a meaningful role in dental utilization. The Israeli military

experience with dental service utilization suggests that in order to decrease disparities and ensure

a dentally fit and ready force, universal cost-free dental coverage, must include a compulsory

component. Recommendations have been made to incorporate compulsory periodic dental

exams in the Israeli military (78).

Similarly, Ismail et al reported that despite universal dental care for children under the age of 10

in Nova Scotia, parental level of education was significantly inversely correlated with the mean

DMFS scores of primary teeth (43). The authors concluded that universal publicly financed

insurance programs are not sufficient to eliminate the disparities in oral health associated with

socioeconomic factors. On the other hand, oral health racial disparities have been shown to be

eliminated in active service personnel in the US military (79). The reason for this is, as is the

case in the CF, is because access to universal dental care in the US military also includes a

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compulsory periodic dental exam and a standardized dental fitness requirement. Hence, even

though newly enrolled members will have differing dental treatment requirements, oral health

disparities will likely be eliminated once the members have been in the CF for one or two years.

2.5 Summary of expected dental treatment needs in newly enrolled CF members

In summary, the dental treatment needs of the newly enrolled CF population will vary in

accordance with demographic composition and the changing patterns of disease. It is expected

that the oral health status of newly enrolled CF members will be tremendously improved since

the 1967 and 1973 CFDS dental surveys, as a result of the significant reduction in dental caries

that has taken place over the last 30 years. Evidence from foreign military studies suggests that

dental fillings will be the most common treatment requirement, followed by the extraction of

third molars. The average treatment time that will be required to render each new member

dentally fit will be approximately 2 hours. A moderate number of recruits should have no

treatment requirements, while a smaller proportion may require a more significant amount of

treatment. Treatment needs and costs will be higher in those that have attained less than a

degree/diploma, were born outside of Canada, resided in disadvantaged neighbourhoods and are

current smokers. Females have been shown to have higher dental service utilization rates than

males and should therefore have fewer treatment needs. French speaking Canadians have

historically had poorer oral health in comparison to English speaking Canadians, and may thus

have higher treatment needs. Lastly, it is anticipated that Canada’s numerous jurisdictions, with

diverse economies and public healthcare policies, will also contribute to observed differences in

treatment needs among newly enrolled personnel.

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Chapter 3 - Manuscript

3 Dental treatment requirements of the 2007 and 2008 recruit population

Major Constantine Batsos DDS, MSc (candidate)

Dental Public Health, Faculty of Dentistry, University of Toronto

Sources of support: The research in this paper was based on data provided by the Canadian

Forces

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3.1 Abstract

Background: Studying the dental treatment requirements of newly enrolled CF personnel

facilitates evidence-based planning for the CFDS; however, the most recent oral health survey of

CF recruits were conducted in 1967 and 1973 and current dental treatment needs statistics of the

young adult of recruit age are not available in Canada.

Aim: To analyze the demographic composition and determine the dental treatment needs of new

members who enrolled in 2007 and 2008.

Methods: Prevalence and severity of dental treatment rendered, PSR scores and treatment costs

were analyzed according to demographic variables- age, gender, rank class, birthplace, province

of residence, first language and tobacco user status. Associations between treatment procedures

and the demographic variables were tested using one way analysis of variance and chi-square

tests. Independent samples T-test was used to compare means. Multiple linear regression

analysis was used to determine the influence of the demographic variables on treatment cost.

Results: The study population consisted of 10,641 recruits (8953 [84.4%] male, 1658 [15.6%]

female; 8547 [80.3%] NCM, 2094 [19.7%] officers) with a mean age of 25.1 years. The average

cost of treatment was $1224. Except for dental extractions, prevalence and severity of treatment

requirement was found to increase with age. NCMs, foreign born members, French speaking

members and tobacco users generally demonstrated a higher prevalence and severity of treatment

requirement as compared to officers, Canadian born members, English speaking members and

non users of tobacco. Females had lower PSR scores but higher costs, and a higher prevalence of

emergency visits and preventive and periodontal procedures. Members residing in Saskatchewan

and Newfoundland and Labrador showed the highest treatment needs and costs. Members from

Ontario had the lowest treatment requirement and incurred the lowest treatment costs. Multiple

linear regression analysis showed that treatment costs were increased by NCM rank status, age,

birthplace outside of Canada, and by personnel reporting French as their first language.

Conclusion: The dental treatment needs of new members were shown to vary with recruit

demographic composition and to have significantly decreased since the early 1970’s. With some

adjustments and standardization, CF dental data, which is collected according to a prescribed

protocol, can assist the public health system in reducing the burden of illness in Canada.

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3.2 Introduction

The dental treatment needs of a population will vary with demographic composition and the

changing patterns of oral diseases and conditions (80). Dental public health planners and policy

makers, both within and outside the military, require current knowledge of population oral health

treatment needs in order to ensure that programs are achieving intended goals and primary care

providers and auxiliary staff are being utilized in the most efficient manner. The most recent

CFDS oral health surveys of new recruits were conducted in 1967 and 1973. These surveys

concluded that the recruit population was a sample of young Canadian adults in the lower

socioeconomic scale and required more than 7.5 hours of treatment time to be brought up to a

state of optimal oral health (4,5).

In Canada, precise normative dental treatment needs data for young adults are not readily

available. Ideally, needs assessment information would have to be collected through a survey

with standardized clinical measurements or systems that capture dental treatment data according

to a specific set of criteria. At the national level, the only sources of needs assessment survey

data are the Nutrition Canada Dental Report (NCDR) (34) conducted from 1971 to 1972 and the

Canadian Health Survey Measures Survey (CHMS) conducted from 2007 to 2009 (27). The

NCDR findings are more than 35 years old and are not entirely reliable, because of the small

sample sizes in certain categories and a lack of sufficient examiner calibration. The CHMS

reported treatment needs statistics in accordance with a systematic protocol but many of the

findings were subject to high sampling variability and provincial comparisons were not possible.

Additionally, neither public nor privately funded treatment data would be an accurate and

reliable representation of the dental treatment requirements of the average Canadian, due to the

potential confounding that would exist as a result of the discrepancies of insurance plan benefits,

and the variability of access and provision of dental care.

Dental treatment data collected by the CFDS is more systematically and routinely collected than

the civilian public sector, more accessible than treatment data in the private sector, and does not

command the financial expenditures necessitated by national oral health surveys. All members of

CF have universal access to cost-free dental care. Compulsory periodic dental examinations and

a standardized dental fitness requirement, ensure that all members receive dental care that is

appropriate to their needs and consistent with the scope of dentistry that is available to the

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Canadian population (14). A significant advantage in studying military data is that dental

treatment in the CF is provided in accordance with standardized criteria established in the

Canadian Forces Dental Care Program (CFDCP) (81). As such, within respective populations, it

represents a clearer picture of actual treatment needs and costs versus those that might be found

in a civilian insurance database. By examining the secondary dental treatment data of new

entrants in the CF, as they move from a civilian to a military environment, this research study

presents a unique opportunity to reveal valuable insight into the dental treatment requirements of

a geographically diverse Canadian, healthy, employable, young adult population.

Authorization for this study was obtained from the CFDS and the Office of Research Ethics at

the University of Toronto. Authorization for the release of CF dental treatment and demographic

data was granted by CF Directorate Access to Information and Privacy.

3.3 Methodology

3.3.1 Study Design

The study comprised the population of Non Commissioned Members (NCM) and officer

candidates that were enrolled in the CF in 2007 and 2008. Demographic statistics and treatment

data were extracted from three databases. Datasets and included study variables are shown in

Appendix 4. Demographic statistics for the study population were obtained from the CF

Department Human Resources Information Management (DHRIM) database. In-service dental

treatment information was derived from the CF Dental Information Systems (DentIS) database

and outsourced dental treatment was obtained from the Federal Health Claims Processing

System, currently administered by Medavie Blue Cross. DentIS provides an accurate account of

the dental treatment a member has received in CFDS clinics during his/her career; however, it

does not include a record of the treatment that was referred to civilian dental practices. At times,

due to various and extenuating circumstances, specialty and basic dental treatment for military

personnel is outsourced to the civilian sector. Medavie Blue Cross is the out-of-service medical

and dental insurance administrator for the CF, and maintains this data. The five digit procedure

codes recorded in DentIS are identical to codes utilized by the Ontario Dental Association

(ODA). During the study period, treatment costs matched the 2006 ODA fee schedule.

Procedure codes recorded by Blue Cross correspond to the province in which the service was

delivered and the fee that was charged by the provider. Military service numbers were used to

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link the DHRIM, DentIS and Blue Cross datasets. Once the datasets were linked, service

numbers were replaced by numeric code.

The study population inclusion criteria are described in Figure 1. According to DHRIM records,

14393 members were enrolled in the CF, and were issued a military service number, in either

2007 or 2008. As of the study end date, January 31 2010, only 12,020 dental records could be

located in DentIS. The minimum amount of time a member would have been enrolled in the CF

was 13 months to a maximum of 37 months. Although it is possible that some new members had

not yet reported to the dental clinic to open a dental file, it appears more likely that the majority

of the members were released from the military prior to having reported to a CF dental clinic. Of

the 12,020 new members who had reported to a military dental clinic for at least one visit

following their enrolment date, 1379 members released from the military at some point prior to

the end of the study period. This resulted in a study population of 10,641 members. The

consequential member release rate, which was more than 26%, is likely explained by members

who do not successfully make it through basic military qualification training, military occupation

training or possibly opt out of pursuing a military career. Table 10 compares demographic

statistics between the 1379 members who were released and the 10,641 members who were still

active at the end of the study period. Statistically, a smaller proportion of members who were

women, officers, reported English as their first language and were older than 20 years of age

dropped out of the military as compared to members who were men, NCMs, reported French as a

first language and were 20 years of age or younger.

There was an adequate representation of all Canadian provinces in our study population. The

distribution of member province of residence is described in Table 11. Ontario was home to most

newly enrolled members followed by Quebec. Prince Edward Island (PEI) was the home of the

smallest group of new entrants. Relative to province population size, higher proportions were

recruited from the Maritime Provinces and lower proportions were recruited from western

provinces. The proportion of enrolment from Quebec and Ontario was somewhat comparable to

the size of the provinces’ populous. Members were categorized as “missing” if there was no

information available on province of residence or if a member resided outside of the country at

the time of enrolment. Only three new members were enrolled from the Territories. These three

members were also categorized as “missing” in our regional analysis.

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Dental treatment procedures and costs were aggregated and calculated, beginning from the date

of a member’s enrolment in the CF, until the study end date. Once enrolled, all CF personnel

have equal access to identical dental coverage and receive treatment, as required, to maintain a

state of dental readiness for deployment in accordance with the “Dental Fitness Classification

System” (Appendix 2). The CFDCP contains specific guidelines and criteria for assessing

patient treatment needs and determining dental fitness classification. As an example, the criteria

for tooth extraction are described in Appendix 5. All military dentists receive formal training and

instruction pertaining to the CFDCP. Dental treatment that is referred to civilian providers also

meets CFDCP criteria. As such, although the dental treatment providers in the study were not

formally calibrated, all diagnosis and treatment was performed compliant with a uniform and

prescribed protocol.

As a minimum, all new members receive a forensic general dental examination with the use of

bite wing and panoramic radiographs; thus, all members were provided with diagnostic services.

Table 12 shows the proportion of the study population that received dental treatment in

accordance with each dental treatment category. After diagnostic services, the most commonly

performed procedures were preventive, restorative, oral surgery, periodontal and endodontic

therapies. Orthodontic and removable and fixed prosthodontic procedures were less commonly

performed on newly enrolled members. Prosthodontic services are typically more common in

older populations and usually encompass elective procedures that can be completed later on in a

member’s career. Orthodontic procedures are not initiated in the military before a member signs

their second term of engagement; however, orthodontic repairs are sometimes necessary for

members who have initiated treatment in the civilian sector prior to entering the military.

3.3.2 Measures

Dependant variables

The dependant variables consisted of the number of emergency visits, preventive procedures,

restorations, root canals, periodontal procedures, dental extractions and the total cost of

treatment. Restorations, including dental fillings and crowns, were calculated in terms of

number of tooth surfaces restored. Dependant variables also consisted of member periodontal

screening and recording (PSR) scores. The PSR is an adaptation of the Community Periodontal

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Index of Treatment Needs (82), which was developed to measure the amount and level of

periodontal workload required in an adult population.

Independent variables

The independent variables consisted of gender, age at the time of enrolment, rank class (officer

candidate or NCM recruit), tobacco user status (user or non-user), first language (English or

French), Birthplace (Canada or Foreign), time in the service, and province of residence at the

time of enrolment. Age was stratified into four age groups, 16 to 19 years, 20 to 29 years, 30 to

39 year and 40 to 59 years. Time in service was calculated as the number of months between a

member’s date of enrolment and the study end date. Since some members would have had 37

months in their military careers to receive dental care and others only 13 months. Because of this

potential confounding, we continuously compared the mean time in service between study

groups in our analysis.

3.3.3 Statistical analysis

The normative dental treatment needs of newly enrolled members were analyzed in terms of

prevalence and severity. Prevalence was defined as the percent of subjects that had undergone

one or more dental procedures. Severity referred to the mean number of procedures required by

subjects requiring a minimum of one procedure. Associations between treatment services and the

independent variables were tested using one way analysis of variance and chi-square tests.

Independent samples T-test was used to compare means. Multiple linear regression analysis was

conducted to determine the influence of the independent variables on treatment cost. Data were

processed using SPSS version 17.0 (SPSS, Inc., Chicago, IL). P-values are 2-sided and

considered significant at the 0.05 level.

3.4 Results

The mean age of all active members was 25.1 (SD 7.1) and ranged from 16.6 to 58.2 years. The

number of enrolled men 8953 (84.4%) outnumbered enrolled women 1658 (15.6%). The study

population consisted of 8547 (80.3%) NCM recruits and 2094 (19.7%) officer candidates.

Canada was the birthplace of 9960 (93.6%) of the population; only 681 (6.4%) members were

born outside of Canada. When recruits were first processed at the recruitment centres, 8025

(75.4%) reported English as their first language and 2616 (24.6%) reported French as a first

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language. At the time of enrolment 2753 (25.9%) members were 16 to 19 years of age, 5915

(55.6%) were 20 to 29 years of age, 1410 (13.3%) were 30 to 39 years of age and 563 (5.3%)

were 40 to 59 years of age.

Multiple linear regression analysis showed that treatment cost was significantly increased by

NCM rank status, age, birthplace outside of Canada, time in the services and by personnel

reporting French as their first language (Table 13). The regression analysis of gender also

showed that females had an increasing effect on total treatment cost, although this finding was

not statistically significant.

Clear trends were observed in the analysis of prevalence and severity according to age group

(Table 14 & 15). With the exception of dental extractions, all treatment categories increased in

prevalence with increasing age group. Likewise, treatment costs also increased. All findings

were statistically significant demonstrating a very compelling association of a greater

requirement for dental treatment with an aging recruit population. In the analysis of severity, the

mean number of emergency visits, restored surfaces, preventive and periodontal procedures, also

increased with increasing age group. Contrarily the prevalence and severity of dental extractions

decreased as age group increased, probably due to a decreased necessity for third molar

extraction in older age groups. Personnel who required restorations, root canals and dental

extractions, required a mean number of 7.5 surfaces to be restored, 1.8 root canals and 2.4 dental

extractions.

Statistical differences were evident between NCM recruits and officer candidates (Tables 16 &

17). Despite the older age of the average officer, which would normally imply an increased

level of treatment requirements and higher cost, the total cost of treatment for an officer was

lower than an NCM. The percentage of officers reporting for emergency appointments and

requiring restorations, root canals, periodontal procedures and dental extractions was smaller

than that of NCMs. On the other hand, a larger proportion of officers received preventive

treatment. Overall, in terms of severity, the treatment requirements (emergency, restoration, root

canal, extraction) for officers were generally lower than that of NCMs. Officers in the oldest age

group showed a higher severity for restored surfaces, root canals and emergency appointments.

The relationship of gender and treatment needs was examined separately for NCMs and officers

in order to obtain a more accurate interpretation of findings, without the confounding effect of

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rank classification. As a whole, the female NCM subpopulation was three years older and

incurred higher treatment costs than the male subpopulation (Table 18). However, this finding

was not always consistent according to age group. It was apparent that 16 to 19 year old and 40

to 59 year old females had higher treatment costs but females between 20 and 39 years of age

had lower costs. The mean cost of treatment for a female NSM in the 40 to 59 age group was

almost $900 higher than a female NCM in the 30 to 39 year age group. A consistently higher

percentage of female NCM reported for emergency appointments and received preventive

treatment. Conversely, a consistently lower percentage of female NCMs received dental

extractions. The mean number of emergency appointments and preventive procedures was

statistically higher for female NCMs; while the mean number of dental extractions was

statistically lower (Table 19). Interestingly, there was a statistically significant smaller mean

number of surfaces restored in females in the 30 to 39 year age group and a statistically

significant higher mean number in the 40 to 59 year age group, as compared to males.

Correspondingly to observations of female NCMs, female officers also incurred higher total

treatment costs as compared to male officers (Table 20). Taken together, a higher fraction of

female officers presented for emergency appointments and received preventive procedures and

dental restorations. On the contrary, a smaller fraction of females required root canals and dental

extractions. As was the case for female NCMs in terms of severity, the mean number of

preventive and periodontal procedures were found to be higher in female officers, and the mean

number of surfaces restored increased significantly for female officers in the 40 to 59 age group,

although this result should be interpreted with some caution due to the small subpopulation size

of this group (Table 21). The mean cost of treatment for a female officer in the 40 to 59 age

group was almost $550 higher than the mean cost for a female officer in the 30 to 39 year age

group.

Differences in treatment requirement between members who reported French and members who

reported English as their first language were compelling. French speaking members incurred

statistically significant higher treatment costs (Table 22). Proportionally, a higher number of

French speaking members reported for emergency appointments, received preventive and

periodontal therapy and required dental restorations, root canals and extractions. In terms of

severity, French speaking members had a higher mean requirement of preventive procedures,

restored tooth surfaces, and completed root canals, and lower mean requirement of dental

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extractions (Table 23). The results clearly show that French speaking members have higher

dental treatment needs, in all treatment categories, when they enter the military.

The average age of members born outside of Canada was four years older than members born in

Canada. Foreign born members incurred higher dental treatment costs (Table 24). A greater

proportion of foreign born members reported for emergency appointments and had a requirement

for dental extractions, preventive, periodontal and root canal therapies as compared to members

who were born in Canada. An interesting finding is that, both in terms of prevalence and severity

(Table 24 and 25), the requirement for dental restorations and root canal is quite low in foreign

born members in the 16 to 19 year age group but rises dramatically in subsequent age groups. In

fact, in the lowest age group, foreign born personnel had lower needs for restorative and root

canal therapy compared to their Canadian born counterparts.

Overall, when the entire recruit population was analyzed (Table 26), members that resided in

Newfoundland and Labrador (NL), at the time of enrolment, demonstrated the highest mean total

dental treatment costs ($1392), followed by members who resided in Saskatchewan ($1330).

Members from Ontario had the lowest mean costs ($1148), followed by members from PEI

($1196). There was no particular province that consistently ranked highest in terms of

prevalence for dental treatment requirement, by category, but some trends were apparent.

Members from NL, New Brunswick (NB), Quebec and Saskatchewan generally demonstrated a

higher prevalence of reported emergency visits, restorative, root canal, periodontal and dental

extraction therapy, as compared to the other provinces. In terms of severity, statistically

significant differences were only observed for mean number of restored surfaces (Table 27). Of

those members requiring restorations, severity was highest in NL, PEI and Quebec. Caution

must be utilized when interpreting prevalence and severity findings in the age group

subpopulation analysis between provinces (Tables 28-35). Provinces with small sample sizes

could erroneously result in overestimated and underestimated observations.

CF dental officers are required to collect patient information regarding tobacco use during the

periodic dental examination and input this information in DentIS. Tobacco user status is an

important population health metric for assessing oral cancer and periodontal disease risk.

Nevertheless, our analysis uncovered that CF dental providers are falling well short of collecting

this data during periodic dental appointments, as they are required to do. Information on tobacco

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was collected in only 3318 (31.1%) members out of the entire 10,641 recruit population. Out of

the 3318 members with recorded tobacco information, 1160 (35.0%) were tobacco users and

2158 (65.0%) were non-users. The association of tobacco use and treatment workload was

undeniable. Despite being of slightly younger age compared to non-users, tobacco users had

statistically significant higher treatment costs (Table 36). A larger proportion of tobacco users

reported for emergency dental appointments and required dental restorations, root canals,

periodontal procedures, and dental extractions. The average tobacco user, that required dental

restorations, required 1.5 more surfaces to be restores, as compared to non-users (Table 37).

Interestingly, in treatment categories where one would normally expect to find an increased

treatment provision in tobacco users; that is, preventive procedures, both prevalence and severity

was found to be higher in non tobacco users.

As part of the intra-oral examination, dental officers are required to determine a member’s

periodontal status and treatment requirement using the PSR System. PSR recording was reported

in 60% of the members in our study. The prevalence of periodontal conditions according to PSR

scores is shown in Table 38. Statistically, despite being more than two years older, females had

less severe periodontal outcomes (PSR 3 & 4), as compared to males. Officers were also two

years older and showed a lower prevalence of PSR 3 scores and a higher prevalence of PSR 4

scores as compared to NCMs. The average tobacco user was one year younger than the non user

and had a higher prevalence of severe periodontal outcomes (PSR 3 & 4). As would be expected,

personnel diagnosed with the most severe periodontal outcome (PSR 4), demonstrated the

highest prevalence of periodontal procedures requirement and the highest severity of preventive

and periodontal treatment requirement as compared to personnel with PSR scores 0 through 3

and those with an undetermined PSR score (Table 39).

3.5 Discussion

Military dental policymakers, require a thorough understanding of population dental treatment

needs in order to assess the effectiveness of dental programs, predict funding and human

resource requirements and ensure that treatment is being provided aptly and equitably to all who

are in need. The dental treatment needs of the newly enrolled 2007 and 2008 CF population were

shown to vary in accordance with demographic composition. In the first 26 months following

enrolment the average NCM recruit and officer candidate received $1268 and $1044 of dental

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treatment. After diagnostic and preventive services, there was a high requirement for restorative

care, followed by oral surgery, periodontal services and endodontic therapy. Similar conclusions

in terms of cost and treatment workload on recruit populations have been reported by other

military dental services (7, 72, 74). Findings from a US Navy study demonstrated that 30% of

posterior restorations on recruits require replacement at the initial examination or within the first

years of military service; significantly more resin based composite restorations required

replacement in comparison to amalgam restorations (23). Oral surgery procedures are a

significant cost driver in the recruit population and largely consist of the extraction of unerupted

or partially erupted third molars. This is not surprising when one takes into account that the

average recruit was 25 years of age. Over a one week period in Ontario general dentistry

practices, pericoronitis associated with third molars and impacted teeth was shown to account for

more than 51% of all extractions in the 13 to 19 year age group and over 33% of extractions in

the 20 to 39 year age group (68). Pain from third molars was also identified as the second most

common dental emergency, after caries, at three medical support facilities supporting Operation

Enduring Freedom, in Iraq (69, 70). For this reason, the military dental services are

recommended to take a more aggressive stance regarding the extraction partially erupted and

unerupted third molars (71).

Overall, recruit dental treatment needs have decreased significantly since the early 1970’s. The

CFDS oral health surveys conducted in 1967 and 1973 reported that less than 10% of recruits

were dentally fit and that the average member required more than 7.5 hours of treatment to be

brought to a state of optimal oral health. Moreover in 1973, 99% of recruits were between 17

and 24 years of age. Our study demonstrated that only 63% of the 2007 and 2008 recruits were

under the age of 25; nevertheless, despite being older, the current generation of recruits requires

far less dental treatment to be rendered dentally fit. This is undoubtedly due to the well

documented decreasing severity of caries that has taken place since the early 1970’s (54, 56-58),

and the increase in population oral health awareness.

As it was reported in the 1967 and 1973 oral health surveys, officers required significantly lower

dental treatment as compared to NCMs. Officer treatment costs were impacted higher by more

preventive treatment as compared to NCMs, whereas NCM treatment costs were impacted higher

by a greater amount of non-preventive treatment as compared to officers (Table 16). A part of

the observed disparities in the dental treatment need and occurrence of dental emergencies

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between officer candidates and NCM recruits can also be explained by the unequal access to

dental services between these two populations in the CF. Inequalities between officers and

NCMs in the number of treatment procedures and the timeliness of treatment provision are

described in Table 40. Despite the requirement of a significantly higher number of non

diagnostic and non preventive treatment procedures among NCMs, the wait time before they

receive attention is greater than that of officers. Furthermore, the average officer receives a

greater number of preventive treatments and much sooner access to preventive care.

To population health planners, the notion that those who are less in need would receive care

before those who are in greater need seems backward, and perhaps even unconscionable;

however, the delivery of timely treatment on newly enrolled members is complicated by the

tremendously demanding basic military qualification (BMQ) training and basic occupational

training qualification (BOQT) schedules. Recruits have little time availability to schedule dental

appointments, and appointments that are scheduled often result in cancellations and no-shows.

Additionally, those who miss even the slightest amount of training time risk having to repeat the

entire course. Training supervisors strongly discourage recruits from missing any training time

and often turn a blind eye when recruits experience dental discomfort or miss dental

appointments. Incidences such as these are not unique to CF recruits, but have also been reported

to occur in the British Army (8). As a result, the CFDS does not make a concerted effort to

pursue dental treatment on students, and dental clinics on CF training bases are only sufficiently

staffed to provide emergency care for these members. Officer candidates typically spend less

time in training than NCM recruits. Following nine weeks of basic training, officer candidates

return to civilian university, where they are no longer under military vigilance, or they proceed to

the Royal Military College (RMC), in Kingston. The RMC has its own staffed dental clinic that

looks entirely after the RMC officer candidate population. Moreover, one of the first

requirements for first year officer candidates at RMC is to make alginate dental impressions and

have custom sports guards fabricated at the RMC dental clinic. This immediate familiarization

and access to the dental clinic at RMC promotes oral health and preventive behaviours. It is also

most likely a contributing reason why a greater proportion of officers reported for preventive

treatment procedures. On the other hand, following basic training, NCM recruits commence

trade training which may take months to years to complete and may also take place in an area

where military dental services are not available. Since many new members join the military with

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outstanding treatment requirements the likelihood of experiencing a dental emergency while in

training is increased for NCMs. NCM recruits have reported dealing with dental pain on their

own, rather than seeking care, in fear of being re-coursed (Appendix 6). This extended period of

time NCM recruits spend in training, delaying comprehensive dental care, will very likely be a

contributing factor influencing the reported number of emergency visits.

The verification of the quality of dental care is yet another reason why military dental health

planners monitor dental treatment data. One of the purposes of the PSR is to assist providers in

determining the periodontal treatment requirements of patients. Patients with PSR 4 scores

would be expected to have a higher prevalence and severity of periodontal procedures, as was the

finding in our research. However, the finding that only 38.9% of PSR 4 patients received

periodontal treatment does appear perplexingly low. Moreover, PSR scores were only recorded

in 60% of recruits. The findings perhaps demonstrate that the PSR, as a population and

individual metric for assessing periodontal treatment needs, is not being implemented very

effectively by CFDS providers. Similarly, information on tobacco use was recorded on less than

one third of the recruit population. It is a little disconcerting that data on a major population

health metric, that has both oral and systemic health implications, is not being collected by

military dental officers. Population risk measure assessments are important tools for planning

and coordinating health services and treatment. Moreover, dentists have an important role to play

in tobacco cessation (83, 84).

The uniform and protocol-based delivery of dental treatment in the CF can also assist the public

health system in Canada. For civilian dental public health planners, CF dental data can provide

valuable insight into aggregate population treatment needs and differences in treatment

requirements between regions and demographic groups, so that appropriate measures can be

taken to reduce the burden of illness for all Canadians. National oral health surveys are

expensive and are not routinely conducted in Canada. They are also limited in their ability to

estimate population treatment needs.

The 2007-2009 CHMS reported estimates on the treatment needs of Canadians (27). This was

carried out according to a hierarchy of need methodology consistent with a 1978 ADA

(American Dental Association) publication (31) and a work done by Otchere et al. (32) on an

elderly population in Ontario. In the 20 -39 year age group, the CHMS reported that two thirds,

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66.8% of Canadians, had no treatment needs identified at examination. Furthermore, 11.5% had

surgical needs, 1.8% had endodontic needs, 14.1% had restorative needs. Because of the

different methodology, it is not entirely appropriate to compare the CHMS findings to those of

our study. When we examined the data of the 7325 members in our study that were 20 to 39

years of age, we found that 50.1% required at least one surface to be restored, 7.4% required root

canal therapy and 25.5% underwent at least one tooth extraction. Furthermore, we found that

only 40.3% did not require a restoration, a root canal or a dental extraction. One can argue that

the military takes a more aggressive stance in extracting third molars, and perhaps even replacing

deficient restorations; however, the proportion of root canal therapy and restorative treatment

appears appreciably greater from that which was reported by the CHMS. A possible explanation

for these differences may be that the CHMS examiners did not have access to dental radiographs.

Without dental radiographs interproximal carious lesions are less likely to be diagnosed (33) and

certainly periapical lesions and pathology would be almost impossible to detect. Thus, the

treatment requirement findings provided by the CHMS are most reliable for comparison with

other population surveys using the same methodology, and likely represent an underestimation of

need.

Notwithstanding the discrepancies in the dental treatment need findings of our study and those of

the CHMS, which were largely related to differing methodologies, the CFDS treatment data in

relation to the recruit demographics proved to be overwhelmingly complimentary to the CHMS

oral health status measurements. For example, the CHMS reported that DMFT scores increased

with age (27). Higher DMFT rates suggest that there are a higher number of dental conditions

that require restoration, maintenance or replacement. Our study showed that dental treatment cost

and workload increased with increasing age group. The CHMS also demonstrated that

household education was associated with oral health status (27). Individuals who emanated from

households where the highest education was less than a post secondary degree or a diploma

displayed a higher prevalence and severity of decayed and missing teeth. Likewise, significant

differences in treatment needs were observed between officer candidates and NCM recruits. In

general, officers in the CF are employed in administrative and managerial positions and achieve

a higher level of education than NCMs. Officer candidates either have obtained, or are in the

process of obtaining, a university degree through the Royal Military College or civilian

universities. On the other hand, NCM recruits can be enrolled in the military with a minimum of

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a grade ten high school education (grade nine in Quebec). The CHMS also reported that

compared to non smokers, a higher prevalence of smokers had decayed teeth, periodontal

pockets greater than 5 mm, and required oral surgery and restorative treatment (27). Our findings

were also in agreement, and showed a larger proportion of tobacco users reported for emergency

dental appointments, presented with more severe PSR scores, and received dental restorations,

root canal therapy, periodontal therapy, and dental extractions.

Our study showed that the differences in dental treatment needs between female and male

recruits were generally mixed but that females had higher mean treatment costs and presented for

dental emergencies in higher proportions. It has been reported that females are more likely than

men to frequent the dentist (17, 27, 37) and even more so when they are 18 to 19 years of age

and have a post secondary education (85). The CHMS reported that the prevalence of lower

debris scores, lower calculus scores and lower periodontal pocket scores were higher in females

as compared to males (27). Similarly, despite having a lower prevalence of periodontal treatment

requirement, as demonstrated by less severe PSR scores, female recruits proved to be higher

consumers of preventive and periodontal dental services, as compared to males. This suggests

that female were more assertive in seeking dental care.

The comparability between military and CHMS findings was evidenced further. The CHMS

reported that adults born outside of Canada had a higher prevalence of decayed teeth, calculus

scores and periodontal pocket scores, and were less likely to have dental insurance. The results

of our study showed that members born outside of Canada generally had higher treatment needs

and treatment costs than members who were born in Canada. In particular, prevalence and

severity for the requirement of periodontal procedures were significantly higher in recruits born

outside of Canada. Moreover, in the 16 to 19 age group, foreign born personnel had lower

prevalence and severity of treatment needs for restorative and root canal therapy compared to

their Canadian-born counterparts. This observation was reversed in subsequent age groups.

Similarly, the CHMS reported that non-Canadian born individuals aged 12 to 19 years had a

higher percent of filled teeth that were once carious (FT/DMFT); an observation that

subsequently reversed in older age groups (27). Although it is impossible to explain this

observation with certainty, it may be that foreign born Canadians have better access to dental

public health programs in schools and thus have fewer unaddressed restorative needs if they

enroll in the CF at a younger age. Locker and colleagues showed that new immigrant children

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had higher dental treatment needs than Canadian born children; however, the treatment needs of

foreign born adolescents who lived in Canada for six or more years were more similar to their

Canadian-born counterparts (86). Older foreign-born CF recruits that immigrated to Canada as

adults may not have had the benefit of school based dental programs.

