Dental Treatment Workload and Cost of Newly Enrolled Personnel in the Canadian Forces

Dental treatment workload and cost of newly enrolled personnel in the Canadian Forces

[A study of the 2007 and 2008 recruit population]

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

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.

Dedication

To Peggy, for her unwavering patience, support and understanding, and for bringing happiness into my life.

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

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Acknowledgments

I owe a great amount of gratitude to my supervisor, the late Dr. David Locker, who left us before this thesis was completed. David left behind a wealth of insight and thought-provoking literature that guided me through my work, as it will guide scholars for years and years. Reading his papers brings a somber smile to my face. I am fortunate to have known him. I miss our luncheons at the Met.

Equally, I would like to thank Dr. Carlos Quiñonez for taking over as my supervisor in his own right. His vast knowledge in many areas and distinct approach to instruction challenged me to think about public health issues and concepts in a different light. I am grateful for his encouragement and exacting standards in writing this thesis.

I wish to thank Dr. Herenia Lawrence for serving on my thesis advisory committee and providing me with advice and statistical expertise.

I would also like to thank Dr. Jim Lai and Dr. Peter Cooney for taking time away from their busy schedules to serve as my internal and external examiners.

Lastly, I would like to acknowledge the support I received from the CFDS: Col S.A Becker LCol J.P. Picard LCol D. Lemon LCol J.J.A. Ouellet LCol (Ret’d) G. Levesque LCol (Ret’d) E. Reid Maj R.R Groves Maj T.L. Russu

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

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

5.1 Abstract ...... 66

5.2 Introduction ...... 67

5.3 Methodology ...... 68

5.3.1 Study Design ...... 68

5.3.2 Data Analysis ...... 69

5.4 Results ...... 70

5.5 Discussion ...... 73

5.6 Conclusion ...... 80

6 Conclusion ...... 82

7 References ...... 83

8 Tables ...... 92

9 Figures ...... 154

10 Appendices ...... 157

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List of Tables

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

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

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

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

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

Table 6. 1977 Nutrition Canada Dental Report – (1)Prevalence. Percentage (%) of the population requiring a dental restoration. (2) Severity. Mean number of dental restorations required by those requiring a minimum of one restoration...... 98

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

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

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

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

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

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

Table 14. Age Group Analysis – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement ...... 106

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

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Table 16. NCM and Officer – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement ...... 108

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

Table 18. NCM Male and NCM Female – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement ...... 110

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

Table 20. Officer Males and Officer Females – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement ...... 112

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

Table 22. First Language English/French – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement ...... 114

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

Table 24. Birthplace Canada and Foreign – Mean Age, Time in Services, Treatment Costs and Prevalence of Treatment Requirement ...... 116

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

Table 26. Treatment Prevalence (All Members) according to province of residence at the time of enrolment ...... 118

Table 27. Treatment Severity (All Members) according to province of residence at the time of enrolment ...... 119

Table 28. Treatment Prevalence (16 yrs – 19yrs) according to province of residence at the time of enrolment ...... 120

Table 29. Treatment Severity (16 yrs – 19yrs) according to province of residence at the time of enrolment ...... 121

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

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

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

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

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List of Figures

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

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

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List of Appendices

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

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

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

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

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

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

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

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List of Abbreviations

AGD – Advanced General Dentist BMQ – Basic Military Qualification BOQT – Basic Occupational Qualification Training CA – Census Agglomeration CBI – Compensations and Benefits Instructions CDA - Center for Data Analysis CF – Canadian Forces CFB – Canadian Forces Base CFDCP – Canadian Forces Dental Care Program CHASS - Computing in the Humanities And Social Sciences CHMS – Canadian Health Measure Survey CMA – Census Metropolitan Area CMP – Chief of Military Personnel CT – Census Tract DentIS – Dental Information System DFC – Dental Fitness Category (fitness classification used by US military services) DHRIM – Department of Human resources Information Management DMFT – Decayed, Missing, Filled teeth DPH – Dental Public Health NATO – North Atlantic Treaty Organization NATO STANAG - North Atlantic Treaty Organization Standing Agreement NCDR – Nutrition Canada Dental Report NCM – Non Commissioned Member NCNS – Nutrition Canada National Survey ODA – Ontario Dental Association PSR – Periodontal Screening and Record RCDC – Royal College of Dentists of Canada RMC – Royal Military College TSCOHS - Tri-Service Comprehensive Oral Health Survey

