AN EPIDEMIOLOGICAL STUDY OF DENl'AL DISEASE AND DENTAL HEALnf BEHAVIOUROF SCHOOLCHIID REN 6 -1AND13·14 YEARSOF AGE
IN RURALNEWFOUNDLAND.CANADA
BY
CIsbera tDoshi .B.D.S.•D.D.P .H.
A thes ts submttte d tothe SChoolofGra duateStudies Inpartial fu1fUlmentof the requiremen ts
forthedegreeof Ma ster of SCIence
Facu ltyofMedicine Memortal Univer:;lly of Newfoundland
April1990
5t.John's.Newfoundland Canadr.
1+1
Nalion;l r Library01"""'"
Bibliol Mqu e naliOnale""","",
The autho rhasgrantedan Irrevocabl enon- F.lxclusivelicenceallowingtheNationalUbraty ofCanadatoreprcdece.joen,distribut eor sell copiesofhislh er thesisby any meansand in ony(000orformat,maltingthisthesis3vailable tointere stedpersons .
Theauthorretains ownershipofthe copyright InhiS/her thesis.Neit.her the thesisnor substantial extractsfromit maybeprinledOf .otherwisereproducedwithout hislher per-
mission.
l's ulwra ecccedeuna licenceirrevocableet nonexdusive penn ettanl
a
IaBibfiolM que naucneredu canadade reprod ulre,prAler, distribuerouvandredescopiesde saIMse dequelquemanime:etsousqeelqueforme Quece soitpourniettredes exemplairesde cettethese atacnsposnoncas personnes intere sse es.l'auteol"cooserveIapropnete du droitd' wteur quiprotege sathese.NisathErsande$extraits
"lUbstantielsde ceae-ci ee dulventAtra imp."itOOsauautrementre" roduits sans son auiOOsaOOn.
Cana da
ABSmACT
KEY WORDS: epidemiology.oral. behaviour,prevalence.dentalcartes.DMFIndex, ruralCana da . ethnJclty.socioeconomic factors,uUllzatlon of services, periodontaldisease
A cross-sectionalepidemiologicalstu dy was carried out U11985 to uwestjgatethe prevalence of and rtskfactorsassociatedWithdentaldiseaseinschoolchlldrenaged6• 7 and13·14 yean;llvtngInCoastalLabradorand remotepart s of theIsla nd of Newfoundland.
The parucipants were selecte dbymeansofastratlfl ed two-s tageprobabilitycluster samplingdesign.Strataconsistedorseven geographic areas.Schoolswitjuneacharea were the prunary sampllng units. With intheschoolsselected fortheeiu dy ,a sampleof school chlldrenWIthineachof tile relevantgrades wasselected.
InformaUon abouttherelevantclinical,soclodemogra phlcand behavioural data was gathered through an oralexamlnaUonofthechildren and aquestlnnaaire adminlste redeither to thechildrenor the irparents.Dataconcerning the dependent vartabje,om!health status . Included measurementof decay ed.missing and fllledtooth surfaces(DMFS).orthodonUc statusand. prevalence andseverity of periodontaldisease (Russell'sPI).
Responseto request forparucipatronInthe studywas28518 2.9%) inthe6•1year oldsand 294 (86.7%JInthe13•14 year aids. The numberand 1%1ofth e conse nte d thatwere examined.recorded and subsequentlyanalysedwas244185 .6%)Inthe youngerage group and229(77 .9%)In the olderstu dents.
The analysesofd<.'u~from 473. 6 •7and13• 14 yearoldschoo tchildre nreSiding Inremotedistricts oftheProvince ofNewfound land.Canada,resultedInthe following conclusIons:
1.Inboth 6·7 and13 · 14year agegroups.increased parental educationlevel was associatedw:I~a significant decreasetnDMFSUldex. largely due todecreas e1.1decayed andmlss:'lgsurfaces,In eonucn.m13·14 yearolds, Increased parental educaUon levelalso Indicated a slgnlflcant Increaseinleveloftreatment .
2. Compared withstudentshavinglittleor no exposure to fluoridated water, the13· 14 year old studentswithhistoriesofone or moreyearsofresidence In fluoridated ecmmunrueshad signlflcantlyle ss cartesexperienceand significantlylower levels of treatment manifestedby restorations:the6•7 year oldswithsimilartustonesof residenceIn f1uortdated communities hadslgnIDcanUyless 011:1surfaces.
3. Compared withslm1Iaraged schoolchildrenlilTIng!noth erareasoftheprovince.
remotechildr en had a greater average numberofteethdecayedandmlssingdueto caries, and a lower averagenum b er of teeth fined: remote children had agreater need for treatmentasmeasuredbythe mean numberorteetn per student needingvarious typesortreatment;andremote childrenhad a greaterproportionofstudents requtrtng vartous dental services.
4. Russcll's periodontal Index(PI)washigher Inrem otechildrenInboth 6.7 and 13·
14year agegroupsthansannaraged chlldrenrestdtng Inlessremoteparts ofthe provtnce.
5.Comparedwith6· 7 and 13 - 14 yearold NativeIndian children,settler {predominantly Caucasian)chIldre nInrem oteareasInbothage groups had~lgn1flcantly greater cartes experience and SIgn1flcantlymoremissingsurfaces.
6. No slgnlflcantdUTc:-enceIncanes expenencewas found betweenInui t and settler {predominantlyCaucasian} childrenInremoteareas In the13·14 year old agegroup.
In remote areas of the Provinceof Ne"lt1ouudland,theriskofdevelopingdental cartes(tooth decay), the most prevalent oftheehroruc oral dtseaeee, appears to below forthose chlldren bavtng a historyofexposuretofluortdated water andfor those chlldrenindicating ahigh parental educaucnlevel.The data from tills study support the noUon thatwa terfluorid a tion Is the prtnclpal choice among the alternativesavailablefor the preventionandcontrolof thismain dentaldisease.Infuture studies,the
efrecUveness and efficacyofdiet,educatjon,tooth·bru3hlng.water fluortdatlon and other preventiveprogramsIn~duc1ngthe Incidence and prevalenceofdental cartes, and 111 erasing thedifferencesIndentalcartes JUtesbetweenthedlO'erent socialeiassee . should beesarmned.
Thl!IN~oundlandand LabradOl'O:lDdren'sOralHealthStudy'WlI$patterned after UteAtlanUccanadaChlldren's Oral HealthSurveyandAstudyofDent alManpower Sy$ttm31n RclaUOntoOralHealth Status!Ontart oi than kstogreatco-operatIC/I":ryDr.
DavidW.Banting.Academk Dean. FacultyofDenUstJy, University ofWestemOntario;
Dr.A.Mu rrayHu n t,FatuityofDenUstry,Unlverslty crrcrer eo:Dr.Dorc·:dW.LewIs, Professor.Fa cultyofDenUs tIy, University ofThronto.
IamgratefultoDr.SUI Bavtngton,Dr.J,George FoWr, Associate Dean for ConununityMedh:lneandBehaviouralSciences,Memo...1Universi ty ofNewfoundl a nll, andDr. RobertJ.
wunees.
AssXlateDep utyMinisteroCHealth.Governmentof Newfoundland,Jc r lhetr consk1era.blehelpInthe suettSdullnlUaUOnofthis studyand conststent help t."uoughout.IthankDr.Jorge&'llovill..ProCC550rotSocIalMedklne, Memortal Unlvers ltyofNewfoundland.and theCo mm unityHaIth StaffoCthe DepartmentofHealth.UndertheguidanceofI}f.DavidBantJng.Drs.DennIsJackman, JimMeaserandROOcrtKavanaghtogetherWUhreccrdersundertoo k atra1nlngprogram to seree as dentalexaminerteamsJorfu ture SUrvqlland toactas reserveteams.although Wsneed did notarise.
I wtshto thank the: mon: thanfivehundredparentsandch1Jdrmwho agreedto be examinedandanswerquesuens.This wasmadepossiblewUhthesu pportofthe Department rlEducatJon,the schoolprtnclpalsand teecbers.
Thepub lichealthnu rs esInthe comm unltlesprovide1 uswithuwaluable essistanceInmaking contactwithschool offictals andpa rents.Inproviding transportatio nIIIremoteareas ar.dInarr rmglngspacefor the cllnlcexaminations and collectionofinformat ionthrou gh questionnaires. eeetoceWat tsandMaryJac~Nul, NorthWest.Rtver,helpedWithtrans lationsIntoIn u ktltukand Innulanguage.
I acknowledge gratefullythehelp givenbyDr.Jon BaskeJV1ne.Manager, SlatLab.
University of Westem Ontario.and that of consultenteat theMemoria! UntveraJtyof Newfou ndlandComputerservices andatNewfoundland andLabradorComputer Services.Ithank KarenMonck at BenchmarkPubllshlngand Design.WlIldsor.for the flnaItypesetttng ofthlsthesl3.
MyspeclalthBIlKSalso goto Dr.GaryRozIer.SChoolofDent alPublic Health.North Carolina.U.S.A..for h ls wlll1ngness to help wtthsummar1l:lngand prese n tationof resultsInthe ear lystages.IacknowledgegratefullythehelpgivenbyDr.TedColton.
BostonUnfveraily , SChoolofPublJc Health.for hISconstructiveCritiqu e.and thankDr.
DaVid Johns ton. University cr weetemOntari o,for reviewlng thefirs tdraftofthls thesis .
Finally.Iespressmy thanks to my wife,Kumud. and children,Shee rna and Shamlr,furthemoral su pport theyhaveshown medurtng thecourseofmy graduate stu dy.