Significant differences in dental treatment requirement that were observed between members

reporting French and members reporting English as their first language. Differences in oral

health status between French and English speaking CF recruits have been reported in the past (5),

and appear to persist to this day. In an epidemiological survey conducted in 1995, Brodeur et al

reported that Anglophone Quebec adults, aged 35 to 44 years, had an average of 5.9 missing

teeth while Francophones had an average of 8.5 missing teeth (36). Hence, the record of dental

treatment that was provided to newly enrolled members in the CF not only mirrors and

compliments the findings of regional and national oral health surveys, but also validates their

assessments with conclusive evidence of actual delivered care.

For federal and regional dental public health planners, provincial comparisons of population

dental treatment needs can facilitate the targeting of resources and help identify the determinants

of treatment needs. In a country that is as large and diverse as Canada our findings of regional

variations in treatment needs are not surprising. Different jurisdictions have varying and distinct

population demographics, and political and economical climates. In a 1994 review of North

American dental data, Burt found “considerable geographic variations in caries experience in the

general populations of the United States and Canada; the highest prevalence and severity [was]

found in Quebec” (35). Considerable geographic variation was also described in the NDCR with

regards to the prevalence and severity of treatment requirement for dental restorations; needs

were greatest in Newfoundland and lowest in Ontario (34).

Our findings demonstrated that members from Quebec and New Brunswick reported for dental

emergencies in greater proportions than members from all other provinces. This could be

somewhat expected since members from those two provinces also demonstrated a relatively high

prevalence for treatment requirement. On the other hand, despite having a higher prevalence for

treatment requirement and incurring the highest treatment costs, members from Saskatchewan

and Newfoundland and Labrador reported for dental emergencies in smaller proportions than

members from Ontario, who in turn, demonstrated a lower prevalence of treatment requirement

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and incurred the lowest treatment costs. It is important to recognize that members who reported

to the dental clinic with a dental emergency also exhibited a degree of dental awareness, that is,

they were able to diagnose and perceive a particular dental problem. Thus, observed differences

in the prevalence of dental emergencies between provinces are not only an indication of

treatment need, but also a level of regional dental awareness and self-perception of oral health.

Regional variations in oral health status may be partly explained by dental service utilization,

access to care and dental insurance coverage. Millar and Locker reported that income and

insurance are important determinants of dental service utilization and that the lowest rates of

insurance coverage were in Quebec and Newfoundland (37). More recently, in an analysis of

2003 Statistics Canada Canadian Community Health Survey data, Bhatti et al found that the

“probability of receiving any dental care over the course of a year was lowest in Newfoundland,

Quebec, Saskatchewan, and New Brunswick, and highest in Ontario, Manitoba, and British

Columbia” (38). The authors also noted that the probability of receiving dental services varied

by region and suggested that the observed differences may be attributed to the supply of dentists.

Provinces with the lowest dentist-to-population ratios, in 2002, were Newfoundland,

Saskatchewan and New Brunswick; whereas, the highest ratios were found in Ontario and British

Columbia (38). Regional community water fluoridation may also be a contributing factor,

especially with regard to restorative treatment needs. In 2007, the provinces with the highest

population coverage for community water fluoridation were Ontario (75.9%), Alberta (74.7%),

Manitoba (69.9%) and Nova Scotia (56.8%) (87). Conversely, the provinces with lowest

coverage were Newfoundland and Labrador (1.5%), British Columbia (3.7%) and Quebec

(6.4%) (87). Lastly, and arguably the most important consideration, provincial dental public

health programs will have an impact on observed regional differences in treatment needs. For

example, the observed low treatment requirements among 16 to 19 year old members from PEI

may have been partly attributed to the province’s free preventive program and partial pay

program that covers children to the age of 17. Therefore, the reasons for the observed

geographic variations in military recruit treatment needs are multi-factorial. The comparison and

analysis of regional variations can inform dental public health planners and policy makers on the

effectiveness of dental programming and highlight the efforts and conditions which are most

successful. Due to funding and logistical considerations, the CHMS was unable to collect oral

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health statistics in all provinces. In this regard, CF military dental data becomes a worthy,

reliable and cost effective alternative.

As already mentioned there are many advantages in using military data; nonetheless, there are

also a number of limitations in this study. Drawing concrete conclusions or formulating causality

regarding associations between dependant and independent variables through secondary data

analysis is not possible. As previously mentioned, it is unclear whether members that were born

outside of Canada were recent immigrants or whether they have been living in Canada for the

majority of their life. Similarly in our analysis of treatment needs according to province of

residence, there is no way of knowing how long a member lived in a particular province. The

nature or reason for certain types of treatment requirement is also suspect. For example, we can

not disclose in confidence the number of teeth that were extracted due to decay or periodontal

conditions, or were partially erupted third molars that were extracted for prophylactic reasons.

Equally, a dental emergency visit may have resulted from an idiopathic aphthous ulceration,

accidental trauma or an abscessed tooth. Due to the high variability it is not possible to assert

whether the emergency visit was precipitated by poor oral health status or just “bad luck”.

There is clearly significant selection bias in the military recruit population which brings to

question the generalizability of our findings. Tables 41 to 44 compare the demographic statistics

of our study population with that of the Canadian population at large. In comparison to the

Canadian population aged 16 to 59 years of age, the 2007 and 2008 military recruit population

will be more representative of younger adults in this age range, males (Table 41), individuals

born in Canada (Table 43) and individuals who are able to speak English and/or French (Table

44). On the other hand, the ratio of the Canadian population that has attained a university

diploma/certificate to the proportion that has attained less than a university diploma/certificate is

more closely matched to the proportion of officer candidates to NCM recruits (Table 42). There

are also health and physical fitness standards in the CF. Young adults who enroll and are

accepted in the military are generally physically fit, motivated and willing to be challenged.

Individuals possessing such attributes may also be more likely to practice better oral hygiene.

Hence, an appropriate way to characterize the military recruit population is as a healthy,

employable, young adult Canadian population, with a male bias.

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3.6 Conclusion

Precise normative dental treatment needs data for newly enrolled CF members or young adult

Canadians are not readily available. Current knowledge of population dental treatment needs can

assist military population oral health planners and policymakers by ensuring that an ideal mix of

primary care providers and auxiliary staff are efficiently employed, so that military dental

programs can achieve their intended goals. In our study, the dental treatment needs of the newly

enrolled 2007 and 2008 CF population were shown to vary in accordance with demographic

composition. The oral health status of newly enrolled CF members has tremendously improved

since the early 1970’s. Treatment needs and costs were higher in NCM recruits versus officer

candidates, members who reported French as their first language versus those who reported

English, those who were born outside of Canada versus those who were born in Canada and

users of tobacco versus non users. Females generally showed higher treatment costs and higher

treatment needs as compared to males. Even though PSR scores in females were significantly

less severe than males, a greater proportion of females received preventive and periodontal

treatment. Thus, the increased amount of treatment provided to females may be partly explained

by their propensity to be more proactive in seeking dental services. Lastly, differing levels of

prevalence and severity of dental treatment requirement were demonstrated according to member

province of residence, at the time of enrolment.

Within certain limitations and respective populations, military dental treatment information can

also benefit population health planners and researchers outside of the military. A significant

advantage in using military data is that dental treatment in the CF is provided in accordance with

standardized criteria established in the CFDCP. With some adjustments and standardization for

variables such as, age and gender, military dental data can become more generalizable and can

serve as a predictor of population dental treatment needs. Moreover, statistics that are routinely

collected by the CFDS, at no extra cost, can compliment national and regional oral health survey

findings by imparting tangible confirmatory evidence of the consequences and magnitude of the

burden of illness in Canada.

Further exploration is recommended in order to fully assess the contribution that can be afforded

through the use of military dental data and research. Future directions include, but are not limited

to, the study of demographic and regional determinants of population dental treatment needs;

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longitudinal dental care and treatment costs in the CF population, and the CFDS model of dental

care delivery as compared to the public sector and the growing consumerism in private practice.

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Chapter 4 - Manuscript

4 Is census tract income an indicator of dental treatment needs in a young adult Canadian military population?

Major Constantine Batsos DDS, MSc (candidate)

Dental Public Health, Faculty of Dentistry, University of Toronto

Sources of support: The research in this paper was based on data provided by the Canadian

Forces and Statistics Canada

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4.1 Abstract

Background: Socioeconomic status, as measured by education, income, occupation and place of

residence, has been shown to be an important determinant of dental treatment requirement in a

population. However, the association between census tract (CT) income and dental treatment for

a young adult Canadian military population has not been explored.

Aim: To examine dental treatment data for young adult Canadians recently enrolled in the

Canadian Forces (CF) and ascertain whether median income from their home residence census

tract at the time of enrolment, is correlated with their dental treatment needs.

Method: The prevalence and severity of dental treatment rendered and the cost to bring each

newly enrolled CF member to a state of dental fitness necessary for overseas deployments was

calculated for 2007 and 2008. Home residence postal code was used to link census tract median

income data with treatment data. Members were categorized into one of five groups relative to

the median income of their Census Metropolitan Area/Census Agglomeration (CMA/CA) - well

below (<-25%), below (-25 % to-7%), equal (>-7% to <7%), above (7% to 25%), or well above

(>25%) - and further stratified by officer and Non Commissioned Member (NCM) rank

classification and age group.

Results: The study population (N = 5670) was 86.9% male, and consisted of 4551 (80.3%)

NCMs and 1119 (19.7%) officers. The mean age was 22.5 years (SD 3.32, range 16.7 to 29.9).

The average member that entered the CF originated from a CT with a median income that was

4.0% higher relative to their CMA. After adjusting for age, sex, rank, first language and

birthplace, members originating from lower median income groups were more likely to require

treatment (restoration, root canal, extraction and periodontal). Prevalence of treatment

requirement, emergency visits and cost increased as CT income advantage decreased; however,

the severity of treatment needs was not statistically significant between the median income

groups. Subpopulation analysis showed that officers and members 16 to 19 years of age residing

in the most disadvantaged neighbourhoods required less treatment, suggesting that these groups

may have benefited from the availability of public dental insurance.

Conclusion: Generally CT median income can act as a risk marker for the dental treatment

needs of Canadian young adults entering the CF. Compared to area-based measures of income,

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individual-level occupation classification (and education level) appeared to be a stronger marker

for treatment needs. Dental public health activities should be directed towards improving the oral

health awareness of the population and the socioeconomic characteristics of the neighbourhoods

in which they live.

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4.2 Introduction

Population health is concerned with both the definition and measurement of health outcomes and

the roles of its determinants (88). Individual level socioeconomic status, as measured by

education, income, occupation and place of residence, has been shown to be an important

determinant of dental service utilization and treatment requirement (3). Lower income groups in

Canada, experience worse oral health outcomes, are less likely to have dental insurance, use

dental services less frequently, and when they do, it is more likely to be for emergencies rather

than preventive services (27, 37).

Studies that have examined the relationship between the socioeconomic characteristics of

neighbourhoods and health have demonstrated that morbidity and mortality are elevated in

disadvantaged neighbourhoods (89). More recently, there has been a growing interest in the

influence of neighbourhood socioeconomic position and characteristics on oral health (46-49).

These studies have concluded that neighbourhoods are significant contributors to population oral

health, perhaps even more than individual based explanations. Evidence suggests that area-based

measures of socioeconomic characteristics are better predictors of population health than

individual level socioeconomic characteristics, and provide additional explanatory power to

models of health inequalities by imparting a broader social and material context (45). Locker

and Ford found that the mean household income of the area in which subjects resided had an

effect on oral health and health related behaviours that was independent of their individual

household socioeconomic status (46). Since Locker and Ford’s study only involved older adults

and self-reported health outcomes, the authors recommended further research using different age

groups and different measures of health outcomes so as to fully assess the predictive merits of

area-based measures.

It is the role of dental public health planners to address population oral health issues such as

access to care and the efficient and effective use of health care resources. It has been

demonstrated that Statistics Canada census tracts (CT) are good proxies for natural

neighbourhood boundaries in studies of neighbourhood effects on health (50). Area-based

measures of socioeconomic deprivation present easily accessible analytic tools that can help

determine neighbourhood advantage and thus inform dental policy, programming and the

targeting of dental resources.

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This study analyzed the dental treatment data for young adult Canadians recently enrolled in the

Canadian Forces (CF) and examined whether the median income from their home residence CT,

at the time of enrolment, was correlated with their individual dental treatment needs. We

hypothesized that CT income advantage should be inversely related to dental treatment needs of

the population residing within the CT. Normative dental treatment needs data for young adults

are not readily available in Canada, nor have any investigators explored whether Statistics

Canada CT income data can be utilized as a risk marker of the dental treatment needs of newly

enrolled CF members. All members of the CF receive necessary and required dental treatment in

accordance with established standards set out in the CF Dental Care Program (CFDCP) in order

to be rendered dentally fit for operational deployment. By examining the dental treatment data

of new entrants in the CF, this study presents a unique opportunity to assess the validity of using

area-based socioeconomic measures for predicting dental treatment needs, on a national segment

of the population. Newly enrolled CF members differ from the civilian population at large in

that they are normally more physically fit and in better health. They also differ from regular

force personnel who have benefitted from access to cost-free comprehensive dental care in the

military. For this reason the dental treatment needs of new military members, as they transition

from a civilian to a military environment, should be comparable to that of healthy, employable,

young adult Canadians.

Authorization for this study was obtained from the CFDS and the Office of Research Ethics at

the University of Toronto. Authorization for the release of CF dental treatment and demographic

data was granted by CF Directorate Access to Information and Privacy.

4.3 Methodology

4.3.1 Study Design

The study comprised the population of Non Commissioned Members (NCM) and officer

candidates that were enrolled in the CF in 2007 and 2008. Demographic statistics and treatment

data were extracted from four databases. Datasets and included study variables are shown in

Appendix 4. Demographic statistics for the study population were obtained from the CF

Department Human Resources Information Management (DHRIM) database. In-service dental

treatment information was derived from the CF Dental Information Systems (DentIS) database

and outsourced dental treatment was obtained from the Federal Health Claims Processing

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System, currently administered by Medavie Blue Cross. DentIS provides an accurate account of

the dental treatment a member has received in CFDS clinics during his/her career; however, it

does not include a record of the treatment that was referred to civilian dental practices. At times,

due to various and extenuating circumstances, specialty and basic dental treatment for military

personnel is outsourced to the civilian sector. Medavie Blue Cross is the out-of-service medical

and dental insurance administrator for the CF, and maintains this data. Statistics Canada CT

income data, for the year 2005, was obtained through the University of Toronto’s Computing in

the Humanities and Social Sciences (CHASS) census analyzer (90). Military service numbers

were used to link the DHRIM, DentIS and Blue Cross datasets. The DHRIM dataset was further

linked to Statistics Canada data using a postal code conversion file. Once the datasets were

linked, service numbers were replaced by numeric code.

The study population inclusion criteria are described in Figure 2. According to DHRIM records,

14393 members were enrolled in the CF and were issued a military service number, in 2007 and

2008. As of Jan 31 2010, only 12,020 dental records could be located in DentIS. The minimum

amount of time a member would have been enrolled in the CF was 13 months to a maximum of

37 months. Although it is possible that some new members had yet to report to the dental clinic

to open a dental file, it appears more likely that the majority of the members were released from

the military prior to having reported to a CF dental clinic. Of the 12,020 new members who had

reported to a military dental clinic for at least one visit following their enrolment date, 1379

(11.5%) members released from the military at some point prior to the end of the study period,

resulting in 10,641 active patient files as of Jan 31 2010. This suggests a member release rate of

over 26% within the study period, which is likely explained by members who do not successfully

make it through basic military qualification training, military occupation training or possibly opt

out of pursuing a military career. Of the 10641 members that remained in the CF, 1973 members

were excluded because they were not less than 30 years of age at the time of enrolment. An

additional, 2998 members were excluded from the study because they did not reside in a CT at

the time of enrolment. This resulted in a study population of 5670 members - 2816 (49.7%)

members enrolled in 2007 and 2854 (50.3%) members enrolled in 2008.

Dental treatment procedures and costs were aggregated and calculated beginning from the date

of a member’s enrolment. Once enrolled, all CF personnel have equal access to identical dental

coverage and receive treatment, as required, to maintain a state of dental readiness for

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deployment in accordance with the “Dental Fitness Classification System” (Appendix 2). The

CFDCP contains specific guidelines and criteria for assessing patient treatment needs and

determining dental fitness classification. All military dentists receive formal training and

instruction pertaining to the CFDCP. Dental treatment that is referred to civilian providers also

meets CFDCP criteria. As such, although the dental treatment providers in the study were not

formally calibrated, all diagnosis and treatment was performed in accordance with a uniform and

prescribed protocol.

Statistics Canada defines Census Metropolitan Areas and Census Agglomerations (CMA/CA) as

an “area of one or more adjacent municipalities situated around a major urban core” (91).The

urban core of a CMA must have a population of at least 100,000, whereas the urban core of a CA

must contain a population of at least 10,000. CTs are defined as “small geographic units

representing urban or rural neighbourhood like communities created in census metropolitan areas

and in census agglomerations” (91). For this reason, the expression of neighbourhood and CT

will be used interchangeably and will have the same meaning. CTs normally encompass a

population of 2,500 to 8,000 residents that should be as homogenous as possible in terms of

economic status and living condition (91). In 2006, Canada had 5,076 CTs located in 33 CMAs

and 11 CAs (92).

The relationship of the CT median income to its respective CMA/CA median income was used

to measure the “neighbourhood income advantage” in a particular jurisdiction. Because the

study population originated from diverse economic regions across Canada it would be

inappropriate to gauge all CTs equally on the same scale. For example, what may be considered

a high CT median income in St John’s, Newfoundland, may be considered a low median income

in Toronto, Ontario. For our analysis, members were grouped into one of five census tract

median income groups by calculating the percentage difference between the CT median income,

of the member’s home residence at the time of enrolment, in relation to the median income of the

respective CMA/CA. Five groupings were structured depending on whether the median income

was well below (<-25%), below (-25 % to -7%), median (>-7% to <+7%), above (+7% to +25),

or well above (>+25%) the CMA/CA median income. Utilizing area-based measures in this

distinctive manner, we were able to more accurately contextualize neighbourhood advantage in a

given locality, and at the same time ensure that the neighbourhood advantage of all CTs was

comparable on a national level.

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We included CT median income data in our study, rather than CT mean income, because it is

considered to be a better indicator of the middle value of income, where 50% of the population

income is above and 50% is below. The lowest income that can be recorded by surveyors is

zero, whereas there is no upper boundary. As a result, the distribution of income in a population

will always be disproportionately skewed higher because of outliers earning high incomes. For

this reason, the mean is unlikely to represent the middle value. The CT median income was

based on the total 2005 income of the population aged 15 years and over. We considered this

metric of income most representative of our young adult study population.

4.3.2 Measures

Dependant variables

The dependant variables included the category of dental procedures, the number of emergency

visits and the total cost of treatment. Procedure codes and associated fees recorded in DentIS are

identical to codes utilized by the Ontario Dental Association (ODA) in 2006. An emergency visit

was demarcated by the “01205” ODA code, defined in DentIS as an “emergency examination

within working hours, diagnosis for the investigation of discomfort and/or infection in a

localized area”. Treatment procedures were grouped by category (Diagnostic, Preventative,

Restorative, Endodontic, Periodontal, Removable Fixed, Surgical, Orthodontic). Procedure codes

recorded by Blue Cross correspond to the province in which the service was delivered and the

fee that was charged by the provider. Restorations, including dental fillings and crowns, were

measured in number of tooth surfaces restored.

Independent variables

The independent variables in this study included, gender, rank class (officer candidate or NCM

recruit), first language (English or French), Birthplace (Canada or Foreign) and CT median

income group.

4.3.3 Statistical Analysis

In order to determine whether an association existed between CT median income and the dental

treatment needs and costs of recruits, data were analyzed in five manners.

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1. Mean Cost: The mean total cost of dental treatment was calculated and further stratified

by gender, rank, first language and birthplace. In cost analysis for health economics,

where the distribution of costs remains unknown, the sample mean has been shown to

perform well and remains the estimator of choice (93). Means were analyzed using one-

way ANOVA and student t-tests.

2. Multiple regression analysis of dental cost adjusting for age, gender, rank, CT income

group, months in service, birthplace and first language.

3. Multiple Logistic regression analysis to predict the likelihood of the members in the well

above and above CT groups requiring dental treatment, in comparison to the well below

and below CT groups.

4. Prevalence: The proportion of subjects requiring one or more restorations, endodontic

fillings, tooth extractions, periodontal procedures and emergency appointments in each

CT group, and further stratified by rank (NCM recruits and Officer candidates) and age

groups (16 to 19 yrs and 20 to 29 yrs). Differences between CT groups were analyzed

using chi-square tests.

5. Severity: Of the subjects in each CT group that required at least one restoration,

endodontic filling, tooth extraction or periodontal procedure, the mean number of

surfaces restored, endodontically filled teeth, dental extractions and periodontal

procedures performed were calculated and further stratified by rank classification. Means

were analyzed using one-way ANOVA and student t-tests.

Orthodontic and prosthodontic procedures are less commonly performed on newly enrolled

members, and where thus not included in the analysis of prevalence and severity. All statistical

analysis was performed using SPSS version 17.0 (SPSS, Inc., Chicago, IL). P-values are 2-sided

and considered significant at the 0.05 level.

4.4 Results

The descriptive statistics of the study population are described in Table 46. The mean age of all

members was 22.5 (SD 3.32) and ranged from 16.7 to 29.9 years. The number of enrolled men

4926 (86.9%) outnumbered enrolled women 744 (13.1%). The average member lived in a

census tract with a median income that was 4.0% (SD 22.03, range -62% to +114%) greater than

the median income of their CMA/CA. Officers originated from higher income neighbourhoods.

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The only statistically significant sub group analysis finding of officers and NCMs was that the

average female NCM was one year older than the average male. Members whose first language

was French resided in CTs and CMA/CAs with a lower income than members whose first

language was English; however, the CT median income relative to the CMA/CA was not

statistically significant. In addition, members whose first language was French incurred higher

treatment costs than members whose first language was English. The average foreign born

member resided in a lower median income CT in comparison to Canadian born members. The

majority (55.6%) of foreign born members resided in CTs where the median income was below

that of the CMA/CA, thus foreign born members resided in lower income neighbourhoods at the

time of enrolment.

Despite being of slightly younger and having less service time, members that did not live in a

census tract at the time of enrolment showed a greater requirement for dental treatment in

comparison to members who resided in a census tract (Table 45). There was no statistically

significant difference in terms of overall treatment cost between members living in CTs and

those not living in CTs. There were also no statistically significant differences found in terms of

prevalence of emergency visits, periodontal procedures and tooth extractions. However, those

living in non CT areas had a higher prevalence of requirement for restorative and endodontic

therapy. The latter findings were statistically significant and imply that the segment of the

recruit population, that was not included in our study because they originated from less

urbanized jurisdictions, had greater treatment requirements. In Canada, individuals living in

rural areas have been shown to be less frequent users of dental services as compared to those

living in urban areas (94).

The study population consisted of 1119 (19.7%) officers and 4551 (80.3%) NCMs. The

population distribution favoured higher income CTs. The middle three income groups were

better represented than the well below and well above income groups. The representation of the

well above group was nearly twice that of the well below group (Table 47). There was a

significant inverse relationship between mean age and income group. As mean age increased the

CT income decreased, with a mean age difference of 1.5 years from lowest to highest. Since

treatment requirements are influenced by age, the observed age differences may have had a

confounding impact on the study findings. There were also statistically significant differences

observed in the mean number of months in service of officers and NCMs, which could have

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potentially influenced the amount of delivered dental treatment. NCMs originating from well

below and well above CTs had more than an extra month to access dental care in comparison to

officers.

Mean cost of treatment provided to members, including the subpopulation analysis, showed a

decreasing trend as CT group median income increased (Table 49). Officers within each income

group consistently had lower treatment costs than NCMs. This was statistically significant in all

groups, with the exception of the well below group.

After adjusting for age, sex, rank, first language, birthplace and months in service, multiple

logistic regression analysis demonstrated that members residing in the well below and below

income groups were more likely to require treatment (restoration, endodontic, oral surgery,

periodontal) in comparison to members originating from the well above and above income

groups (Table 50). Multiple linear regression analysis showed that treatment cost was

significantly increased by NCM rank status, age, birthplace outside of Canada, time in the

services and French as first language (Table 51). Additionally, treatment costs were also lowered

as neighbourhood income advantage increased.

Although not statistically significant there was a decreasing trend in the prevalence of emergency

visits from the well below to the well above income group (Table 48). In the subpopulation

analysis, this trend was not apparent for officers. Most notably, officers from the well below

income census tract showed the lowest prevalence of emergency visits. Overall, the results show

that officers reported statistically fewer emergency visits than NCMs.

Prevalence of treatment requirement (restorations, root canals, extractions, periodontal

procedures) increased from the well above income group to the well below income groups (Table

52). The increasing prevalence rate was progressive except in three areas. There was a slight

decrease in the restoration prevalence rate moving from the below income group to the well

below income group, and there was a slight increase in the endodontic and periodontal

prevalence rates moving from the above to the well above income groups.

When the study sample was stratified into age groups (Table 53) the prevalence of treatment

requirement generally followed the same decreasing trend as neighbourhood income increased,

except in a few notable observations. In the 16 to 19 year old age group, a smaller proportion

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required restorations and root canals in the well below income group as compared to the below

income group. On the other hand in terms of extractions the 16 to 19 year old members in the

well below income group showed the highest prevalence. This was contrary to the general trend

where the older cohort showed higher prevalence in all treatment procedures, as would normally

be expected.

The severity of treatment requirement, in other words, of those individuals that required

treatment, the number of surfaces restored, root canals completed and teeth extracted were not

significantly different between median income groups (Table 54). Severity of periodontal

procedures was the only exception, showing a decreasing trend from the well below income

group to the above income group followed by an increase in the well above income group. The

change in the trend for periodontal procedures is unexpected, especially when one considers that

the mean age of the study population decreased as neighbourhood advantage increased. In every

CT income group, officers consistently demonstrated a requirement for a smaller average

number of tooth surfaces to be restored.

4.5 Discussion

The results validated that individuals that resided in income disadvantaged neighbourhoods

incurred higher treatment costs, and experienced dental emergencies and required dental

treatment in higher proportions as compared to members that emanated from income advantaged

neighbourhoods. However, with the exception of periodontal treatment, of those who required

treatment the average amount of treatment required did not differ greatly. The increase

requirement for dental restorations, root canals, tooth extractions and periodontal procedures in

the lower CT income groups corresponds with a wide epidemiological body of knowledge

regarding social distribution of dental disease. Caries experience is more extensive and more

severe among lower socioeconomic classes (3). Teeth with severe caries are in turn more likely

to necessitate endodontic therapy, or extraction. In addition, persons in lower income groups and

those living in lower income neighbourhoods have been shown to have higher edentulous rates

than individuals in higher income groups and higher income neighbourhoods (37,49).

Nevertheless, one must be mindful that most dental extractions on new military members are not

due to tooth non restorability. CF dental officers follow strict guidelines in determining whether

or not third molars require extraction for operational readiness. The fact that fewer extractions

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were observed among members from the higher CT income groups may suggest that these

members were more likely to have had third molars extracted prior to enrolment. Lastly, the

increased requirement of periodontal services for members residing in the below CT income

groups may be explained by poorer oral hygiene. Gingival and periodontal health is closely

associated with socioeconomic status with greater dental awareness and better hygiene practices

among the more educated (27).

These findings indicate that population dental health planners can use CT median income as a

surrogate marker for dental treatment needs for this respective population. Although the cause of

the association can not be confirmed with certainty, it is believed that the area-based measures of

income represent neighbourhood socioeconomic characteristics and substitute for individual-

level socioeconomic characteristics of residents. For example, neighbourhood health influencing

features, such as dentist-patient ratios tend to be greater in higher income areas. Additionally, the

2007-2009 CHMS highlighted inequalities in oral health that were observed between higher and

lower income Canadians: 46.6% of lower income individuals required treatment as compared to

25.6% of those with higher incomes (27).

Population health in Canada is influenced by health care delivery and financing systems. Every

Canadian citizen has access to insured medical benefits and 98% of physician payments are

publicly funded (95). On the other hand, recently published data from the CHMS reported that,

only 5.5% of dental care funding is derived from public sources and that less than 63% of the

population has coverage under a private dental insurance plan (27). Therefore, low income

families and the working poor, who are entirely able to access medical care at no cost, may not

be able to afford dental care. Indeed, this was made evident in a Statistics Canada report (1999)

that showed that in a 12 month period, families earning greater than $50,000 visited a dentist

65% of the time and a physician 81% of the time, while families earning less than $20,000

visited a dentist 39% of the time and a physician 82% of the time (94).

There were two observations in our study that possibly indicated that access to public dental

insurance improved the dental treatment outcomes in the well below CT income group. When

the sample population was stratified by age group there was a notable change in the overall

trend. The percentage of 16 to 19 year olds, in the well below income group requiring

restorations or root canals was less than those in the below income group. Moreover, in terms of

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requirement of restorations for the 16 to 19 age group, the well below income group appeared

almost equal to the well above income group. The same pattern however is not evident in the 20

to 29 age group. This benefit demonstrated in the 16 to 19 year olds of the well below income

group is lost in terms of requirement for extraction. This may suggest that this group of 16 to 19

year olds had a greater frequency of non-restorable teeth that required extraction; however, this

is probably not the correct answer. Findings from the CHMS showed that those aged 12 to 19

were more likely to have public dental insurance coverage (27). Thus, it is could well be that 16

to 19 year olds in the well below income group were able to access public insured dental

benefits, such as school based dental programs that are available in some jurisdictions. Of

course, the benefit that brought the well below income group on a more equal level with the

higher income groups was lost in terms of extractions because public dental programs do not

cover the prophylactic extraction of third molars. If this explanation is correct, then this is yet

another indication that the working poor (low income earners with no private insurance and no

public insurance eligibility) may indeed be the segment of the Canadian population with the

greater dental treatment needs.

The second notable exception was found in the sub-population analysis for officers and NCMs.

individuals in the well below CT income group demonstrated the lowest prevalence of

restorations and emergencies of all the other groups. With the exception of the well above

income group, officers in the well below income group also showed the lowest prevalence for

dental extractions. Findings from the CHMS showed that 17.7% of individuals that made up the

lower income group had coverage under public dental insurance (27). However, as it has been

previously reported in Canadian dental research (43), simply having access to this enabling

resource does not eliminate oral health disparities. Clearly, the advantage that was shown in the

lowest CT income group in officers is not evident in the lowest CT income group of NCMs. As

a matter of fact, the NCMs in the lowest CT income group consistently showed the highest

prevalence for treatment needs, treatment costs and emergencies, of all other groups. Seeking

dental treatment is not only dependent on having enabling resources, nor is it solely a process of

resolving a dental condition. Seeking dental care is a reflection of an awareness of oral health

and how to obtain dental care. It is more likely that officers, being better educated, and more

likely to come from a household of higher education, have a higher level of dental awareness and

the wherewithal to navigate the public health system in order to obtain dental treatment.

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Furthermore, it has been suggested that education and household income represent different

socioeconomic pathways to oral health (49) and that the probability of receiving any dental care

over the course of a year increases with level of education (38). By stratifying the recruit

population into officer and NCM subpopulations, our study also enables the analysis of the

association of individual-level measures of education level and occupation class. In general,

officers in the CF are employed in administrative and professional positions and achieve a higher

level of education than NCMs. Officer candidates either have obtained or are in the process of

obtaining a university degree through the Royal Military College or civilian universities. On the

other hand, NCM recruits can be enrolled in the military with a minimum of a grade ten high

school education (grade nine in Quebec). The results of our study indicated that officers residing

in the two lowest CT income group showed a lower prevalence for emergency visits,

restorations, root canals, and extraction when compared to NCMs in the two highest CT income

groups. Since age was associated with higher treatment costs, the fact that officers in the lower

CT income groups were also older makes this finding that much more significant. This suggests

that individual-level characteristics (education, occupation class) had a greater influence on

dental treatment needs as compared to area-based measures of neighbourhood advantage. As

stated by Locker in a review of the literature, “area-based measures of deprivation supplement

rather than substitute for conventional measures of socioeconomic status and add explanatory

power to models of health inequalities” (96).