Executive Summary

In Canada, precise normative dental treatment needs data for young adults are not readily available. Dental public health planners and policy makers, both within and outside the military, require current knowledge of population oral health treatment needs, in order to ensure that programs are achieving intended goals and health care providers are being utilized efficiently. This study comprised a data analysis of the dental treatment that was provided to CF members enrolled in 2007 and 2008, from the date of their enrolment until 31 January 2010. The principal strength in using military data is that dental treatment in the Canadian Forces (CF) is provided in accordance with standardized criteria established in the CF Dental Care Program. As such, it represents a more reliable picture of actual treatment needs and costs.

The dental treatment needs of the newly enrolled 2007 and 2008 CF population were shown to vary in accordance with demographic composition. The study population consisted of 10,641 recruits, including 8953 (84.4%) males and 1658 (15.6%) females. There were 8547 (80.3%) Non Commissioned Members (NCM) and 2094 (19.7%) officers. The mean age of all active members was 25.1 (range 16.6 to 58.2 years). The mean total treatment cost observed per recruit was $1224 over an average time period of 26 months. Approximately 44% of new members did not require any restorations, root canals or dental extractions.

Except for dental extractions, prevalence and severity of treatment requirement (preventive, restorative, endodontic, periodontal) was found to increase with age. Treatment needs and costs were higher in NCM recruits versus officer candidates; members who reported French as their first language versus those who reported English; those who were born outside of Canada versus those who were born in Canada; and users of tobacco versus non users.

Females generally incurred higher treatment costs and received more treatment as compared to males. Even though Periodontal Screening Record scores in females were significantly less severe than males, a greater proportion of females received preventive and periodontal treatment. Thus, the increased amount of treatment provided to females may be partly explained by a propensity to be more proactive in seeking dental services.

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Considerable regional differences in treatment needs were noted. Members residing in Saskatchewan and Newfoundland and Labrador showed the highest treatment needs and costs. Members from Ontario had lower treatment requirement and incurred the lowest treatment costs.

Individual-level socioeconomic statistics were not studied; however, an analysis of area-based measures confirmed that the majority of recruits living in census tracts at the time of enrolment, resided in neighbourhoods with a median income that was 4% higher than the median income of the census metropolitan area or census agglomeration. Prevalence of treatment requirement, emergency visits and cost increased as neighbourhood income advantage decreased. It was demonstrated that census tract median income can act as a risk marker for the dental treatment needs of Canadian young adults entering the CF. Recruits originating from less urban (non census areas) showed slightly higher treatment needs compared to recruits living in census tracts. These findings suggest that, unlike the recruits enrolled in the late 1960’s and early 1970’s, who were shown to represent the lower socioeconomic scale of the Canadian population, current recruits appear to be more representative of middle class and upper middle class Canada.

Disparities in treatment requirement and inequalities in access to care between the officers and NCMs were observed. Despite the higher treatment requirement among NCMs, the wait time before they receive attention was greater than that of officers. Furthermore, the average officer received a greater number of preventive treatments and sooner access to preventive care.

Caries risk assessments were not routinely completed and the proportion of the restorative treatment that was delivered remained relatively constant throughout the 36 month observation period. This may be an indication of inefficient preventive care and a lack of provider compliance with protocol.

Dental detachments were unable to handle the dental workload at a uniform level of proficiency, resulting in excessive outsource treatment costs. Detachments on training bases, which were only staffed to provide emergency treatment on recruits, were much more adept at handling dental treatment within the detachment. Large detachments designated as specialty centres were less capable of delivering care within the detachment. The employment of clinical specialists (Compensation and Benefits Instructions (CBI) 204.217), particularly the Advanced General Dentists, was shown to be inconsistent in reducing the need for outside referrals and patient

xvii travel. These findings suggest that NCM recruits, whose comprehensive treatment is normally deferred until after training, encounter additional delays prior to receiving necessary dental care.