SCIENI1FICPAPERS PRESENTED BASED ON 1HIS11iESJ5:
Doshi,S. :Dental cartesPrevalenceInRural SChool ChlldrenIn Newfoundland.49th AnnualMeetingAmelican'\SSOClaUon ofPubltcHealthDenUs try. Miami,Florida, October.1986
DoshI. 5,: Dental Sta tusandPreventive BehnvtoursAmongRural Sch ool Children .lith CongressInternationalAssoctaUonof DentistryforChildren,Toronto.Ontario . June,1987
PUBUCATION BASED ONnnsTIiESIS:
Doshi,S.:Dental CartesPrevalenceInRural SChool ChildrenInNewfoundland.JPub lic Health Dent19 87;~!:37Abstract .
INFORMATION PRESENTE D1'0FOlLOWINGCOMMUNflY ORGANIZATIONS:
DoshI. 5.:DentalHealthStatus andPreventive StrategiesInNewfou ndlandand Labrador.Annual MeeUng Newfoundland Branch canadian PublicWorks AssoclaUon.Gander,Newfoun dla nd.November,1987
Op Cit: Annual Meetlng Newfou n dlan d Den talAssistan tsAssoclaUon. St.John's, Newfoundland ,November,1987
Op Cit:School PrIncipals MeetingAvalonConsolidated SchoolBoard.51,John's, Newfou nd lan d. December,1987
OpCit:ElementaryTeachersExecutive Coun cil, Newfoundland Teachers Assocfatton, 51.John 's,Newfoundland,December ,1987
TABLE OF CONIENl'S
ABSTJ::.\CI' ..
ACKNOWlEDGEMENI'S .
. u
SCIENTIFIC PAPERS PRESENlED BASED ONnnsTHESiS vu
PUBUCA110NBASED ON nilS 1HESIS vU
INFORMATION PRESENTED TO FOUOWING COMMUNrn' ORGANIZATIONS vu
TABLE OF CON1ENI'S. •. .. v1U
UST OF TABLES x1v
UST OF FIGURES xvU
PREFACE xvW
CHAPTER 1
INIRODUC1l0N ..
1.1 Purpose oflhe research.
... ... .... ... ...1
.. 1
1.1.1 ObjectIVes 1
1.1 .2 Hypolhesls 2
1.2 Study destgn 3
1.2 .1 Target groups , 4
1.3 5ampUng 7
1.3.1 Exclusions 10
1.3.2 Samplesize ... ... ...10
1.3.3 5aJnpleselection 13
1.3.4 Select1onl.!schools 14
1.3 .5 5eIectlonoCstudents 14
1.4 Summary , 15
Ix
CHAPIER2
DEMOGRAPHIC.SOCIOECO NOMIC ANDDENI'ALSYSl'EMSFEAroRES.. ...••16
2.1 Introductlon 16
2.2 Demographk:andsocJoeconomic features 16
2.3 Oralhealth status 19
2.3,1 Fluortdestu dJes 19
2.4 A br:ll'fhlstoryofhealth caredevelopment...•....•...24
2.5 Provincialsystem 25
2.5.4 Dentist services ..
2.5.4.1Children 'sdental plan .
2.6. 2 Hospital services ..
2.5 .3 Phannaclstservices .
2.5.1 Physician sewtc es•• . . 25
. 25 ..26 .. . . ....26 ...26
2.5.4.2SUrglcal-d entalStI l'lces 27
2.5 .4.3sociai-eeweescare 27
2.5.4.4ThIrd-partydental plan 28
2.5 .5 DenUsts 28
2.5.6 TaJgetedpreventfveservices .. 28
2.5.7 Dentalauxlli art es 29
~.6 Costs . ...29
2.1 Oral health aWlu des 31
2.8 Sununary 31
CHAPIER'
MA1E':'~ANDME11iODS . .. 33
3.1 Oral '.lealth statu sinperspective 33
3.1.1 TheoreticalortentaUon . 33
'.2
Instrumentation 343.2.1 Oral examtnation 35
3.2.2 guCSUOnna1reS•...••...•..••••...••....•••••H•• • • • • •••••• • • • • • • •'••• • • • • •• • • • • • • • • ••• • •36 3.3 l''leklwodl.•.•H• • ••• • • • • • • • • • • • •••••• • • • • •• •• • • • • • • • • • • • • • • • • • ••• • • • • • • • •• • • • • • •• • • • • •• • • ••• • • •• ••• •38 3.3.1 Staff••••.•••.•.•..••..••••.•••••.•..•...••.•....•...•.••....•...•...••...38 3.3.2 Pretest••..•.••••••..•••...••...•...••••..•...•...••.•...•...•.••39 3.4 FleJdProcedures•••.•••••••...•••.••••.•••.•••.••..•..••••..•.•.•...••..••••••••••••••••••.•.••39
3.4.1
on
sUearnuJgClDent 393.4.2 Contactingrespondents 41
3.4.3 Pc:rsuasJon 42
3.5 netaprocess1n gandanalysis 42
3.5 .1 StaUsUca1analys is 43
3.5 .2 Estlmates of assocl aUon 44
3.5.3 Comp utaUon ofesurnates 45
3.5.3.1CompulaUOIlof overallmeansandstratum means 45
3.5.3.2Conlpu taUon of stratummears- 45
3.5.3 .3CornrulatJonofoveraUtneaIllJ ...•....•..•••..•••.•...•...•.•.46
3.5.4 ec.nputaUon of8ub popula uon means 46
3.5.5 RegressIonanaIysJs•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••49
3.5.5.1AnalystsofCOV"arian::elANCOVAJ 50
3.5.6 ~W-nxansandstandarderrol1J 50
3.5.7 PossIble8DUrces olblas••••••••.•••••.••...••••••.•••••.••••••••_.••••••.• .. ••.•.•...•••.51
3.5.7.1 sampleandtargetpopulation 51
3.5.7.2Non·respon.se 51
3.5.7 .3Exam1nerdl'ects 66
3.6 Responserate 57
3.7 Sununary 57
3.8 Expected relaucnshfp between
system feature s andsystem perromumc e 57
CHAPTER,
1lfE ORALHEAl-TIl SfAnJS OF REMOTE NEWFOUNDLAND
AND LABRADOR SAMPIE
6 TO 7 YEAR OLD CHILDREN . ...61
4.1 Oral morbidityinthetotal sample 61
4.1.1 Overall estimatesofDMFSandDMFT 53
4.1.1.1Pr1maIyteeth .
4.1.1.2Pennanent teeth..
4.1.2 Glnglvalhealth 4.1.3 Treatment needs
4.1.3.1Restorations. extrecuone and sealants..
4.1.3.2Percent ofchlldcen needingtreatment..
4.1.3.3Periodonaltreatment requirements . 4,1.3.4 Othertreatmentrequirements .
...63
. 63
. 66
... 66 ... ..66
. 66
. 68
.. 68
4.1.4 Visitto thedentist 68
4.2 Differencestnoral morbIdttyby selected characterisucs 71
4.2.1 Gender .
4.2.2 Strata ...
4.2 .3 InDuence offluortde . 4.2.4 Socioeconomic factors .
... 71 ...•.75
.. 79
. 79
4.2.5 EthnicgroupS .. 80
4.2.6 Pastdentalhealthactions ...•.81
4.2.6.1Tooth-brushing ..
1.2.6 .2Between-mealsweet snacks 4.2.6.3Floss1ng...
4.2.6.4 Fluortda tedtooth-paste.
...81 ...82
. 83
. 83
4.2.7 Dentalservices 83
4.3 RegreSSionana!ysls... ... . 84
4.4 Needfer treatment andothercneracierreuce... .. 86
4.5 Summary ofmamfindings . 88
xU
4.6 Interprovtnc1al comparison ofchildren 89
4.6 .1 Background , 89
4.6.2 Findings.. . 89
4.7 SU!lUIll:tI)' 92
CHAPIERS
mEORAL HE.'.LTIi STATUS OF REMOTE NEWFOUNDlAND
AND lABRADOR SAMPlE
131'0 14 YEAR OW STUDl".NI'S " 94
••.94 ...94
. 98
, 98
...101 5.1.4 Treatmentneeds .
5.1.4.1Restorations,extractionsand sealants 101 5.1 OralmorbidityInthetotal sample .
5.1.1 Overn11estlmatesoCDMFSandDMFT .
5.1.3 OrthodonUcassessm ent 5.1.2 Glngtvalhealth .
5.1.4.2Percentofst udents needingtreatment 101
...103 ... 103 ...103
.. 103
5.1.4.3Pertodontal treatmentrequirements ..
5.1.4.4OrthodonUc treatmentneeds 5.1.4.50thertreatmentneeds...
5.1.5 Vlslt tothe dentist.
5.2 Dlffere ncesinoral morbldltybyselectedcnerectensuce 104
5.2.1 Gender 104
5.2.2 Strata .. . 104
5.2.3 Influence ofOuortde 11 1
5.2.4 Soctoeconomlcfactcre 113
5.2.5 EthnIc:groups 113
5.2.6 Pastdent al health actlons .. ...114
5.2.6.1 'rooth-brushlng 114
5.2.6.2 Between -meal swee t snacks 116
5.2,6 .3Flossing , , .
xW ... ... ...116
5.2.6,4 Fluortdated tooth-paste , 116
5.2.7 Dental servsces... ...117
5.3 Regress1onanalysls... ... ... ... .., 118 5.4 NeedCortreatmentandothe r charactenstJcs . 118 5.5 SummaryoCntaln~s.... . . .... ... . 121 5.6 Interprovincialand intercountrycomparisonofstudents 122
5.6,1 Background .
5.6.2 Findings ..
5.7 Summary .
CIlAl'IER6 CONCLUSION
CHAPIER 7
RECOMMENDATIONS .
...122
. , 122
• 126
... ...12 7
.. 129
REFERENCES...
APPENDIX A APPENDIXB
. 130
... 138 ... ...139
UST OFTABLES
TABLEI:Structural charactensucs orthestudy strata ldistI1cts) 5 TABLE2: Allocatlon of sampletostrata. Grade I•
TABLE3:Allocatlonofsampletostrata.GradeVDI ...••••••...