This study demonstrates how military dental treatment information can also benefit population

health planners and researchers outside of the military. The principal strength in using military

data is that dental treatment in the CF is provided in accordance with standardized criteria

established in the CFDCP. As such, it represents a more reliable picture of actual treatment

needs and costs versus those that might be found in a civilian insurance database, where for

example, one might see higher costs for higher income families specifically because they can

afford the more expensive treatments, or have the more robust insurance plans. Military data is

also arguably more accessible than treatment data in the private sector, and more systematically

and routinely collected than the little that is currently available in the civilian public sector.

The demographic composition of new members enrolled in the CF is influenced by recruitment

and retention policies, the appeal of service benefits, the state of local and the national

economies and unemployment levels. Young adults who are accepted in the military are

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generally physically fit, willing to be challenged and possess a greater sense of duty to serve

their country. Individuals possessing attributes of health, motivation and pride are also more

likely to practice better oral hygiene. Some may argue that the likeness of young adult

Canadians attracted to the military is an inherent weakness in generalizing military dental

treatment data. Nevertheless, in the context of what this study is trying to accomplish, similarity

in individual-level characteristics is not necessarily a shortcoming. The main objective of this

study was to determine whether neighbourhood level statistical data is correlated with individual-

level treatment data. If the individual-level characteristics of a study sample fluctuate then it

becomes more difficult to separate the neighbourhood influence from that of the individual

because internal reliability would be compromised. Therefore potential confounding attributable

to the population social and behavioural characteristics is more controlled in our study, and thus,

the area-based income data will be more representative of the neighbourhood contextual effect

on population treatment needs.

Despite the advantages of utilizing military dental treatment data, there are also some limitations.

Most notably there is selection bias in a military recruit population that weakens the

comparability of any findings to the general Canadian population at large. The profession of

arms is dominated by men. As such, there is a disproportionate representation of women who

enroll in the military. In 2007 and 2008, the proportion of newly enrolled members who were

women was less than 14%. The representation of foreign born individuals is also much lower in

the recruit population as compared to the general population. Statistics Canada reported that

19.8% of Canadians are immigrants to Canada whereas only 6.7% of our study population was

born outside of Canada (98). The military recruit population is also biased towards individuals

who are able to speak English and/or French; the most often spoken language of 11.3% of

Canadians is neither English nor French. Furthermore, as was apparent in our study population,

there were a disproportionately lower number of members enrolled from lower income CTs. The

population distribution of 2007 and 2008 CF recruits favoured middle class and upper middle

class neighbourhoods, with an average neighbourhood median income that was more than 4.0%

greater than the CMA/CA median income. As a result of this condition, it becomes more

obscure to show the precise relation of treatment needs for members originating from low

income CTs.

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The first 18 months are an extremely busy time in a serviceman’s and servicewoman’s career

and will take precedence over elective and some routine dental procedures. Since our study

population included members enrolled in 2007 and 2008 and consisted of treatment data up until

31 Jan 2010, some members would have had 37 months in their military careers to access dental

care and others only 13 months. Consequently, all new members may not have had sufficient

time to obtain all required treatment. This is why time in service was such a significant

determinant of overall dental treatment cost in the linear regression model in Table 52.

Additionally, some potential confounding bias may have resulted from the mean age distribution

that was identified in the CT groups. As the CT income increased age decreased, and at the same

time, age was found to increase treatment costs. It is recommended that future research

incorporates a larger military recruit population of a minimum of four years and a treatment

follow-up period of two years, in order to ensure that sufficient time is permitted to capture all

treatment data. Linear regression modeling can partly control for some of these imbalanced

proportions and improve the generalizability of recruit dental treatment data to the Canadian

population.

4.6 Conclusion

To date, this is the first study that demonstrates the association of neighbourhood income

advantage, using area-based measures statistics, and individual-level normative dental treatment

data, of a young adult population entering the CF. The decreased requirement for dental

treatment among recruits originating from higher income neighbourhoods could possibly be

explained by the individual-level socioeconomic characteristics in higher income

neighbourhoods and the contextual effects of the neighbourhood itself. However, the findings

also suggest that access to public dental programs may be decreasing the disparities in dental

treatment requirement in the most disadvantaged neighbourhoods, with implications that the

working poor are transforming into the segment of the population with the highest treatment

needs in Canada. Compared to neighbourhood income advantage, individual-level

socioeconomic characteristics (occupation classification / level of education) appeared to be

more strongly associated with a lower prevalence of dental treatment requirement.

Publicly financed dental care in Canada is in a time of renewal (98). Today, more than ever,

dental public health planners require knowledge of the determinants of oral health in order to

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ensure that programs and funding are being targeted to populations that exhibit the highest

treatment needs. For population health planning and research, CF dental data appears to be a

worthy, reliable and cost-effective instrument. With some adjustments and standardization for

variables such as, age and gender, CF recruit dental treatment data can become more

generalizable and may serve as a predictor of young adult dental treatment needs. While this

study demonstrated the utility of using military data, it is only a preliminary study. Further

investigation is recommended in order to fully assess the contribution that can be afforded by CF

dental treatment data in understanding and relieving the burden of illness for all Canadians.

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Chapter 5 - Manuscript

5 The impact of recruit dental treatment workload on Canadian Forces dental detachments

Major Constantine Batsos DDS, MSc (candidate)

Dental Public Health, Faculty of Dentistry, University of Toronto

Sources of support: The research in this paper was based on data provided by the Canadian

Forces

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5.1 Abstract

Background: New members entering the CF have substantial dental treatment needs; however,

the scale of the recruit dental treatment workload impacting CFDS dental detachments has never

been explored.

Aims: To examine the type, amount and cost of dental treatment that was required by members

who enrolled in 2007 and 2008 and determine the timeliness and effectiveness of the dental

detachments in meeting recruit treatment needs.

Methods: In-service dental treatment data were derived from the CF Dental Information

Systems database and outsourced dental treatment data were requested through the Federal

Health Claims Processing System. The number and cost of dental procedures completed were

reported for each dental detachment. The timeline of treatment delivery was analyzed in six

month intervals following the recruit enrolment date.

Results: A total of 150,003 procedures were performed on 12,020 recruits. In aggregate, dental

detachments on training bases St Jean, Borden and Gagetown responded to 2367 emergency

visits and completed 537 root canals, demonstrating that recruits require a considerable amount

of urgent treatment. In-service dental treatment was valued at $10.6M; outsourced charges were

$2.9M. Thirty-eight cents out of every dollar of non-diagnostic and non-preventive treatment

services was outsourced to civilian dentists in private practice. The capability to perform oral

surgery and endodontic procedures within the detachments varied extensively and was found to

be a significant driver of outsource costs. Contrary to what would be expected, large specialty

centre detachments referred a greater proportion of dental extractions and root canals than small

and mid-size detachments.

Conclusions: The findings validate that the employment of clinical specialists (CBI 204.217) in

large detachments is inconsistent in reducing the need for outside referrals and patient travel.

Incorporating dental treatment during BMQ training could eliminate inequalities and make the

delivery of dental services more efficient and cost-effective. Additionally, CMP policy makers

must consider the cost savings that would be realized by preventing the deterioration of recruit

dental state as early as possible and by conveying a positive oral health promotion message that

could have enduring beneficial implications throughout a new member’s career.

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5.2 Introduction

The concept of need is at the core of health care planning, and in turn, the planning of healthcare

services is rooted in the ethical imperative to use resources appropriately (99). Dental public

health planners in the CF require current measurements of population oral health status and

treatment needs, in order to ensure that a suitable mix of primary care providers and auxiliary

staff are employed to address the treatment workload. Moreover, dental public health planners

must continuously monitor and evaluate the quality and capability of the dental services to

achieve desired patient outcomes efficiently and cost-effectively.

The Canadian Forces Dental Services (CFDS) currently employ more than 650 military and

civilian personnel and are responsible for providing comprehensive dental services to

approximately 75,000 regular and reserve force members. The provision of dental treatment is

delivered through 24 in garrison dental detachments in Canada and two in Europe. Dental

detachment operations and treatment delivery is comparable to a prepaid managed healthcare

staff model, whereby all clinics are owned by the Department of National Defence and dentists,

dental hygienists and dental assistants are salaried employees of the organization.

Although the CFDS train their own military dental specialists through subsidized dental

programs in civilian universities and through US military institutions, a substantial amount of

specialty dental treatment is referred to civilian dental practices on a fee-for-service basis. In

recent years, the CFDS have struggled to keep up with the treatment workload and have also had

to outsource a significant portion of general dental treatment. From April 2007 to Mar 2010, the

CFDS paid more than $27.4M to civilian dental practices for the provision of dental treatment to

military personnel (11).

As a measure to address the rising dental treatment workload, the CFDS are in the middle stages

of implementing Operation RESTORE, the planned initiative to increase the number of dental

personnel by over 35% and at a cost of $15.3M in additional annual salaries (12). Op RESTORE

is based on the commonly used provider/population ratio planning method that expresses the

supply of human resources in terms of the number of patients per health care worker. More

precisely, the new establishment under Op RESTORE is founded on a retrospective review that

compares dental provider/population ratios in recent years to those of the early 1990’s, a time

when the CFDS consistently achieved 90% dental fitness levels (12). Although this

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methodology is simple and requires minimal data and analysis, it does not address the dynamics

and determinants of health service utilization or the population demographic and treatment need

differences that exist on distinct CF bases and wings. In addition, the validity of the population

ratio approach has been questioned because it does not consider the effect of technology, the

changing patterns of disease and the role and efficiency of primary and auxiliary healthcare

workers (13). In order to determine precise personnel levels, the CFDS requires pertinent and

current data on epidemiologic and dental treatment trends of the CF population, and the

effectiveness of its healthcare personnel in meeting those needs.

The intent of this descriptive study is to examine the type and amount of dental treatment that is

required for new members entering the military. A thorough assessment of dental treatment

workload and the dental detachments that are most affected by incoming recruits, will provide

valuable information as to how dental resources may be predictably deployed and managed, so

that optimal and timely care can be delivered. Additionally, this report will determine the

effectiveness of the dental detachments in meeting recruit treatment needs, by analyzing the

proportion and type of treatment that is being outsourced. The findings will provide guidance for

CFDS, CF Health Services Group, CF Recruiting Group and Chief Military Personnel policy

makers. Dental program and policy planning must be supported by scientific evidence and

grounded on ethics in order to ensure that the dental services are utilized in a manner that

economically maximizes productivity, while improving the oral health of CF members.

Authorization for this study was obtained from the CFDS and the Office of Research Ethics at

the University of Toronto. Authorization for the release of CF dental treatment and demographic

data was granted by CF Directorate Access to Information and Privacy.

5.3 Methodology

5.3.1 Study Design

The study comprised the population of Non Commissioned Member (NCM) recruits and officer

candidates that were enrolled in the CF in 2007 and 2008. Treatment data were extracted from

two databases. Datasets and included study variables are shown in Appendix 4. In-service dental

treatment data were derived from the CF Dental Information Systems (DentIS) database and

outsourced dental treatment data were requested through the Federal Health Claims Processing

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System. DentIS provides an accurate account of the dental treatment a member has received in

CFDS detachments during his/her career; however, it does not include a record of the treatment

that was referred to civilian dental practices. At times, due to various and extenuating

circumstances, specialty and basic dental treatment for military personnel is outsourced to the

civilian sector. Medavie Blue Cross is the dental third party provider for the CF and administers

all outsource treatment data. DentIS and Blue Cross datasets were aggregated and analyzed

conjointly.

Dental treatment procedures and costs were calculated, beginning from the date of a member’s

enrolment in the CF, until the study end date, 31 January 2010. Once enrolled, all CF personnel

have equal access to identical dental coverage and receive treatment, as required, to maintain a

state of dental readiness for deployment. The Canadian Forces Dental Care Program (CFDCP)

contains specific guidelines and criteria for assessing patient treatment needs and determining

dental fitness classification (Appendix 2). All military dentists receive formal training and

instruction pertaining to the CFDCP. Dental treatment that is referred to civilian providers also

meets CFDCP criteria. As such, although the dental treatment providers in the study were not

formally calibrated, all diagnosis and treatment was performed in accordance with a uniform and

prescribed protocol.

5.3.2 Data Analysis

Descriptive statistics were reported for the type, number and cost of dental treatment procedures.

Treatment procedures were grouped by category (Diagnostic, Preventive, Restorative,

Endodontic, Periodontal, Removable, Fixed, Surgical, Orthodontic, Miscellaneous). The five

digit procedure codes used by professional dental associations were used to demarcate the

treatment category. Procedure codes recorded in DentIS are identical to codes utilized by the

Ontario Dental Association (ODA) and fees are representative of the ODA’s 2006 fee schedule.

It is important to note that DentIS fees are strictly for CFDS record keeping and civilian

comparison purposes; they do not represent actual paid services. Procedure codes recorded by

Blue Cross correspond to the province in which the service was delivered and the fee that was

charged by the civilian provider. Blue Cross costs represent real charges paid by the CF. In

order to shed further clarity on procedures that are of particular significance to newly enrolled

members, the number of emergency visits, completed root canals and dental extractions were

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also examined separately from their respective treatment categories. In-service (DentIS) and

outsourced (Blue Cross) treatment procedures and costs were reported for all 24 dental

detachments in Canada and Her Majesty’s Canadian Ship (HMCS) PRESERVER. The dental

detachments are designated, in Appendix 1, as a specialty centre (consisting of a number of

dental specialists), mid-size clinics (which normally have an Advanced General Dentist (AGD)

specialist) or small general dentistry detachments.

The timing of treatment delivery was analyzed, by treatment category, in six month intervals

following the recruit enrolment date. The dental treatment provided by each dental detachment

was stratified into six month intervals, beginning from the date of enrolment, in order to assess

the timeline of the treatment impact on specific dental detachments. Data were processed using

SPSS version 17.0 (SPSS, Inc., Chicago, IL).

5.4 Results

The quantity and cost of treatment provided to12,020 recruits (including recruits who were

released from the military) is reported in Table 55. Almost one-half (48.1%) of the 150,003

services provided, in total, consisted of diagnostic services, while another 23.3% consisted of

preventive services. At 15.3%, restorative procedures were the third most common procedure,

followed by oral surgery (6.6%). Periodontal and endodontic procedures made up 1.4% and

1.2% of procedures respectively. Combined, prosthodontic and orthodontic procedures made up

less than 1% of delivered services.

The in-service dental treatment costs provided to the 2007 and 2008 recruit population totaled

more than $10.6M, based on the 2006 ODA fee schedule. The Blue Cross charges were greater

than $2.9M. In terms of outsourced costs, the biggest cost driver was oral surgery, which made

up more than 34.5% of Blue Cross charges. The impact of oral surgery on cost is enhanced

further by Blue Cross miscellaneous charges, the majority of which stemmed from anesthesia

and sedation procedures administered in conjunction with exodontias. Restorative treatment

procedures contributed nearly 20% of Blue Cross costs followed by endodontic treatment at

13.6%.

Table 56 depicts the progressive shift in recruit dental treatment workload in six months intervals

following enrolment. Not surprisingly, the detachment in St Jean shoulders most of the workload

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in the first six months of a member’s career. Almost all recruits must complete Basic Military

Qualification (BMQ) in St Jean; a smaller portion of members complete BMQ in Borden. It is

during BMQ that most members are processed through a military dental clinic for the first time.

An electronic dental file is created for every patient, radiographs are taken and an enrolment

(forensic) dental examination is performed. Following BMQ the treatment burden shifts to

training bases that house military schools, where Basic Occupation Qualification Training

(BOQT) is instructed to new members. For NCMs most of the trade specific training is

conducted at CFB Gagetown and CFB Borden. Navy cap badges report to the Canadian Forces

Fleet Schools in Quebec City and Esquimalt. On the other hand, most officer candidates proceed

to the Royal Military College at CFB Kingston, where they pursue post secondary studies for

four years. Following trade specific training, most army NCMs will make their way to one of

three large bases (Valcartier, Petawawa, Edmonton), most navy NCMs report to either Halifax or

Esquimalt. Air force personnel are posted to one of several CF wings, which are mostly

supported by mid-size dental detachments.

Table 57 shows the impact in terms of the number of procedures and treatment costs imposed on

each dental detachment. In aggregate, the highest number of procedures were provided in St

Jean (14.9%), followed by Valcartier (11.1%), Borden (10.5%), Edmonton (9.5%) and Gagetown

(8.5%). Proportionally, the highest number of outsourced procedures were referred by Edmonton

(18.2%), followed by Gagetown (10.2%), Petawawa (9.4%), Valcartier (8.8%) and Esquimalt

(8.7%). It is important to keep in mind that these proportions are a reflection of the treatment

provided during the study period. Some of the recruits within the study population had as little

as 13 months of service while others had up to 36 months. As already demonstrated, St Jean,

Borden and Gagetown take on a greater share of the workload in the first 12 months of a

member’s career, but the workload shifts to the home units following the completion of training.

Hence, if our study included the first 36 months of service for every recruit, it could be expected

that the overall proportion of the treatment, would decrease in the training bases and increase in

the bases that become a member’s home unit following the completion of training.

A more specific dental treatment workload description, for each detachment, is provided in Table

58. The highest proportion of emergency visits were received in Gagetown (14.6%), followed by

St Jean (14.1%), Borden (13.2%) and Valcartier (13.0%). For restorative procedures, it was

Valcartier (13.7%), followed by Edmonton (13.0%), Borden (10.4%) and Gagetown (9.8%). The

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highest proportion of endodontic procedures were recorded in Borden (14.4%) followed by

Valcartier (13.0%), St Jean (12.3%) and Gagetown (10.9%). Lastly, the highest proportion of

oral surgery procedures were performed in Valcartier (14.3%), followed by Borden (14.0%),

Edmonton (12.7%), and Petawawa (11.5%).

Proportionally, the type of treatment that is delivered to recruits also changes over time. Table

59 shows the proportion of treatment, by treatment category (excluding diagnostic services other

than emergency visits), provided in six month intervals following enrolment. Preventive

procedures consistently make up the greatest share of treatment and increase as time progresses.

The proportion of emergency procedures peaks in the first six months and continues to decrease

over time. The same can be said for the proportion of endodontic procedures and completed root

canals, which mirrors the pattern observed for emergency procedures. The share of restorative

treatment maintains a consistent level, between 23.7% and 28.8 %, throughout the first 36

months of a member’s career. Contrarily, the proportion of oral surgical procedures increases

steadily from the date of enrolment, peaks during the 13th to 18th month, and steadily decreases

afterwards.

Dental detachments must have appropriate military dental specialist support to serve their

population needs, without excessive avoidable referral costs. Since outsourced referrals for

endodontic treatment and oral surgery procedures compose more than 50% of costs, for those

treatment categories, it is essential to study the impact of root canals and dental extractions more

closely, at the detachment level. Table 60 illustrates the proportion of dental extractions

completed by each detachment, and more importantly, the proportion of dental extractions

completed within the detachment or outsourced to civilian dentists. Overall, more than four out

of every ten extractions were referred to civilian dental practices. The data show that specialty

centres tend to refer a greater proportion of dental extractions than mid-size and small

detachments. This is contrary to what would normally be expected, considering that the

specialty centres employ a minimum of one AGD and some will even employ an oral

maxillofacial surgeon. Mid-size detachments are intended to employ an AGD specialist;

nevertheless, the detachment of Borden and Winnipeg only employed an AGD for a part of the

study duration, while Trenton did not employ an AGD at all. The detachment of Kingston also

runs the annual CF Dental Services School (CFDSS) oral surgery course, during which

complicated extractions are performed by younger dentists under the supervision of an oral

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maxillofacial surgeon. Small detachments are strictly staffed by general dentists with varying

degrees of experience. The detachment level ratios of in-service to outsourced extractions

spanned from one extreme to another. For instance, in the detachment of Wainwright almost all

extractions were completed in-house. On the other hand, in Trenton almost all extractions were

referred. To a lesser degree these extremes were also notable in the mid-size clinics of

Gagetown, Kingston and Cold Lake, where AGDs commanded the detachments throughout the

entire study period.

As a whole, in terms of outsourced root canals, the dental detachments performed slightly better

(Table 61). Still, more than one in every four root canals was referred to civilian practices. As

was the case for dental extraction, the specialty centres referred a greater proportion of root

canals when compared to mid-size and small detachments. Mid-size dental clinics also referred

a greater proportion of root canals as compared to small detachments, even when Trenton, which

was not staffed with an AGD, was excluded from the analysis. Detachment level ratios of in-

service root canals to outsourced root canals varied radically. All root canals in Moosejaw and

almost all in Trenton were referred. Contrarily, in Valcartier, Wainwright and St Jean almost all

root canals were completed within the detachments.

5.5 Discussion

Recruits carry a backlog of treatment requirements when they join the military. A survey

questionnaire that was distributed to US military recruits prior to examination in the Tri-Service

Comprehensive Oral Health Survey (TSCOHS) revealed that 61% of the recruits perceived a

need for dental care (26). Additionally, it was shown that 38% of recruits had not seen a dentist

in the past year, while 30% had not visited the dentist in over three years (26). Once a recruit

decides to join the military it is understandable that they would forgo paying for dental care out-

of-pocket, knowing that free dental care becomes a service benefit upon enrolment. The high

prevalence of observed emergency procedures in the first 12 months of service is indicative of

the amount of carried-in dental treatment needs. Conflictingly, the first 18 months are an

extremely busy time in a serviceman’s and servicewoman’s career. Military training takes

precedence over elective and routine dental procedures. Recruits have little time availability to

schedule dental appointments, and appointments that are scheduled often result in cancellations

and no-shows. As a result, the CFDS does not make a concerted effort to pursue dental treatment

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on recruits in training. Moreover, the dental fitness of recruits, which is normally between 45%

and 55%, is not a consideration in the dental fitness attainment goals of the CFDS. Dental

detachments on training bases, CFB St Jean, CFB Borden and CFB Gagetown, are only

sufficiently staffed to provide emergency care on the members of the recruit population. Once

all training is complete and the members arrive at their home unit, dental detachment personnel

will actively pursue the individuals to schedule appointments. The additional time that passes

before members with needs receive necessary treatment most likely leads to a further

deterioration of their dental state, and the requirement of more complicated definitive treatment

later on.

Other than diagnostic and preventive procedures, the most commonly performed procedures on

new members tend to be restorations, root canals and extractions. Very rarely are prosthodontic

and orthodontic procedures performed. Prosthodontic services are more common in older

populations and often encompass elective procedures that can wait to be completed at a later

date. Orthodontic procedures are not initiated in the military before a member typically signs

their second term of engagement. The small number of orthodontic procedures that were

observed in the data was most likely orthodontic repairs that were necessitated by members who

had initiated treatment in the civilian sector prior to entering the military.

In 2000, Chisick and Piotrowski estimated the dental treatment cost for recruit and active duty

personnel in the US military (7). The results of the study showed that recruits had higher mean

costs for oral surgery, endodontic and restorative care, whereas the active duty personnel had

higher mean costs for prosthetic and periodontal care. Similarly, in our analysis, oral surgical

procedures made up a significant portion of the outsourced and total treatment costs. Oral

surgery procedures in the recruit population largely consist of the extraction of unerupted or

partially erupted third molars. Dental extractions were shown to peak between the 13th and 18th

month of a member’s career. This coincides with a period where most recruits have completed

occupational training. Although pain and infections from third molars can be urgent conditions

requiring immediate treatment, they are most often treated with medications while a member is

in training. Dental extractions are deferred until recruits are out of the training environment and

have available time for healing and recovery.

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Military dental research in the US has shown that restorative treatment accounts for more than

two thirds of dental procedures required to convert Dental Fitness Category (DFC) 3 recruits to

DFC 2 (72). Findings from a US Navy study demonstrated that 30% of posterior restorations on

recruits require replacement at the initial examination or within the first years of military service

(23). Dental services of other nations have also reported that recruits have an excessive

requirement for restorative treatment (73, 74). Our analysis showed that, excluding diagnostic

and preventive services, restorative treatment accounted for the greatest amount of procedures.

The provision of restorative treatment also remained constant throughout the first 36 months of

service, consisting of approximately one out of every four non-diagnostic and non-preventive

procedures.

This finding reveals that recruits are receiving a steady load of restorative work even after being

with the military for more than two and three years. This raises questions about how care is

delivered in the CFDS. Are the recruits not getting required restorative treatment early because

of the patient availability, detachment scheduling or the lower urgency of some restorative

procedures? Or are dental providers not making the most of preventive opportunities? Current

research shows that dental caries are taking longer to penetrate through tooth structure than in the

past. A 2001 Danish study, conducted by Hintze, that investigated the rate of caries progression

on recruits concluded that the “development of new approximal lesions and the progression of

enamel caries was a slow process” (59). The slow progression of caries also suggests that

military dentists can take a more preventive approach and may consider monitoring dentine

lesions rather than immediately opting to restore teeth with dental fillings, especially in an

environment where periodic dental examination is compulsory. A caries risk assessment protocol

for treating dental caries can reduce operative dental treatment and decrease the need for

restorative care during a military career (60). The monitoring and remineralization of dental

lesions using fluoride varnish can also be done by auxiliary staff, thus freeing the dentist to treat

other patients. The CFDCP contains a caries risk assessment protocol. Nevertheless, according

to data extracted from DentIS on 01 Jun 2010, the caries risk status of more than 58% of the

regular force population was “unknown” (Table 2). The combined observations that the amount

of restorative work does not appear to decrease and that caries risk assessments are not routinely

completed by dental providers, may be an indication of overtreatment, inefficient care, and a lack

of provider compliance with protocol.

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The requirement for endodontic therapy is lower than that of restorative and oral surgery

treatment. However, in terms of cost, endodontic therapy is a significant driver impacting

outsourced expenditures. The major share of endodontic procedures was performed very early, in

the immediate months following enrolment, and decreased over the 36 month study period. This

is indicative of the urgency of endodontic therapy. As such, the training bases of St Jean, Borden

and Gagetown shouldered a good part of the root canal workload.

Understanding the type and changing pattern of the recruit treatment workload is a fundamental

step in ensuring that area dental detachments are properly staffed to provide adequate and cost-

effective dental support. The treatment demands of newly enrolled personnel necessitate that

treating dentists are especially skilled in complex restorative procedures, exodontias and

endodontics. The St Jean and Borden dental detachments provide the lion share of dental

treatment during BMQ training, in the first six months. CFBs Borden, Gagetown, and Valcartier

house the occupational schools that draw the vast majority of recruits from the seventh to the

12th month of training. Since dental detachments do not make a concerted effort to pursue

dental treatment on recruits in training, treatment provided to recruits consists mainly of

emergency treatment. Additional routine dental treatment will only be provided if recruits can

make themselves available with certainty. Somewhere between the 13th and 24th month,

recruits complete their initial occupational training and will make their way to their home unit.

As a result, the dental workload for delivering treatment to recruits is distributed to all dental

detachments, requiring that all detachments are sufficiently staffed with appropriately skilled

personnel.

The high variability in proportions of in-service and outsourced costs between detachments is an

indication that detachments are not equally prepared to deal with the workload. Particularly, the

large dental specialty centres were less capable of providing treatment within the detachment as

compared to the detachments on the training bases. This is an unexpected finding considering the

detachment on training bases are only staffed to provide emergency treatment on recruits,

whereas specialty centres, staffed with dental specialists, are expected to provide definitive and

comprehensive treatment. This finding implies that recruits, who have had their treatment

deferred until they arrive at their home unit, have to wait even longer in order to schedule

appointments with private practice dental clinics. The organizational structure of the specialty

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centres are thus not achieving their expected goals of reducing outside referrals and patient

travel, and providing timely care with less administrative burdens.

The challenges in providing timely dental care to newly enrolled members are not particular to

the CFDS. The British and US Armies have experienced similar issues. Until recently in the

UK, most recruits were only offered emergency treatment to relieve pain. In 2007, a new

initiative was put in place to change delivery from a vertically equitable model, where routine

treatment was prioritized to only those recruits with the worst dental health, to a horizontally

equitable model, whereby all recruits access routine dental care during training, on training

establishments (8). Similarly in 2004, the US Army formalized a program that incorporates time

in the training cycle to treat recruits at basic training, advanced individual training and officer

basic courses (100). The program has proven to be very successful allowing over 95% of trainees

to arrive at their first duty location dentally fit. The US Navy also identifies treatment needs and

ensures the completion of all urgent care on recruits before they leave basic training (100).

Adopting the example of the British army and US army and navy may be an approach worth

considering for the CF. There are a number of benefits that would be afforded by adopting a

strategy that integrates dental care during BMQ training at CFB St Jean and CFB St Borden.

Firstly, it would establish dental readiness on new members at the earliest point in their military

career, decreasing the number of future emergencies and the likelihood of deterioration of

existing dental pathology. Ultimately this would also decrease the necessity for more significant

definitive care and time away from the workplace. Secondly it would focus sufficient and

appropriately skilled dental resources to two dental detachments (St Jean, Borden), thereby

increasing efficiency and cost-effectiveness. Thirdly, it would eliminate inequalities in the

delivery of care between recruits who are educationally disadvantaged and not as responsible in

seeking dental care, and those who are more assertive and seek dental care early. Fourthly, it

would champion oral health promotion and oral health behaviors on an equal degree of

importance with dress and deportment, physical fitness, general hygiene and other military

attributes strongly emphasized during BMQ. The current environment defers dental treatment

until after training, thus portraying oral health as a less important consideration in one’s military

career. By strongly encouraging positive oral health behaviours as new members are integrated

into the military culture, improved oral health outcomes may be reflected in the CF population in

future years, reducing the cost of dental services over a member’s career. Opponents to

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providing treatment to BMQ recruits have reservations about whether it is appropriate to provide

dental services to all recruits, knowing that roughly 10% of recruits do not pass BMQ and are

released from the CF. The question of whether the efficiencies and long-term benefits, which

could potentially be gained by an early treatment model demands further economic evaluation.

What is certain, however, is that adopting a strategy that integrates dental treatment with BMQ

training would call for highly synchronized block appointment scheduling between BMQ

platoons and dental staff, and the expansion of current clinic facilities.

The cost of outsourced treatment during the study period totaled more than $2.9M. Thirty-eight

cents out of every dollar of non-diagnostic and non-preventive treatment services was outsourced

to civilian dentists in private practice. When miscellaneous charges were included, the cost of

extracting teeth made up more than 50% of the Blue Cross charges. The outsourcing of root

canals was also a significant cost driver. Interestingly, the CFDS does not track outsourced

expenditures for their own record keeping and program evaluation. The CFDS only tracks the

dental treatment a member has received in CF dental detachments. In order to obtain accurate

information on referred dental services, at the dental detachment level, this information has to be

requested through the Federal Health Claims Processing System. For a military population health

planner, having a clear understanding of operational performance and productivity, including the

determinants of outsourced procedures and expenditures, is essential for determining and

establishing an appropriate composition of health care personnel. The reasons behind the large

discrepancies in outsourced treatment, that were evident between detachments, must be

identified and corrected if quality assurance of treatment delivery and cost control are to be

upheld in the organization. Are differences in outsource costs between detachments the result of

staffing, training or efficiencies in the employment of human resources? In order to ensure

quality assurance in any health care organization, structural, process and outcome measures, as

described by Donabedian’s classic evaluation model (101), must be continuously monitored and

amended.

In 1974, the CFDS set the establishment for specialists at six periodontists, five oral surgeons,

two prosthodontists, four public health dentists (PHD) and 13 AGDs (Appendix 7). The oral

health state of new recruits entering the CF during the late 1960’s and early 1970’s was much

worse than it is today (27, 28). Despite the heavier treatment workload outsourced referrals were

almost nonexistent. In 2008, the CFDS had more than 37 dental specialists under salary. This

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included 8 AGDs, 3 prosthodontists and 3 periodontists in the ranks of Lieutenant Colonel and

Colonel, who did not count against the set establishment. Clinical specialists in the CFDS have

benefited from subsidized dental training and receive specialty pay allowances. However, many

clinical specialists are employed as detachment commanders or in other command positions

where non-clinical activities prevent them from working in the clinic full-time, or any time at all.

This is not the most efficient use of these clinically skilled providers, and undoubtedly the most

significant contributor to the high cost of outsourced treatment. Furthermore, for an organization

that currently employs more than 650 health providers and is expected to look after the oral

health of over 75,000 personnel, the CFDS only supports one position for a dental public health

specialist in its establishment. Population oral health program planning, implementation, and

evaluation has been principally administered by clinical specialists and general dentists, who

have not had the benefit of any formal training in the dental public health competencies, as

defined by the RCDC (10).

