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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)
ii
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.
iii
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.
iv
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
v
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
vi
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
vii
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
viii
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
ix
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
x
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
xi
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
xii
Table 60. Detachment impact of completed tooth extractions ................................................... 152
Table 61. Detachment impact of completed root canals ............................................................. 153
xiii
List of Figures
Figure 1. 2007 and 2008 recruit population inclusion criteria .................................................... 155
Figure 2. Recruit population residing in census tracts ................................................................ 156
xiv
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
xv
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
xvi
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.
xvii
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
xviii
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.
xix
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.
xx
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.
xxi
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
xxii
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.
xxiii
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.
xxiv
“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)
1
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
2
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
3
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
4
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
5
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
6
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
7
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.
8
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.
9
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
10
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
11
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
12
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
13
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).
14
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
15
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
16
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
17
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.
18
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
19
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).
20
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
21
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).
22
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.
23
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
24
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
25
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.
26
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
27
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.
28
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
29
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
30
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.
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
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
39
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,
40
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
41
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
42
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
43
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
44
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.
45
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;
46
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.
47
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.
50
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.
65
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
80
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
81
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.
82
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.
83
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8 Tables
93
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
94
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
95
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.
96
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.
97
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.
98
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
99
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.
100
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.
101
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.
102
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
103
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%)
104
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
105
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
106
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
107
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
108
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
109
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
110
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
111
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
112
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
113
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
114
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
115
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
116
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
117
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
118
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
119
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
120
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
121
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
122
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
123
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
124
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
125
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
126
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
127
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
128
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
129
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
130
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
131
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.
132
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
133
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%)
1
(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
134
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
135
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%)
136
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%)
137
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)
$1180 (1305)
841 (28.1%)
1380 (46.0%)
205 (6.8%)
202 (6.7%)
833 (27.8%)
χ2 test, T-test p-value
<.001 .003 .266 .173 .043 .017 .195 .073
138
Table 46. Census tract population descriptive statistics
Descriptive Statistics
Age
Mean (SD)
[Range]
CT IncomeMedian$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
139
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
140
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
141
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
142
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)
143
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
144
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
145
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
146
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
147
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%
148
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 %
149
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
150
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%
151
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%
152
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
153
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
170
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.
171