TABLE4:Numberof students and schoolsexcluded
.. 8
.. 9
... .11
... ..20 fromsampling framedue to size or school.GradeI
TABLE5: Nu mber orstudentsandsch oolsexcluded
from samplingframedue to size or school,Gradevm 12 TABLE6:Periodontal diseaseIndicesofchildre n and adolescents
inNewfoundland and Labrador TAB LE7:Cartesexperienceofschoolchildren
inNewfoundlandand Labrador1954~ 1985 , 21
TABLE8: Cartesexperienceofadolesce n ts
inNewfoundlandand Labrador1954-1965 ...,•••••22 TABLE9: Cartes expertenceor school children andadolescents
influcridated community . ... .23
TABLE10: Healthexpenditure1970~1983.Newfoundland.doUars per capita 30 TABLE11:Statusofrespon de ntsselected forpretest.
GooseBay,Labrador,March1985 .. 40
TABLE12:WeightsandsamplingrracuonsrcrSuperCarp.Ages6·7 .47 TABLE13:WeightsandsamplingrracuonsJorSuperCarp.Ages13·14 48 TABLE 14:ExclusIons from sampllng frame.Age s6-7 .
TABLE15: zxctosrcnsfrom sampllng frame.Ages 13·14 . TABLE16: Responseratesand exam1naUonsferGradeI ..
TABLE17: Responserates and exam1natJonsrcrGrade VIn ..
... .52
.. 53
.. 54
. 55
TABLEId:Populatlon and sampledlstrtbutlons ferstuden ts at Ages6-7 ,•••••58 TABLE 19 :Populatio nandsample dlstrtbuUonsIcrstudentsatAges1:\·14 59
TABLE20: mstrrboucnbynumber and percentofGrade1schools visitedby samplIngstratum.
RemoteNewfou ndland and LabradorStudy 1985 •...••..•.
TABLE21:Overall mean DMFS and components- lhstandard errors bytooth and surfacetype.6-7year age group . TABLE22:Overall meanOMITand components withstandarderrors
. 62
...64
...64
...72
... .... 67
bytooth type,6-7yea r age group TABLE23: AddtUOnal oral health characteristicsfor 6·7 year agegroup Inremote Newfoundland and Labrador(19851.. ... ... ...65
TABLE24:Mean numberandstandard devreuons( )ofteet h needing treatmentper studenttnvarious categoriesfor 6-7year age group InremoteNewfoundland and Labrador(1985).• TABLE25: Subpopulatlonmeansand et-mdarderrors of DMFS. OMIT and PIbyselectedvariables.Ages 6 and 7•. TABLE 26:MeanDMFS and componentswith standarderrors bystratum. tooth. andsurface typefor 6-7yearagegroup... ...•76
TABLE27:Mean DMFT and components with standarderrors bystratum and tooth type for 6-7year age group .. TABLE 28:Regressionccemciente and p-values () for theeffectsofcertainfactors on DMFS and Its components. Ages6and 7 (n=182) ...•...•78
...85
TABLE29:Adjus tedmean DMFS and componentsfor strata.Ages 6 and 7 ••..•...87
TABLE30: Meannumberofdecayed.missingandruled teeth [prim aryplus permanent
teeuu.
Child sample 6 to 7 years 90 TABLE31:Mean periodontal index (Russ ell'sPJ), Child sample6to7 years 91 TABLE32:Distribution bynum ber and percent ofGrade VIII schools viSitedbysampling stratum, RemoteNewfoundland and Labrador Study 1985.. . 95 TABLE33:Overall mean DMFS and componentswithstandarderro rsbytoolbandsurfacetype.13·14yearagegrou p 96
TABLE34:Overallmean DMFr andcom pone ntswithstandarderro rs
bytooth type.13-14year agegroup 96
TABLE 35:Additto naloralhealthcnaractensucsfor13-14yearagegroup Inremote Newfoundlandand Labrador (19851 .•. ..99 TABLE36: Mean numberandstan dard deviations ()ofteeth needingtreatme n t
perstudentinvancuscategcnes ror13-14year agegroup
InremoteNewfou ndla nd and Labrado r11985} , 102 TABLE 37:SubpopulaUonmeansandstandardC".TOr8of
DMFS.OMITandPIbyselectedvariables.Ages13and14 10 5 TABLE38 :Mean DMFSan dcompo nentsWIthstandarderrors
bystratu m.toothandsurfacetypefor13-14yearagegrou p TABLE39:MeanOMFI'andcompone ntswithstan da rderrors
bystratumand tooth typefor1::>·14year agegrou p . ...10 8
. 110
TABLE40:AdjustedmeanOMFSand compone nts for strata,Ages13 and 14.. . ...112 TABLE41: Regression coefficients and p-values11for thedfecls ofcertain
factor son DMFSandits compone nt s . Ages13and14 yearsIn"'17 4}...115 TABLE 42: Mean numberofdecayed .missingandffiledteeth ,
Stu de nt sample13to14 years 123
TABLE43: Meanpenodnn t al md ex(Russell 'sPII. Studentsample13 to14years 124
usr
OF FIGURESFICURE 1:DlstItbuUonofOMFsurfaa:samong S·1year age group InNewfoundlandand Labrador..•••...
FIGliRE2:Dlstrlbutlon ofOMF teethamong 6-1year agegroup InNewfoundland and Labrador•.•.•.
FIGURE 3:DlstrtbuUon orOMF surfaces among13· 14 y e al"age group
InNew fou ndlan d and Labrador .
FIGURE 4:Dlstrlbu Uon orDMFteethamong13-14year age group InNewfoundlan d and Labrador .
...69
...10
... .119
...120
PREFACE
ThIs is theFinalReportCorGrant84-97fromtheHoo pltal For Sick ChUdrtn FoundaUon, Toronto,Canada.Theresearch was entitledMNewfoundJandandLabrador ChUdrt n'sOralHealthStudy.w
The roots for this studygo back to September1978to theconveningof a meeting inWlnnl.peg,Mani toba concerningCanadian Provinces Dental Surveys.Thismeeting was arranged bythe CommunityDentlslJy DepartmentsoCthetrnwersureeofTomnto, McGillandWestern Ontario .andbyHealth and Welfare Canada.Atthattimefour prcvmces•Manitoba,Ontario,Alberta and Quebec·had completedorwere about to embark on children's dentalhealthstudiesall of which. with the exceptionofManitoba, were patternedafter theoriginalWorldHealthOrganizationInternationalccneboratwe StudiesofDental Manpower In RelaUon toOralHealth Status.Followingthe completionofthesefol.<£ provtne:la1 studies Dr.DavidBantingwas ableto InterestDr.
HuntIn plann ing foranEastern Canada DentalSurvey.Theirefforts resultedIn1982In a dentalsurveyoCthe fourprovlncesof AtlanticCanada combined, thatIs.New Brun5W:Ick, NovaSCotia,PrinceEdwardIsland and Newfoundland. Althoughthe AtlanticcanadaChUdren'sOralHealthSurveyIncluded Newfoundland.Correasonsof design,bud get and tImJng,Labrador andremoteareas ofNewfou ndlan dwereexcluded.
Theprtmarypu rposeoCthe prese ntstudywasto surveytheseexcludedareas of LabradorandUteremoteparts
or
Newfound landInordertoprovide a morecomplete provlnclaldataset.Preparations for theAtlantlcCanada Children'sOrnlHealthSurvey,resultedInthe Ont3110andQuebec studyep idemlologists ,Dr.AMurrayHuntandDr.Johnstammto standardize ate amofdentalexaminers.includingtheauthor,durtngathree-day trnJn1ngcourse In Halifax.Nova ScoUa.
One other eventthat ledto thedevelopmentof a successfu lgrant application was
theholdin&ofa Dental HealthCare EvatuaUonSemInarinFebruary,1984 atthe Facultyof.Denttstry.UnlversltyofToronto.TheSeminarprovtdedan opportunityfor consultationwithexperts such as nrs.DennIsLeverett,D1lV1dBanting,DonLewIS, Brtan Burt. John Stamm, and Geoffrey Nonnan.Thegrantwas approvedInOctober, 1984 and the projectwas undertaken fromJanu:uyI. 1985 toDecember,19 8 6.
AddlUonal Cundlng support from theNewfoundland Departmentof Health hasbeen approved and thisw1Upermitcombiningthe data from this remoteareastudywith the Newfoundland portion oCthe data from theAtlanUc canada Study for a preparauonofa report on the Oral Health Statusor ChildrenInNewfoundlandand Labrador11982 to 1005) as a whole.
CHAPreR1 lNlRODUCTION
1.1 Purposeof theresearch
Thisreport presentsresult s froma stu dy of oralhealth care consumersIntwo target agegroups· 6to 7 year ctdeand 13 to 14 year oldsl'CsldlnginCoastal Labrador
andpo""..late Areasofthe IslandofNewfoundlandintheProvinceofNewfoundlandand
Lab r a d or, Canada.The study attemptedtodetectthe enect thatse le cted oral health carepractices and uUllzaUOnofdentalcareservice shas on theoralhealth statusof the dl1ldren.In order to ach ievesu c hresult s , theresearch designand analysisstrategy wereadaptedfrom theexperienceofthe AtlanUc CanadaChildren'sOralHealth Survey (Banting.Hun tand Baskerville.1984and 19851and lhe study of DentalManpower SystemsInRelaUonto Oral Healthstatus(Ontario){Hunt,Lewisand Banting, 19781.It was envisage dthat once such data were collectedandanalysed,the tnIonnaUonwould beused toImprovetheoral health pracucee and de1Jveryofthe type of oralhealth services that can resultInbetter oral health levelsinthe ch ildren.