As of April 2010, the Canadian Forces Dental Services (CFDS) employed 651 personnel, including 103 military dentists, 36 military dental specialists and 44 civilian dentists, and were responsible for the provision of comprehensive dental treatment to 75,000 CF members. That is, approximately one dentist for every 420 patients. CFDS personnel annual salaries add up to more than $55M. From April 2007 to March 2010, the CFDS paid more than $27.4M to civilian dental practices for the provision of treatment on CF personnel, including more than $2.9M for our study population. Thirty-eight cents out of every dollar of non-diagnostic and non-preventive treatment services, performed on recruits, was outsourced to civilian dentists in private practice. If this trend continues, the CFDS may soon provide the majority of the cost of diagnostic and hygiene services while general and specialist dentists in private practice provide the greater share of the cost of the treatment workload.

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Recommendations

The protocol based delivery of dental treatment in the CF can assist the Canadian public health system with regards to population health planning and research. Treatment statistics that are routinely collected on new CF members were shown to compliment national and regional oral health surveys by imparting tangible and confirmatory evidence to their findings. With some adjustments and standardization for variables such as, age and gender, CF recruit dental treatment data can become more generalizable and may serve as a predictor of young adult dental treatment needs. Further exploration is recommended in order to fully assess the contribution that can be afforded through the use of military dental data and research in understanding and relieving the burden of illness for all Canadians. Future directions include, but are not limited to, the study of demographic and regional determinants of population dental treatment needs, dental treatment requirements and costs in the CF population over time, and the CFDS model of dental care delivery as compared to the public and private sectors.

The CFDCP is overdue for a review. One of the areas that will require revisions is the integration of population risk assessment metrics, such as caries risk, periodontal disease risk, oral cancer risk and tobacco user status into the current fitness classification system. By doing so, the program will represent a more valid assessment of the oral health status and preparedness of CF personnel, and will allow resources to be more effectively targeted. Provider adherence to these population risk protocols will facilitate the use of preventive procedures and may provide some relief to the CFDS burdened recall system by assigning an 18 month and 24 month recall to low risk patients. Dental hygiene appointments can nonetheless be prescribed in shorter time intervals as necessitated by a patient’s needs. Furthermore, quality assurance criteria must also be integrated into the CFDCP and monitored routinely, in order to ensure that structural, process and outcome components are being carried out efficiently and consistently in all 26 detachments.

Similarly, the CF Health Information System (CFHIS) and Dental Information System (DentIS) must be overhauled and aligned to function in accordance with a modernized CFDCP. The collection of population health risk measures and outsource treatment data should be included in DentIS. Additionally, dental health planners should be able to extract aggregate information captured in the CFHIS, such as forensic dental chart data and treatment plan time units, in order to assess population oral health status and treatment workload. xix

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.

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

xxi 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. xxii

Chapter 4 (Manuscript 2) is an analytical study that explores the association between census tract income data and the dental treatment requirements of the young adult military population. This manuscript will examine the validity of using neighbourhood area-based measures to determine population dental treatment requirement. Information such as this could potentially assist population oral health planning and surveillance activities.

Chapter 5 (Manuscript 3) is a descriptive study that will examine the footprint that is being created by new recruits from the time they enter the CF up until they are rendered dentally fit. Uncovering the dental detachments that are most affected by incoming recruits will enable dental resources to be predictably managed so that optimal and timely care can be provided. Additionally, this manuscript will assess the proportion and type of treatment that is being outsourced. The findings will inform human resource planning so that the CFDS can ensure an ideal mix of primary providers and auxiliary personnel to look after the needs of CF members.

It is hoped that the knowledge gained from this thesis will assist the CFDS to improve the delivery of dental services and the oral health of CF members, and provide valuable insight into the dental treatment needs of the young adult Canadian population.

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“The concept of need is at the core of health care planning. Panning health services is, in turn, rooted in the ethical imperative to use resources appropriately.”

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

xxiv 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

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

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

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.

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.

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

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

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

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).

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 socioeconomic 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

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.

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).

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

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).

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.

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

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.

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

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.

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

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.

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

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

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

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,

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

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

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.

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.