According to the AGD position paper (Appendix 7), that was prepared by the CFDS Dental

Directorate in 2005 in order to justify the dental specialty status of the AGD (a dental specialty

that is otherwise not recognized by the RCDC), the AGD is described to be “the backbone of the

CFDS dental specialist classification”. In the paper, the AGD specialty is to “provide the full

spectrum of dental treatment in order to treat at least 90% of the specialty needs of personnel in

locations where specialists are not available”, “recognize and treat most conditions to the level of

competency of a specialist”, and “reduce the need for single specialists, outside referrals and

patient travel, with the added benefit of better patient care and less administrative burden on

units” (Appendix 7). Regarding the specific disciplines of oral surgery and endodontics the paper

highlights the advanced capabilities of the AGD to “perform any extraction, up to the most

difficult impaction, that can be done intraorally” and “be capable of performing any type of

surgical endodontic procedure indicated” (Appendix 7). However, our analysis has demonstrated

that almost all clinics with AGDs were unable to meet these high expectations. In many cases,

clinics staffed entirely by general dentists referred a much smaller fraction of these procedures.

Of particular significance was the observation that the Ottawa dental detachment referred close

to 50% of their root canals, even though during the study period the Ottawa detachment

employed one full time civilian AGD (ex-military), one (and at times two) full-time military

AGDs and at least two part-time AGDs. Our findings suggest that the position paper outlining

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the superior skills of the AGD over the general dentist is unsubstantiated. Moreover, the CFDS

does not appear to be employing these specialists in an appropriate manner that makes use of

their clinical expertise. Recent reports concerning the misdirected employment of CFDS “well-

paid specialists” have appeared in the mainstream media (102).

The intent of this study was to describe the impact of recruit dental treatment workload on CF

dental detachments, and in particular, the high cost of outsourced dental services. Any

inferences, however, are not without limitations. This study involves the examination of

secondary treatment data and does not take into account any constraints that may have transpired

over the course of the study period, at the detachment level. Furthermore, this research is also

limited in that it examines strictly the treatment needs of the recruit population which makes up

roughly 13% of the CF population, over a 36 month period. Nevertheless, unlike analytic studies

that are intended to answer questions, descriptive studies raise questions that in turn lead to

analytic examination. The significant cost of outsourced dental treatment in the recruit

population, and in the CF population as a whole, stands out as a notable concern. Critical

questions that are raised in this study ask whether the CFDS resources are being used efficiently

to deliver timely and appropriate dental treatment to newly enrolled personnel and whether

CFDS clinical specialists (Compensation and Benefits Instructions (CBI) 204.217) can be used

more effectively in order to utilize their clinical expertise and reduce the high costs for

outsourced dental care. To this end, further investigation in the context of the entire CF

population is strongly recommended.

5.6 Conclusion

Health organizations track structural, process and outcome measures for quality assessment and

quality assurance in order to ensure the provision of the best possible health care (3). Similarly,

the CFDS must monitor the impact of treatment workload at the detachment level, including the

amount of outsourced dental treatment, so as to ensure dental resources are being managed

efficiently and cost-effectively, while delivering timely and necessary patient care. Providing

dental treatment to recruits in training is a challenge because of tight schedules and the

outstanding treatment needs that recruits bring with them when they enroll. Dental emergencies

and urgent procedures, such as root canals, dental extractions and restorations, make up a

significant portion of the dental treatment during the first 12 months following enrolment. The

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policy of the CFDS is to defer definitive treatment until recruits are out of training. Just the

same, dental detachments on training bases, which were only staffed to provide emergency

treatment on recruits, were much more adept at handling dental treatment within the detachment

and not having to outsource services. As recruits fanned out to the bases that would make up

their home units, dental detachments were less capable of delivering care within the detachment.

This was found to be especially the case for the large detachment specialty centres.

Incorporating dental treatment during BMQ training may be a more efficient use of dental

resources, prevent the deterioration of the recruit dental state and send the positive oral health

promotion message at the beginning of a recruit’s career, while these members are being

integrated into the military culture.

Even though the oral health of Canadians has increased considerably since the 1970s (4,5) and

the CFDS have the benefit of more military dental specialists under salary than at any other time,

the number of outsourced referrals and costs are also greater than at any other time in CFDS

history. If this trend continues, the CFDS may soon provide the majority of the cost of diagnostic

and hygiene services while civilian dentists in private practice provide the greater share of the

cost of the treatment workload. The number of military dental specialists will increase further

once Op RESTORE is fully deployed. Highly skilled clinical specialists are expected to carry-

out complicated dental procedures and mentor younger dental officers to expand their clinical

skills. Further study is recommended to identify how non-clinical responsibilities can be shifted

away from dental specialists so that they can be more gainfully employed in the clinic and help

contain the rising cost of outsourced dental treatment and prevent the decline in the standard of

quality that the CFDS is known for.

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6 Conclusion

The dental treatment needs of new CF members enrolled in 2007 and 2008 (N=10,641) varied

analogous with their demographic composition. Needs were shown to have decreased

significantly in comparison to the CFDS oral health surveys conducted in 1967 and 1973, which

reported that less than 10% of new members were dentally fit and that the average recruit

necessitated more than 7.5 hours of treatment to be brought to a state of optimal oral health. As

opposed 1973, when 99% of the new recruits were between 17 and 24 years of age, only 63% of

2007 and 2008 recruits were under the age of 25. Despite the difference in age our study revealed

that 44% of new personnel did not require a dental restoration, a root canal, or an extraction.

Individual-level socioeconomic data was not studied; however, an analysis of area-based

measures confirmed that the majority of recruits living in census tracts at the time of enrolment,

resided in neighbourhoods with a higher median income as compared to the median income of

their census metropolitan area or census agglomeration. Recruits originating from less urban

(non census) areas showed only slightly higher treatment needs. These findings suggest that,

unlike the 1967 and 1973 recruits who were shown to represent the lower socioeconomic scale of

the Canadian population, the 2007 and 2008 recruits appear to be more representative of middle

class and upper middle class Canada.

Although recruits still had substantial urgent and routine dental treatment needs, all indicators

imply that the current generation of CF personnel will have a much smaller requirement for

dental treatment services, other than preventive care, than previous generations. A stronger

emphasis on oral health promotion will also serve to further decrease the prevalence of

periodontal treatment requirement.

On a macro level, the 2008 CFDS employment of 97 military dentists, 37 military dental

specialists and 17 civilian dentist contractors appeared to be more than sufficient to look after the

treatment needs of 75,000 personnel. However, this study validated that new personnel did not

receive dental care equally and that the dental detachments were unable to handle the dental

workload at a consistent level of proficiency, resulting in excessive outsource treatment costs.

Incorporating dental treatment during BMQ training could eliminate such inequalities and make

the delivery of dental services more efficient and cost-effective.

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52. Stanmeyer WR. The Problem of Dental caries in Military Dentistry. J Dent Res 1964; 43: 997-8. 53. Robinson B, Pethybridge RJ, Rugg-Gunn AJ. Dental Caries experience of 16-17-year-old naval recruits related to the water fluoridation level in their hometown. Community Dent Oral Epidemiol 1983; 11: 183-187. 54. Hopcraft MS, Morgan MV. Exosure to fluoridated drinking water and dental caries experience in Australian Army Recruits, 1996. Community Dent Oral Epidemiol 2003; 31:68- 55. Mahoney G, Slade GD, Kitchener S, Barnett A. Lifetime fluoridation exposure and dental caries experience in a military population. Community Dent Oral Epidemiol 2008 Dec;36(6):485-92. 56. Hopcraft MS, Morgan MV. Dental caries experience in Australian army recruits 2002-2003. Australian Dental Journal 2005;50(1):16-20. 57. Ankkuriemi O., Ainamo J. Dental health and dental treatment needs among recruits of the Finnish Defence Forces, 1919-91. Acta Odontologica Scandinavia 1997; 55(3):192-197. 58. Antoft P., Rambusch E., Antoft B., Christensen H.W. Caries experience, dental behaviour and social status – three comparative surveys among military recruits in 1972, 1982 and 1993. Community Dent Health 1999; 16(2):80-84. 59. Hintze H. Approximal Caries prevalence in Danish recruits and progression of caries in the late teens: A retrospective radiographic study. Caries Research 2001; 35:27-35. 60. Cook L.J. The implications of protocol-based care on dental services in the military. Military Medicine 1999; 164(8):556-61. 61. Millar W.J., Locker D. Smoking and oral health status. J Can Dent Assoc 2007; 73(2). Internet accessed 01 June 2010: www.cda-adc.ca/jcda/vol-73/issue-2/155.html 62. Vered Y., Livny A., Zini., Sgan-Cohen H.D., Periodontal health status and smoking among young adults. J Clin Periodontal 2008; 35: 768-772. 63. Machuca G., Rosales I., Lacalle J.R., Machuca C., Bullon P. Effect of cigarette smoking on periodontal status of healthy young adults. J periodontal 2000; 71:73-78. 64. Diefenderfer K.E., Ahlf R.L., Simecek J.W. Periodontal health status in a cohort of young US navy personnel. American Association of Public Health Dentistry 2007;67 (1):49-54.

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65. Covinggton L., Breault L., Hokett S. The application of Periodontal Screening and Recording (PSR) in a military population. J Contemp Dent Prac 2003; 4(3) 1-10. 66. York A.K., Poindexter F.R., Chisick M.C. 1994 Tri-Service Comprehensive Oral Health Survey: Active duty report. Washington: Office of the Assistant Secretary for Health Affairs; June 1995. National Defense Research Institute report PR-9503. 67. United states department of Labor. Consumer Price Index. Internet accessed 01 June 2010: http://stats.bls.gov/bls/inflation.htm. 68. Murray H., Locker D., Kay E.J. Patterns of and reasons for tooth extractions in general dental practice in Ontario, Canada. Community Dent Oral Epidemiol 1996; 24:196-200. 69. Dunn W.J., Langsten R.E., Flores S., Fandell J.E. Dental emergency rates at two expeditionary medical support facilities supporting operations enduring and Iraqi freedom. Mil Med 2004; 169(7): 510. 70. Dunn W.J. Dental emergency rates at an expeditionary medical support facility supporting operations enduring freedom. Mil Med 2004; 169(5): 349. 71. Moss D.L. Dental emergencies during SFOR 8 in Bosnia. Mil Med 2002; 167(11):904-6. 72. Chaffin J., Marburger T., Fretwell D. Dental class 3 intercept clinic: a model for treating class 3 soldiers. Mil Med 2003; 168(7):548-52. 73. Richardson P.S., McIntyre I.G. Dental treatment needs of a cohort of Royal Air Force recruits over 5 years. Community Dent Health 1996; 13(1):11-6. 74. Logan T.P., Cutress T.W., Garrett N., Trengrove H.G. Dental treatment profile of New Zealand Defence Force personnel. New Zealand Dental Journal 2009;105(3):77-81. 75. Chaffin J.G., Mazuji N. Class 3 Dental Treatment Time. Mil Med 2004; 169(9):696-699. 76. Chisick M.C. Predicting dental treatment workload of US military personnel. Mil Med 2001; 166(6):541-3. 77. Sgan-Cohen H.D., Katz., Horev T., Dinte A., Eldad A. Trends in caries and associated variables among Israeli adults over 5 decades. Community Dent Oral Epedimiol 2000; 28:234-240.

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78. Zadik Y., Zusman S.P., Galor S., Dinte A.F. Dental attendance and self-assessment of dental status by Israeli military personnel according to gender, education, and smoking status, 1998-2006. Mil Med 2009;174(2):197-200. 79. Hyman J.J., Reid B.C., Mongeau S.W., York a.K. The military oral health care system as a model for eliminating disparities in oral health. Journal of the American Dental Association 2006; 137:372-8. 80. Eklund S.A., Changing treatment patterns. Journal of the American Dental Association 1999;130:1707-1712. 81. Ottawa Canada. Department of National Defence. Canadian Forces Dental Care Program. Issued on Authority of the Chief of the Defence Staff. Director Dental Services. Amended 2007-01-05. 82. Cutress T.W., Ainamo J., Sardo-Infirri J. The community periodontal index of treatment needs (CPITN) procedure for population groups and individuals. International Dental Journal 1987;37:222-233. 83. Brothwell D.J., Should the use of smoking cessation products be promoted in dental offices? An evidence-based report. J Can Dent Assoc 2001;67(3):149-55. 84. Kunzel C., Lalla E., Lamster I.B., Albert D.A., Yin H. On the primary care frontlines: the role of the general practitioner in smoking cessation activities and diabetes management. Journal of the American Dental Association 2005; 136(8):1144-1153. 85. Kosteniuk J., D’Arcy C. Dental service use and its correlates in a dentate population: Analysis of the Saskatchewan population health and dynamic survey 1999-2000. Journal of the Canadian Dental Association 2006; 72(8). 731-731. 86. Locker D., Clarke M., Murray H. Oral health status of Canadian-born and immigrant adolescents in North York, Ontario. Community Dent Oral Epedimiol 1998; 26:177-81 87. Rabb-Waytowich D. Water fluoridation in Canada: Past and Present. J Can dent Assoc 2009;75(6):451-54. 88. Kindig D, Stoddart G. What is population Health? Am J Public Health 2003, 93:380-383. 89. Kawachi I, Berkman LF, Neighborhoods and Health. New York: Oxford University Press; 2003. 90. Canada. Statistics Canada. Census of Canada, 2006: [Profile of Census Tracts 2006 Census / Income and earnings and housing and shelter costs] [computer file]. Ottawa, Ont.: Statistics

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Canada [producer and distributor], [updated 13-11-2008] (Series title; [94-581-xcb2006006]) http://dc1.chass.utoronto.ca.myaccess.library.utoronto.ca/cgibin/census/2006/displayCensusCT.cgi?c=inc. 91. Statistics Canada. 2006 Census Dictionary. Ottawa, Ontario, Canada. Internet accessed 01 January 10: http://www12.statcan.ca/census-recensement/2006/ref/dict/geo013-eng.cfm. 92. Statistics Canada. Geographic units by province and territory, 2006 Census. Internet accessed 13March 2010. http://www12.statcan.ca/english/census06/reference/dictionary/tables/table1-dictionary.htm. 93. Briggs A., Nixon R., Dixon S., Thompson S. Parametricmodelling of cost data: some simulation evidence. Health Econ 2005; 14: 421–428. 94. Statistics Canada, Health Division. Health Care services – Recent Trends. Health Reports, Winter 1999 Vol 11. No 3. Internet accessed 31 July 2010: http://dsp-psd.pwgsc.gc.ca/Collection-R/Statcan/82-003-XIE/0039982-003-XIE.pdf. 95. Leake J. Why Do We Need an Oral Health Care Policy in Canada? J Can Dent Assoc 2006; 72(4):317. Internet accessed 30 June 2010: http://www.cda-adc.ca/jcda/vol-72/issue-4/317.pdf 96. Locker D. Deprivation and oral health: a review. Community Dent Health 2000; 28:161-9. 97. Ottawa Canada. Statistics Canada (2006). Canada at a glance Demography. Internet accessed 19 July 2010: http://www45.statcan.gc.ca/2009/cgco_2009_001-eng.htm#t04. 98. Quiñonez C, Sherret L, Grootendorst P, Shim MS, Azarpazhooh A, Locker D. An environmental scan of provincial/territorial dental public health programs. Office of the Chief Dental Officer, Health Canada. Internet accessed 20 Nov 2009: http://www.fptdwg.ca/English/eenvironmental.Html. 99. Sheiham A., Tsakos G. “Oral health needs assessments,” in Community oral health, ed Pine C., Harris R. (United Kingdom: Quintessence Publishing:2007), 59-79. 100. Dela Cruz G., Williams L.N., Chaffin J.G., Mongeau S. “Dental treatment of recruits,” in recruit medicine, ed DeKoning B. (Washington:office of the Surgeon General at TMM. Publications Borden Institute: 2006), 383-395. Internet accessed 01 July 2010, http://www.bordeninstitute.army.mil/published_volumes/recruit_medicine/Recruit_FM.pdf 101. Donabedian A. Evaluating the quality of medical care. Milbank Q 1966; 44: 166-203.

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102. Payton L. Military dentist alleges waste. Ottawa Sun, 24 August 2010. Internet accessed 13 September 2010: http://www.ottawasun.com/news/canada/2010/08/24/15128936.html

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8 Tables

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Table 1 DentIS Tobacco User Status 01 June 2010.

Client Status

Client Status Description Total Tobacco

User

Tobacco user status

A REGULAR FORCE (TRAINED) 7899 Yes

A REGULAR FORCE (TRAINED) 22124 No

A REGULAR FORCE (TRAINED) 31674 Unknown

B REGULAR FORCE (RECRUITS/TRAINEES) 293 Yes

B REGULAR FORCE (RECRUITS/TRAINEES) 715 No

B REGULAR FORCE (RECRUITS/TRAINEES) 5621 Unknown

C RESERVE (CLASS C / CLASS B >6 MOS.) 506 Yes

C RESERVE (CLASS C / CLASS B >6 MOS.) 1867 No

C RESERVE (CLASS C / CLASS B >6 MOS.) 3377 Unknown

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Table 2. Carries Risk Status 01 June 2010

Client Status

Client Status Description Count Of Caries Risk

Caries Risk

A REGULAR FORCE (TRAINED) 1033 High

A REGULAR FORCE (TRAINED) 2387 Medium

A REGULAR FORCE (TRAINED) 21837 Low

A REGULAR FORCE (TRAINED) 36440 Unknown

B REGULAR FORCE (RECRUITS/TRAINEES) 83 High

B REGULAR FORCE (RECRUITS/TRAINEES) 128 Medium

B REGULAR FORCE (RECRUITS/TRAINEES) 519 Low

B REGULAR FORCE (RECRUITS/TRAINEES) 5899 Unknown

C RESERVE (CLASS C / CLASS B >6 MOS.) 57 High

C RESERVE (CLASS C / CLASS B >6 MOS.) 217 Medium

C RESERVE (CLASS C / CLASS B >6 MOS.) 1540 Low

C RESERVE (CLASS C / CLASS B >6 MOS.) 3936 Unknown

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Table 3. CHMS Severity of coronal caries

Characteristics Mean number of permanent teeth

Decay Missing Filled DMFT

Age 12-19 .37 .02 2.10 2.49

Age 20-39 .81 .39 5.65 6.85

Age 40-59 .45 2.42 9.43 12.30

Female (age 20-79)

Male (age 20-79)

.45

.72

2.26

2.03

8.54

7.34

11.25

10.09

Adults Born in Canada

Adults Born Outside Canada

.56

.66

2.02

2.53

8.14

7.35

10.72

10.54

Adults - Highest Household

Education = degree/diploma

Adults - Highest Household

Education < degree/diploma

.45

1.01

1.80

3.11

8.03

7.79

10.27

11.92

Health Canada. Report on the findings of the oral health component of the Canadian Health Measures Survey 2007-2009.

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Table 4. CHMS Prevalence of periodontal conditions according to CPITN scores

Characteristics Healthy Gingivitis Calculus Pockets

4-5mm

Pockets

>5mm

Female

Male

10.2

4.8

29.9

20.9

43.1

50.8

13.3

18.8

3.5

4.7

Age 20-39 10.9 27.9 48.3 11.2 n/a

Age 40-59 5.8 24.0 46.7 18.1 5.4

Adults Born in Canada

Adults Born Outside Canada

8.0

6.0

27.2

20.1

47.7

44.6

14.4

20.8

2.7

8.5

Adults - Highest Household

Education = degree/diploma

Adults - Highest Household

Education < degree/diploma

8.5

5.1

26.8

22.3

47.0

47.3

14.1

20.7

3.7

4.7

Health Canada. Report on the findings of the oral health component of the Canadian Health Measures Survey 2007-2009.

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Table 5. Nutrition Canada Dental Report 1970 – 1972. Mean number of DMF teeth per person

Mean number of permanent teeth (tooth range 1-28)

Decay Missing Filled DMFT

Male & Female 16 – 18 years

3.6 2.5 5.3 11.4

Male 19 years 3.3 2.9 6.2 12.4

Female 19 years 3.1 2.6 7.5 13.2

Male 20 – 29 years 3.7 4.4 6.4 14.5

Female 20 – 29 years 3.3 4.7 7.8 15.9

Male 30 – 39 years 2.8 7.7 6.7 17.2

Female 30 – 39 years 2.5 7.5 7.5 17.4

Male 40 – 49 years 2.5 8.9 5.8 17.2

Female 40 – 49 years 1.8 9.7 8.1 19.6

Male 50 – 59 years 2.3 11.5 5.0 18.8

Female 50 – 59 years 1.3 11.9 6.3 19.5 Nutrition Canada. Dental report: a report from Nutrition Canada by the Bureau of Nutritional Sciences, Food Directorate, Health Protection Branch, Department of National Health and Welfare. Ottawa: Minister of National Health and Welfare.

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Table 6. 1977 Nutrition Canada Dental Report – (1)Prevalence. Percentage (%) of the population requiring a dental restoration. (2) Severity. Mean number of dental restorations required by those requiring a minimum of one restoration.

Nutrition Canada. Dental report: a report from Nutrition Canada by the Bureau of Nutritional Sciences, Food Directorate, Health Protection Branch, Department of National Health and Welfare. Ottawa: Minister of National Health and Welfare.

CAN BC AB SK MN ON QC NB NS PE NL Male & Female 16 – 18 years Prevalence

Severity

57.9 5.1

47.7 4.0

66.9 3.6

76.1 4.1

73.3 6.2

22.5 4.6

94.3 5.4

81.0 5.7

61.8 5.2

69.7 6.7

84.0 8.3

Male 19 years Prevalence Severity

53.8 4.5

84.3 3.0

61.2 2.0

62.7 4.2

100 8.9

31.1 4.1

67.5 5.5

69.9 2.0

100 5.4

100 5.4

100 11.0

Female 19 years Prevalence Severity

57.7 4.8

68.6 2.8

55.9 2.3

100 2.8

46.9 6.7

43.6 3.9

95.7 6.7

31.6 2.0

100 6.0

100 6.5

97.8 6.3

Male 20 – 29 years Prevalence Severity

60.4 4.9

75.4 5.3

79.7 4.2

67.4 4.1

77.6 6.1

29.0 3.7

68.7 5.1

65.2 5.3

84.7 4.2

83.4 4.2

74.2 7.1

Female 20 – 29 years Prevalence Severity

61.6 4.5

63.6 3.5

55.9 4.9

79.0 4.4

62.7 4.8

37.8 3.8

92.8 4.9

77.9 4.3

59.5 5.1

36.6 6.0

88.7 4.9

Male 30 – 39 years Prevalence Severity

66.6 3.7

46.7 3.3

55.7 3.6

69.8 3.8

64.6 5.0

59.8 2.7

90.5 4.6

86.3 3.4

50.9 3.7

51.5 4.8

70.7 2.6

Female 30 – 39 years Prevalence Severity

57.9 3.9

44.2 3.0

56.2 5.1

67.8 4.2

46.2 4.0

38.4 3.9

90.5 3.8

64.4 3.6

69.0 3.5

47.6 4.7

75.5 4.9

Male 40 – 49 years Prevalence Severity

58.7 3.7

61.5 3.4

50.8 4.3

77.7 3.5

39.6 4.8

40.2 2.2

79.3 4.5

60.6 3.4

31.5 3.6

56.4 3.2

74.1 2.5

Female 40 – 49 years Prevalence Severity

44.4 3.4

53.6 2.9

57.2 3.1

62.0 3.3

24.7 4.4

27.4 3.0

67.8 4.0

65.3 3.7

46.0 4.4

56.8 3.3

65.8 2.4

Male 50 – 59 years Prevalence Severity

57.3 3.3

43.4 2.6

93.5 3.8

87.7 3.2

33.3 4.7

41.8 2.7

78.6 3.6

72.3 3.5

33.3 2.3

23.6 2.0

68.5 2.6

Female 50 – 59 years Prevalence Severity

47.4 2.7

59.7 2.3

21.4 2.0

52.9 2.5

64.5 2.1

37.7 2.5

62.4 3.3

66.7 2.4

33.6 3.3

78.3 2.6

49.1 3.2

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Table 7. 1977 Nutrition Canada Dental Report – (1) Prevalence. Percentage (%) of population requiring a dental extraction. (2) Severity . Mean number of dental extractions required by those requiring a minimum of one extraction. CAN BC AB SK MN ON QC NB NS PE NL Male & Female 16 – 18 years Prevalence

Severity

16.6 2.7

13.8 2.5

6.8 3.7

6.1 2.0

5.8 3.7

7.7 2.4

29.1 2.8

36.1 2.2

16.8 4.0

19.9 2.0

41.2 2.4

Male 19 years Prevalence Severity

20.0 2.4

N/A 2.0

N/A N/A

N/A N/A

29.1 8.0

14.9 2.0

40.0 2.5

N/A N/A

88.1 2.0

N/A N/A

N/A N/A

Female 19 years Prevalence Severity

29.9 2.3

4.0 2.0

6.2 2.0

N/A N/A

45.3 3.1

27.4 2.0

54.5 2.3

N/A N/A

33.5 2.0

58.9 2.0

17.4 2.0

Male 20 – 29 years Prevalence Severity

18.5 3.3

18.6 2.1

1.6 3.1

10.9 2.0

26.6 3.7

19.3 2.6

18.5 4.4

33.2 2.3

19.7 2.8

4.5 2.0

26.5 5.3

Female 20 – 29 years Prevalence Severity

12.2 2.5

8.7 2.2

15.0 2.0

8.9 2.0

18.3 2.7

4.4 2.2

20.2 2.8

30.3 2.2

25.1 2.3

12.5 2.0

15.9 2.4

Male 30 – 39 years Prevalence Severity

13.5 2.3

4.2 2.2

12.6 2.0

23.2 2.9

9.6 2.1

16.8 2.1

13.5 2.5

13.8 4.8

18.9 2.0

9.4 2.0

6.9 2.0

Female 30 – 39 years Prevalence Severity

11.6 2.5

3.4 2.1

0.6 2.0

2.4 2.0

14.4 2.0

8.0 2.0

18.4 2.4

32.5 5.0

27.8 2.5

23.7 2.0

25.3 4.4

Male 40 – 49 years Prevalence Severity

12.4 2.6

13.1 3.1

13.9 3.0

23.8 2.8

28.8 2.2

4.0 2.1

13.1 2.8

44.4 2.4

9.5 2.0

23.4 2.0

9.6 2.8

Female 40 – 49 years Prevalence Severity

10.4 3.1

95.3 4.2

20.8 2.5

10.1 2.5

14.7 5.0

5.3 4.5

17.4 2.4

6.7 2.0

23.9 2.8

23.4 5.7

20.5 2.0

Male 50 – 59 years Prevalence Severity

24.3 2.5

9.2 2.1

58.6 2.0

28.8 5.8

1.9 2.0

19.8 2.1

24.5 2.1

26.5 2.9

42.5 3.2

32.4 2.9

54.7 4.1

Female 50 – 59 years Prevalence Severity

7.6 2.1

3.8 2.1

0.9 2.0

5.6 2.0

27.4 2.0

6.8 2.1

7.3 2.0

11.5 3.7

12.4 2.0

N/A N/A

13.4 4.1

Nutrition Canada. Dental report: a report from Nutrition Canada by the Bureau of Nutritional Sciences, Food Directorate, Health Protection Branch, Department of National Health and Welfare. Ottawa: Minister of National Health and Welfare.

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Table 8. The Dental condition of the Canadian Forces (1967). Presented in mean teeth, surface or time and (SD)

Teeth (tooth range 1-28) Surfaces (tooth range 1-28) Clinical

chair

time to

be fit

Decay Missing Filled DMFT Decay Missing Filled DMFS

NCM Male (2400)

7.2 (4.1)

4.5 (5.5)

2.9 (3.9)

14.6 (5.5)

11.0 (7.5)

12.6 (14.2)

7.1 (10.2)

30.6 (14.6)

8.9

NCM Female (160)

5.4 (3.7)

4.5 (5.6)

6.2 (5.6)

16.1 (5.4)

7.1 (5.4)

12.6 (14.9)

14.2 (14.5)

33.9 (15.2)

5.6

Officer Male (492)

5.6 (4.1)

2.8 (4.3)

5.9 (5.1)

14.4 (5.1)

7.8 (6.8)

7.9 (11.4)

13.8 (12.6)

29.5 (14.2)

6.9

Ottawa Canada (1967). Director General Canadian Forces Dental Services. The dental condition of the Canadian Forces: report of a two year study.

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Table 9. The dental condition of the Canadian Forces recruits (1973). Presented in mean teeth, surface or time and (SD)

Teeth (tooth range 1-28) Surfaces (tooth range 1-28) Clinical

chair

time to

be fit

Decay Missing Filled DMFT Decay Missing Filled DMFS

Male Cornwallis (315)

8.2 2.7 3.3 14.2 11.6 8.5 8.9 29.0 7.5

Female Cornwallis (113)

4.9 3.0 6.1 14.0 6.2 8.3 13.3 27.7 5.5

Male St. Jean (217)

8.3 7.5 1.1 16.9 14.4 20.4 2.6 37.4 7.6

Female St. Jean (25)

6.2 7.7 2.1 16.0 10.7 21.0 5.0 36.76 6.4

Ottawa Canada (1974). Director General Canadian Forces Dental Services. A study of the dental condition of the Canadian Forces -1973.

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Table 10. Comparison of active and released members.

  

       

         

 

 

 

 

 

 

 

 

 

 

  

  Active Members  Released Members  

All Members  10641  1379 

 

Gender 

         Male  8953 (84.4%)  1195 (86.7%) 

         Female  1658 (15.6%)  184 (13.3%) 

χ²  P‐Value=.030 

Rank Class 

        NCM  8547 (80.3%)  1143 (82.9%) 

        Officers  2094 (19.7%)  236 (17.1%) 

χ²  P‐Value=.023 

Birthplace 

         Canada  9960 (93.6%)  1278 (92.7%) 

         Foreign  681 (6.4%)  101 (7.3%) 

χ²  P‐Value=.190 

First Language 

         English  8025 (75.4%)  951 (69%) 

         French  2616 (24.6%)  428 (31%) 

χ²  P‐Value <.001 

Age Groups 

         16 to 19  2753 (25.9%)  472 (34.2%) 

         20 to 29  5915 (55.6%)  705 (51.1%) 

         30 to 39  1410 (13.3%)  134 (9.7%) 

         40 to 58  563 (5.3%)  68 (4.9%) 

χ²  P‐Value <.001 

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Table 11. Recruit province of residence at the time of enrolment. 