1.1.1 Objectives
The generalgoalofthe st u d y canbe definedas:to prondedescnpweand analytical data concerningtheoral healthdiseaseandoralhealthbehevtcu rof cbtldren InselectedregionInNewfoundlandand Labrador.Specifically, the objectivesofthis study were:
l.To obtain lnformaUonabout the dentalhealthstatus ofthe childr enInCoastal Labrador andtileRemoteAreasoCtheIsl an doCNewfoun dland, includingunmetdental needs,dentaltreatmentlevelsand personaloralhealth behavlour and snacking behaviour.
2.To providea baselineCor monitortngthe effectofdlrectinterventionsto prevent dentaldiseasesandeffectofdiv e rse systcmsofdeliveryofdentalservicesInLabrador
andrer.llrte areas
u
Newfoundland..3.To~thcxdatawtt.btheNewfoundlan<lport1OD. dlhe datafromth(: 1tllanUc CanadaChlIJren'sOJaJHeal. hSurvqtommtnd a prdlIe oltbedentalbealth01 chlk1rc:nlntllef'r'oortnceoff;ewfoundla:nd.and lprollle old1lIerentg:roupsol~1n theflvePubl1cHe.Jth~Un1ts lnthel'rcJ¥tncc.
4.Toasslslth c provtncc lndeYclop~ cxpc:rtlse b thcHea1lh Unltswtt.b rcspcctlo admlnlstra tJonandIlalsonaspectsofOralHeal thSwveys.
5.To ge ne ratedental ll~ncSllinhealthprdesston a1sgenerally.andat Memol1al Unlvers ltyoC:'iewfound landInpartJcular.throu~theirlnYommmtinthestu dy.
1.1,2 Hypoth es is
KeyIactcrethat Influencedentalhealthpracticesare the avallabili tyand aettSStblIltyoitheprevcnUveeduca uonaj-curanse 5etvlces.and.tile socte-demcgraphie chaTacter1sticsorthe individuals whk:henoliethemorprtdlsposcthem topractisethe accepteddental hea1lh~..haYloUfSrwanandYates.1975:Otft.1984;Arn!\Ol.Bannes.
Cohen.Hunterand Ship.19851.It LSgencraIly assumed that ch1ldrcnandaduhs possessquiteac:eur.tte lnJ"onnallonabouttnemostcoounonJraccepted.dertaIhcahh practJces.thtRgular and conslstent usc ofwhlch shouldresu ltlnopUmwn01""1health (SwIneh art,19741.IIIsalsosomcumes assumedtha tthose~tourbanlUIUTl\lntt ltS 1m'Can Oral bealthstatusUtatIsdifferent fromthoselMnginremoteandrural envlromnents 1Stamm. 1984;Enwomru.198 1}.
Withthese 3S$umpUonsInmindItmaybepostu lated.Iforalhea l t hstat u s were lbcdependentvarl able.thatbydetc rTIllnlngtheamountand r-egulartty cruese practice sandpla ceofreenrenceone wouldalsoben:vealin,l!someofthetonuencee on the oralhealthstatus.Thus, an individualwhose envtrorunental ,soc1aland demographiccha rac terist ics predispose him orhertopractise accepted dentalhealth behm10urs wouldpractis e these behavioursat opUffium ICI'elreg ardless dthe avatllbUltyandaettSSibliltyofservice or thetypeofenvtronmenl.Consequenll y.thts study was used totest Uterollowlng researchhypoth esis:
1.ThereIsnod1IIerenceII'.theprevalenceofdentalcartes. pertodontal disease.and oroIac1al anomaliesbetwee n chUdrcnInLabrador and. remote areasofNewfoundland compared tothoselivingIntherestoCtileProvInceoCNewfoundlandas determJnedby theAtlanueCanad aChll~n'sOralHealth~urvey.
2.ThereIsnodtlferenceintheneed Cortreatment amongchil d ren 10 Labr&dorand remoteareasof Newfoundla ndcom pared to thoselMngIntherestofthe Provtnce.
3. InLabradorand remote areasofNewfoundl and,there Isno differenceIncartes rate andtreatment levelsamong childrenofdifferentcategoriesoCeccroecon omicstatus.
4.InLabra dorandremoteareasoCNewfou ndl and, there Is nodifferenc eInthe prevalenceof dentalcartesorpertodonta ldiseasebetweennati ve (lnnu/InultJand non- native{s ettler; ch ildren.
5.InLabradorand remoteareas ofNewfoundland,thereIsno differenceIncartesrate andtreatmentlevelsamongcnudrenof differenteth nicong lnsIlnnu,Inuit. settler).
6.The more reg u lar thedallytoothbrushing/flo ssingbehaviour,tilebettertheoral health sta tus.
7.InLabradorand remo teareas DCNewfoundland, thereIsno differenc eIncanesrate andtreatmentlevels among chUdrenhavtngdlfferen tfrequencyofsnack1r.gbeh aviours.
1.2 Studydes l£tl
Inorder to testthehypothesis.the (oDowing featureswere IdenUfledasbelng lmport antInsetecucnofthesludy populatio n :
1.Populationserved:The targetarea mayor maynot have a resIdentdenust.
2.Paymentmech anism :Thepaymen tmechanismmaybegovernmentfee-for-service or governme nt salaried.
3. Soctc- cultu ralInlluence:Byuuswasmeant areaswherepopulation was predomtnanUynauveIlnnu, Inu it orMlanac)ornon- na tive (settler).
With theexistenceof dJITerencesInthesefeaturesinmind. thestudy area was straUfledIntoseve nd1strtcts or strata:NorthernPenJns ula, NorthernLabrador, South ern Labra d or. Fogo-Burg eo.St. Anthony.NorthWesllUverand Forteau.
The survey design can be described as a two-stage clustersamplewith strauncaucn oflhe pl1maly sampling units or clustersof students(schools).
The reasonlngbeh lndthis procedurewas thatIfthe pcpulatjon to be sampledwas etraunedso thatthe unltsIneach groupweremorehomogeneous than thoseofthe populationasa whole. theaccuracy ofaneeumate Cora gwen samplesue may be bnprovedbytaklngeeparate simplerandom samplesCromeachoCthestrata(Osb orn . 1974).Table1illustrates eachoCthe seven originalstrataInthe studyareaIntermsof tbese tbree cnaractensucs.
From the strata, designat edsamplesofthe populatlon for selectedage groups were tobe drawn, Thestudydesign provided for conecucn ofdata on a cross-eecucnar'basls.
Over thecourseofapproxtmatelythreemonths,itwasplanne d to collectdatafrom 380 children attend1ng 56 schools. Due to inclementweather,Itwas not possibletoVisit three oelhe schoolsInNorthern LabradorandtwoschoolsInForteau.AGradeVm class from Mary'sHarbourAllGradeSchoollnSouthem Labradorwas later plac e dasa
·substltute"CorFerteau.
DUr1ngfieldwork, about10% ofthe study populationwasre-examinedInorderto test forexaminerreliablilty.
1.2.1 Targetgroups
The age groups selectedwere6to7year olds (GradeI) and 13to14 year olds (Grade WO. The 6 to 7 year olds were selectedinorderto provideagroupof children thatare at anage that Is generally considered to be the age of flrstcontact with the denUSt,especiallytllJu rlsdlctions where governments operate a children 'sdental plan suc has the oneinNewfoundlandand Labrador.Childrenare eligibleforcareunde r the NewfoundlnndandLabradorChUdren's Denial Planup to the age of 12 years (thatrs.
thirteen th birthday). Theeeecucn oCchUdrenaged 13 to 14 years would also provide an mdsceuc noftheeffectivenessofthe dentalplan .
Ethicalconsiderationsnecessitated all sampled children to have a signed consent fromparentor guardianInorder toperncipateinthe stUdyte ens .1980: Barmes, 198 0:
TABLE 1
structural characteristics of the study strata (dlstt1ctsl
Stratum 1)'peof Payment Soclo-cultural
service mechanism Jnfiuencc
Northern Predominantly Predmnlnantly Non-nattve(settlerl
Peninsula residentdentist government fee-for-service Somesalarted
Northern Predominantly Salaried Pn:domtnanUy
Labrador non-resident Innu,In u it or
Visitingdentist Micmac
Southern Predomlnantly Salaried Predominantly
Labrador non-resIdent non-native(settler)
visiting dentist
Fogo/Burgeo Predomtnantly Government Non-native (settler) non-resident
ree-rcr-eervice
VisItingdenUst
St. Anthony ResIdent dentist Salaried Non-native(settler) Nort h WestRIver Non-residen t Sal""'" Non-nativeIsetnen
dentist
Forteau Predominantly Salaried Non-na tive(settler)
residentdentist
Stamm, 19801.InaddJUon.allperents of6to 1year old cltlldren wouldbeasked to completeaq~Coreouecucnof s0d01ogk:a1.demognlph'C and.children's dental healthpracUceslnCaflllaUon.
S1ml1arIy,Cocthe13toByear old group.consents and soclo1ogk:aland danographJc lnConnaUOnwould becollectedthro ughquts tJonna tres toparents.The students'dentalheahh reaeuce elnf'ormatJon. however,wouldbeprovided bythe 13 to 14 yearold students themselves. This quesUOnna1re(or13 to14year old students wouldbeadmirustered IndividuallyCoUowlng the cl1ntcal exammatjcnInthe schoolll..tth theresponde nts fillingout thequest ionnairesthemse lves.
A minor devtaUonCromtheAtlanUccanada Ch lldre n'sOralHealthSt u dy wasth is couecu cn of addlUonnllnC onna Uon about the children 'sden talhealthbehaviour . Second mod lficaUonwas that,InconsrderaucnwithschoolsInpredom1nanUy native communltles,allth e parents or cturdren111thetwo tdent1f1edage groupsweretobe noWledthatthe childrenbe pennltledto parUdpateinthe study.In thisway.as many ofthe native chlkiren aspossiblewou ld be Includedinthe study.This routewas necessitated becauseoflack or documentedInforma'·..non cthnlcltyInthe Provtnoe.