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

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,

49 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.

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.

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.

4.3 Methodology

4.3.1 Study Design

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

53 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.

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.

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.

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

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

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

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

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.

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

62 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.

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

64 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.

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

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.

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

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.

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

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

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

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

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

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

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.

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.

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

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

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

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

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

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.

6 Conclusion

The dental treatment needs of new CF members enrolled in 2007 and 2008 (N=10,641) varied analogous with their demographic composition. Needs were shown to have decreased significantly in comparison to the CFDS oral health surveys conducted in 1967 and 1973, which reported that less than 10% of new members were dentally fit and that the average recruit necessitated more than 7.5 hours of treatment to be brought to a state of optimal oral health. As opposed 1973, when 99% of the new recruits were between 17 and 24 years of age, only 63% of 2007 and 2008 recruits were under the age of 25. Despite the difference in age our study revealed that 44% of new personnel did not require a dental restoration, a root canal, or an extraction.

Individual-level socioeconomic data was not studied; however, an analysis of area-based measures confirmed that the majority of recruits living in census tracts at the time of enrolment, resided in neighbourhoods with a higher median income as compared to the median income of their census metropolitan area or census agglomeration. Recruits originating from less urban (non census) areas showed only slightly higher treatment needs. These findings suggest that, unlike the 1967 and 1973 recruits who were shown to represent the lower socioeconomic scale of the Canadian population, the 2007 and 2008 recruits appear to be more representative of middle class and upper middle class Canada.

Although recruits still had substantial urgent and routine dental treatment needs, all indicators imply that the current generation of CF personnel will have a much smaller requirement for dental treatment services, other than preventive care, than previous generations. A stronger emphasis on oral health promotion will also serve to further decrease the prevalence of periodontal treatment requirement.

On a macro level, the 2008 CFDS employment of 97 military dentists, 37 military dental specialists and 17 civilian dentist contractors appeared to be more than sufficient to look after the treatment needs of 75,000 personnel. However, this study validated that new personnel did not receive dental care equally and that the dental detachments were unable to handle the dental workload at a consistent level of proficiency, resulting in excessive outsource treatment costs. Incorporating dental treatment during BMQ training could eliminate such inequalities and make the delivery of dental services more efficient and cost-effective.

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8 Tables

Table 1 DentIS Tobacco User Status 01 June 2010.

Client Status Description Total Client Tobacco Tobacco Status user status User

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

Table 2. Carries Risk Status 01 June 2010

Client Client Status Description Count Of Caries Risk Status 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

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) .45 2.26 8.54 11.25

Male (age 20-79) .72 2.03 7.34 10.09

Adults Born in Canada .56 2.02 8.14 10.72

Adults Born Outside Canada .66 2.53 7.35 10.54

Adults - Highest Household .45 1.80 8.03 10.27 Education = degree/diploma

Adults - Highest Household 1.01 3.11 7.79 11.92 Education < degree/diploma

Health Canada. Report on the findings of the oral health component of the Canadian Health Measures Survey 2007-2009.

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

Characteristics Healthy Gingivitis Calculus Pockets Pockets 4-5mm >5mm

Female 10.2 29.9 43.1 13.3 3.5

Male 4.8 20.9 50.8 18.8 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 8.0 27.2 47.7 14.4 2.7

Adults Born Outside Canada 6.0 20.1 44.6 20.8 8.5

Adults - Highest Household 8.5 26.8 47.0 14.1 3.7 Education = degree/diploma

Adults - Highest Household 5.1 22.3 47.3 20.7 4.7 Education < degree/diploma

Health Canada. Report on the findings of the oral health component of the Canadian Health Measures Survey 2007-2009.

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 3.6 2.5 5.3 11.4 16 – 18 years

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.