 

*Province/territory not specified or outside of Canada  ** 2009 Statistics Canada     

 

               

Province  Active Regular Force MembersRecruitment Year 

Provincial ProportionOf Canadian Population** 

2007  2008 Combined Total 

British Columbia  463  415 878 (8.3%)  13.2%

Alberta   341  352 693 (6.5%)  10.9%

Saskatchewan  92  89 181 (1.7%)  3.1%

Manitoba 162 

167 329 (3.1%)  3.6%

Ontario  1857 1902 3759 (35.3%)  38.7%

Quebec  1272 1212 2484 (23.3%)  23.2%

New Brunswick  345  318 663 (6.2%)  2.2%

Nova Scotia  508  449 957 (9.0%)  2.8%

Prince Edward Island  40  43 83 (0.8%) 0.4%

Newfoundland and Labrador  127  106 233 (2.2%)  1.5%

Missing *  30  351 381 (3.6%)   

Total  5237 5404 10,641 (100%)   

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Table 12. Prevalence of dental treatment requirement, by treatment category  

Procedure Category  

CountN = 10641 

Percent (%) 

Diagnostic        (Emergency Visit) 

10641        (2977) 

100       (28.0) 

Preventive  

6609 62.1

Restorative         (Completed Restorations) 

5072        (4964) 

47.7        (46.6) 

Endodontic         (Completed Root Canals) 

766         (719) 

7.2         (6.8) 

Periodontal  

1077 10.1

Removable Prosthodontics 

155 1.5

Fixed Prosthodontics  

126 1.2

Oral Surgery            (Dental Extraction) 

2735         (2616) 

25.7          (24.6) 

Orthodontic  

184 1.7

    

 

 

 

       

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 Table 13. Multiple linear regression analysis of dental treatment cost. Independent Variable Parameter

estimate β P-value

Constant -554.18 <.001

Time in Service (months since enrolment) 48.55 <.001

Rank Class (NCM=0, officer=1) -268.03 <.001

Gender (female=0, male=1) -39.60 .273

Age (years, at enrolment) 25.53 <.001

First Language (French=0,English=1) -61.96 .041

Birthplace (Canada=0,Foreign=1) 208.81 <.001

R2= .084

                     

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Table 14. Age Group Analysis – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement 

AGE GROUP (n)  

MEAN (SD)  PREVALENCE COUNT (%) 

AGE  MONTHS IN 

SERVICE 

TREATMENT COST   $ 

Emergency Visits 

Preventive Procedures 

Restorations Root Canals 

Periodontal Procedures 

Extractions

All Age Groups (10641) 

25.1 (7.1) 

25.9 (7.0) 

1224 (1399) 

2977(28.0%) 

6609(62.1) 

4964(46.6%) 

719 (6.8%) 

1077(10.1%) 

2617(24.6%) 

16 to 19 

years (2753) 

18.7 (0.8) 

25.4 (6.9) 

983 (1081) 

654(23.8%) 

1639 (49.7) 

955(34.7%) 

116 (4.2%) 

96(3.5%) 

682(24.8%) 

20 to 29 

years (5915) 

23.9 (2.7) 

26.1 (7.0) 

1239 (1387) 

1700(28.7%) 

3724 (63.0) 

2906(49.1%) 

404 (6.8%) 

531(9.0%) 

1625(27.5%) 

30 to 39 

years (1410) 

34.0 (2.8) 

26.6 (7.1) 

1425 (1618) 

439(31.1%) 

1052(74.6) 

761(54.0%) 

141 (10.0%) 

270(19.1%) 

245(17.4%) 

40 to 59 

years (563) 

45.7 (4.0) 

25.6 (7.0) 

1737 (1974) 

761(54.0%) 

464(82.4) 

342(60.7%) 

58 (10.3%) 

180(32.0%) 

65(11.5%) 

ANOVA /χ² P‐

Value 

<.001  <.001  <.001  <.001 <.001 <.001 <.001  <.001 <.001

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Table 15. Age Group Analysis – Severity of Treatment Requirement 

 

                             

AGE GROUP

MEAN (SD) EMERGENCY

VISITS PREVENTIVE PROCEDURES

RESTORED SURFACES

ROOT CANALS

PERIODONTAL PROCEDURES

EXTRACTION

All Age Groups

1.7 (1.3)

5.0 (3.0)

7.5 (8.4)

1.8 (1.1)

1.9 (1.7)

2.4 (1.5)

16 to 19 years

1.7 (1.2)

4.1 (2.1)

6.4 (7.4)

1.7 (0.9)

1.3 (0.6)

2.6 (1.3)

20 to 29 years

1.7 (1.2)

4.8 (2.7)

7.6 (8.8)

1.9 (1.1)

1.6 (1.1)

2.4 (1.4)

30 to 39 years

1.8 (1.4)

6.0 (3.6)

7.9 (8.2)

1.8 (1.0)

2.1 (1.9)

2.1 (2.2)

40 to 59 years

1.8 (1.7)

7.0 (4.6)

8.1 (7.6)

1.4 (0.7)

2.7 (2.6)

1.4 (0.8)

ANOVA P-Value

.624 <.001 <.001 .013 <.001 <.001

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Table 16. NCM and Officer – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement  

  

 

Mean (SD)  Prevalence Count (%) 

Age  

Months In 

Service 

Treatment Cost ‐ $ 

Emergency Visit 

Preventive Restoration Root Canal 

Periodontal 

Extraction

All Members (10641) 

  NCM (8547) 

24.7 (6.6) 

25.9 (7.0) 

1268 (1401) 

2515 (29.4%) 

5236 (61.3) 

4167 (48.8%) 

629 (7.4%) 

 892 (10.4%) 

2292 (26.8%) 

  Officer (2094) 

26.4 (8.7) 

25.7 (7.0) 

1044 (1378) 

462   (22.1%) 

1373 (65.6) 

797   (38.1%) 

  90 (4.3%) 

 185 (8.8%) 

 325 (15.5%) 

T‐Test/χ²   P‐value 

<.001  .056  < .001  < .001 <.001 < .001 < .001   .029 .001

16‐19 Years (2753) 

  NCM (2081) 

18.8 (0.7) 

25.4 (7.0) 

1051 (1152) 

534 (25.7%) 

1016 (48.8%) 

780 (37.5%) 

102 (4.9%) 

89  (4.3%) 

578 (27.8%) 

  Officer (672) 

18.8 (0.7) 

25.3 (6.6) 

773  (786) 

120 (17.9%) 

353 (52.5%) 

175 (26.0%) 

14 (2.1%) 

7  (1.0%) 

104 (15.5%) 

T‐Test/χ²   P‐value 

<.001  .662  < .001  <.001 .095 <.001 .002  <.001 .001

20 – 29 Years (5915) 

  NCM (5057) 

23.8 (2.7) 

26.1 (7.0) 

1275 (1380) 

1531 (30.3%) 

3152 (62.3%) 

2576 (50.9%) 

374 (7.4%) 

462 (9.1%) 

1474 (29.1%) 

  Officer (858) 

25.0 (2.6) 

25.8 (7.3) 

1028 (1413) 

169 (19.7%) 

572 (66.7%) 

330 (38.5%) 

30 (3.5%) 

69  (8.0%) 

151 (17.6%) 

T‐Test/χ²   P‐value 

<.001  .270  <.001  <.001 .015 <.001 <.001  .300 <.001

30 – 39 Years (1410) 

  NCM (1036) 

33.8 (2.8) 

26.6 (7.0) 

1486 (1690) 

329 (31.8%) 

763 (73.6%) 

575 (55.6%) 

112 (10.8%) 

201 (19.4%) 

191 (18.5%) 

  Officer (374) 

34.4 (2.8) 

26.5 (7.1) 

1256 (1389) 

109 (29.1%) 

289 (77.3%) 

186 (49.7%) 

29 (7.8%) 

 68  (18.2%) 

53 (14.2%) 

T‐Test/χ²   P‐value 

.001  .749  .010  .344 .167 .053 .090  .601 .061

40 ‐59 Years (563) 

  NCM (373) 

45.4 (3.8) 

26.0 (7.1) 

1776 (1794) 

120 (32.2%) 

305 (81.8%) 

236 (63.3%) 

41 (11.0%) 

139  (37.3%) 

48 (12.9%) 

  Officer (190) 

46.5 (4.4) 

24.8 (6.7) 

1661 (2290) 

64 (33.7%) 

159 (83.7%) 

106 (55.8%) 

17 (8.9%) 

41  (21.6%) 

17 (8.9%)

T‐Test/χ²   P‐value 

.004  .051  .513  .717 .573 .086 .450  < .001 .169

  

     

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Table 17. NCM and Officers – Severity of Treatment Requirement  

  Mean (SD)

Emergency Visits 

Preventive Procedures 

RestoredSurfaces 

Root canals 

Periodontal Procedures 

Extractions

All Members 

  NCM  1.7 (1.3)  5.0 (3.0) 7.7 (8.6) 1.8 (1.1) 1.8 (1.7)  2.4 (1.5)

  Officer  1.6 (1.3)  5.1 (3.3) 6.1 (6.9) 1.7 (0.7) 2.0 (1.9)  2.3 (1.4)

          T‐Test P‐value 

.101  .119 < .001 .257 .156  .122

16 ‐19 years 

  NCM  1.7 (1.2)  4.3 (2.1) 7.0 (7.9) 1.7 (0.9) 1.3 (0.6)  2.6 (1.3)

  Officer  1.6 (1.1)  3.8 (2.1) 4.0 (3.7) 1.4 (0.5) 1.4 (0.8)  2.5 (1.3)

          T‐Test P‐value 

.734  <.001 < .001 .304 .490  .822

 20 ‐29 years 

  NCM  1.8 (1.3)  4.8 (2.7) 7.8 (9.0) 1.9 (1.2) 1.5 (1.1)  2.4 (1.4)

  Officer  1.5 (0.9)  5.1 (2.9) 5.8 (6.8) 1.9 (0.8) 1.6 (1.3)  2.4 (1.5)

          T‐Test P‐value 

.004  .018 <.001 .866 .605  .882

30 ‐39 years 

  NCM  1.9 (1.5)  6.0 (3.7) 8.3 (8.4) 1.9 (1.1) 2.2 (2.0)  2.2 (2.4)

  Officer  1.5 (0.9)  6.0 (3.3) 6.8 (7.5) 1.5 (0.7) 2.1 (1.6)  1.7 (1.0)

          T‐Test P‐value 

.004  .987 .033 .065 .710  .184

40 ‐59 years 

  NCM  1.6 (0.9)  7.1 (4.5) 7.6 (6.9) 1.3 (0.6) 2.7 (2.5)  1.5 (0.8)

  Officer  2.1 (2.5)  6.8 (4.9) 9.3 (8.9) 1.8 (0.8) 2.8 (3.0)  1.4 (0.7)

          T‐Test P‐value 

.111  .488 .082 .011 .872  .828

   

 

                

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Table 18. NCM Male and NCM Female – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement 

        

   

  Mean (SD)  Prevalence Count (%) 

Age  

Months In 

Service 

Treatment Cost ‐ $ 

Emergency Visit 

Preventive Restoration Root Canal 

Periodontal Extraction

All Members (8547) 

  Male (7320) 

24.3 (6.3) 

26.1 (6.9) 

1258 (1394) 

2105 (28.8%) 

4360 (59.6%) 

3569 (48.8%) 

526 (7.2%) 

716  (9.8%) 

2049 (28.0%) 

  Female (1227) 

27.3 (7.5) 

26.0 (7.0) 

1326 (1447) 

410 (33.4%) 

876 (71.4%) 

598 (48.7%) 

103 (8.4%) 

176  (14.3%) 

243 (19.8%) 

T‐Test/ χ²  P‐value 

<.001  .527  .113  .001 <.001 .990 .133  <.001 <.001

16‐19 Years (2081) 

  Male (1905) 

18.8 (0.7) 

25.4 (7.0) 

1034 (1132) 

465 (24.4%) 

907 (47.6%) 

705 (37.0%) 

87 (4.6%) 

75  (8.0%) 

530 (27.8%) 

  Female (176) 

18.9 (0.7) 

25.4 (6.5) 

1237 (1334) 

69 (39.2%) 109 (61.9%) 

75 (42.6%) 

15 (8.5%) 

14  (3.9%) 

48 (27.3%) 

T‐Test/ χ²  P‐value 

.325  .940  .025  <.001 <.001 .142 .020  .012  .876

20 – 29 Years (5057) 

  Male (4357) 

23.6 (2.6) 

26.1 (7.0) 

1282 (1398) 

1308 (30.0%) 

2658 (61.0%) 

2247 (51.6%) 

323 (7.4%) 

381  (8.7%) 

1322 (30.3%) 

  Female (700) 

24.4 (2.8) 

26.1 (7.0) 

1231 (1264) 

223 (31.9%) 

494 (70.6%) 

329 (47.0%) 

51 (7.3%) 

81  (11.6%) 

152 (21.7%) 

T‐Test/ χ²  P‐value 

<.001  .950  .327  .326 <.001 .025 .905  .016  < .001

30 – 39 Years (1036) 

  Male (783) 

33.7 92.8) 

26.7 (7.0) 

1541 (1731) 

248 (31.7%) 

571 (72.9%) 

443 (56.6%) 

89 (11.4%) 

157  (20.1%) 

159 (20.3%) 

  Female (253) 

34.1 (2.8) 

26.5 (7.2) 

1316 (1543) 

81 (32.1%) 

192 (75.9%) 

132 (52.4%) 

23 (9.1%) 

45  (17.8%) 

33 (13.0%) 

T‐Test/ χ²  P‐value 

.053  .739  .051  .889 .352 .244 .320  .429  .010

40 ‐59 Years (373) 

  Male (275) 

45.6 (3.8) 

26.4 (7.1) 

1625 (1615) 

84 (30.5%) 

224 (81.5%) 

174 (63.3%) 

27 (9.8%) 

103  (37.5%) 

38 (13.8%) 

  Female (98) 

44.8 (3.6) 

25.9 (7.1) 

2199 (2174) 

36 (36.7%) 

81 (82.7%) 

62 (63.3%) 

14 (14.3%) 

36  (36.7%) 

10 (10.2%) 

T‐Test/ χ²  P‐value 

.089  .549  .006  .260 .792 .999 .225  .899  .359

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Table 19. NCM Male and Female‐ Severity of Treatment Requirement  

  Mean (SD)

Emergency Visits 

Preventive Procedures 

RestoredSurfaces 

Root canals 

Periodontal Procedures 

Extractions

All Members 

  Male   1.7 (1.2)  4.9 (2.9) 7.7 (8.7) 1.8 (1.1) 1.8 (1.7)  2.5 (1.5)

  Female  1.9 (1.4)  5.5 (3.5) 7.3 (7.5) 1.7 (1.0) 1.9 (1.4)  2.2 (1.3)

          T‐Test P‐value 

.040  <.001 .233 .181 .762  .007

16 ‐19 years 

  Male   1.6 (1.1)  4.2 (2.1) 6.9 (8.0) 1.7 (0.9) 1.3 (0.6)  2.6 (1.3)

  Female  2.0 (1.6)  4.4 (2.3) 7.2 (7.3) 1.8 (0.9) 1.2 (0.6)  2.5 (1.4)

          T‐Test P‐value 

.021  .366 .782 .603 .771  .528

20 ‐29 years 

  Male   1.7 (1.2)  4.7 (2.6) 7.9 (9.1) 1.9 (1.2) 1.5 (1.1)  2.4 (1.4)

  Female  1.9 (1.4)  5.1 (3.1) 7.2 (7.6) 1.6 (1.0) 1.6 (1.2)  2.3 (1.4)

          T‐Test P‐value 

.177  .006 .122 .151 .769  .164

30 – 39 Years 

  Male   1.8 (1.5)  6.0 (3.7) 8.7 (8.8) 1.9 (1.0) 2.2 (2.2)  2.3 (2.6)

  Female  1.9 (1.4)  6.3 (3.7) 6.9 (7.0) 1.8 (1.4) 2.0 (1.3)  1.6 (0.9)

          T‐Test P‐value 

.852  .335 .014 .778 .512  .119

40 ‐59 Years 

  Male   1.6 (0.9)  6.8 (4.4) 6.9 (6.2) 1.3 (0.5) 2.7 (2.8)  1.5 (0.8)

  Female  1.6 (1.0)  7.8 (4.8) 9.5 (8.4) 1.4 (0.6) 2.6 (1.8)  1.3 (0.5)

          T‐Test P‐value 

1.000  .088 .033 .601 .857  .471

                       

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Table 20. Officer Males and Officer Females – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement 

             

  Mean (SD)  Prevalence Count (%) 

Age  

Months In 

Service 

Treatment Cost ‐ $ 

Emergency Visit 

Preventive Restoration Root Canal 

Periodontal Extraction

All Members (2094) 

  Male (1663) 

26.0 (8.1) 

25.7 (6.8) 

1009 (1267) 

358 (21.5%) 

1049 (63.1) 

612 (36.8%) 

75 (4.5%) 

147  (8.8%) 

270 (16.2%) 

  Female (431) 

26.5 (8.9) 

25.6 (7.0) 

1181 (1182) 

104 (24.1%) 

324 (75.2) 

185 (42.9%) 

15 (3.5%) 

 38  (8.8%) 

55 (12.8%) 

T‐Test/ χ²  P‐value 

.314  .848  .054  .246 <.001 .020 .348  .988 .076

16‐19 Years (672) 

  Male (526) 

18.3 (0.7) 

25.7 (6.6) 

749  (793) 

91 (17.3%) 

261 (49.6%) 

126 (24.0%) 

9 (1.7%) 

6  (1.1%) 

84 (16.0%) 

  Female (146) 

18.2 (0.6) 

25.1 (6.5) 

858  (753) 

29 (19.9%) 

92 (63.0%) 

49 (33.6%) 

5 (3.4%) 

1  (0.7%) 

20 (13.7%) 

T‐Test/ χ²  P‐value 

.046  .290  .140  .474 .004 .019 .200  .631 .502

20 – 29 Years (858) 

  Male (687) 

24.8 (2.60 

25.9 (7.4) 

987  (1230) 

130 (18.9%) 

441 (64.2%) 

254 (37.0%) 

27 (3.9%) 

54  (7.9%) 

125 (18.2%) 

  Female (171) 

25.3 (2.7) 

25.5 (7.0) 

1193 (1982) 

39 (22.8%) 

131 (76.6%) 

76 (44.4%) 

3 (1.8%) 

15  (8.8%) 

26 (15.2%) 

T‐Test/ χ²  P‐value 

.042  .503  .088  .253 .002 .206 .187  .005 <.001

30 – 39 Years (374) 

  Male (291) 

34.4 (2.9) 

26.4 (7.3) 

1206 (1243) 

86 (29.6%) 

213 (73.2%) 

143 (49.1%) 

25 (8.6%) 

51  (17.5%) 

48 (16.5%) 

  Female (83) 

34.5 (2.6) 

26.6 (6.8) 

1430 (1809) 

23 (27.7%) 

76 (91.6%) 

43 (51.8%) 

4 (4.8%) 

17  (20.5%) 

5 (6.0%) 

T‐Test/ χ²  P‐value 

.819  .842  .197  .745 <.001 .668 .257  .538 .016

40 ‐59 Years (190) 

  Male (159) 

46.8 (4.4) 

22.8 (6.5) 

1600 (2174) 

51 (32.1%) 

134 (84.3%) 

89 (56.0%) 

14 (8.8%) 

36  (22.6%) 

13 (8.2%) 

  Female (31) 

44.9 (3.9) 

25.2 (6.7) 

1972 (2831) 

13 (41.9%) 

25 (80.6%) 

17 (54.8%) 

3 (9.7%) 

5  (16.1%) 

4 (12.9%) 

T‐Test/ χ²  P‐value 

.030  .073  .410  .288 .617 .907 .876  .420 .399

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Table 21. Officer Male and Female‐ Severity of Treatment Requirement  

  Mean (SD)

Emergency Visits 

Preventive Procedures 

RestoredSurfaces 

Root canals 

Periodontal Procedures 

Extractions

All Members     

  Male  1.6 (1.0)  5.0 (3.2) 6.1 (6.7) 1.8 (0.8) 2.0 (1.9)  2.3 (1.4)

  Female  1.8 (2.0)  5.5 (3.5) 6.1 (7.5) 1.6 (0.7) 2.3 (1.9)  2.1 (1.3)

          T‐Test P‐value 

.227  .046 .981 .454 .320  .406

16 ‐19 years     

  Male  1.5 (1.1)  3.7 (1.8) 4.0 (3.3) 1.4 (0.5) 1.1 (0.4)  2.6 (1.3)

  Female  1.9 (1.3)  4.2 (2.7) 4.1 (3.8) 1.4 (0.5 3.0 (3.0)  2.3 (1.5)

          T‐Test P‐value 

.118  .094 .879 .884 .009  .488

20 ‐29 years     

  Male  1.6 (0.9)  4.8 (2.8) 5.6 (6.2) 1.9 (0.8) 1.5 (1.2)  2.4 (1.5)

  Female  1.5 (0.8)  5.8 (2.4) 6.6 (8.5) 2.0 (1.0) 2.1 (1.7)  2.2 (1.3)

          T‐Test P‐value 

.570  .003 .354 .825 .093  .494

30 – 39 Years     

  Male  1.5 (0.8)  6.0 (3.3) 7.1 (7.6) 1.4 (0.7) 2.2 (1.8)  1.8 (1.1)

  Female  1.5 (1.1)  6.1 (3.4) 5.9 (7.5) 1.8 (1.0) 1.6 (1.0)  1.2 (0.4)

          T‐Test P‐value 

.962  .174 .373 .445 .211  .249

40 ‐59 Years     

  Male  1.8 (1.4)  6.8 (4.7) 9.1 (8.6) 1.6 (0.7) 2.5 (2.8)  1.8 (1.0)

  Female  3.2 (4.8)  6.6 (5.8) 10.4 (8.6) 2.3 (0.6) 5.0 (3.08)  1.3 (0.6)

          T‐Test P‐value 

.072  .842 .586 .155 .072  .292

                      

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Table 22. First Language English/French – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement 

             

  Mean (SD)  Prevalence Count (%) 

Age  

Months In 

Service 

Treatment Cost ‐ $ 

Emergency Visit 

Preventive Restoration Root Canal 

Periodontal Extraction

All Members (10641) 

  English (8025) 

25.0 (7.0) 

26.4 (7.0) 

1201 (1388) 

2134 (26.6%) 

4866 (60.6) 

3698 (46.1%) 

530 (6.6%) 

792 (9.9%) 

1870 (23.3%) 

  French (2616) 

25.1 (7.1) 

25.8 (7.0) 

1295 (1433) 

843 (32.2%) 

1743 (66.6) 

1266 (48.4%) 

189 (7.2%) 

285  (10.9%) 

747 (28.6%) 

T‐Test/ χ²  P‐value 

.540  <.001  .004  < .001 <.001 .039 .272  .131  <.001

16‐19 Years (2753) 

  English (2041) 

18.8 (0.7) 

25.2 (6.9) 

974  (1073) 

476 (23.3%) 

981 (48.1%) 

695 (34.1%) 

87 (4.3%) 

71  (3.5%) 

476 (23.3%) 

  French (712) 

18.5 (0.9) 

25.7 (6.8) 

1010 (1103) 

178 (25%) 

388 (54.5%) 

260 (36.5%) 

29 (4.1%) 

25  (3.5%) 

206 (28.9%) 

T‐Test/ χ²  P‐value 

<.001  .119  .437  .365 .003 .234 .828  .967  .003

20 – 29 Years (5915) 

  English (4522) 

23.9 (2.7) 

25.9 (7.0) 

1208 (1357) 

1211 (26.8%) 

2777 (61.4%) 

2201 (48.7%) 

298 (6.6%) 

380  (8.4%) 

1176 (26.0%) 

  French (1393) 

24.1 (2.7) 

26.5 (7.0) 

1340 (1477) 

489 (35.1%) 

947 (68.0%) 

705 (50.6%) 

106 (7.6%) 

151  (10.8%) 

449 (32.2%) 

T‐Test/ χ²  P‐value 

.034  .010  .003  <.001 <.001 .206 .187  .005  <.001

30 – 39 Years (1410) 

  English (1022) 

34.0 (2.8) 

26.4 (7.1) 

1402 (1641) 

304 (29.8%) 

750 (73.4%) 

543 (53.2%) 

99 (9.7%) 

204  (20.0%) 

169 (16.6%) 

  French (388) 

33.9 (2.8) 

26.9 (6.9) 

1487 (1528) 

134 (34.5%) 

302 (77.8%) 

218 (56.2%) 

42 (10.8%) 

65  (16.8%) 

75 (19.3%) 

T‐Test/ χ²  P‐value 

.395  .274  .377  .085 .086 .312 .528  .168  .218

40 ‐59 Years (563) 

  English (440) 

45.9 (4.1) 

25.1 (7.1) 

1713 (1985)

142 (32.3%)

358 (81.4%) 

259 (58.9%)

46 (10.5%)

136 (30.9%)

48 (10.9%)

  French (123) 

45.1 (3.8) 

27.1 (7.1) 

1823 (1940)

42 (34.1%)

106 (86.2%) 

83 (67.5%)

12 (9.8%)

44 (35.8%)

17 (13.8%)

T‐Test/ χ²  P‐value 

.064   .005  .586  .695 .215 .084 .822 .307 .372

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Table 23. First Language English and French ‐ Severity of Treatment Requirement  

  Mean (SD)

Emergency Visits 

Preventive Procedures 

RestoredSurfaces 

Root canals 

Periodontal Procedures 

Extractions

All Members 

  English   1.7 (1.2)  4.9 (3.0) 7.2 (8.2) 1.7 (0.9) 1.9 (1.7)  2.5 (1.5)

  French   1.8 (1.3)  5.2 (3.3) 8.1 (8.9) 1.9 (1.3) 1.9 (1.8)  2.3 (1.3)

          T‐Test P‐value 

.152  .002 .002 .013 .637  .037

16 ‐19 years 

  English   1.6 (1.1)  4.2 (2.2) 6.3 (7.2) 1.6 (0.9) 1.3 (0.7)  2.6 (1.3)

  French   1.8 (1.3)  4.1 (2.0) 6.7 (7.9) 1.7 (1.0) 1.2 (0.5)  2.5 (1.3)

          T‐Test P‐value 

.114  .555 .512 .626 .775  .352

20 ‐29 years 

  English   1.7 (1.2)  4.7 (2.6) 7.4 (8.7) 1.8 (1.0) 1.5 (1.1)  2.5 (1.5)

  French   1.8 (1.4)  5.1 (3.0) 8.4 (9.1) 2.1 (1.5) 1.6 (1.2)  2.3 (1.3)

          T‐Test P‐value 

.143  .001 .010 .035 .682  .076

30 – 39 Years 

  English   1.8 (1.4)  5.9 (3.4) 7.5 (7.7) 1.8 (1.0) 2.1 (1.9)  2.1 (2.5)

  French   1.7 (1.2)  6.3 (4.0) 9.0 (9.3) 1.9 (1.1) 2.4 (2.0)  1.9 (1.2)

          T‐Test P‐value 

.368  .113 .017 .446 .320  .559

40 ‐59 Years 

  English   1.8 (1.8)  6.9 (4.6) 8.1 (7.4) 1.4 (0.6) 2.7 (2.5)  1.5 (0.8)

  French   1.7 (1.4)  7.3 (4.8) 8.3 (8.4) 1.6 (0.8) 2.8 (3.1)  1.4 (0.5)

          T‐Test P‐value 

.901  .400 .880 .368 .884  .828

                      

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Table 24. Birthplace Canada and Foreign – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement 

 

           

  Mean (SD)  Prevalence Count (%) 

Age  

Months In 

Service 

Treatment Cost ‐ $ 

Emergency Visit 

Preventive Restoration Root Canal 

Periodontal Extraction

All Members (10641) 

  Canada (9960) 

24.8 (6.9) 

26.0 (7.0) 

1211 (1372) 

2767 (27.8%) 

6167 (61.9) 

4644 (46.6%) 

660 (6.6%) 

958  (9.6%) 

2767 (27.8%) 

  Foreign (681) 

28.5 (9.2) 

25.1 (7.0) 

1406 (1743) 

210 (30.8%) 

442 (64.9) 

320  (46.9%) 

59 (8.7%) 

119  (17.5%) 

210 (30.8%) 

T‐Test/ χ²  P‐value 

<.001  .001  .003  .086 .120 .854 .040  <.001 .086

16‐19 Years (2753) 

  Canada (2624) 

18.7 (0.8) 

25.4 (6.9) 

983  (1086) 

624 (23.8%) 

1302 (49.6%) 

920 (35.1%) 

112 (4.3%) 

89  (3.4%) 

642 (24.5%) 

  Foreign (129) 

18.6 (0.7) 

25.2 (7.0) 

986  (963) 

30 (23.3%) 

67 (51.9%) 35 (27.1%) 

4 (3.1%) 

7  (5.4%) 

40 (31%)

T‐Test/ χ²  P‐value 

.366  .812  .972  .891 .607 .065 .519  .219  .093

20 – 29 Years (5915) 

  Canada (5597) 

23.9 (2.7) 

26.1 (7.0) 

1229 (1356) 

1604 (28.7%) 

3524 (63.0%) 

2749 (49.1%) 

374 (6.7%) 

491  (8.8%) 

1536 (27.4%) 

  Foreign (318) 

24.4 (2.7) 

24.6 (6.9) 

1424 (1854) 

96 (30.2%) 

200 (62.9%) 

157 (49.4%) 

30 (9.4%) 

40  (12.6%) 

89 (28.0%) 

T‐Test/ χ²  P‐value 

.001  <.001 .065  .557 .980 .929 .058  .021  .833

30 – 39 Years (1410) 

  Canada (1274) 

33.9 (2.8) 

26.7 (7.0) 

1415 (1584) 

390 (30.6%) 

957 (75.1%) 

695 (54.6%) 

125 (9.8%) 

237  (18.6%) 

217 (17.0%) 

  Foreign (136) 

35.0 (2.9) 

25.3 (7.4) 

1527 (1914) 

48 (35.6%) 

95(69.9%) 

66 (48.9%) 

16 (11.9%) 

32  (23.7%) 

27 (20.0%) 

T‐Test/ χ²  P‐value 

<.001  .028  .440  .238 .180 .209 .453  .152  .386

40 ‐59 Years (563) 

  Canada (465) 

45.8 (4.1) 

25.5 (7.0) 

1738 (2003) 

149 (32%) 

384 (82.6%) 

280 (60.2%) 

49 (10.5%) 

141  (30.3%) 

53 (11.4%) 

  Foreign (98) 

45.6 (3.7) 

26.2 (7.0) 

1731 (1837) 

35 (35.7%) 

80 (81.6%) 62 (63.3%) 

9 (9.2%) 

39  (39.8%) 

12 (12.2%) 

T‐Test/ χ²  P‐value 

.663   .357  .974  .481 .823 .574 .689  .068  .812

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Table 25. Birthplace Canada and Foreign – Severity of Treatment Requirement  

  Mean (SD)

Emergency Visits 

Preventive Procedures 

RestoredSurfaces 

Root canals 

Periodontal Procedures 

Extractions

All Members 

  Canada  1.7 (1.3)  5.0 (3.0) 7.4 (8.2) 1.8 (1.1) 1.8 (1.7)  2.4 (1.5)

  Foreign  1.7 (1.2)  5.4 (3.3) 8.5 (10.9) 1.9 (1.0) 2.3 (1.8)  2.3 (1.5)

          T‐Test P‐value 

.640  .019 < .001 .319 .012  .172

16 ‐19 years     

  Canada  1.7 (1.2)  4.1 (2.1) 6.5 (7.5) 1.7 (0.8) 1.2 (0.6)  2.6 (1.3)

  Foreign  1.5 (0.7)  4.3 (2.7) 5.1 (5.2) 1.3 (0.5) 1.7 (1.0)  2.3 (1.3)

          T‐Test P‐value 

.402  .534 .296 .349 .235  .109

20 ‐29 years 

  Canada  1.7 (1.2)  4.8 (2.7) 7.5 (8.5) 1.8 (1.1) 1.5 (1.1)  2.4 (1.4)

  Foreign  1.8 (1.4)  5.1 (3.0) 9.0 (12.8) 2.2 (1.1) 1.9 (1.3)  2.5 (1.6)

          T‐Test P‐value 

.496  .158 .158 .094 .134  .761

30 – 39 Years 

  Canada  1.8 (1.4)  6.1 (3.6) 7.7 (8.0) 1.8 (1.1) 2.1 (1.9)  2.1 (2.3)

  Foreign  1.5 (0.9)  5.7 (3.0) 9.7 (10.2) 1.8 (0.9) 2.2 (1.9)  1.8 (1.3)

          T‐Test P‐value 

.161  .302 .129 .835 .763  .523

40 ‐59 Years 

  Canada  1.8 (1.8)  7.1 (4.7) 8.2 (7.5) 1.4 (0.6) 2.7 (2.8)  1.4 (0.6)

  Foreign  1.7 (1.3)  6.6 (4.2) 7.7 (8.2) 1.6 (0.7) 2.8 (2.1)  1.7 (1.2)

          T‐Test P‐value 

.927  .428 .612 .538 .846  .263

                       

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Table 26. Treatment Prevalence (All Members) according to province of residence at the time of enrolment All Active Members – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement  

Province  Mean (SD)  Prevalence Count (%) 

Age Mean 

Months in 

Service 

Total cost $ 

EmergencyVisits 

Preventive Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC  (878) 

25.1 (7.6) 

26.3 (6.8) 

1250 (1573) 

186 (21.2%) 

530 (60.4%) 

388 (44.2%) 

54 (6.2%) 

118  (13.4%) 

191 (21.8%) 

AB  (693) 

24.4 (6.2) 

26.3 (7.2) 

1208 (1315) 

148 (21.4%) 

442 (63.8%) 

334 (48.2%) 

38 (5.5%) 

82  (11.8%) 

137 (19.8%) 

SK  (181) 

24.7 (6.7) 

26.4 (7.0) 

1330 (1316) 

42 (23.2%) 

123 (68.0%) 

108 (59.7%) 

17 (9.4%) 

21  (11.6%) 

48 (26.5%) 

MB (329)  25.6 (7.1) 

26.4 (6.9) 

1238 (1230) 

88 (26.7%) 

232 (70.5%) 

167 (50.8%) 

16 (4.9%) 

40  (12.2%) 

97 (29.5%) 

ON (3759)  24.8 (6.9) 

25.8 (6.9) 

1148 (1351) 

1035 (27.5%) 

2156 (57.4%) 

1609 (42.8%) 

227 (6.0%) 

318  (8.5%) 

861 (22.9%) 

QC (2484)  24.6 (6.7) 

26.5 (6.9) 

1283 (1416) 

804(32.4%) 

1600 (64.4%) 

1191 (47.9%) 

185 (7.4%) 

256  (10.3%) 

739 (29.8%) 

NB  (663) 

25.2 (6.7) 

26.5 (7.2) 

1263 (1390) 

231 (34.8%) 

419 (63.2%) 

349 (52.6%) 

58 (8.7%) 

48  (7.2%) 

177 (26.7%) 

NS (957)  26.1 (7.7) 

26.2 (6.9) 

1205 (1376) 

251 (26.2%) 

611 (63.8%) 

465 (48.6%) 

69 (7.2%) 

110  (11.5%) 

194 (20.3%) 

PE  (83) 

24.4 (7.6) 

25.8 (7.3) 

1196 (1192) 

22 (26.5%) 

48 (57.8%) 

33 (39.8%) 

5 (6.0%) 

6  (7.2%) 

23 (27.7%) 

NL  (233) 

23.8 (6.7) 

26.2 (6.7) 

1392 (1860) 

62 (26.6%) 

144 (61.8%) 

115 (49.4%) 

22 (9.4%) 

21  (9.0%) 

67 (28.8%) 

Missing (381) 

29.5 (9.6) 

19.4 (4.9) 

1379 (1443) 

108 (28.3%) 

304 (79.8%) 

115 (49.3%) 

28 (7.3%) 

57  (15%) 

83 (21.8%) 

TOTAL  25.1 (7.1) 

25.9 (7.0) 

1224 (1400) 

2977 (28.0%) 

6609 (62.1%) 

4964 (46.6%) 

719 (6.8%) 

1077 (10.1%) 

2617 (24.6%) 

ANOVA/χ²   P‐value 

<.001  <.001  .004  <.001 <.001 <.001 .046  <.001  <.001

                 

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Table 27. Treatment Severity (All Members) according to province of residence at the time of enrolment All Active Members – Severity of Treatment Need, measured in mean number of procedures among those requiring a minimum of one procedure.  