The strategy employed to cet egcrteeethnic ues wasbased ontwoassessments - the language spok'!:l.~thome and.cIasslficaUonofnativeandnon·natlve cnndrenbasedon lnCormauon provided byaknowledgeable personIntheeommuruty,such as pu blic health nurse or teacher.Aswen. liaison wouldbeestabllshed with the threeknown BandCouncLls·The Naskaupl.MonlagnaJseInnuAssoeiatJon,Labnldor Inu it Association and the counc1lofthe CQnne RJvt:r Micmacs.Thequestionnaire.consent Cormsand otherConro/ leUerstoparen ts wcc jd bemade avallableInthreelangu ages - Inu kUt u k.InnuandEnglish,and an interpre terwouldbehired whererequired.
Other factorsoCInterestwere defined asfollows :
Socloeeono mle Sta tus:Highes t category attntn ed byeith er parentbase d on a modlClcaUonorthe Bllshe nSocIoeconomicInd ex(m lsh en ,1958 : Blishen and McRoberts.1976:Blish en and Carroll,19781. whereby categor:tesoforiglnalscale are combined as foUows:Iand2.3 and 4, 5 and 6,1and 8. 9 and 10,11and12.and13,
14 and 15.Categories1 and 2 representlow socioeconomicstat us (SESI and categories 13.14and15 highSES.Parents/guardians whowen:full-tunestudents.housewives.
unemp loyedorretired were notassigneda category. Based on this lnfonnaUon.
categortzaUOnwasachIeved using thetechniqueof-straunceucnaftereelecuon"
(Stamm.rnnerandLanglais.1980[a)).
FlUorideStatu s:Ach ild wascon.slderedto hav ebeen exposedto fiuorldated dr1nk1ngwater for a sufllc1entumeIfhe/ shehad I1vedina fluoridat edarea for at least twelvemonth sorlonger [Burt,Ekl u ndand Loesche.1986) .
1.3 Sampling
Thesamp le fortheNewfoundl an dandLabrador studywas select ed using a strat ifiedsamplingdesignofchlldren6 to 7and13 to14 years ofageal'ending elementaryor Juni orhighschoolsInthe remote area s of theProv1nce.In order to ensu re a representativeregtonalsample.the studydesign,as descrtbe d earlier, n-cessne ted strat1fleatlon of thestudy areaIntoseven district s or strata .
Iftheprimarypurp ose ofthtsstudy wa sto com pare outcome meas ures amongthe seven strata, thegreates t prectsicnwould be gamedIfequal number ofschool children wereselected from eachstra tum (Cochran.19771.However,the predominant Interest wasInob tatnIng estimatesfor the remotearea as a whole that can be compared with thoseof Atlantic Canada , otherCanadianand NaUonStudies .Therefore. subsample wasalloca tedproportional to thesue ofthe stratumpopula tiontoprodu ce amore precis eestimatorby mlnJrnlz1ng vari ance.Forexam ple. the number ofchildre n selected fromFogo/Burgeo strat u m was pro portlonal to that stratum 's contrib u lJonto thetotal papulat ionInthat age group.Thecalculations andresu ltingallocatio n of the Grade I sample are sh ownInTable2 and of theGrade VIn sampleInTatle3.
TABLE2
AllocationCJlsampletostrata Gradel
Stratum Number Number%or Children NumberofNumber of Actual Number
of
or
per Childrento SChools to ofSChoolsSChools ChJkhen Stratum be sampledbe Sampled Sampled Northern
Penntnsu la 29 339 50.2% 95
" !.
Northern
Labrado r 10 130 19 .3% 37
Southe rn
Labrado r
••
6.7% 13Fogo/Burgeo
•
76 Il.3% 21St.Anthony 50 7.4%
"
NorthWest
Rrver 10 1.5%
Forteau 2. 3.7%
Total 59 675 100.0*1 190 2. 29
NOIE:Pleasesee Pages7and 10foradiscussionoftheraUOnalefor sampling of schoolsandfor childrenwithinschools.
TABlE3 AIJocaUonor sampletostrata
GradeVlll
Stratum Numbe, Nt'.nbcr %
or
Ch11dren Numberol NumberoCActual Number0 '
ol per ChUdrmto SChoolsto oISCboolsSChools ChIldren Stratum beSampledbesampled Sampjed Northern
_uJ.
17 439 45.1% 86 12 12Northern
Labrador 11 129 13.2% 2'
Southern
Labrador 53 5.4% 10
I.'
Fogo/Burgeo
•
20. 21.0% 40st.Anthony 82 8.4% 16
Northwest RM"
"
1,4%Forteau 52 5.3% 10
I. '
Tolal 48 97 . 99.8%- 190 27 27
NOTE:Pleasesee Pages7and10fora dlscusslonoltheraUOnaleforsampling or schoolsand for chlJdrmwtthinschools.
•Roundlngerror
10 1.3.1 Exclualons
The numberof schools Includedinthe sampling frame was the resu ltor a decision to sample at least seven studentsfrom each schoollnthe Grade I and Grade vm samples.There were a numberofccnemereucnerelevant to thls decJslon.A first consideration related to theprecisionofthesample es tlma tes . More schools chosen wtth fewer students from each would resultIn.greater precision. A second consideraucn wa s that there were a numberofschoolsInrural areaswithsmallenro llm en ts . A requirement that all theschoolsbe Included would have resultedInconsiderable increase crtoe cost and time of travel between schools.Theresult or the exclusion of schoolswithenrollmenllessthan seven was that a verysmall number of schoolsin remotest areas werenotIncludedInthesampllng frame.Tables4 and 5 show the percentage of GradeIand Grade vm population excluded from the frame dueto consIderationofschoolsize. Overall the exclusionrate was 9% for GradeI and 3% for Grade vm students.However.wtth the clustering of schoolsInseven strata, the primary sampling stage ensured adequate representation from the dlfIerent charactertstics of the widely dispersed population and resulted Inthe geographiCal concentraUon ofDeldwork withoutafI"ecUngpreciston too adversely.The schools selectedare listed by strataInAppendixA
Bias can only occurifthestudentsInexcluded schoolspossess oral health characteristicsthatare markedly and systematically dtfferent {rom thoseo{students IncludedIntheframe,Thel1kelJhoodand magnitude or such bias Is discussedInthe studyresults.
1.3.2 Sample size
When data are to be collected on a numberofvartableslncludlng orthodontiC status,periodontal disease,decayed,mtssIng,filledteeth and surfaces.and whenthese are to be subcJass1fiedIna numberofways, then the detenninatlon of a scienUflcal1y acceptable,yet eoonomlcnllyfeasible , samp lesee uwolces compromises(Stamm et aI., 198O(al).
11 TABLE 4
Numberofstudentsandschools excluded fromsampling frame due to sJzeof school
D"""" Gradel
Number of Number of
Students SChools
Excludedl%J Excluded
Northern Prn1nsula 23 (6.7%) Northern Labrador 11 (9.7%) Southern Labrador IS (35.6%)
Fogo/Burgeo (o.em)
St.Anthony 10.0%)
North West RIver (0.0%1
Fortcau 10 (40.0%)
overan
60 (9.1%) 17D~t
TABLE • Number ofstudents andschoolseJ;;(;luded fromsamplingframedue to sfzeofschool
Cra de VnI
12
Numberof Numberof
Students SChools
Excluded(%) Excluded
Northern Peninsula (1.4%)
Northern Labrador 13 113.7%1 Southern Labrador 12 {22.6%1
Fogo/Burgee (0 .0% )
St.Anthony (O.O%I
NorthWest RIver rO.O%)
Forteau (0 '<)% )
Overall 31 13.3%)
I '
ncprimary purposed thissurveywastoobtain ancstJmat cof.themeanDecayed, MissJrtt.FilledSurface(DMFS)o;.~pel'stIdent for Labradorandnmotcatt89of Newfou ndland as a whok.IntheA1luntkCanada~n'a0nJHealthSurvey of13 to14year olds CorNewfoundlandsample.the mean Decayed,MLsstng. FIIledSurface count was11.42WithastandarddC'Viauonof 13.7.
Forthedesignotthisst u dy an estimateofthenumber oCCrndeI orGrade~ stu den tsrequiredtoesumatethemean Decayed , Miss ing,Filled Surfacecounttowlthin 1.7surfaceswith95% confideJlCCwasobtainedfromrrreeee.1962: Cochran.1977):
n . - - , - - -
A' +1
tl_S D1 N
'88
WhereA • 1,7 t.Oll 1.96
SO 13.7
N Totalnumbe r of stu den tsinGradeI lOrcoaevnnIn stu dyarea asa whole.
samp1eslze Both theagegroupawere uvu-sampled to allowCor-tncIwkmofaDthedllJd renIn GradesIandvmInschooLsInp~om1rlmtlynaUve commun1Ues,andfor absenteeism, rd'usalsand CaJIureto respond.Thu sttwasdetennt..edthatanovttaIlsamplesize01 260 Grade Istu den ts and 260 Gradevm students woukl yield adequatepredslon.
1.3.3 Sampleselection
The survey design calledCortwostagesofsampling.
The firststageO~prtmary sampling unrts {P$tr slweresch ools.Within eachchosen school Grae!:lorG:ad eVIII students were sampled aathesecond-stageunits (Mcser and Kaltan.1971).
Sincetheprotocolrequ ire d an independent assessme ntofthe oral healthofGrade 1and Grade vmstu dentswtthequalemphasis,twoIndepend entsarr.plesofPSU's were:
taken.Thls wasnecessi tatedbythe fact that many schools did not havebothGradeI andGra de VIII classes.