CAN BC AB SK MN ON QC NB NS PE NL Male & Female 16 – 18 years Prevalence 57.9 47.7 66.9 76.1 73.3 22.5 94.3 81.0 61.8 69.7 84.0 Severity 5.1 4.0 3.6 4.1 6.2 4.6 5.4 5.7 5.2 6.7 8.3 Male 19 years Prevalence 53.8 84.3 61.2 62.7 100 31.1 67.5 69.9 100 100 100 Severity 4.5 3.0 2.0 4.2 8.9 4.1 5.5 2.0 5.4 5.4 11.0 Female 19 years Prevalence 57.7 68.6 55.9 100 46.9 43.6 95.7 31.6 100 100 97.8 Severity 4.8 2.8 2.3 2.8 6.7 3.9 6.7 2.0 6.0 6.5 6.3 Male 20 – 29 years Prevalence 60.4 75.4 79.7 67.4 77.6 29.0 68.7 65.2 84.7 83.4 74.2 Severity 4.9 5.3 4.2 4.1 6.1 3.7 5.1 5.3 4.2 4.2 7.1 Female 20 – 29 years Prevalence 61.6 63.6 55.9 79.0 62.7 37.8 92.8 77.9 59.5 36.6 88.7 Severity 4.5 3.5 4.9 4.4 4.8 3.8 4.9 4.3 5.1 6.0 4.9 Male 30 – 39 years Prevalence 66.6 46.7 55.7 69.8 64.6 59.8 90.5 86.3 50.9 51.5 70.7 Severity 3.7 3.3 3.6 3.8 5.0 2.7 4.6 3.4 3.7 4.8 2.6 Female 30 – 39 years Prevalence 57.9 44.2 56.2 67.8 46.2 38.4 90.5 64.4 69.0 47.6 75.5 Severity 3.9 3.0 5.1 4.2 4.0 3.9 3.8 3.6 3.5 4.7 4.9 Male 40 – 49 years Prevalence 58.7 61.5 50.8 77.7 39.6 40.2 79.3 60.6 31.5 56.4 74.1 Severity 3.7 3.4 4.3 3.5 4.8 2.2 4.5 3.4 3.6 3.2 2.5 Female 40 – 49 years Prevalence 44.4 53.6 57.2 62.0 24.7 27.4 67.8 65.3 46.0 56.8 65.8 Severity 3.4 2.9 3.1 3.3 4.4 3.0 4.0 3.7 4.4 3.3 2.4 Male 50 – 59 years Prevalence 57.3 43.4 93.5 87.7 33.3 41.8 78.6 72.3 33.3 23.6 68.5 Severity 3.3 2.6 3.8 3.2 4.7 2.7 3.6 3.5 2.3 2.0 2.6 Female 50 – 59 years Prevalence 47.4 59.7 21.4 52.9 64.5 37.7 62.4 66.7 33.6 78.3 49.1 Severity 2.7 2.3 2.0 2.5 2.1 2.5 3.3 2.4 3.3 2.6 3.2

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.

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 16.6 13.8 6.8 6.1 5.8 7.7 29.1 36.1 16.8 19.9 41.2 Severity 2.7 2.5 3.7 2.0 3.7 2.4 2.8 2.2 4.0 2.0 2.4 Male 19 years Prevalence 20.0 N/A N/A N/A 29.1 14.9 40.0 N/A 88.1 N/A N/A Severity 2.4 2.0 N/A N/A 8.0 2.0 2.5 N/A 2.0 N/A N/A Female 19 years Prevalence 29.9 4.0 6.2 N/A 45.3 27.4 54.5 N/A 33.5 58.9 17.4 Severity 2.3 2.0 2.0 N/A 3.1 2.0 2.3 N/A 2.0 2.0 2.0 Male 20 – 29 years Prevalence 18.5 18.6 1.6 10.9 26.6 19.3 18.5 33.2 19.7 4.5 26.5 Severity 3.3 2.1 3.1 2.0 3.7 2.6 4.4 2.3 2.8 2.0 5.3 Female 20 – 29 years Prevalence 12.2 8.7 15.0 8.9 18.3 4.4 20.2 30.3 25.1 12.5 15.9 Severity 2.5 2.2 2.0 2.0 2.7 2.2 2.8 2.2 2.3 2.0 2.4 Male 30 – 39 years Prevalence 13.5 4.2 12.6 23.2 9.6 16.8 13.5 13.8 18.9 9.4 6.9 Severity 2.3 2.2 2.0 2.9 2.1 2.1 2.5 4.8 2.0 2.0 2.0 Female 30 – 39 years Prevalence 11.6 3.4 0.6 2.4 14.4 8.0 18.4 32.5 27.8 23.7 25.3 Severity 2.5 2.1 2.0 2.0 2.0 2.0 2.4 5.0 2.5 2.0 4.4 Male 40 – 49 years Prevalence 12.4 13.1 13.9 23.8 28.8 4.0 13.1 44.4 9.5 23.4 9.6 Severity 2.6 3.1 3.0 2.8 2.2 2.1 2.8 2.4 2.0 2.0 2.8 Female 40 – 49 years Prevalence 10.4 95.3 20.8 10.1 14.7 5.3 17.4 6.7 23.9 23.4 20.5 Severity 3.1 4.2 2.5 2.5 5.0 4.5 2.4 2.0 2.8 5.7 2.0 Male 50 – 59 years Prevalence 24.3 9.2 58.6 28.8 1.9 19.8 24.5 26.5 42.5 32.4 54.7 Severity 2.5 2.1 2.0 5.8 2.0 2.1 2.1 2.9 3.2 2.9 4.1 Female 50 – 59 years Prevalence 7.6 3.8 0.9 5.6 27.4 6.8 7.3 11.5 12.4 N/A 13.4 Severity 2.1 2.1 2.0 2.0 2.0 2.1 2.0 3.7 2.0 N/A 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