  Mean (SD) 

Province  Emergency Visits 

Preventive Procedures 

Restorations Root Canals 

Periodontal Procedures 

Extractions

BC  1.5 (0.8)  5.1 (2.9)  7.7 (9.2)  1.8 (0.8)  1.8 (1.5)  2.6 (1.5) 

AB   1.6 (1.0)  4.9 (3.0)  7.7 (8.8)  1.6 (1.1)  1.6 (1.4)  2.6 (1.3) 

SK   1.5 (1.0)  4.9 (2.6)  7.4 (7.6)  1.8 (0.9)  1.7 (1.2)  2.4 (1.3) 

MB   1.6 (1.0)  5.5 (3.4)  6.5 (6.7)  1.8 (1.1)  1.9 (1.7)  2.4 (1.2) 

ON   1.8 (1.2)  4.7 (2.7)  7.1 (8.3)  1.7 (1.0)  1.9 (1.5)  2.5 (1.4) 

QC   1.8 (1.4)  5.1 (3.2)  8.2 (8.6)  2.0 (1.3)  1.8 (1.5)  2.3 (1.3) 

NB   1.8 (1.4)  5.0 (3.1)  7.1 (7.4)  2.0 (1.1)  1.5 (1.0)  2.2 (1.3) 

NS   1.6 (1.1)  5.4 (3.1)  7.3 (8.3)  1.7 (1.0)  2.0 (1.7)  2.4 (2.4) 

PE   2.1 (1.4)  5.6 (3.9)  8.9 (8.1)  1.4 (0.5)  2.3 (1.2)  2.4 (1.2) 

NL   1.8 (1.4)  5.0 (3.3)  8.6 (9.2)  1.8 (0.9)  2.5 (3.4)  2.6 (2.0) 

Missing   1.7 (1.2)  5.9 (4.2)  6.4 (6.4)  1.5 (0.6)  2.4 (3.3)  2.3 (1.4) 

Total   1.7 (1.3)  5.0 (3.0)  7.5 (8.4)  1.8 (1.1)  1.9 (1.7)  2.4 (1.5) 

ANOVA p‐value 

.078  <.001  .012  .272  .117  .141 

                           

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Table 28. Treatment Prevalence (16 yrs – 19yrs) according to province of residence at the time of enrolment Age group 16 yrs to 19 yrs (2753) – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement

             

Province  Mean (SD)  Prevalence Count (%) 

Age Mean 

Months in 

Service 

Total cost  $ 

EmergencyVisits 

Preventive Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC  (240) 

18.7 (0.7) 

25.7 (7.0) 

1005 (1184) 

46 (19.2%) 

107 (44.6%) 

81 (33.8%) 

7 (2.9%) 

12 (5.0%) 

58 (24.2%) 

AB  (191) 

18.8 (0.6) 

25.7 (7.3) 

1133 (1270) 

37 (19.4%) 

96 (50.3%) 

67 (35.1%) 

10 (5.2%) 

10  (5.2%) 

47 (24.6%) 

SK  (51) 

18.8 (0.7) 

25.8 (6.9) 

839   (792) 

8 (15.7%) 

27 (52.9%) 

23 (45.1%) 

2 (3.9%) 

4  (7.8%) 

8 (15.7%) 

MB  (66) 

18.7 (0.7) 

26.4 (7.0) 

1045 (987) 

15 (22.7%) 

36 (54.5%) 

29 (43.9%) 

1 (1.5%) 

0  (0%) 

20 (30.3%) 

ON  (967) 

18.7 (0.7) 

25.0 (6.8) 

920   (1023) 

228 (23.6%) 

452 (46.7%) 

292 (30.2%) 

31 (3.2%) 

25  (2.6%) 

216 (22.3%) 

QC  (713) 

18.4 (0.9) 

25.6 (6.8) 

1016 (1116) 

180 (25.2%) 

383 (53.7%) 

258 (36.2%) 

30 (4.2%) 

24  (3.4%) 

214 (30.0%) 

NB  (136) 

18.8 (0.6) 

26.5 (7.1) 

1002  (893) 

38 (27.9%) 

74 (54.4%) 

58 (42.6%) 

9 (6.6%) 

7  (5.1%) 

31 (22.8%) 

NS  (238) 

18.8 (0.6) 

25.4 (6.7) 

858   (850) 

54 (22.7%) 

117 (49.2%) 

83 (34.9%) 

11 (4.6%) 

6  (2.5%) 

44 (18.5%) 

PE  (25) 

18.7 (0.7) 

24.6 (7.4) 

831   (1050) 

8 (32.0%) 

8 (32.0%) 

8 (32.0%) 

1 (4.0%) 

0  (0%) 

8 (32.0%) 

NL (90) 

18.6 (0.6) 

26.1 (6.5) 

1355  (1512) 

26 (28.9%) 

48 (53.3%) 

40 (44.4%) 

13 (14.4%) 

7  (7.8%) 

24 (26.7%) 

Missing (36) 

19.0 (0.7) 

19.6 (5.3) 

1100  (1126) 

14 (38.9%) 

21 (58.3%) 

16 (44.4%) 

1 (2.8%) 

1  (2.8%) 

12 (33.3%) 

Total  18.7 (0.8) 

25.4 (6.9) 

983   (1081) 

654 (23.8%) 

1369 (49.7%) 

955 (34.7%) 

116 (4.2%) 

96  (3.5%) 

682 (24.8%) 

ANOVA/χ²   P‐value 

<.001  <.001  .009  .104 .069 .009 .001  .045  .006

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Table 29. Treatment Severity (16 yrs – 19yrs) according to province of residence at the time of enrolment Age group 16 yrs to 19 yrs – Severity of Treatment Need, measured in mean number of procedures among those requiring a minimum of one procedure. 

Province  Mean (SD) 

Emergency Visits 

Preventive Procedures 

Restorations Root Canals 

Periodontal Procedures 

Extractions

BC   1.3 (0.6)  4.6 (2.6)  5.2 (5.2)  1.6 (0.8)  1.5 (0.8)  2.7 (1.1) 

AB   1.5 (0.6)  4.1 (2.1)  8.2 (9.1)  1.5 (0.8)  1.3 (0.7)  2.8 (1.3) 

SK   1.5 (1.1)  3.8 (1.8)  4.1 (4.6)  2.0 (1.4)  1.3 (0.5)  3.0 (0.9) 

MB   1.6 (1.1)  4.2 (2.4)  6.1 (7.0)  2.0 (0)    2.6 (1.2) 

ON   1.8 (1.3)  4.0 (1.9)  5.9 (6.7)  1.6 (1.0)  1.1 (0.3)  2.6 (1.3) 

QC   1.7 (1.2)  4.1 (1.9)  6.8 (8.0)  1.8 (1.0)  1.3 (0.5)  2.5 (1.3) 

NB   1.4 (0.6)  4.7 (2.7)  6.3 (5.0)  1.4 (0.5)  1.4 (1.1)  2.3 (1.2) 

NS   1.6 (0.9)  4.1 (1.9)  5.7 (6.8)  1.5 (0.7)  1.3 (0.8)  2.3 (1.2) 

PE   2.1 (1.1)  3.8 (1.7)  7.9 (6.2)  1.0 (0)    2.0 (1.1) 

NL   1.9 (1.7)  4.2 (2.8)  9.6 (11.3)  2.0 (0.9)   1.4 (0.8)  2.7 (1.3) 

Missing   1.7 (0.9)  4.5 (2.6)  7.5 (10.0)  1.0 (0)  1.0 (0)  2.9 (1.5) 

Total   1.7 (0.9)  4.1 (2.1)  6.4 (7.4)  1.7 (0.9)  1.3 (0.6)  2.6 (1.3) 

ANOVA  P‐value 

.296  .163  .038  .876  .755  .434 

                         

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Table 30. Treatment Prevalence (20 yrs – 29yrs) according to province of residence at the time of enrolment. Age group 20 yrs to 29 yrs (5915) – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement. 

          

Province  Mean (SD)  Prevalence Count (%) 

Age Mean 

Months in 

Service 

Total Cost 

EmergencyVisits 

Preventive Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC  (463) 

23.5 (2.6) 

26.3 (6.6) 

1290 (1614) 

102 (22.0%) 

287 (62.0%) 

217 (46.9%) 

32 (6.9%) 

55  (11.9%) 

109 (23.5%) 

AB  (397) 

23.9 (2.7) 

26.4 (7.2) 

1180 (1288) 

86 (21.7%) 

264 (66.5%) 

204 (51.4%) 

22 (5.5%) 

44  (11.1%) 

79 (19.9%) 

SK  (99) 

24.0 (2.8) 

26.6 (7.2) 

1477 (1342) 

25 (25.3%) 

69 (69.7%) 

65 (65.7%) 

10 (10.1%) 

9  (9.1%) 

35 (35.4%) 

MB (196) 

24.0 (2.6) 

26.3 (7.1) 

1320 (1357) 

53 (27.0%) 

141 (71.9%) 

104 (53.1%) 

11 (5.6%) 

23  (11.7%) 

66 (33.7%) 

ON (2172) 

23.9 (2.7) 

26.0 (6.9) 

1164 (1376) 

601 (27.7%) 

1251 (57.6%) 

981 (45.2%) 

126 (5.8%) 

160  (7.4%) 

556 (25.6%) 

QC (1330) 

24.0 (2.7) 

26.6 (7.1) 

1329 (1441) 

474 (35.6%) 

878 (66.0%) 

678 (51.0%) 

105 (7.9%) 

142  (10.7%) 

442 (33.2%) 

NB  (402) 

24.0 (2.7) 

26.6 (7.2) 

1242 (1112) 

143 (35.6%) 

251 (62.4%) 

219 (54.5%) 

38 (9.5%) 

24  (6.0%) 

122 (30.3%) 

NS  (493) 

24.2 (2.8) 

26.5 (7.0) 

1220 (1257) 

129 (26.2%) 

321 (65.1%) 

255 (51.7%) 

36 (7.3%) 

50  (10.1%) 

117 (23.7%) 

PE  (46) 

23.4 (2.2) 

26.7 (7.1) 

1213 (1106) 

9 (19.6%) 

31 (67.4%) 

20 (43.5%) 

2 (4.3%) 

4  (8.7%) 

13 (28.3%) 

NL  (107) 

23.8 (2.4) 

26.3 (6.9) 

1403 (2192) 

27 (25.2%) 

65 (60.7%) 

56 (52.3%) 

7 (6.5%) 

3  (2.8%) 

37 (34.6%) 

Missing (210) 

24.2 (2.8) 

19.5 (5.1) 

1222 (1075) 

51 (24.3%) 

166 (79.0%) 

107 (51.0%) 

15 (7.1%) 

17  (8.1%) 

49 (23.3%) 

Total (5915) 

24.0 (2.7) 

26.0 (7.0) 

1239 (1388) 

1700 (23.8%) 

3724 (63.0%) 

2906 (49.1%) 

404 (6.8%) 

531  (9.0%) 

1625 (27.5%) 

ANOVA/ χ²   P‐value 

.005  <.001  .046  <.001 <.001 <.001 .166  .001  <.001

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Table 31. Treatment Severity (20 yrs – 29yrs) according to province of residence at the time of enrolment Age group 20 yrs to 29 yrs – Severity of Treatment Need, measured in mean number of procedures among those requiring a minimum of one procedure.

Province  Mean (SD) 

Emergency Visits 

Preventive Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC   1.5 (0.8)  4.9 (2.8)  8.9 (10.6)  1.8 (0.6)  1.7 (1.0)  2.8 (1.6) 

AB   1.6 (1.2)  4.8 (3.0)  7.1 (8.8)  1.9 (1.2)  1.4 (1.0)  2.5 (1.4) 

SK   1.3 (0.7)  4.9 (2.6)  7.7 (7.5)  1.9 (1.0)  1.6 (1.1)  2.5 (1.4) 

MB   1.7 (1.1)  5.2 (3.1)  6.9 (7.1)  1.9 (1.2)  1.7 (1.5)  2.4 (1.3) 

ON   1.8 (1.2)  4.5 (2.5)  7.2 (8.9)  1.8 (1.0)  1.6 (1.2)  2.5 (1.5) 

QC   1.8 (1.3)  5.0 (3.0)  8.4 (9.0)  2.0 (1.5)  1.6 (1.1)  2.3 (1.3) 

NB   1.8 (1.2)  4.8 (2.7)  7.0 (7.2)  2.1 (1.1)  1.4 (0.8)  2.1 (1.2) 

NS   1.6 (1.2)  5.1 (2.7)  7.7 (9.2)  1.8 (1.2)  1.7 (1.4)  2.3 (1.4) 

PE   2.1 (1.6)  4.8 (2.2)  8.4 (8.7)  1.5 (0.7)  2.3 (1.0)  2.9 (2.4) 

NL   1.8 (1.3)  4.5 (2.4)  8.4 (8.0)  1.7 (0.8)  1.0 (0)  2.8 (2.4) 

Missing   1.7 (1.4)  5.1 (2.8)  5.8 (5.6)  1.6 (0.6)  1.2 (0.4)  2.6 (1.5) 

Total   1.7 (1.3)  4.8 (2.7)  7.6 (8.8)  1.9 (1.1)  1.6 (1.1)  2.6 (1.6) 

ANOVA  P‐value 

.458  .001  .040  .877  .736  .021 

                        

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Table 32. Treatment Prevalence (30 yrs – 39yrs) according to province of residence at the time of enrolment Age group 30 yrs to 39 yrs (1410) – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement Province  Mean (SD)  Prevalence Count (%) 

Age Mean 

Months in 

Service 

Total cost 

EmergencyVisits 

Preventive Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC  (113) 

33.8 (2.6) 

27.6 (6.5) 

1382 (1783) 

21 (18.6%) 

86 (76.1%) 

62 (54.9%) 

13 (11.5%) 

25  (22.1%) 

19 (16.8%) 

AB  (84) 

33.8 (2.7) 

26.7 (7.5) 

1347 (1386) 

19 (22.6%) 

64 (76.2%) 

50 (59.5%) 

3 (3.6%) 

24  (28.6%) 

10 (11.9%) 

SK  (23) 

33.9 (2.6) 

26.6 (6.9) 

1652 (1789) 

5 (21.7%) 

20 (87.0%) 

14 (60.9%) 

3 (13.0%) 

7  (30.4%) 

4 (17.4%) 

MB  (50) 

34.0 (3.1) 

27.8 (6.2) 

1090 (780) 

15 (30.0%) 

39 (78.0%) 

24 (48.0%) 

2 (4.0%) 

11  (22.0%) 

9 (18.0%) 

ON (437) 

34.0 (2.9) 

26.7 (7.2) 

1338 (1534) 

141 (32.3%) 

305 (69.8%) 

223 (51.0%) 

52 (11.9%) 

75  (17.2%) 

68 (15.6%) 

QC  (344) 

33.8 (2.7) 

27.4 (6.7) 

1538 (1615) 

116 (33.7%) 

261 (75.9%) 

190 (55.2%) 

38 (11.0%) 

60  (17.4%) 

70 (20.3%) 

NB  (99) 

33.8 (2.6) 

26.6 (7.3) 

1590 (2079) 

42 (42.4%) 

72 (72.7%) 

61 (61.6%) 

9 (9.1%) 

12  (12.1%) 

21 (21.2%) 

NS  (158) 

34.2 (2.9) 

26.5 (7.0) 

1503 (1750) 

49 (31.0%) 

120 (75.9%) 

86 (54.4%) 

16 (10.1%) 

31  (19.6%) 

29 (18.4%) 

PE  (6) 

33.7 (3.7) 

23.6 (8.1) 

1189 (935) 

3 (50.0%) 

3 (50.0%) 

2 (33.3%) 

1 (16.7%) 

0  (0%) 

1 (16.7%) 

NL  (26) 

33.6 (2.2) 

26.4 (6.6) 

1373 (1655) 

7 (26.9%) 

21 (80.8%) 

12 (46.2%) 

1 (3.8%) 

8  (30.8%) 

5 (19.2%) 

Missing (70) 

34.7 (3.0) 

18.9 (4.1) 

1371 (1495) 

21 (30.0%) 

61 (87.1%) 

37 (52.9%) 

3 (4.3%) 

17  (24.3%) 

9 (12.9%) 

Total (1410) 

33.9 (2.8) 

26.6 (7.1) 

1425 (1618) 

439 (31.1%) 

1052 (74.6%) 

761 (54.0%) 

141 (10.0%) 

270  (19.1%) 

245 (17.4%) 

ANOVA/ χ²   P‐value 

.482  <.001  .683  .024 .083 .626 .249  .065  .717

                

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Table 33. Treatment Severity (30 yrs – 39yrs)  according to province of residence at the time of enrolment. Age group 30 yrs to 39 yrs – Severity of Treatment Need, measured in mean number of procedures among those requiring a minimum of one procedure.

Province  Mean (SD) 

Emergency Visits 

Preventive Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC   1.7 (0.8)  5.5 (2.5)  7.0 (8.6)  1.8 (1.0)  1.5 (1.2)  1.9 (1.2) 

AB   1.7 (1.6)  6.5 (3.3)  7.3 (7.5)  1.0 (0)  2.0 (2.0)  1.7 (1.1) 

SK   2.0 (1.4)  5.4 (2.6)  11.7 (10.8)  1.3 (0.6)  2.0 (1.5)  1.3 (0.5) 

MB   1.3 (0.5)  7.6 (4.6)  4.5 (4.4)  1.5 (0.7)  2.5 (2.3)  1.9 (1.1) 

ON   1.8 (1.3)  5.5 (3.0)  7.4 (7.4)  1.7 (1.0)  2.1 (1.6)  2.0 (1.2) 

QC   1.8 (1.3)  6.2 (3.9)  9.3 (9.3)  2.1 (1.1)  2.3 (2.0)  1.9 (1.2) 

NB   2.1 (2.3)  6.0 (4.1)  8.5 (10.0)  2.0 (1.6)  1.7 (1.2)  2.8 (1.7) 

NS   1.6 (1.1)  6.2 (3.1)  7.7 (7.7)  1.7 (0.9)  2.0 (1.4)  2.9 (5.4) 

PE   1.0   5.7 (3.2)  11.0 (5.7)  2.0    1.0 

NL  1.3 (0.5)  7.5 (5.1)  7.0 (8.1)  1.0  4.5 (5.0)  1.6 (0.9) 

Missing   1.7 (1.1)  6.9 (5.0)  6.2 (5.6)  1.3 (0.6)  2.2 (1.8)  1.3 (0.5) 

Total   1.8 (1.4)  6.0 (3.6)  6.2 (5.6)  1.8 (1.0)  2.1 (1.9)  2.1 (2.1) 

ANOVA  P‐value 

.699  .004  .070  .701  .044  .477 

                       

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Table 34. Treatment Prevalence (40 yrs – 59yrs)  according to province of residence at the time of enrolment. Age group 40 yrs to 59 yrs (563) – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement

                 

Province  Mean (SD)  Prevalence Count (%) 

Age Mean 

Months in Service 

Total cost 

EmergencyVisits 

Periodontal Procedures 

Restorations Root Canals 

Periodontal Procedures 

Extractions

BC  (62) 

45.6 (3.7)

25.8 (6.9)

1645 (2018)

17 (27.4%) 

50 (80.6%) 

28 (45.2%) 

2 (3.2%) 

26  (41.9%) 

5 (8.1%) 

AB  (21) 

45.9 (3.8)

26.0 (6.6)

1862 (1761)

6 (28.6%) 

18 (85.7%) 

13 (61.9%) 

3 (14.3%) 

4  (19.0%) 

1 (4.8%) 

SK  (8) 

44.9 (3.6)

28.4 (6.2)

1721 (1479)

4 (50.0%) 

7 (87.5%) 

6 (75.0%) 

2 (25.0%) 

1 (12.5%) 

1 (12.5%) 

MB  (17) 

46.3 (4.3)

25.0 (6.1)

1481 (1544)

5 (29.4%) 

16 (94.1%) 

10 (58.8%) 

2 (11.8%) 

6  (35.3%) 

2 (11.8%) 

ON (183) 

45.7 (3.9)

26.4 (6.9)

1709 (1789)

65 (35.5%) 

148 (80.9%) 

113 (61.7%) 

18 (9.8%) 

58  (31.7%) 

21 (11.5%) 

QC  (97) 

44.7 (3.7)

27.5 (6.8)

1702 (1876)

34 (35.1%) 

78 (80.4%) 

65 (67.0%) 

12 (12.4%) 

30  (30.9%) 

13 (13.4%) 

NB  (26) 

46.5 (4.6)

24.9 (6.8)

1704 (3005)

8 (30.8%) 

22 (84.6%) 

11 (42.3%) 

2 (7.7%) 

5  (19.2%) 

3 (11.5%) 

NS  (68) 

45.6 (4.2)

26.1 (6.8)

1622 (2201)

19 (27.9%) 

53 (77.9%) 

41 (60.3%) 

6 (8.8%) 

23  (33.8%) 

4 (5.9%) 

PE  (6) 

46.7 (5.4)

26.0 (8.6)

2589 (1746)

2 (33.3%) 

6 (100%) 

3 (50.0%) 

1 (16.7%) 

2  (33.3%) 

1 (16.7%) 

NL  (10) 

45.2 (2.1)

25.7 (8.4)

1655 (1143)

2 (20.0%) 

10 (100%) 

7 (70.0%) 

1 (10.0%) 

3  (30.0%) 

1 (10.0%) 

Missing (65) 

47.0 (4.3)

19.4 (5.0)

2050 (2215)

22 (33.8%) 

56 (86.2%) 

45 (69.2%) 

9 (13.8%) 

22  (33.8%) 

13 (20.0%) 

Total (563) 

45.7 (4.0)

25.6 (7.0)

1737 (1974)

761 (54.0%) 

464 (82.4%) 

342 (60.7%) 

58 (10.3%) 

180  (32.0%) 

65 (11.5%) 

ANOVA/ χ²   P‐value 

.134 <.001 .965 .920 .660 .131 .666  .614  .543

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Table 35. Treatment Severity (40 yrs – 59yrs) according to province of residence at the time of enrolment. Age group 40 yrs to 59 yrs – Severity of Treatment Need, measured in mean number of procedures among those requiring a minimum of one procedure. 

 

Province  Mean (SD) 

Emergency Visits 

Periodontal Procedures 

Restorations Root Canals 

PeriodontalProcedures 

Extractions

BC   1.4 (0.8)  6.4 (4.1)  7.5 (7.2)  2.0 (1.4)  2.7 (2.5)  1.2 ((0.4) 

AB   1.3 (0.5)  5.0 (3.3)  14.6 (9.5)  1.0 (0)  2.0 (1.0)  2.0 

SK   2.5 (1.7)  7.6 (3.0)  6.7 (3.1)  1.5 (0.7)  2.0  1.0 

MB   2.0 (1.2)  6.2 (2.6)  8.6 (5.6)  1.0 (0)  1.5 (0.8)  1.5 (0.7) 

ON   1.7 (0.9)  6.5 (3.9)  7.8 (7.6)  1.4 (0.5)  2.8 (2.1)  1.6 (1.0) 

QC   2.1 (3.2)  7.4 (5.1)  8.8 (8.8)  1.7 (0.9)  2.6 (2.1)  1.5 (0.7) 

NB   1.8 (1.5)  6.2 (3.4)  6.4 (7.7)  2.0 (1.4)  2.0 (1.4)  1.3 (0.6) 

NS   1.8 (1.1)  8.0 (5.4)  7.3 (6.0)  1.2 (0.4)  2.7 (2.5)  1.5 (0.6) 

PE  3.5 (2.1)  12.2 (6.6)  13.6 (11.5)  1.0  2.5 (2.1)  1.0 

NL   1.5 (0.7)  7.2 (2.5)  7.6 (7.7)  1.0  1.3 (0.6)  1.0 

Missing   1.6 (1.2)  7.8 (6.1)  7.6 (6.8)  1.4 (0.5)  3.6 (4.9)  1.3 (0.6) 

Total   1.8 (1.7)  7.0 (4.6)  8.1 (7.6)  1.4 (0.7)  2.7 (2.6)  1.4 (0.8) 

ANOVA  P‐value 

.832  .035  .194  .581  .875  .434 

 

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Table 36. Tobacco User – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement 

                                

  MEAN (SD)  PREVALENCE COUNT (%) 

AGE  MONTHS IN 

SERVICE 

TREATMENT COST $ 

EMERGENCY VISITS 

PREVENTIVE PROCEDURES 

RESTORATIONS  ROOT CANALS 

PERIODONTAL PROCEDURES 

EXTRACTIONS 

Tobacco Users (1160) 

24.8 (6.0) 

27.3 (6.8) 

1686 (1658) 

411 (35.4%) 

816 (70.3%) 

772 (66.6%) 

114 (9.8%) 

178 (15.3%) 

396 (34.1%) 

Non Tobacco Users (2158) 

25.4 (7.6) 

27.5 (6.8) 

1451 (1533) 

635 (29.4%) 

1600 (74.1%) 

1136 (52.6%) 

160 (7.4%) 

295 (13.7%) 

570 (26.4%) 

T‐Test/χ² P‐Value 

.007  .590  <.001  <.001  .019  <.001  .016  .188  <.001 

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Table 37. Tobacco User – Severity of Treatment Need, measured in mean number of procedures among those requiring a minimum of one procedure.

MEAN (SD) EMERGENCY

VISITS PREVENTIVE RESTORATIONS ROOT

CANALS PERIODONTAL PROCEDURES

EXTRACTIONS

Tobacco Users

1.8 (1.3)

3.6 (3.4)

8.4 (9.6)

1.8 (0.9)

1.8 (1.4)

2.5 (1.4)

Non Tobacco

Users

1.8 (1.4)

3.9 (3.6)

6.9 (7.2)

1.8 (0.9)

1.9 (1.6)

2.5 (1.3)

T-Test P-Value

.584 .017 <.001 .662 .107 .516

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Table 38. Periodontal Screening and Recording (PSR) Score Prevalence  

    

PSR is 0 if probing depth < 3.5mm, no bleeding and no calculus. PSR is 1 if probing depth < 3.5mm, bleeding on probing and no calculus. PSR is 2 if probing depth < 3.5mm, bleeding on probing and calculus is present. PSR is 3 if probing depth is 3.5 - 5.5mm. PSR is 4 if probing depth is > 5.5mm.                

Age Mean (SD)

PSR Score Prevalence Count (%) 0 1 2 3 4

All Members with PSR Score (6898)

25.6 (7.4)

13 (0.2%) 231 (3.3%) 3981 (57.7%) 2187 (31.7%)

486 (7.0%)

Male (5738) 25.3 (7.3) 11 (0.2%) 161 (2.8%) 3231(56.3%) 1894

(33.0%) 441 (7.7%)

Female (1160) 27.4 (7.9) 2 (0.2%) 70 (6.0%) 750 (64.7%) 293 (25.3%) 45 (3.9%) T-Test

P value <.001

Chi-square P-Value <.001

NCM (5579) 25.3 (6.9) 10 (0.2%) 151 (2.7%) 3213 (57.6%) 1819

(32.6%) 386 (6.9%)

Officer (1319) 27.2 (9.0) 3 (0.2%) 80 (6.1%) 768 (58.2%) 368 (27.9%) 100 (7.6%) T-Test

P value <.001

Chi-square P-Value <.001

Tobacco User (924) 24.9 (6.0) 0 (0.0%) 10 (1.1%) 506 (54.8%) 339 (36.7%) 69 (7.5%) Tobacco Non User (1697)

25.9 (7.9) 1 (0.1%) 61 (3.6%) 993 (58.5%) 511 (30.1%) 131 (7.7%)

T-Test P value <.001

Chi-square P-Value <.001

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Table 39. PSR Status – Prevalence and Severity of preventive and periodontal treatment requirement   

  Age Mean (SD) 

Prevalence Count (%) Severity Mean (SD) 

Preventive Procedures 

Periodontal Procedures 

Preventive Procedures 

Periodontal Procedures 

PSR 0 through 3 (6412) 

25.4 (7.1)  5241 (81.7%) 773 (12.1%) 5.1 (3.0)  1.7 (1.6)

PSR 4 (486) 

29.3 (9.7)  397 (81.7%) 189 (38.9%) 6.4 (4.3)  2.8 (2.3)

PSR Undetermined (3743) 

24.0 (6.4)  971 (25.9%) 115 (3.1%) 4.0 (2.1)  1.5 (1.0)

  ANOVA P value <.001 

Chi‐Square P value <.001 

Chi‐Square P value <.001 

ANOVA P value <.001 

ANOVAP value <.001 

   

PSR is 0 if probing depth < 3.5mm, no bleeding and no calculus. PSR is 1 if probing depth < 3.5mm, bleeding on probing and no calculus. PSR is 2 if probing depth < 3.5mm, bleeding on probing and calculus is present. PSR is 3 if probing depth is 3.5 - 5.5mm. PSR is 4 if probing depth is > 5.5mm.                               

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Table 40. Dental Treatment Inequities between Officers and NCMs.  