14 1.3.4 serecuceofschools
With the exceptions mentionedbelow. the schoolsInthe Grade I sample were selectedwithprobabtltues proportional to the number ofCrade Istudents per school withIneach stratum. Thus, schoolswtth greater Grade I enrollmentsbada greater chance o(betng selected. SChoolsInthe Grade vm sample were selected slm1larly.with probabWty proportion:!!to the number of Gradevm studentsineach school.Thts was accomplished by employing the method proposedbyLahlrt 11951).The sampUng frame foreachstratum was prepared from uete of schools(rom each SChoolBoard,with enrollmentby gradefor the1984-85school year.SChools were chosenIneach stratum innurubers tndicated1nTable 2 and Table3.
However,Inthe stratumId en Ufled as St.Antllony.therewas only ODCGradeI schocl-thusthis school was purposefully selected.In the stratum Identifiedas Northern Labrador,the schoolswithsamplesieeless than seven were excluded but all the remalnlng scnootstnthis group were purposefully selected since all thenaUve chUdren were known to be cnrolledIn all the schools UstedInthls stratum (Bavlngton.
19831.
nus resultedIntheeeiecucnof29 schoolsfor the GradeIsample and an IndependentselectJonof27 schools forthe Grade VIII sample.
1.3.5 SelecUonof students
A sJrnple random sample of studentswas selected from theenrollmentI1sts obtained from the chosenschools. However,due to ethnic considerations and the fact thatInsome schools with small class size random sampling would resultInleaving out from the class perhapsoneor two students.itwas decided.forthes e schools,basedon local suuanon. toInc lu deallof the studentsinthe sample.The schoolsamplejlererore varied from 5 to 25InGradeJand 7 to 26InGrade VIII.Thls resultedinan unequal selectionprobabilityfor some Grade I and Gradc VIII students WIthin a stratum.The resultingImbalancewas taken Into accountInthe analysis.
15 1.4 Summary
Thepurpo..~ofthis regtonalstudywastoexaminethe relaUonshlpbetween selected dent alhealth practicesandthe typeofenvironmen t, and the0J'D1 healthstot us ofthcch1ldren.
The central hypothesis proposedthat themoreopumally a population practised certa in dental health behaVIoursureapecuve of the avallabWty and accessibilityof servicethe more positivewould bethe effect on that populaUon'soral health.
InordertoyteldlnfonnaUon from thepersonsInvolved. 190 childrenIneachofthe twodistlnct agegroupswere rdenunedfor stu dy. The sampling designpravtcledfor the selectio n ofa popul auonto allow fordlfferencesInmethodsofdel1vety.payment mechanism and culturalmnuences.While the6to 7 year old samplewas to be cltntcallyexaminedInIts schoolswithparentseompletinga questlonna.lTedistributed through the schools.the13to14 year old sample wastobeexaminedandasked to complete a dentalhealthbeh aviourquestionnaire. and their parents to complete sociological and demographIclnfonnaUon through theschools.
The next chapt erdealswiththedemographiC.eocroecoocrruc and dentalS)'5te:tt\5 featuresInNewfoundlandand Labrador.
16 CHAPTER 2
DEMOGRAPHIC,SOCIOECONOMIC ANDDENTAL SYSTEMS FEAnJRES
2.1 Introdu cUon
TIuschapterprovidesan overviewoCthedemographic.sccrceconomrcand dental system featu resof theProvinceof Newfoundland,
2.2 Demogra ph icandsocioecon omic featu res
Politically.Cana da Ismadeupoftenprovinces and theYukon and Northw est 'rerrrtcnes.TheProvinceofNewfoundlandisthemosteas terlyand geogra phicallythe seventhlargestprovince of Canada.cons ist ingof the islan d ofNewfoun dland and Labrador.whichIspart of the Provincethatlteson themaJn1andof Cana da. The ProVInceoCNewfou n dland stretchesmore than 1,500kmfromSt.Joh n's .Inthesou th . totheUpof Labrad or near Hudson'sBay.Inthe north.Itcovers404,517 eqkm (156.185sq mil ofwhich34.032sqkmor 8.4%(13,140sq mills wa te r area.
Thetotalpopulatlonor meProvincewas recordedas567 ,681tnthe 1981 Canada Census Surveyts tcusuce Canada,1983).of whichJus tover 3,2 00 was native.The populationdensity15about 4 persona persq ml12persqkro).Thebulk of the populationIs concentrated on the Isla nd partolthe Province an dmostly alongthe coas t In severalhundr ed smallconununtUes.In1981.the populaUonwasclas siJled asbeing 59%urban and41% rural.91.5%ofthepopulation hadBrlUshorigin. 2.7% Fren ch and 0.6%NaUvePeoples. Native population IncludeoljbothInuit and lunu lNas kapl - MontagnalseJ and theMicmacsett lement atConne River.Othe r ethnic groups that makeup thepopulaUonare Aeum,italian.Chinese.German, DutchandScan d in avian.
Thepopulati onnfCoastalLabradorand RemoteAreasof Newfoundlan d.wherethe st u dy was «Indu cted.was 43,644and Included mostof theNative Peoples.
Newfoundlandhasa.ela Uvely youngpopulation with a highproportionof children andad olescents . Thelargestfive-year gro up Is15-19yearsor age.In1984, 9.011
brrthewere recorded compared to 9,581 blrth s 1n 1983.The Total Fertility Rate for Newfoundland women has declined to approach that
erceoede.
that19,below the replacement level {NewfoundlandStausttcsAgency{NSA:I,lOOn.In1985,ofthe 224,<:00 persons 15 yearsofageandover Ill.
me
labourforce.60.1%weremalesand39.9% werefemales.For males, 63.8%ofthepopulaUon15and over wereInthetabc u r Jorce, and for females42,0% ,21,3%
or
the populaUonwas unemployed-17.mbIn urban areas and 26.5%tnrural areas. The unemploymentrate has traditlonaUybeen the hlgilestrateInCanada and thal problem continues.In1985, the employed 1ahourforcewas dlstrtbuted <isfollows: 31.8%InBusiness and Personal Service,18.2%inTrad... 12.6%InFishing Industry,10.2%InPublic Administration, 8.5%InTransport and UUUUes,5.7%inConstruction and 4.3%InForestry and MtnJng {NewfoundlandStilUsUCSAgency, 198n.The per capita racemeInNewfoundlandIn1985 was $10,600. comparedto the Canadian percapita income of $15,851for tile sameyear.
SchoolsIntheprovince arecrgaruzed on thebastsofthe provlnce's religious denominaUons. Thlrty-fiveSchool Boards throughout the provinceadrruntste r the dally operations of the schools. Prov1nctallaw requires efuldren to attendschool from age6 years through16 years.IUndergartento GradeVI in elementary school and Gradevn 10 GradeXIIInJunior and High SChool. TheProv1l'lctalGovernmentpays almostall educational costs.Thetotal amount budgeted for elemen taryandsecond ary education Inthe 1986-87 fiscal year was$4:....6 mnnon or 16.ffib cr tne totalexpenditurefor the Province.The cost of educationforeach pupllin theprovincehas Increased from $460 In1971-72to about$3,273m1986-87.Part ofthls 19probably reflectedinthe number ofstudentsthat hasbeendeclining since1971-72 whenenro llmentingradesK-XI totalled162,818students.In 1986-87 therewere 139,378stud".ntsIngradesK-XII,a dropof14 .4% from 1971-72(Newfoundland DepartmentofEducaUon,19871..28%of thepopulatJon overage15,in1981.had acqutred someform of post-secondary edacaucn either at uruversttyor In community collegesandtecn mc at msututee. with 32% having GradeVIII educatJon or less (Statistics Canada,1983 1.
'8 Asfar as the charactensucs olthe Province relevanttooral health are concerned.
in198 5. 7.4%(lethe population resrdedIntnuniclpelrtiesWithOuortdated water supp~.thisIsapproxtmately11.4%or thepopulaUonontreatedwater supply and thisputs the Province at the very bottomoftheCanadlan Prcvtnces FluorldaUonUst [Clarkand Trahan. 19 83 ).The three communitiesthat are Ouortclated are Gander, GooseBay and ComerBrook. Noneofthe communities selected foruue study were fluoridated.
The Provtnce has neither a FluortdaUonActnor an active fluoridation program.
Exceptfor the capitalC1tyof51.John's. JIIsleft entirely up to theloca lmurucrpahty councll memberahtp to initiateany actionInthis regard.In St. John's, whichhas never been a fluortdatedcity. unllkeToronto.Ottawa.Halifax,Charlottetownand other cities tnCanada IHeallJl and WelfareCanada,19 781.the situation has alItUetwistto It.
According to theCityofSt. John'sAct(1970).before Iluortdatmg the citywatersupplyIt 1:9necessary for thecccncu toholda pleblsclteof theelcct c rate e. Shouldthe resu ltof suc hapleb~ltebe negeuve.a furtherpleblsclte cannot beht1dunUlthree yearslater.
Afluorida Uon plebiscitehas never been heldInSt.John's.Thls suuaucnIsfurther complicatedbythe fact that four other communities,Moun tPearl,Conception Bay South, Gouldsand Paradee, arealsoservedfrom thesame watersupp lyas St.John's.
Although thesefour conununlUes are Independent ,governedbytheir own muntefpalitjes,It wouldappear that the determlnaUonof whether theseconnnunlUes have access to this particulardentalhealth feature rest.'!with thest. John'sMunJClpai Counc UIlIldnotWiththem.
Sugar ccnsumptfen ratefor theProv1nceIsnot available,but forCanadaIn19 8 5 was 42 kg/person/yearICanadlan Sugar Institute, 1987) .Theclimateofthe Province , Influencedby the Labradorcurrent,resultsIna shortgrowingseason that does not encourage agneukure,Thus grains.grainprod uctsand mostofthe vegetablesand lrnlls have been Imported(Fodorand Rusted,19 80).Familyfoodexpend it ure (money spentonfoodllnNewfoundland and Labrad or(or 1982showsthatNewfoundlanders spent more than the natlona1 averageon sweetfoods and sugar1$6.33 vs $4.77)
19 (StatJstlcsCanada,1982).