  N Mean SD  T‐Test P Value

Total procedures   

  NCM  8547 13.14 10.00 

  Officer 2094 11.99 9.06  <.001

Total Procedures excluding Diagnostic and Preventive  

  NCM  8547 3.89 5.34 

  Officer 2094 2.52 4.27  <.001

Total Preventive Procedures   

  NCM  8547 3.05 3.37 

  Officer 2094 3.37 3.60  <.001

Months prior to  first appointment (excluding DiagnosticProcedure) 

 

  NCM  6772 10.31 8.36 

  Officer 1614 9.80 8.86  .029

Months prior to first Preventive appointment  

  NCM  5236 12.72 8.71 

  Officer 1373 11.31 8.98  <.001

   

                            

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Table 41. Demographic comparison of Canadian population and recruit age group

  Demographic Comparison 

Segment of Canadian Population in 2009 Statistics Canada* 

2007/2008 CF Recruit Population 

Total  Male  Female  Total  Male  Female 

Age Group 

Persons in thousands (% of group total) 

Persons in thousands (% of group) 

Persons in thousands (% of group) 

Persons  (% of group total) 

Persons  (% of group) 

Persons  (% of group) 

Total 

15 ‐ 59 

21,553.1 

(100%) 

10,854.5

(50.4%)

17,007.4

(49.6%)

10,641

(100.0%)

8983 

(84.4%) 

1658

(15.6%)

15 to 19  2,252.1 

(10.4%) 

1,153.3

(51.2%)

1,098.8

(48.8%)

2753

(25.9%)

2431 

(88.3%) 

322 

(11.7%) 

20 to 24  2,321.4 

(10.8%) 

1,192.6

(51.4%)

1,128.9

(48.6%)

3923 

(36.9%) 

3437 

(87.6%) 

486 

(12.4%) 

25 to 29  2,347.9 

(10.9%) 

1,185.6

(50.5%)

1,162.3

(49.5%)

1992 

(18.7%) 

1607 

(80.7%) 

385 

(19.3%) 

30 to 34  2,261.7 

(10.5%) 

1,131.7

(50.0%)

1,130.0

(50.0%)

913 

(8.6%) 

701 

(76.8%) 

212 

(23.2%) 

35 to 39  2,303.0 

(10.7%) 

1,160.6

(50.4%)

1,142.4

(49.6%)

497 

(4.7%) 

373 

(75.1%) 

124 

(24.9%) 

40 to 44  2,484.7 

(11.5%) 

1,251.8

(50.4%)

1,232.9

(49.6%)

281 

(2.6%) 

204 

(72.6%) 

77 

(27.4%) 

45 to 49  2,790.1 

(12.9%) 

1,402.8

(50.3%)

1,387.3

(49.7%)

184 

(1.7%) 

146 

(79.3%) 

38 

(20.7%) 

50 to 54  2,575.4 

(11.9%) 

1,282.9

(49.8%)

1,292.5

(50.2%)

87 

(0.8%) 

74 

(85.1%) 

13 

(14.9%) 

55 to 59  2,216.8 

(10.3%) 

1,093.2

(49.3%)

1,123.6

(50.7%)

11 

(0.1%) 

10 

(90.9%) 

(9.1%) 

*Ottawa Canada. Statistics Canada (2009). Population by sex and age group. Retrieved 19 Jul 2010: http://www40.statcan.gc.ca/l01/cst01/demo10a-eng.htm           

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Table 42. Demographic comparison of Canadian population level of education versus recruits

rank classification

Demographic Comparison

Education  Rank Classification 

Statistics Canada 2006 Census Data*  2007&2008 CF Recruit Population 

Total of persons aged 15 years and over 

25,664,220  Total Number of recruits 

10641 

Less than University certificate or diploma 

19,872,305 (77.4%)  NCMs  8547 (80.3%) 

University certificate or diploma and above 

5,791,915 (22.6%)  Officers  2094 (19.7%) 

*Ottawa Canada. Statistics Canada (2006). Population 15 years and over by highest degree,

certificate or diploma. Retrieved 19 Jul 2010: http://www40.statcan.ca/l01/cst01/educ42-eng.htm

          

                

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Table 43. Demographic comparison of Canadian population birthplace and recruit birthplace

                 

 

* Ottawa Canada. Statistics Canada (2006). Canada at a glance Demography. Retrieved 19 Jul

2010: http://www45.statcan.gc.ca/2009/cgco_2009_001-eng.htm#t04

                         

  Demographic Comparison 

Statistics Canada 2006 Census Data* 

2007 & 2008 

CF Recruit Population 

Total Population  31,241,030  10641 

Birthplace 

                    Born In Canada  25,054,080 (80.2%)  9960 (93.6%) 

                    Immigrant to Canada  6,186,950 (19.8%)  681 (6.4%) 

     

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Table 44. Demographic comparison of Canadian population most spoken language and recruit first language as reported at enrolment.  

 

* Canada. Statistics Canada. Census of Canada, 2006: [2006 Census / Language, immigration, 

citizenship, mobility and migration] [computer file]. Ottawa, Ont.: Statistics Canada [producer 

and distributor], [updated 13‐11‐2008] (Series title; [94‐581‐xcb2006006]) 

<http://dc1.chass.utoronto.ca.myaccess.library.utoronto.ca/cgibin/census/2006/displayCensus

CT.cgi?c=inc>  

               

  Demographic Comparison  

Statistics Canada 2006 Census Data* 

2007 & 2008 

CF Recruit Population 

First Language  Most common language spoken at home 

As reported at recruitment centre 

                                   Total Population  30,665,025 (100%)  10,641 (100%) 

                                    English   20,584,775 (67.1%)  8,025 (75.4%) 

                                    French  6,608,125 (21.5%)  2,616 (24.6%) 

                                    Other  3,472,130 (11.3%)  0 (0%) 

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Table 45. Comparison of treatment requirements between members living in a census tract and

members not living in a census tract.

Mean Prevalence

Age (SD)

Months In Service (SD)

Treatment Cost (SD)

Emergency Visits Count (%)

Restorations Count (%)

Root Canals Count (%)

Periodontal Procedures Count (%)

Extractions Count (%)

In Census Tract (5670)

22.5 (3.3)

26.0 (7.0)

$1146 (1302)

1513 (26.7%)

2481 (43.8%)

315 (5.6%)

425 (7.5%)

1474 (26.0%)

Not In Census Tract (2998)

21.8 (3.3)

25.5 (7.1)

$1180 (1305)

841 (28.1%)

1380 (46.0%)

205 (6.8%)

202 (6.7%)

833 (27.8%)

χ2 test, T-test p-value

<.001 .003 .266 .173 .043 .017 .195 .073

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Table 46. Census tract population descriptive statistics

Descriptive Statistics

Age

Mean (SD)

[Range]

CT IncomeMedian$Mean (SD)

CMA/CA Income Median $Mean (SD)

Above/BelowCMA/CA

% Mean (SD) [Range]

Above CMA/CA Count (%)

TreatmentCost

$Mean (SD)

All Members (5670)

22.5 (3.32)

[16.7-29.9]

28388 (6484.7)

27305 (2482.0)

4.02% (22.0) [-62 to 114]

3201 (56.5%)

1146 (1302.8)

Officers (1119)

22.3 (3.85)

29619 (7077.2)

27551 (2528.9)

7.5% (23.40)

689 (61.6%)

913 (1275.0)

NCM (4551) 22.5 (3.17)

28084 (6294.5)

27245 (2466.9)

3.2% (21.55)

2512 (55.2%)

1204 (1303.3)

T-Test/χ2 test, p-value

.060 <.001 <.001 <.001 <.001 <.001

Officers Male (885) 22.3

(3.77) 29713

(7033.5) 27603

(2550.4) 7.6%

(23.30) 545

(61.6%) 865

(1110.3) Female (234) 22.3

(4.11) 29265

(7244.6) 27355

(2441.3) 6.8%

(23.70) 144

(61.5%) 1095 1755.5

T-Test/ χ2 test, p-value

.932 .398 .171 .638 .990 .058

NCM Male (4041)

22.4 (3.14)

28091 (6264.6)

27344 (2468.9)

2.7% (21.38)

2231 (55.2%)

1206 (1307.4)

Female (510)

23.5 (3.30)

28035 (6532.4)

27344 (2450.6)

2.7% (21.90)

281 (55.1%)

1187 (1271.5)

T-Test/ χ2 test, p-value

<.001 .852 .335 .582 .962 .754

First Language English (4264)

22.5 (3.24)

28747 (6465.3)

27305 (2499.3)

4.3% (21.83)

3033 (57.3%)

1112 (1263.1)

French (1406)

22.5 (3.53)

27295 (6422.8)

26272 (2539.3)

4.1% (22.90)

771 (54.8%)

1250 (1411.8)

T-Test/ χ2 test, p-value

.662 <.001 <.001 .947 .158 .001

Birthplace Canada (5292)

22.5 (3.30)

28457 (6427.4)

27305 (2499.3)

4.3% (21.83)

3033 (57.3%)

1136 (1269.4)

Foreign (378)

22.8 (3.56)

27415 (7178.1)

27306 (2228.2)

0.2% (23.81)

168 (44.4%)

1289 (1698.1)

T-Test/ χ2 test, p-value

.064 .006 .998 .001 <.001 .086

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Table 47. Census tract group descriptive statistics, age, and months of service in relation to

median income Groups

Census Tract Median Income in Relation to CMA/CA

Well Below <-25%

Below -25% to

-7%

Median >-7% to

<7%

Above 7% to 25%

Well Above >25%

TOTAL

ANOVAp-value

Count (%) All Members

492 (8.6%)

1299 (22.8%)

1410 (24.8%)

1571 (27.6%)

898 (15.8%)

5670 n/a

Officers 76 (6.8%)

238 (21.3%)

254 (22.7%)

316 (28.2%)

235 (21.0%)

1119 n/a

NCM 416 (9.1%)

1061 (23.2%)

1156 (25.3%)

1255 (27.5%)

663 (14.5%)

4551 n/a

Age Mean

(SD) All Members

23.3 (3.26)

22.9 (3.30)

22.5 (3.32)

22.3 (3.26)

21.8 (3.33)

22.5 (3.32)

<.001

Officers 23.6 (3.30)

23.0 (3.83)

22.5 (3.91)

22.2 (3.86)

21.1 (3.65)

22.3 (3.85)

<.001

NCM 23.3 (3.26)

22.8 (3.17)

22.4 (3.17)

22.3 (3.08)

22.1 (3.17)

22.6 (3.17)

.004

T-test, p-value

.392 .567 .815 .703 .001 .060

Months in

Service Mean(SD) All Members

25.9 (7.02)

26.3 (7.00)

26.1 (6.91)

25.9 (6.98)

25.5 (6.82)

26.0 (6.95)

.131

Officers

24.1 (6.76)

26.6 (7.05)

26.3 (7.20)

25.3 (6.88)

24.7 (6.64)

25.6 (6.97)

.004

NCM

26.1 (7.04)

26.3 (6.99)

26.1 (6.84)

26.1 (7.00)

25.9 (6.87)

26.1 (6.94)

.854

T test, p-value

.025 .456 .593 .073 .030 .042

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Table 48. Census tract group prevalence of emergency visits

Prevalence Count (%)

Census Tract Median Income in Relation to CMA/CA Well

Below <-25% (492)

Below -25% to

-7% (1299)

Median >-7% to

<7% (1410)

Above 7% to 25%

(1571)

Well Above >25% (898)

TOTAL (5670)

χ2 test p-

value EMERGNCY

All Members (5670)

153

(31.1%)

363

(27.9%)

366

(26.0%)

409

(26.0%)

222

(24.7%)

1513

(26.7%)

.077

Officers (1119)

12/76

(15.8%)

49/238 (20.6%)

44/254 (17.3%)

59/316 (18.7%)

41/235 (17.4%)

205/1119 (18.3%)

.834

NCM (4551)

141/416 (33.9%)

314/1061 (29.6%)

322/1156 (27.9%)

350/1255 (27.9%)

181/663 (27.3%)

1308/4551

(28.7%)

.119

χ2 test, p-value .002 .005 .001 .001 .003 <.001

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Table 49. Census tract group mean treatment cost

Treatment

COST $mean(SD)

Census Tract Median Income in Relation to CMA/CA

Well Below <-25%

Below -25% to

-7%

Median >-7% to

<7%

Above 7% to 25%

Well Above >25%

TOTAL

One-Way

ANOVAp-value

C O S T

All Members (5670)

1331

(1477.3)

1245

(1469.1)

1153

(1344.1)

1060

(1076.6)

1044

91218.90

1146

(1302.8)

<.001

Officers (1119)

1131

(1531.9)

1000

(1409.0)

995

(1751.1)

821

(772.80

788

(904.7)

913

(1275.0)

.081

NCM (4551)

1367

(1464.7)

1300

(1477.8)

1188

(1235.0)

1120

(1132.7)

1134

(1301.0)

1204

(1303.1)

.001

T-test, p-value .202 .004 .038 < .001 .001 < .001

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Table 50. Multiple logistic regression - likelihood of dental treatment requirement, by treatment

category, in the combined well below and below groups vs. the above and well above groups.

(below=0, above=1)

Treatment Category Adjusted Odds

Ratio*

95% CI p-value

Preventative .966 .870, 1.14 .996

Restorative .803 .706, .914 .001

Endodontic .742 .572, .971 .023

Periodontal .794 .630, 1.00 .050

Removable 1.00 .543, 1.85 .991

Fixed .725 .359, 1.46 .370

Surgical .839 .727, .966 .016

Orthodontic 1.06 .666, 1.69 .807

*Adjusted for age (continuous, years), gender, rank (officer/NCM),

first language (English, French), Birthplace (Canada, Foreign)

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Table 51. Multiple linear regression analysis of dental treatment cost.

Independent Variable Parameter

estimate β

P-value

Constant -569.35 <.001

Time in Service (months since enrolment) 46.06 <.001

Rank Class (NCM=0, officer=1) -264.45 <.001

Gender (female=0, male=1) -19.78 .723

Age (years, at enrolment) 29.25 <.001

First Language (French=0,English=1) -100.25 .009

Birthplace (Canada=0,Foreign=1) 246.11 <.001

CT Median Income (percentage point

gain relative to CMA/CA median income)

-2.44 .001

R2= .083

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Table 52. Census tract group prevalence of treatment requirement, stratified by rank class.

Prevalence Count (%)

Census Tract Median Income in Relation to CMA/CA Well

Below <-25% (492)

Below -25% to -

7% (1299)

Median >-7% to

<7% (1410)

Above 7% to 25%

(1571)

Well Above >25% (898)

TOTAL (5670)

χ2 test p-

value R E S T O R T I ON

All Members (5670)

234

(47.6%)

630

(48.5%)

625

(44.3%)

650

(41.4%)

342

(38.1%)

2481

(43.8%)

<.001

Officers (1119)

19/76 (25.0%)

95/238 (39.9%)

87/254 (34.3%)

95/316 (30.1%)

61/235 (26.0%)

357/1119 (31.9%)

.008

NCM (4551)

215/416 (51.7%)

535/1061 (50.4%)

538/1156 (46.5%)

555/1255 (44.2%)

281/663 (42.4%)

2124/4551 (46.7%)

.001

χ2 test, p-value <.001 .003 <.001 <.001 <.001 <.001 R O O T

C A N A L

All Members (5670)

42

(8.5%)

81

(6.2%)

75

(5.3%)

73

(4.6%)

44

(4.9%)

315

(5.5%)

.012

Officers (1119)

5/76 (6.6%)

8/238 (3.4%)

6/254 (2.4%)

7/316 (2.2%)

6/235 (2.6%)

32/1119 (2.9%)

.311

NCM (4551)

37/416 (8.9%)

73/1061 (6.9%)

69/1156 (6.0%)

66/1255 (5.3%)

38/663 (5.7%)

283/4551 (6.2%)

.082

χ2 test, p-value .507 .042 .020 .022 .052 <.001 E X T R A C T I O N

All Members (5670)

149

(30.3%)

364

(28.0%)

363

(25.7%)

390

(24.8%)

208

(23.2%)

1474

(26.0%)

.015

Officers (1119)

11/76 (14.5%)

35/238 (14.7%)

42/254 (16.5%)

55/316 (17.4%)

33/235 (14.0%)

176/1119 (15.7%)

.813

NCM (4551)

138/416 (33.2%)

329/1061 (31.0%)

321/1156 (27.8%)

335/1255 (26.7%)

175/663 (26.4%)

1298/4551 (28.5%)

.022

χ2 test, p-value .001 <.001 <.001 <.001 <.001 <.001 P E R I O DON T A L

All Members (5670)

50

(10.2%)

119

(9.2%)

94

(6.7%)

100

(6.4%)

62

(6.9%)

425

(7.5%)

.005

Officers (1119)

6/76 (7.9%)

17/238 (7.1%)

10/254 (3.9%)

16/316 (5.1%)

12/235 (5.1%)

61/1119 (5.5%)

.481

NCM (4551)

44/416 (10.6%

102/1061 (9.6%)

84/1156 (7.3%)

84/1255 (6.7%)

50/663 (7.5%)

364/4551 (8.0%)

.022

χ2 test, p-value .477 .232 .054 .289 .206 .004

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Table 53. Census tract group prevalence of treatment requirement, stratified by age groups (16-19 & 20-29 yrs)

 

Prevalence Count (%) 

Census Tract Median Income in Relation to CMA/CA 

Well Below  <‐25% (492) 

Below ‐25% to ‐7% 

(1299) 

Median >‐7% to <7% (1410) 

Above 7% to 25% (1571) 

Well Above >25% (898) 

 TOTAL (5670) 

χ2 test p‐

valueR E S T O R T I O N 

All Members (5670)  

234 (47.6%) 

630 (48.5%) 

625 (44.3%) 

650 (41.4%) 

342 (38.1%) 

2481 (43.8%)  <.001 

         16 ‐19 yrs (1631)  

30/101 (29.7%) 

116/303(38.3%) 

141/407 (34.6%) 

147/482 (30.5%) 

97/338 (28.7%) 

531/1631 (32.6%)  .063 

20 – 29 yrs (4039)  

204/391(52.2%) 

514/996(51.6%) 

484/1003(48.3%) 

503/1089(46.2%) 

245/560 (43.8%) 

1950/4039(48.3%) 

.010

            χ2 test, p‐value  <.001  <.001  <.001  <.001  <.001  <.001 

R O O T  C A N A L 

All Members (5670)  

42 (8.5%) 

81 (6.2%) 

75 (5.3%) 

73 (4.6%) 

44 (4.9%) 

315 (5.5%)  .012 

         16 ‐19 yrs (1631)  

4/101 (4.0%) 

16/303 (5.3%) 

13/407 (3.2%) 

15/482 (3.1%) 

10/338 (3.0%) 

58/1631 (3.6%)  .484 

20 – 29 yrs (4039)  

38/391 (9.7%) 

65/996 (6.5%) 

62/1003 (6.2%) 

58/1089 (5.3%) 

34/560 (6.1%) 

257/4039 (6.4%) 

.049

            χ2 test, p‐value  .065  .432  .024  .055  .036  <.001 

E X T R A C T I O N 

All Members (5670)  

149 (30.3%) 

364 (28.0%) 

363 (25.7%) 

390 (24.8%) 

208 (23.2%) 

1474 (26.0%) 

.015 

         16 ‐19 yrs (1631)  

38/101 (37.6%) 

80/303 (26.4%) 

93/407 (22.9%) 

112/482 (23.2%) 

75/338 (22.2%) 

398/1631 (24.4%) 

 .017 

20 – 29 yrs (4039)  

111/39128.4%) 

284/996(28.5%) 

270/1003(26.9%) 

278/1089(25.5%) 

133/560 (23.8%) 

1076/4039(26.6%) 

.238 

            χ2 test, p‐value  <.072  <.474  <.113  <.332  <.591  <.082   

PERIODONTAL 

All Members (5670)  

50 (10.2%)

119 (9.2%) 

94 (6.7%) 

100 (6.4%) 

62 (6.9%) 

425 (7.5%) 

.005 

         16 ‐19 yrs (1631)  

6/101 (5.9%) 

14/303 (4.6%) 

10/407 (2.5%) 

13/482 (2.7%) 

15/338 (4.4%) 

58/1631 (3.6%) 

.206 

20 – 29 yrs (4039)  

44/391 (11.3%) 

105/996(10.5%) 

84/1003 (8.4%) 

87/1089 (8.0%) 

47/560 (8.4%) 

367/4039 (9.1%) 

.121 

            χ2 test, p‐value  .115  .002  <.001  <.001  .024  <.001   

EMERGENCY 

All Members (5670)  

153 (31.1%) 

363 (27.9%) 

366 (26.0%) 

409 (26.0%) 

222 (24.7%) 

1513 (26.7%) 

 .077 

         16 ‐19 yrs (1631)  

27/101 (26.7%) 

81/303 (26.7%) 

93/407 (22.9%) 

100/482 (20.7%) 

66/338 (19.5%) 

367/1631 (22.5%) 

 .150 

20 – 29 yrs (4039)  

126/391(32.2%) 

282/996(28.3%) 

273/1003(27.2%) 

309/1089(28.4%) 

156/560 (27.9%) 

1146/4039(28.4%) 

.475 

            χ2 test, p‐value  .288  .591  .090  .001  .005  <.001 

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Table 54. Census tract group severity of treatment requirement, stratified by rank class. *Restoration severity is measured as surfaces restored

Severity Mean (SD) 

Census Tract Median Income in Relation to CMA/CA 

Well Below <‐25% 

Below ‐25% to ‐7% 

Median>‐7% to <7%  

Above7% to 25% 

Well Above >25% 

 TOTAL 

 

ANOVAp‐value

R E S T O R T I O N 

All Members   

8.1 (9.37) 

7.5 (9.75) 

7.4 (9.34) 

6.5 (7.15) 

7.2 (7.74) 

7.3 (7.73) 

.104 

                 Officers  

5.4 (6.06) 

6.0 (6.92) 

6.2 (8.73) 

4.6 (4.14) 

4.4 (4.52) 

5.4 (6.44) 

.303 

NCM                

8.3 (9.58) 

7.8 (10.15) 

7.7 (9.43) 

6.8 (7.50) 

7.8 (8.20) 

7.6 (8.20) 

.222 

            T‐test, p‐value  .194  .104  .168  <.001  <.001  <.001   

R O O T  C A N A L 

All Members   2.1(1.97) 

1.8(0.99) 

1.8(0.90) 

1.91(1.08) 

1.77  (0.94) 

1.85(1.16) 

.498 

Officer  

1.8(0.83) 

2.0(1.07) 

1.5(0.55) 

1.7(0.49) 

1.8 (0.75) 

1.8(0.75) 

.828 

NCM  

2.2(2.08) 

1.7(0.99) 

1.8 (0.92) 

1.9 (1.12) 

1.8 (0.97) 

1.9 (1.20) 

.431 

            T ‐ test, p‐value  .706  .463  .399  .602  .867  .710   E X T R A C T I O N 

All Members   2.5 (1.42) 

2.4 (1.39) 

2.55 (1.44) 

2.5 (1.37) 

2.4 (1.28) 

2.4 (1.38) 

.556 

Officer  

3.3(1.55) 

2.1(1.16) 

2.7(1.91) 

2.3(1.29) 

2.5 (1.37) 

2.4(1.48) 

.130 

NCM  

2.4(1.40) 

2.4(1.41) 

2.5(1.37) 

2.5(1.37) 

2.4 (1.27) 

2.4(1.37) 

.754 

            T ‐ test, p‐value  .055  .322  .313  .348  .609  .805   PERIODONTAL 

All Members   2.0 (1.60) 

1.6 (1.13) 

1.5 (1.08) 

1.3 (0.67) 

1.5 (1.11) 

1.5 (1.11) 

 .025 

Officer  

3.3(2.33) 

1.9(1.79) 

1.6(0.69) 

1.3(0.60) 

1.1 (0.28) 

1.7 (1.37) 

.010 

NCM  

1.8(1.41) 

1.5(0.98) 

1.5(1.12) 

1.3(0.68) 

1.6 (1.21) 

1.5(1.06) 

.256 

            T ‐ test, p‐value  .166  .428  .803  .910  .167  .410   

EMERGENCY 

All Members   1.9 (1.6) 

1.6 (1.1) 

1.7 (1.1) 

1.7 (1.1) 

1.6 (1.1) 

1.7 (1.2) 

.136 

Officer  

1.9 (1.7) 

1.5 (0.9) 

1.6 (0.9) 

1.7 (1.1) 

1.5 (0.8) 

1.6 (1.1) 

.594 

NCM  

1.9 (1.6) 

1.7 (1.1) 

1.7 (1.2) 

1.7 (1.1) 

1.6 (1.1) 

1.7 1.2 

.257 

            T ‐ test, p‐value  .985  .324  .495  .800  .475  .278 

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Table 55. Treatment workload by treatment category – number of procedures and cost

Treatment Category

All treatment Data DentIS Data Blue Cross Data Procedures Total

Cost $

Procedures Cost $

Procedures Cost $

Diagnostic 72173 4667012 69705 4517692 2468 149320% of Total Sum (Emergency Procedure)

48.1%

(5650) (3.8%)

34.5%

(673342) (5.0%)

51.3%

(5583) (4.1%)

42.5%

(668577) (6.3%)

17.5%

(67) (0.5%)

5.1%

(3766) (0.1%)

Preventive 34915 1889721 33494 1799086 1421 90635% of Total Sum 23.3% 14.0% 24.6% 16.9% 10.1% 3.1%

Restorative 22932 3006117 19123 2430754 3809 575363% of Total Sum 15.3% 22.2% 14.1% 22.9% 27.0% 19.7%

Endodontic 1802 778307 1330 381935 472 396372% of Total Sum (Root Canals completed)

1.2%

(1386)(0.9%)

5.7%

(725535)(5.4%)

1.0%

(1008)(7.2%)

3.6%

(368485) (3.5%)

3.3%

(378)(2.7%)

13.6%

(357050)(12.2%)

Periodontal 2137 282770 2023 248664 114 34105% of Total Sum 1.4% 2.1% 1.5% 2.3% .8% 1.2%

Removable 417 90015 413 83581 4 6435% of Total Sum .3% .7% .3% .8% .0% .2%

Fixed 315 67202 306 56635 9 10567% of Total Sum .2% .5% .2% .5% .1% .4%

Oral Surgery 9841 1976670 6343 969884 3498 1006786% of Total Sum (Extractions)

6.6%

(8133)(5.4%)

14.6%

(1798528)

(13.3%)

4.7%

(4797)(3.5%)

9.1%

(855768) (8.0%)

24.8%

(3336)(23.6%)

34.5%

(942760)(32.3%)

Orthodontic 332 41521 266 26323 66 15199% of Total Sum .2% .3% .2% .2% .5% .5%

Miscellaneous 5139 745587 2895 109814 2244 635773% of Total Sum 3.4% 5.5% 2.1% 1.0% 15.9% 21.8%

Total 150003 13544921 135898 10624366 14105 2920556% of Total Sum 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

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Table 56. Detachment workload at 6 month intervals following recruit enrolment.

Detachment

0-6 Months

7-12 Months

13-18 Months

19 -24 Months

25-30 Months

31-36 months

Total

SPECIALTY

Valcartier 2551 3628 5006 3245 1648 633 16,711

5.6% 12.1% 14.9% 14.7% 11.9% 13.8% 11.1%Edmonton 919 2053 4284 3934 2439 637 14,266

2.0% 6.9% 12.7% 17.9% 17.6% 13.8% 9.5%Petawawa 841 1416 3570 2621 1915 887 11,350

1.8% 4.7% 10.9% 11.9% 13.8% 19.3% 7.6%Halifax 2107 1780 2466 1616 1142 348 9460

4.6% 6.0% 7.3% 7.3% 8.2% 7.6% 6.3%Esquimalt 1741 2436 1822 1230 655 221 8105

3.8% 8.1% 5.4% 5.6% 4.7% 4.8% 5.4%Ottawa 1145 978 980 801 670 251 4825

2.5% 3.3% 2.9% 3.6% 4.8% 5.5% 3.2%

MIDSIZE

Borden 6158 4826 3336 875 430 112 15,737 13.4% 16.1% 9.9% 4.0% 3.1% 2.4% 10.5%

Gagetown 3226 3552 2983 1824 899 267 12,751 7.0% 11.9% 8.9% 8.3% 6.5% 5.8% 8.5%

Kingston 2570 1554 2519 951 1087 118 8799 5.6% 5.2% 7.5% 4.3% 7.8% 2.6% 4.8%

Trenton 292 691 786 667 425 203 3064 .6% 2.3% 2.3% 3.0% 3.1% 4.4% 2.0%

Winnipeg 617 630 679 567 373 102 2968 1.3% 2.1% 2.0% 2.6% 2.7% 2.2% 2.0%

Cold Lake 199 277 444 469 419 141 1949 .4% .9% 1.3% 2.1% 3.0% 3.1% 1.3%

S MA LL DETACHMENT

St Jean 19,227 1691 787 451 156 72 22,384 41.9% 5.7% 2.3% 2.0% 1.1% 1.6% 14.9%

Shilo 425 1075 1109 566 249 97 3521 .9% 3.6% 3.3% 2.6% 1.8% 2.1% 2.3%

Wainwright 1078 1189 458 240 97 65 3127 2.3% 4.0% 1.4% 1.1% .7% 1.4% 2.1%

Greenwood 429 335 486 437 340 100 2127 .9% 1.1% 1.4% 2.0% 2.5% 2.2% 1.4%

Toronto 654 398 352 215 116 60 1795 1.4% 1.3% 1.0% 1.0% .8% 1.3% 1.2%

Bagotville 225 297 329 393 281 96 1621 .5% 1.0% 1.0% 1.8% 2.0% 2.1% 1.1%

Moose Jaw 180 244 261 225 124 57 1091 .4% .8% .8% 1.0% .9% 1.2% .7%

Comox 153 149 335 263 119 51 1070 .3% .5% 1.0% 1.2% .9% 1.1% .7%

North Bay 311 273 193 140 81 5 1003 .7% .9% .6% .6% .6% .1% .7%

Longue-Pointe 365 183 124 99 86 38 895 .8% .6% .4% .4% .6% .8% .6%

Gander 456 172 95 73 51 12 859 1.0% .6% .3% .3% .4% .3% .6%

Preserver 6 80 109 62 34 22 313 .0% .3% .3% .3% .2% .5% .2%

Goose Bay 42 3 86 36 39 6 212 .1% .0% .3% .2% .3% .1% .1%

Total 45,917 29,910 33,699 22,000 13,875 4602 150,003

100.0% 100.0% 100% 100.0% 100% 100 % 100 %

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Table 57. Detachment workload impact – Total procedures and cost Detachment Total Procedures DentIS (In-Service) Procedures Blue Cross (Out-Service)

Procedures %

Count Cost $ %

Count (% row)

Cost $ %

Count (% row)

Cost $

S P E C I A L T Y

Valcartier 11.1 16,711 1,540,260 11.4 15,468 (92.6%)

1,261,121 8.8 1243 (7.4%)

279,139

Edmonton 9.5 14,266 1,584,023 8.6 11,698 (82.0%)

964,608 18.2 2658 (18.0)

619,415

Petawawa 7.6 11,350 1,102,115 7.4 10,019 (88.3%)

752,138 9.4 1331 (11.7)

349,977

Halifax 6.3 9460 815,967 6.4 8662 (91.6%)

638,290 5.7 798 (8.4%)

177,677

Esquimalt 5.4 8105 798,911 5.1 6874 (84.8%)

572,128 8.7 1231 (15.2)

226,784

Ottawa 3.2 4825 489,630 3.2 4366 (90.5%)

409,318 3.3 459 (9.5%)

80,312

Spec Sub total 43.1 64,717 6,330,906 42.1 57,087 (88.2%)

4,597,603 54.1 7630 (11.8)

1,733,304

M I D S I Z E

Borden* 10.5 15,737 1,356,231 10.8 14,677 (93.3%)

1,153,460 7.5 1060 (6.7%)

202,771

Gagetown 8.5 12,751 1,136,929 8.3 11,313 (88.7%)

940,138 10.2 1438 (11.3%)

196,791

Kingston** 5.9 8799 691,577 6.0 8120 (92.3%)

540,311 4.8 679 (7.7%)

151,266

Trenton*** 2.0 3064 275,870 1.9 2541 (82.9%)

156,596 3.7 523 (17.1)

119,273

Winnipeg* 2.0 2968 232,319 2.0 2703 (91.1%)

195,810 1.9 265 (8.9%)

36,508

Cold Lake 1.3 1949 152,342 1.3 1800 (92.4%)

117,768 1.1 149 (7.6%)

34,574

Mid Sub total 30.2 45,268 3,845,268 30.3 41,151 (90.9%)

3,104,083 29.2 4114 (9.1%)

741,183

S M A L L D E T A C H M E N T

St Jean 14.9 22,384 1,888,182 16.0 21,775 (97.2%)

1,766,777

4.3 609 (2.8%)

121,406

Shilo 2.3 3521 289,359 2.3 3166 (90.0%)

212,815 2.5 355 (10.0)

76,544

Wainwright 2.1 3127 271,130 2.3 3060 (97.9%)

257,012 .5 67 (2.1%)

14,118

Toronto 1.2 1795 161,531 1.2 1657 (92.3%)

135,101 1.0 138 (7.7%)

26,431

Bagotville 1.1 1621 147,160 1.0 1409 (86.9%)

100,789 1.5 212 (13.1)

46,370

Greenwood 1.4 2127 169,438 1.4 1928 (90.6%)

122,424 1.4 199 (9.4%)

47,014

Moose Jaw .7 1091 97,790 .6 843 (77.3%)

54,505 1.8 248 (22.7)

43,284

Comox .7 1070 96,488 .7 975 (91.1%)

74,437 .7 95 (8.9%)

22,051

North Bay .7 1003 69,173 .7 933 (93.0%)

59,211 .5 70 (7.0%)

9962

Longue-Pointe .6 895 64,761 .7 895 (100%)

64,761 0 0 (0%)

0

Gander .6 859 79,503 .4 498 (58.0%)

41,710 2.6 361 (43.0)

37,793

Goose Bay .1 212 15,285 .2 205 (96.7%)

14,188 .0 7 (3.3%)

1097

Preserver .1 313 18,947 .2 313 (100%)

18,947 0 0 (0%)

0

Small Sub total 26.7 40,018 3,368,747 27.7 37,649 (94.1%)

2,922,677 16.8 2361 (5.9%)

446,070

Total 100 150,003 13,544,921 100 135,898 (90.6%)

10,624,366 100 14,105 (9.4%)

2,920,556

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Table 58. Detachment workload by treatment category

DETACHMENT

Diag Pr Emerg visit Prev Pr Resto Pr

Endo Pr

Perio Pr

Oral Surgery

Misc Prostho Ortho

SPECIALTY

Valcartier 5905 734 4994 3121 235 227 1410 698 121

8.2% 13.0% 14.3% 13.6% 13.0% 10.6% 14.3% 13.6% 11%Edmonton 5157 249 3697 2991 116 254 1252 732 67

7.1% 4.4% 10.6% 13.0% 6.4% 11.9% 12.7% 14.2% 6.3%Petawawa 4803 574 2687 1900 171 104 1136 431 118

6.7% 10.2% 7.7% 8.3% 9.5% 4.9% 11.5% 8.4% 11.1%Halifax 3472 179 3449 1247 86 149 547 363 147

4.8% 3.2% 9.9% 5.4% 4.8% 7.0% 5.6% 7.1% 13.8%Esquimalt 3112 99 2326 1545 103 203 492 290 34

4.3% 1.8% 6.7% 6.7% 5.7% 9.5% 5.0% 5.6% 3.2%Ottawa 1917 172 1484 634 43 91 390 235 31

2.7% 3.0% 4.3% 2.8% 2.4% 4.3% 4.0% 4.6% 2.9%

MIDS I ZE

Borden 8225 746 2428 2383 259 351 1374 581 13611.4% 13.2% 7.0% 10.4% 14.4% 16.4% 14.0% 11.3% 12.8%

Gagetown 5494 826 3406 2238 196 102 875 378 627.6% 14.6% 9.8% 9.8% 10.9% 4.8% 8.9% 7.4% 5.8%

Kingston 5122 385 2013 865 74 57 403 230 357.1% 6.8% 5.8% 3.8% 4.1% 2.7% 4.1% 4.5% 3.3%

Trenton 1258 114 979 428 40 117 115 111 161.7% 2.0% 2.8% 1.9% 2.2% 5.5% 1.2% 2.2% 1.5%

Winnipeg 991 79 1107 452 28 47 163 138 421.4% 1.4% 3.2% 2.0% 1.6% 2.2% 1.7% 2.7% 4.0%

Cold Lake 862 101 643 198 16 75 78 65 111.2% 1.8% 1.8% .9% .9% 3.5% .8% 1.3% 1.0%

S MA LL DETACHMENT

St Jean 18,883 795 610 1734 221 52 532 288 6426.2% 14.1% 1.7% 7.6% 12.3% 2.4% 5.4% 5.6% 6.0%

Shilo 1173 101 1129 715 56 31 256 148 131.6% 1.8% 3.2% 3.1% 3.1% 1.5% 2.6% 2.9% 1.2%

Wainwright 1217 183 596 777 58 90 246 124 171.7% 3.2% 1.7% 3.4% 3.2% 4.2% 2.5% 2.4% 1.6%

Toronto 875 43 493 221 15 17 103 50 211.2% .8% 1.4% 1.0% .8% .8% 1.0% 1.0% 2.0%

Bagotville 635 63 436 245 19 51 116 63 56.9% 1.1% 1.2% 1.1% 1.1% 2.4% 1.2% 1.2% 5.3%

Moose Jaw 360 3 397 187 10 16 73 43 5.5% .1% 1.1% .8% .6% .7% .7% .8% .5%

Greenwood 824 83 772 292 16 31 93 78 211.1% 1.5% 2.2% 1.3% .9% 1.5% .9% 1.5% 2.0%

Gander 388 11 155 211 9 8 60 16 12.5% .2% .4% .9% .5% .4% .6% .3% 1.0%

Comox 480 8 237 204 12 33 64 29 11.7% .1% .7% .9% .7% 1.5% .7% .6% 1.0%

North Bay 384 28 410 128 6 6 32 24 13.5% .5% 1.2% .6% .3% .3% .3% .5% 1.2%

Goose Bay 81 6 70 35 3 5 8 6 4.1% .1% .2% .2% .2% .2% .1% .1% .4%

Longue-Pointe 390 62 324 128 9 13 16 9 6.5% 1.1% .9% .6% .5% .6% .2% .2% .5%

Preserver 165 6 73 53 1 7 5 9 0.2% .1% .2% .2% .1% .3% .1% .2% 0%

Total 72,173 5650 34,915 22,932 1802 2137 9841 5139 1063

100.0% 100.0% 100% 100.0% 100 % 100.0% 100.0% 100.0% 100%

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Table 59. Timeline for treatment delivery, by category (not including diagnostic services, other than emergency visits), in 6 month intervals following date of enrolment

Treatment Category

TIMELINE

0-6 Months

7-12 Months

13-18 Months

19 -24 Months

25-30 Months

31-36 Months

Total

Emergency Visits % of Total Sum

148810.2%

14897.7%

12175.4%

8415.6%

472 5.2%

1434.6%

56506.8%

Preventive 5538 7391 9587 6373 4282 1580 34,915

% of Total Sum 37.9% 38.4% 42.6% 42.5% 47.5% 50.4% 41.8%

Restorative 4214 4931 6016 4052 2139 788 22,932

% of Total Sum 28.8% 26.6% 26.7% 27.0% 23.7% 25.2% 27.5%

Endodontic 443 454 420 281 156 48 1802

% of Total Sum (Root Canals completed)

3.0%

(3382.3%)

2.4%

(3561.8%)

1.9%

(3231.4%)

1.9%

(2141.4%)

1.7%

(121 1.3%)

1.5%

(341.1%)

2.2%

(13861.7%)

Periodontal 341 530 559 345 253 109 2137

% of Total Sum 2.3% 2.8% 2.5% 2.3% 2.8% 3.5% 2.6%

Removable 72 81 93 84 61 26 417

% of Total Sum .5% .4% .4% .5% .7% .8% .5%

Fixed 70 59 74 48 52 12 315

% of Total Sum .5% .3% .3% .3% .6% .4% .4%

Oral Surgery 1516 2254 3001 1861 964 245 9841

% of Total Sum (Extractions)

10.4%

(12568.6%)

11.7%

(18829.8%)

13.3%

(250911.2%)

12.4%

(152610.2%)

10.7%

(790 8.8%)

7.8%

(1705.4%)

11.8%

(81339.7%)

Orthodontic 47 85 67 64 55 14 332

% of Total Sum .3% .4% .2% .4% .6% .4% .4%

Miscellaneous 887 1129 1389 1002 569 163 5139

% of Total Sum 6.1% 5.9% 6.2% 6.7% 6.3% 5.2% 6.2%

Total 14,616 19,256 22,490 14,978 9014 3132 83,480

% of Total Sum 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

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Table 60. Detachment impact of completed tooth extractions

Detachment Total Extractions DentIS (In-Service) Blue Cross (Out-Service) %

Procedure Count Cost $ %

Procedure Count

(% row) Cost $ %

Procedure Count

(% row) Cost $

S P E C I A L T Y

Valcartier 14.1 1150 268,253 14.4 689 (59.9%)

140,574 13.8 461 (40.1%)

127,679

Edmonton 13.7 1114 334,160 10.1 486 (43.6%)

105,548 18.8 628 (56.4%)

228,612

Petawawa 10.8 878 213,089 9.0 432 (49.2%)

80,511 13.4 446 (50.8%)

132,578

Halifax 5.1 417 84,282 5.4 259 (62.1%)

46,122 4.7 158 (37.9%)

38,160

Esquimalt 5.1 416 90,349 2.3 108 (26.0%)

13,347 9.2 308 (74.0%)

77,002

Ottawa 3.8 305 61,177 5.4 258 (84.6%)

49,131 1.4 47 (15.4%)

12,046

Spec Sub total 52.6 4280 1,051,310 46.6 2232 (52.1%)

435,233 61.3 2048 (47.9%)

616,077

M I D S I Z E

Borden* 14.0 1135 196,441 18.7 898 (79.1%)

137,328 7.1 237 (20.9%)

59,113

Gagetown 9.7 791 158,109 13.4 642 (81.2%)

120,883 4.5 149 (18.8%)

37,226

Kingston** 4.0 326 73,001 2.7 128 (39.3%)

21,512 5.9 198 (60.7%)

51,489

Winnipeg* 1.8 148 25,927 2.2 106 (71.6%)

16,057 1.3 42 (28.4%)

9869

Trenton*** 1.1 91 22,210 .1 6 (6.6%)

538 2.5 85 (93.4%)

21,672

Cold Lake .7 57 15,631 .4 20 (35.0%)

3284 1.1 37 (65.0%)

12,347

Mid Sub total 31.3 2548 491,319 37.5 1800 (70.7%)

299,602 22.4 748 (29.3%)

119,717

S M A L L D E T A C H M E N T

St Jean 5.5 451 84,857 7.4 353 (78.3%)

56,997 2.9 98 (21.7%)

27,860

Shilo 2.7 222 44,083 .8 38 (17.1%)

4096 5.5 184 (82.9%)

39,987

Wainwright 2.3 186 33,111 3.8 182 (97.8%)

32,337 .1 4 (2.2%)

775

Toronto 1.1 92 19,007 1.4 68 (73.9%)

12,082 .7 24 (26.1%)

6924

Bagotville 1.1 93 19,752 .5 23 (24.7%)

2967 2.1 70 (75.3%)

16,785

Moose Jaw .8 64 16,687 .2 9 (14.0%)

1119 1.6 55 (86.0%)

15,568

Greenwood .8 62 14,716 .3 15 (24.2%)

1547 1.4 47 (75.8%)

13,169

Gander .6 52 10,242 .3 14 (26.9%)

1689 1.1 38 (73.1%)

8553

Comox .5 43 7377 .5 26 (60.5%)

2649 .5 17 (39.5%)

4728

North Bay .3 25 3654 .5 25 (100%)

3654 0 0 (0%)

0

Goose Bay .1 5 861 .0 2 (40%)

243 .1 3 (60.0%)

618

Longue-Pointe .1 7 1236 .1 7 (100%)

1236 0 0 (0%)

0

Preserver .0 3 317 .1 3 (100%)

317 0 0 (0%)

0

Small Sub total

15.9 1305 255,900 15.9 765 (58.6%)

120,933 16.3 540 (41.4%)

206,966

Total 100% 8133 1,798,528 100% 4797 (59.0%)

855,768 100% 3336 (41.0%)

942,760

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Table 61. Detachment impact of completed root canals Detachment Total Root Canals DentIS (In-Service) Blue Cross (Out-Service)

% Procedure

Count Cost $ % Procedure

Count (% row)

Cost $ % Procedure

Count (% row)

Cost $

S P E C I A L T Y

Petawawa 11.4 158 93,894 7.8 79 (50.0%

22,627 20.9 79 (50.0%)

71,267

Valcartier 10.6 147 58,346 13.9 140 (95.2%)

54,079 1.9 7 (4.8%)

4267

Edmonton 7.1 99 83,777 3.2 32 (32.3%)

13,665 17.7 67 (67.7%)

70,113

Esquimalt 6.3 87 55,222 6.3 64 (73.6%)

28,459 6.1 23 (26.4%)

26,763

Halifax 4.7 65 37,654 3.1 31 (47.7%)

11,442 9.0 34 (52.3%)

26,212

Ottawa 2.3 32 20,489 1.7 17 (53.1%)

6766 4.0 15 (46.9%)

13,723

Sub total 42.4 588 349,382 36 363 (61.7%)

137,038 59.6 225 (38.3%)

212,344

M I D S I Z E

Borden* 15.4 214 93,842 17.9 180 (84.1%)

61,758 9.0 34 (15.9%)

32,084

Gagetown 10.9 151 75,001 13.1 132 (87.4%)

55,588 5.0 19 (12.6%)

19,413

Kingston** 4.8 66 35,312 4.4 44 (66.7%)

15,296 5.8 22 (33.3%)

20,016

Trenton*** 1.9 27 25,370 0.2 2 (7.4%)

495 6.6 25 (92.6%)

24,875

Winnipeg* 1.4 20 9740 1.5 15 (75.0%)

6877 1.3 5 (25.0%)

2864

Cold Lake 0.6 9 5530 0.7 7 (77.8%)

3570 0.5 2 (22.2%)

1960

Sub total 35.0 487 244,795 37.8 380 (78.0%)

143,584 28.2 107 (22.0%)

101,211

S M A L L D E T A C H M E N T

St Jean 12.4 172 55,075 15.7 158 (91.8%)

42,450 3.7 14 (8.2%)

12,624

Wainwright 3.0 42 18,534 3.9 39 (92.8%)

16,028 0.8 3 (7.2%)

2506

Shilo 2.4 33 15,474 2.7 27 (81.8%)

10,124 1.6 6 (18.2%)

5351

Toronto 1.0 14 10,331 0.9 9 (64.3%)

4503 1.3 5 (35.7%)

5828

Bagotville 0.7 10 5871 0.8 8 (80.0%)

3596 0.5 2 (20.0%)

2275

Greenwood 0.7 10 6661 0.6 6 (60.0%)

2992 1.1 4 (40.0%)

3669

Gander 0.5 7 6330 0.3 3 (42.9%)

2011 1.1 4 (57.1%)

4318

Moose Jaw 0.4 6 4328 0 0 (0%)

0 1.6 6 (100%)

4328

Comox 0.4 5 3786 0.4 4 (80.0%)

2725 0.3 1 (20.0%)

1061

North Bay 0.4 5 2587 0.4 4 (80.0%)

1054 0.3 1 (20.0%)

1533

Longue-Pointe 0.4 5 1696 0.5 5 (100%)

1696 0 0 (0%)

0

Goose Bay 0.1 1 495 0.1 1 (100%)

495 0 0 (0%)

0

Preserver 0.1 1 190 0.1 1 (100%)

190 0 0 (0%)

0

Sub total 22.6 311 131,358 26.2 265 (85.2%)

87,863 12.2 46 (14.8%) 43,495

Total 1386 725,535 1008 (72.7%)

368,485 378 (27.3%)

357050

*commanded by AGD and GD during study period ** Location for Annual CFDSS Oral Surgery Course *** commanded by GD during study period

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9 Figures

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Figure 1. 2007 and 2008 recruit population inclusion criteria

Figure 1. 14393 Members Enrolled 2007 & 2008 ‐ DHRIM  

12020 Records in DentIS Database                 

2373 Excluded –No Dental Data                     

10641 Members with Active Dental Records                     

1379  Released from CF                

5404 Enrolled in 20085237 Enrolled in 2007

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Figure 2. Recruit population residing in census tracts

Figure 2. 14393 Members Enrolled 2007 & 2008 ‐ DHRIM  

12020 Records in DentIS Database                 

2373 Excluded –No Dental Data                     

5670 Members Residing in a CTIncluded in the Study

10641 Members with Active Dental Records                     

1379  Released from CF                

2998 Did not Reside in a CT               

2854 Enrolled in 20082816 Enrolled in 2007

1973 were over the age of 30               

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10 Appendices

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Appendix 1. CFDS Dental Detachments

Dental Detachments with dental specialists Edmonton Esquimalt Halifax Ottawa Petawawa Valcartier Dental Detachments with an advanced in education general dentist Borden Cold Lake Gagetown Kingston Winnipeg Dental Detachments with general dentists Bagotville Casteau Comox Gander Geilenkirchen Goose Bay Greenwood Longue-Pointe Moose Jaw North Bay Saint Jean Shilo Toronto Trenton Wainwright SHAPE (Belgium) Geilenkirchen (Germany)

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Appendix 2. CFDS Dental Fitness Classification System

Class 1 dental fitness is a state of optimal oral health. The individual is healthy and

satisfied with his or her state of oral health. Additional treatment, other than routine

preventive care, is neither required or requested. The risk of a dental emergency within

the next 12 months is low. Based on an oral health risk assessment, the Phase I

interval is set at 12, 18 or 24 months. The individual is deployable and coded GREEN.

Class 2 dental fitness is a state of operational dental fitness. The individual has a

stable dental condition, which is unlikely to result in a dental emergency within 12

months. Treatment of a non-urgent nature, or that required to satisfy an individual’s

aesthetic concern is needed to restore optimal oral health. The Phase I interval is set at

12 months. The individual is deployable and coded GREEN.

Class 3 dental fitness is a potential dental casualty state. The individual has an

unstable dental condition that is likely to result in a dental emergency within 12 months.

Urgent treatment is needed to stabilize the individual’s condition or rehabilitative

treatment that compromises operational deployment is ongoing. The individual is not

recommended for operations (non-deployable) and is coded Yellow.

Class 4 dental fitness is an undetermined state. The individual has either not been

examined within the prescribed Phase I interval or has no dental record or an

incomplete record. The individual is not recommended for operations (non-deployable)

and is coded YELLOW.

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Appendix 3. Dental Fitness Standards

Service members are considered dentally fit (Class 1 and 2) when the following conditions are

satisfied:

Documentation:

CFDS possess a dental record, complete with a forensic examination, such as that documented on a DND 1636 Dental Examination Record.

A current panoramic radiograph of diagnostic quality, and current intraoral radiographs for dentate patients, are contained in the dental record.

Dental Caries:

There is no evidence of active (progressing) caries extending into the dentine. Active (progressing) caries is limited to the enamel and preventive care is indicated.

Note: The determination of whether interproximal caries is active (progressing) is made by

radiographic monitoring of the lesion. At least two radiographic images are necessary to

make this determination.

Pulp and Periapical Tissue:

There are no teeth with symptoms and signs of irreversible pulpal damage or necrotic pulps.

There are no teeth with incomplete endodontic treatment. There are no endodontically treated teeth with symptoms or with a periradicular

radiolucency that has increased in size six months after treatment.

Notes: Pulp capping or inadequate treatment should not necessarily negate dental fitness provided there is good evidence of clinical and radiographic stability.

Direct pulp capping is usually unacceptable for personnel subject to barometric pressure

changes (e.g. aircrew, divers)

Periodontal Diseases

There is no evidence of active periodontal diseases that are beyond control by primarily self-care. Professional care in the form of maintenance therapy may be required as a secondary measure to control the patient's condition.

There are no periodontally involved teeth with associated apical involvement, which are untreated, and when treated do not show both clinical and radiographic signs of resolution.

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Tooth Mobility:

There is no significant tooth mobility, which interferes with speech, oral function or occupational function, such as the wearing of oxygen masks or diving mouthpieces.

Occlusion and TMD:

Occlusion is stable with speech and function uncompromised. Parafunctional activity is not excessive and the potential for long term damage is

considered to be minimal. TMD or occlusal dysfunction is being managed and the patient is asymptomatic. Orthodontic condition is stable.

Note: Personnel on deployment must be in a stable orthodontic condition.

Restorations:

There are no defective permanent restorations (cracked, loose or leaking) that are causing symptoms or tissue damage or cannot be maintained by the patient.

There are no temporary restorations with interim material present. There are no posterior teeth requiring immediate protective cuspal coverage to maintain

the structural integrity of the tooth.

Dental Prostheses:

Dental prostheses are retentive and stable in function commensurate with the occupational commitment of the individual.

Dental prostheses permit adequate mastication and communication, and are aesthetically acceptable.

No temporary fixed prostheses are present. Note: In this policy document, restorations and prostheses are classified as either

permanent or temporary in nature. A permanent restoration or prostheses is considered a definitive treatment whereas a temporary restoration or prostheses is intended for short term use and may be fabricated from interim restorative materials or materials of a more permanent nature.

Aesthetics:

Natural or prosthetic teeth are present in sufficient numbers to provide a degree of orofacial aesthetics sufficient for normal life in society.

Third Molars:

There are no unerupted, partially erupted, or malposed third molars with historical, clinical, or radiographic signs or symptoms of pathosis that require extraction.

Note: The presence of third molars, in communication with the oral cavity, which are unlikely

to erupt into functional occlusion and have a history of repeated pericoronal infection, may

preclude the dentally fit classification. Where the prognosis is unclear, individual

occupational and operational commitments must be taken into consideration.

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Teeth and Roots (Nonrestorable, Unerupted, Partially Erupted, Malposed):

There are no unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that require extraction.

There are no non-restorable teeth. There are no functionless roots in communication with the oral cavity.

Note: Buried roots with no associated pathology may be left in situ and monitored.

Pain, Infection and Problems of Probable Dental Origin:

Individual is free of pain. There are no chronic oral infections or pathological lesions, including pulp or periapical

pathology. There is no history of recent unresolved problems diagnosed as of probable dental

origin.

Soft Tissue

Tissues are free from abnormality. There are no suspicious lesions that require evaluation or biopsy.

Note: Benign oral lesions may be present that require monitoring.

Radiography

Current radiographs are free from suspicious lesions that require evaluation or biopsy.

Benign radiographic lesions may be present that require monitoring

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Appendix 4. Data Set Variables

DHRIM DentIS Blue Cross CHASS 1. Service Number 2. Postal Code

1. Service Number

1. Service number 1. Postal Code

3. Date of Birth 4. Gender 5. Place of Birth 

(city, Province, country) 

6. Address at time of enrolment 

7. Enrollment date 8. First Language 

 

2. Rank 3. Treatment 

procedure codes 

4. Treatment dates 

5. Treatment cost  

2. Outsourced treatment codes 

3. Treatment cost  

2. CT Median 

Income 

3. CMA/CA 

Median 

Income 

              

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Appendix 5. CFDCP criteria for third molars, teeth and roots

Class Third Molars Teeth and Roots

(unerupted, partially erupted, malposed)

1

Unerupted, partially erupted, or malposed third molars are without historical, clinical, or radiographic signs or symptoms of pathosis, and are NOT recommended for prophylactic removal.

Unerupted, partially erupted, or malposed teeth or roots are without historical, clinical, or radiographic signs or symptoms of pathosis, and are NOT recommended for prophylactic removal.

2

Unerupted, partially erupted, or malposed third molars are without historical, clinical, or radiographic signs or symptoms of pathosis, but are recommended for prophylactic removal. NOTE: The presence of third molars, in communication with the oral cavity, which are unlikely to erupt into functional occlusion and have a history of repeated pericoronal infection, may preclude the dentally fit classification. Where the prognosis is unclear, individual occupational and operational commitments must be taken into consideration.

Unerupted, partially erupted, or malposed teeth or roots are without historical, clinical, or radiographic signs or symptoms of pathos’s, but are recommended for prophylactic removal. NOTE: Buried roots with no associated pathology may be left in situ and monitored.

3

Unerupted, partially erupted, or malposed third molars have historical, clinical, or radiographic signs or symptoms of pathosis, and require removal.

Unerupted, partially erupted, or malposed teeth or roots have historical, clinical, or radiographic signs or symptoms of pathosis, and require removal. Non-restorable teeth and functionless roots in communication with the oral cavity require extraction.

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Appendix 6. Example: Recruit dental experience while in training

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Appendix 7 The Advanced General Dentist Position Paper

Background Prior to 1969 the CF had no dental specialists in the clinical disciplines, although as early as 1957 the requirement had been established for Public Health Dentists (PHD), the first of whom graduated in 1958. Training in clinical specialties was limited to short courses, four weeks to eight months in duration, during which dental officers learned many of the skills required to enable them to perform specific specialty treatment procedures. In 1969, the CF produced its first clinical specialists. Two periodontists, one prosthodontist and one oral surgeon completed their training and were certified as specialists that year. From 1969 until the present the CFDS has produced a steady stream of dental specialist officers. The large majority of specialty training has historically been provided by the US Army Dental Corps (USADC); in recent years, due to lack of training positions at USADC installations, much of the specialty training has been undertaken at civilian institutions, both in Canada and the United States. At the DGDS/Unit Commanders Conference of 1974, the CFDS set the establishment for specialists at six periodondists, five oral surgeons, two prosthodontists, four PHDs, and thirteen advanced general dentists (AGDs). The AGDs were to be trained exclusively in the US Army General Dentistry Residency, which is currently called the Advanced Educational Program Dentistry - 2yr. The current specialist establishment differs slightly, but still calls for thirteen AGDs. Advanced General Dentistry Specialists The Advanced General Dentist is the backbone of the CFDS dental specialist classification. The specialty is one of only two with a doctrinal operational role (OMFS is the other). AGDs deployed in the Gulf War and, more recently, during Op Athena. Since the AGD has advanced training in many of the dental specialties, doctrine recommends AGD deployment with large concentrations of troops in demanding conditions, as the AGDs are deemed better able to cope with the dental and oro-facial emergencies that might arise in these areas of operation, diminishing the requirement for patient evacuation. They have also undertaken advanced training in trauma management, including the closed reduction of facial fractures. In most clinics where they are employed, the AGD coordinates and participates in effecting complex treatment plans, often involving other CFDS and civilian dental specialists. They also act as mentors to inexperienced dental officers, providing much needed and sought after guidance as these officers develop their clinical skills. Partly due to the variety of positions they can serve in, the CFDS tends to retain AGDs, and the availability of PG positions in this specialty has been a great incentive factor for dental officers to remain in the CFDS past their periods of obligatory service. AGDs have received the dental specialty allowance since the inception of DOSA/MOSA in the early 90s, and are currently compensated as dental specialist officers IAW CBI 204.217. AGD specialist officers usually act as the first point of specialty referral, as their training in the dental specialties is extensive compared to undergraduate dental school. In most

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undergraduate programs the graduating dentist has been taught to recognize and manage conditions by referral to specialists; the AGD is taught to recognize and treat most conditions to the level of competency of a specialist. In the CFDS, the AGD is also used as a mentor in the Officer Clinical Specialty Courses, enjoying the same standing as the course director, who is usually a specialist in the discipline being taught. As we have no CFDS specialists in Endodontics, an AGD is employed as course director for the Clinical Endodontcs course. Since 1973, almost without exception, the CFDS has sent two dental officers on this very demanding post-graduate specialty program every year. The decision was taken in 1974 that every Dental Detachment with more than three dentists on staff should employ an AGD in order to minimize referrals to specialists. In addition, AGD specialist positions at CFDSS and the Directorate were established. The net result was intended to reduce the need for single discipline specialists, outside referrals and patient travel, with the added benefit of better patient care and less administrative burden on units. History of the Advanced General Dentist Specialty During the late 1950s and early 1960s, the USADC expanded its investment in graduate and post-graduate training in order to keep up with the trend toward specialization. They quickly realized that although large centers were well served by specialists, the majority of army installations were staffed by a small number of dentists and lacked most, if not all, of the specialist services. It was not economical to place three or four specialist officers, providing a limited scope of dentistry, in the smaller installations, as there was not enough treatment needs to challenge their skills and keep them fully occupied with clinical care. From an analysis of this situation a new concept evolved - that of an individual trained to a level that would free him/her of a reliance on specialists, a dentist who could manage the majority of cases that are normally referred to single discipline specialists for treatment. This dentist would be trained to a semi-specialty level in each major discipline. A program was developed; the guidance given to the directors was to produce a dentist who could, at a minimum, function in these capacities: Provide the full spectrum of dental treatment in order to treat at least 90% of the specialty needs of personnel in locations where specialists are not available. Act as the head of a group practice dental service, who provides technical supervision for both professional and auxiliary personnel. Command a dental unit in a mobile or static situation. Act as a treatment coordinator in cases in which a multidisciplinary approach is required and available specialists are geographically remote from one another Instruct in professional subjects at a sub-specialty level. The programs were set up at select bases with a patient census of at least 50,000, and with at least one clinic large enough to house several specialty departments, to encourage consultation and cross training. The residents were to have access to a hospital with an accredited dental service, as the oral surgery portion of the training was to be conducted in a hospital setting. The minimal teaching staff was to include board certified (or eligible) specialists in oral surgery, fixed prosthodontics, removable prosthodontics,endodontics, periodontics, and either oral pathology or oral medicine. At bases where dependent care was authorized, it was desirable to

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have a pedodontist and orthodontist on staff. The first program was initiated in 1962; by 1969, five programs were running, producing 20 residents a year. For the most part, individuals selected for training had practiced dentistry for five or more years and had various degrees of experience in the separate disciplines. This principle is still in place today, with experienced clinicians competing for positions in this residency in order to enhance their clinical skills to the specialty level. In January 1970 the US Army Dental Corps began certifying qualified graduates of the AGD program as specialists, awarding them the same "B" prefix awarded to those clinical dental specialists who pass their American specialty board examination, and accorded them the same pay scale. They considered that the AGD residents had completed a concentrated two-year experience in which their education exceeds that required by some specialties. Scope of AGD Training and Capabilities of AGD Graduates A minimum curriculum was developed for each discipline in the program. With no attempt to be all-inclusive, and with the inclusion of some updated procedures, the following points highlight the objectives of training and the advanced capabilities of the AGD graduate, by discipline: Oral Surgery - Perform any extraction, up to the most difficult impaction, that can be done intraorally Manage any complication that might reasonable result from an extraction procedure Perform closed reductions of the tooth bearing bones, and know when an open reduction is indicated Provide emergency treatment of acute maxillo-facial injuries Establish diagnoses of lesions of the oral regions Periodontics - Establish a periodontal diagnosis, prognosis, and treatment plan. Understand the capabilities and limitations of the various treatment techniques available, and exercise judgment in choosing a conservative or surgical approach Be able to perform the basic periodontal surgical techniques Understand to role of occlusion in periodontics and be able to correct occlusal disharmonies Understand and emphasize the importance of patient education and motivation in the maintenance of periodontal health Fixed prosthodontics Know enough about occlusion to locate the hinge axis, accurately mount diagnostic casts, and correct occlusal disharmonies Understand the contraindications as well as the indications for fixed prostheses Be able to design fixed appliances that not only restore missing structures, but preserve the existing ones Be able to prepare teeth for full crowns, partial veneers, or pin-type retainers, and know the advantages and disadvantages of each Know the advantages and disadvantages of the various impression materials, and be skilled in their use Be skilled enough in laboratory procedures to instruct laboratory personnel in the various techniques

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Be able to seat, adjust and finish a completed fixed partial denture Removable prosthodontics - Develop a diagnosis and treatment plan based on oral anatomy, physiology, and biotechnical influences Thoroughly evaluate patients physically and psychologically, and anticipate problem areas Construct satisfactory complete denture for most patients with problems (including inadequate lower ridges, prognathic mandible or retrognathic maxilla, minimal intermaxillary space, tendency to gag, and so forth Design and construct all types of removable partial dentures. Thoroughly understand the use of the surveyor, and the benefits that often can be obtained by modification of remaining teeth. Design and construct surgical splints Endodontics - Be able to accurately diagnose pulpal and periapical pathologic conditions Be fully competent in the treatment of endodontic emergencies, whether they are infectious or traumatic Have a broad knowledge of sterilization techniques and the chemotherapeutic agents and bacteriology involved Be experienced in the treatment of posterior as well as anterior teeth Be capable of performing any type of surgical endodontic procedure indicated Oral medicine and pathology - Recognize congenital lesions Be able to make a differential diagnosis among the various soft tissue and bony lesions occurring in and around the oral cavity Be able to identify oral manifestations of systemic disease and make proper referrals Understand the hemorrhagic disorders, and arrange for their management when necessary Be competent in exfoliative cytology and, in conjunction with his surgical training, in biopsy techniques Discussion These skills (and knowledge levels) far exceed those of the dentist in general practice, and are the same as those expected of specialists in each of the single clinical specialty disciplines. Since this minimum curriculum was developed, changes in the way dentistry is practiced, in particular the advent of the use of implants, have resulted in corresponding changes to the curriculum. Placement and restoration of dental implants is now part of the curriculum. In addition, all residents experience a rotation in anesthesiology as part of their program. A more appropriate term might be "Comprehensive" dentist or "Advanced Comprehensive" dentist, since most treatment provided is well above the level of expertise of the undergraduate trained general dentist. Having undergone advanced education and training, to the level of single discipline dental specialists in the majority of specialty procedures, the presence of an AGD specialist reduces the need for single discipline specialists and civilian referrals in the CFDS. This greatly reduces patient time away from work and overall civilian treatment costs. The

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patient experiences a higher level of care than he/she would otherwise receive, especially in geographical areas under- serviced by single discipline specialists, and the administrative burden on units arranging patient travel is reduced. The title Advanced General Dentistry specialist perhaps does not do the discipline justice. Summary The rationale for the existence and retention of the AGD specialist group is multidimensional and sound. The Medical and Dental MOSID advisors have agreed that there is simply no medical equivalent with which to compare due to the wide breadth of multidisciplinary knowledge and specifically multidiscipline hands-on procedural activity, and, they are required to be Board certified. There is a clear and compelling business case for having the AGD specialists because of this multidisciplinary capability. Validation of the AGD specialist was done in the Treasury Board Pay review passed in 2000. It was ultimately included in the Compensation and Benefits Instruction 204.217 with the introduction of the new specialist pay field. It has effectively already met the highest level of outside scrutiny and survived. This should be considered a dead issue. The long-standing existence of this specialty is a significant retention factor for the CFDS and removal of same would create such a backlash from the dental officer corps that a mass exodus would be expected. Recovery from the subsequent dental officer manning shortage would be difficult or impossible to recover from. The AGD specialists form the backbone of the CFDS, supporting both single discipline specialists and undergraduate trained general dentists alike. The perpetuation of this specialty discipline is essential to the successful future of the CFDS.

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