'nue study for Coastal Labrador and Remote AreasofNewfoundlandwascompleted tn1985.
2.3 Oralhealth status
Although dataavailableon thedental bea1thstatusofthe ch11drenIn Newfoundland and Labrador are somewhat flawed, thereIssufficient evidenceofcaries experienc e and periodontal diseaseof schoolchlld..." and adolescentsinthe Province (Doshi,1980).Datafromsome of the stu dies are giventn Tables6 to9. Unfort u na te ly, findingsfromthesevarious stu d ies cannot becompared directlybeca useofthe differencesInage grouping of thesample.theexperimentaldesignand thecrttertaand sta n dard s usedbythe exammcrts l,
DatafromtheNutrition Ca na da Survey (l97G-n)lndlcat ethat theaverage1 year oldInNewfoundlandha dameanDecayed.Missing andFilled Teeth(DMFO score Iprunarypluspermanentteeth) or 5.6 and theaverage12to14year old a DMFTscore of 8.5.madeup of5.2decayed,2.6mlsslngand0.7ruledpermanentteeth(Nutrition Canada,19 7 7).
2.3 .1 F1uortdestudies
Twosurveys todocument theeffectsoffluorideindr1nk1ngwater onthedental healthofschoo lchildre n wereundertakeninthenaturally flUoridatedcommunity of St.
Lawrence(approxtmateconcentrationof 2.2parts per mtI110n(ppm)offluorideat umeof study) (Brett-WillIams.1956: Chaytor, 1966). Thecommunity watersupply hassince been changedand tnere 19only a negligibleamount {lessthan 0.4ppm ofIlucndelin the drinking watertoday (Gibbons, neweand wagenbauer,1985).Comparabledata werecollect edfrom non-fluoridated-comrc r'sitesofBurtnand51. John's .Results from St. Lawrence aresummartzed 111 Table9 and thosefrom"control"sites are shown on Tables 7 and a(Studies 1 and 2).What fanoteworthy15the percentageof population surveyed that wascart es -freeIn1954 and 19661nfluortdated compared to non-
TABlE 6 Periodontal diseasetndicesof children and adolescentsInNewfoundlandandLabrador
Study V"" Author Nell No. Ag, Percent Percent Mean
Sertal
'"
of Stu dents StudentsPerIodontalNumber Study cnudren wtthsoR with Index
Debnscn GtngMUlI per
Teeth ChJld
3. 1968-70 Lewis Nnd 298 15yean
60 .""
36.0%(913)
. .
1970 -12 NutrtUOncanada Nnd 73 12-14years 59.6%(1917)
5. 1977 DoshIand 51.Thomas 209 S·15yt ars 82.3%
Monholl (19711
6. 1982 llantmg. NOd 317 13-14years 0.38
Hunt.
Baskeovillo 119811
7. 19 64 C=feD
ureereu
630 )5yean )1.6%",port
"'-
(19 85)
B. 19 85 Dosh i Remo te 229 13-14yean
lP=<nt NOd
Rc.-ort) Labrador
!l
TABLE 7
cartesespenenceorschoolchlk1rtnInNewfoundlnnd andLabl'1ldor1954-1985
St"eIy y"" Author Am No. Age Mean Cartes-F1uor1dated
SemI
'" '"
DMFT-...
Yes /N oNumber Study cnudren percent
I. 1954 Brett·W illJams St.John's ? 7~a l"9 10.3 No
(l9 56)
2. 1966 Chaytor(1966) aurm 26 6-8yeara 9.2 4.0% No
3. 1968-70 Lew1s{l97~' NOd 331 7years S... No
' .
Hl70-72 NutrltlonCanada (1977) Nod 19 7yoars 5.6 7.8% No5. 19?? Doshtand St.Thomas 209 5·1 5~ar.I 6.8 3.3% No
Marshall(1977)
e, 1962 BantJng.Hun t, NOd 360 6-7 yelll'll 5.7
Baskerville (1984)
I_
Grenfen ~port Grecren 672 7 ,oars 6.2(198 5)
8. 1985 DosItl RemotcNDd 244 6-7 yean 7.' 9.4% No
-
Report) LabradorDMFT:: DECAYED.MlSSING, FILLEOTEE:ni PERCHIlD. INCLUDES PRJMARY' ANDPERMANENI''TEETH.
•• CARIES·FRE E",DMFTOF ZERO
~
TABLE8
Cartesespertenceof adolescentsInNewfoundland and Labrad or 1954·1985
Stu dy y~ Au!hoc
-.
No. Ag' M,~ Cartes- nuoI1datedsener
of of OM f7- 1=" Yes/NoNumOO- Study C"",,",n omen'
1. 1954 B~-WUliams St.John's ? 13"..,., 11.3 No 1l956J
2. 1966 Chaytor(l966) 8unn 38 12-14yeaTS 8.3
0.""
No3. 1968 -70 Lewts(1973) NOd 295 13"..,.,
.. ""
No4. 1970- 72 NutrtUon NOd ?3 12 -14yealS 8.' 12.15% No
Canada(1977 )
8. 19 n
"""" -
St.111omas 209 5-1 5year.J 8.8 3.3% NoMarshall(19 77)
6. 1982 Banting.Hunt. NOd 334 13-1 4 years 5.9
"'kcMll,
(1984)
7. 1984 GrenfellReport ClrenfeU 830 15 yeanl 5.8
119851
8. H~35 Doshi RemoteNOd 22. 13-1 4 years 5.6 8.7%
(PresentReport) Labrador
DMFr..DECAYED,MISSING,FlLLEDTEETHPERCHnD.INCWDES PRIMARY AND PERMANENT1EETH.
••CARIES-FREE""DYFT OF ZERO
II
TADLE9
Cariesespeneoce
or
schoolchildrenandedcieecentein fluoridatedcommunity...Study Yoar AnlbM
-.
N~ Ag. M.ansmaJ of of DMFT ·
N""""," stu dy C...n
1. 1954 B~-W1ll1ams 5t.tewreoce ? 7years 3.7
(l956)
2. 19 66 Chayt Of St. La~nce 3. 6-8yean 2.'
{l966}
1. 1954 Brett-W1Il1ams51. Lawrence ? 13yean 3.2
(l9 56)
2. 1966 Chaytor 51. Lawrence 27 12- 14years 2.2
(l966)
DMFT,.,DECAYED, MISSING,f1U.EDTEETH PER CHIlJ),INCUIDESPRIMARY AND PERMANENTTEETH.
.. CARIES·FREE=DMFT OF ZERO
SEETABLES 16 AND17 FOR·CONTROL-SITES (STUDIESSERIALNO.1 AND 2)
Can
...
ee-.
percent
31.4%
25.9%
~
25 In 1949.uponJo!nlng theConfederationNewfoundland'sdeliveryoCheahhcare scMceschangedas aresult orthe FederalHos pltaJlnsul'W1CeandDtaenostJC .5en1tes Act(1957),and. theMedicalCareJd.II967).In 1950 the DepartmentolHeahh opened adentalc1lnIctoStJohn's.One othc"event oCstgn1lkancewas theopeningoCtil e Mn1lcal SChools· MemorialUniversityinSL Joh n'sIn1969.The:flIstmedical graduates emergroIn1973.
2.5 ProvIncialsystem
The ProvincialGovenunen tofNewfoundland. aswithallotherProvinces.Is respons ible for theregulaUOnsofhealthcare and operationsofHospital and Medical·
Careprograms .In addition,the Governmenthasesta blished a Children'sDentalPlan and aProvincialDrugProgr am.
2.5.1 Physk:1anscrvtces
ThemaInmethodforddtveryoCmedlcaJcare Is thepneate practjee,fee·for-se rvice system. AlmostaD198J)% 1physldansarereglsteredwnhtheNewfoundlandMedicare Planthatadm1n1ster.>theJolnlFederal-Prov1ndalfunds (orthisprogram.
Patientsarefree:to chose a physicia noftheir ownllk1ngand thephyslc1an Isnot obllg~(0 accept a partk:ular paUent.PaymentIsmadebybtllingthe MedJ-<:are Plan dtttctly. lnwhichcaseth ephysldanIsparda pereentegeofthe Newfoundland leeguide.
1beratioofphysldantothe populatio nforNewfoundland andLabra dorwas 1:1.751In1971and 1:l,27 3ln1981.65.4%ofphyslcla.nsan::Inpriva te pract ice as geneml pratUUonersor spcclaUsls(Osborn.Pateyand Pynn.19841.
2.5.2 Hosp ita lservice s
Careinhos pitals .excluding mental hospitals. Is coveredbythe Hospital Insurance Plan (1958) and the costsaresh aredbytheProvtncJalandFede ral Governmen ts .Most hospitals are board operatedand financed through the DepartmentofHealth.
Then: are a totalof44hospitals including cottage hospitals.nursing stations.one
2.
fluorida tedareas(Study21. canes-treechildrentilthis defln1Uon were thosechildren that did nothave any decayed teeth norliad everanyfillingsplaced .orteeth extracted because ordecay.
Thenext section willreviewtheNewfoundlandand Lab ra dorhealth caredelivery systemfromhtstoncalperspective.
2.4 AbrtefhJ st ory oCheal thcare development
Newfou ndland's health caredevelopmentbegan to take sha pefromIl9 earlyas 1814when Newfoundlandwas formally recognized to be a Brrttsh Colony(perlln.1970) . Theflrstcwrc hospitalwasestnbUshedtost. John'sin18 13(Miller,1959). Fromthis ume 011therewerefour brtejperiodsofpolltte aldevelopm en tthathad an Infl uen ce on developmentofhealthcareinNewfoundland. Thefirstwas the establlshmentDC repre sen ta tive governmentin183 2until1854:from 1855to1934Newfoundland was granted responsiblegovernment.In193 4 Newfoundland'sconstit u tio nproviding responsiblegovernment wa s suspended and a Commissiongovernm en t was estabuched In 19 49 Newfoundlan denteredConfederatio nand becam e theten th province of Canada.
DUringthe periodofreprese ntativegovernment aBoardofHealth{l8321was establishedtodealwithth ematn problemoftheday .epidemi Cdiseases.Oneeventof notewas thepassing ofthePublicHealthAct(Ie'.:Itwa s durtngthe periodof responsIblegovernmentthat slgn1ficantdevelopmentsInhealth caretook place. In 1892. Dr.WllfredCreme U.a Brtttshdoctorbeganhts medic almissionary workIn Nort h ernNewfou n dla nd . His workledtotheestablish mentof the GrenfellRegional Heal th Services, apart of theInte maUOnaIGrenfellAssocraucn.Theorganizationsetup aprivat ehosp ital program In St.Anthony.Similarhospital programs wereta ter setup by Unite dChurch of Canada and suchagenciesInother part s of Newfoundla nd.
In 19 36,with est abllsh mentofthe Commiss iongovernment,five or theeventual seventeencottagehos pi tal swere opened and operatedby theGovernment.Ingeneral , this was the extentoftheheallh careprogramuntil19 49 .
26 menta)hospU.aJ. a chl1dren'sh06p lta1 1n~'t.John'sand.ch1ldnn'arehabilitation centre.
2.5.3 Pharmacistee:rvk:ea
The NewfoundlandPharmacyBoardwas estab lishedIn1910(Newfoundland DepartmeerofHealth1987). ThengulaUon andl1cc:nslngofphannac1sls b set outIn thePh armadsls Act(l 910).TheFoodand DrugActandthereareeuceandControl DrugRegulatwnscontroladv~ruslnganddispensmgof dnJgs.1MNewfoundland InterchangeableDrug ProductsFormulaJyguidesthepharmac iston thebasecostof product selecUon.
The Newfoundlan dDepartmen toCHealt hoperates three drul!progr ams: Senior CIUzensDrug SubsIdyProgram. Seeml servicesDrugPrognunandNewfoundlandand LabradorPrescrtptjon DrugProgram.
In1986-87thecostofthe Seni or("Uze nsDrugSubsidy ProgramandSoctal Sen1ceDrugPrograIrulwasesUmatedat $18.2millionlNewfo u ndland I>tpartment
or
Health.I987J.
The numberolllcensedpban:naclstsb1 1987 was407.~aphannadstto popula UOn ratlo 0(1:1,400. r.ewfo undland PtIlU'Ul'lCeutkalSociety.19871.
2.5.4 Denustservres
TheflrstDentalAd \\'3 5passedIn1893.This Actalsoled10theset.Ungup01a Dental Boardwhichcons1st ed
or
threedentists lUldfourmedicalmen . andoth e rs appointedbytheGovernm ent(Kavanag h.19521.2.t5.4.1 Childre n'sdental plan
In19 50 a curuc was ct'ltabUshcdbytheProvincialClovern men1(o rdental careoC childrentn51.Joh n's.Freetreatmentwasorreredto5 and6 yearoldchildren whowere Inregu larschoo lattendancelKavaI<3gh. 19 52:Gullett.19111.Itwasatthisumethat the dentalprogramwallfo rmalized.Newfou ndlandIsm:ognlz.edastheIlrstprovinceto
27 have a untversalchl1rlren's dentalcareprogram[HealthandWelfarecanada. 19861.
Theprogram was IntroducedIn19 50 -51 lh ro ugh an Ordcr-ln-Counc ll.
The eeeee availability and populationcoverage has continuedto expand suchthat since1978 the program providesfordental careofchlldren up to theirthirteenth blrthds.y.In1984-85 there were appromnately 140.000chtldrenunder the ageof13ln theprovince.The number
er
cnudrentreatedIn that ycarwas 78.674 and the costof the Chddrrn'sDental J'rogramwas esUmated tobe $6.46mJ.l.11on,glvinga peruse rcost of$82.07for1984-85.All baslede n tal careservices are covered,lllCludillg preventive care.'rneretea user servicecharge01'$5.00payable(or each curativedenial service.Fundingofthe programIs raised through generaltaxation.andtheme thod ofpayment to tbedenusteisree-rcr-service.
zauents are free\0chooseadentistof theirownl1king. Payment forthechildren's dental seweesismadeby billingthedenta lsectionoftheMedl-C4rePian (MCP),Afee structureIsnegotiatedbetweenthe MCPand represeatateesofthedental essoctaucn usuallyon an annualbas is (Newfounclland Department oCHealth, 19651.
2.5.ol.2 Surgll:a1-dentalservlces
Anotherplan through which residents can obtain dental serviceslstheHospital SurgicalDental Services.WhereanIndividual requires hospitalizationand dental care Is medically necessary. paymentfor this Iscoveredby theMedl·Can:Plan under surgtcej-dcntalprocedures. The expenditureforthisservceIn1981-82was$476,900 (Hcahhand Welfare Canada,1986 ).
2.5.4.3 sceer-eerveescare
LimIteddentalcare 15 availableforadu lts",hoare social service beneneartcs.
CwerageIs also extendedfor the dependent childrenofsccrar service recipients to the eighteenthbirthday.and for orphans and wardsoftheDirector orChJJdWell'are.to the twenty·fJrsl birth d ay (Health and Wetrare Canada.19 8 6).
28 2. 5 .4.4Third.partydental plan
Datafrom the canadian AssocJatJonofAccidentand Sickness Insurances, largest group among theprivatethird-partypaymentsponsors. tnd1catethatlJ1the nine years (rom1970to1979,thenumberofNewfoundlanderscoveredbythirdpartydental paymentgrewfrom 768 to 10,343(Canadlan DenialAssodatlon.19801.
2.5.5 Dentists
In1985 there were134 denusrsIn the Province.includingspeclallstsIndental publichealth (two).crtbcdcnnce (fIVe)and oralsurgery(t wo),serving apop ulationof about 570.000givingadenUs ttopopulatjc.rratioof1:4, 300.Some of thedentis tshave been encouragedto settleinto ruralareas through the provtsion ofgran t s and eubstdres.PraCUcallyall thedentistsareInprivatepractrce(NewfoundlandDental Board,19 8 51.
In the areas of study.thatis,remoteNewfourn:liand and Labrador,in1985,there
WeJ1"an equIValentofapproxJmatelynlnefull-ttmedentists servtng a populationof
43 .64<1, gtvingadentist populationraUo of1:4.849.
2.5.6 Targetedpreventrve services
TheDentalDivisionof theDepartmentofHealthwas establishedtn1952 and contlnued toaeeumster cnudren'sdentalplan andprovideprevenUve·educaUonal servicesuntil19B2.
In1982 OcvemmeursMinute-of·Co uncU1833·'821,author1zedtheDepartmentof He al thto separatetheadmtnJstnlUveaspectsofthechildren'sdentalprogramfrom the preventiveandpubllC hcalUlas pects. Thisledto the merging of thechildren'sdental planwith theMcdi·CarePlan(MCP]andto theestabl.1sh mentofa division ofcommu nlty dentistry. The community denUsUydivisionwasset upIn1982· 8 3 within the prcvuee'e publlchealthstru cture, and a directorofcommunity denUSlry was appolnttd.
29 2.5.1 Dental alOOllartea
Fou r type sof auxlllar1esan:engagedInthedeliveryof dental servicesaU~wbom.
except dentalassistants,receive theJrtraIn1ngoutsidethe prov1nce.Slnce 1985. a dentalassistanttra1n1ngprogram has been avaJIableat a privatelyoperated instncteIn St. John's. Thecertlfleddental assistants are trainedInoneyear.Itshould be noted here thatassistants mayalso receivetmlningina dentist's office.
In1985 there were 21dental hygienistsregisteredwiththe Newfoundland Dental Board.The other auxmanesare dentaltechniciansanddenturtsls. The denturtsts function under the irownact.TheDcntur1stsAct.thatwas estabusbedin19BO.
2.6 Costs
Ithas beenestimated thatInNewfoundlandIn1983 thecostper person fordenUst service was $25.60. The total bill for dentalserviceswas $14.7mUllon(Healthand Welf"-cCanada. 1987),or 2.1%of thetotal Newfoundland healthexpenditure which amountedto $683.8million.Health care represented11littleover 13.9% cf the Newfoundland GrossDome sUcProductand dental serviceswere0.3% cf theG.D.P.
INewfoundland StausucsAgency.19871Abreakdownofexpenditure per person on healthcare1nNewfoundlandIsgwenInTable 10. Per caplla expenditurefordentist's servicesrose522.9%from1970 to1983.Forevery$4.80 spenton aU physIcian services combined,$1.00wasspen t ondentist services.In1970thisratio had beencloserto 7:1.
Stncelessthan5QI)(,ofthepop ulaUonInNewfoundlandvtsitsa dentistItI anygtven year (Canada HealthSurvey.198 1).thetrue costoforal diseases andtheir treatment 19 underestimated.In addition.there Is theadded burdenoflime lostfromwork,lost schoolJ~~emotional.psychologicaland sociologicalaspectsof theImpactof oral diseases at both the Individual and socJetallevelOral erseeeee, especiallydent al can es. present a vast publichealthproblem(Federation bematre Intematlonale11''0 1).
19811.
30 TABLE10
Health expendlture 1970-1983 Newfoundland. doUan percapita
HospitalC..,
'''''1cIan
sevicee DenUst's5eM«. PrescribedDrug. ExpenditureTotal19 70 93.72 29.38 4.11 12.07 187.83
19113 565.85 122.04 25.60 84.97 1187.19
Percent Increase
1970-1983 503 .• 315.4 522.9 804.0 532.1
Source:Health and Welfare Canada (1987)