Decay Missing Filled DMFT Decay Missing Filled DMFS chair time to be fit

NCM 7.2 4.5 2.9 14.6 11.0 12.6 7.1 30.6 8.9 Male (4.1) (5.5) (3.9) (5.5) (7.5) (14.2) (10.2) (14.6) (2400)

NCM 5.4 4.5 6.2 16.1 7.1 12.6 14.2 33.9 5.6 Female (3.7) (5.6) (5.6) (5.4) (5.4) (14.9) (14.5) (15.2) (160)

Officer 5.6 2.8 5.9 14.4 7.8 7.9 13.8 29.5 6.9 Male (4.1) (4.3) (5.1) (5.1) (6.8) (11.4) (12.6) (14.2) (492) 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 Decay Missing Filled DMFT Decay Missing Filled DMFS time to be fit

Male 8.2 2.7 3.3 14.2 11.6 8.5 8.9 29.0 7.5 Cornwallis (315)

Female 4.9 3.0 6.1 14.0 6.2 8.3 13.3 27.7 5.5 Cornwallis (113)

Male 8.3 7.5 1.1 16.9 14.4 20.4 2.6 37.4 7.6 St. Jean (217)

Female 6.2 7.7 2.1 16.0 10.7 21.0 5.0 36.76 6.4 St. Jean (25) 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 Active Regular Force Members Provincial Proportion Recruitment Year Of Canadian Population**

Combined Total 2007 2008 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 167 329 (3.1%) 3.6% 162 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%)

*Province/territory not specified or outside of Canada ** 2009 Statistics Canada

104

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

Procedure Category Count Percent (%) N = 10641 Diagnostic 10641 100 (Emergency Visit) (2977) (28.0) Preventive 6609 62.1

Restorative 5072 47.7 (Completed (4964) (46.6) Restorations) Endodontic 766 7.2 (Completed Root Canals) (719) (6.8) Periodontal 1077 10.1

Removable Prosthodontics 155 1.5

Fixed Prosthodontics 126 1.2

Oral Surgery 2735 25.7 (Dental Extraction) (2616) (24.6) Orthodontic 184 1.7

105

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

Independent Variable Parameter P-value estimate β

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 MEAN (SD) PREVALENCE COUNT (%) GROUP AGE MONTHS TREATMENT Emergency Preventive Restorations Root Periodontal Extractions (n) IN COST Visits Procedures Canals Procedures SERVICE $ All Age 25.1 25.9 1224 2977 6609 4964 719 1077 2617 Groups (7.1) (7.0) (1399) (28.0%) (62.1) (46.6%) (6.8%) (10.1%) (24.6%) (10641) 16 to 18.7 25.4 983 654 1639 955 116 96 682 19 (0.8) (6.9) (1081) (23.8%) (49.7) (34.7%) (4.2%) (3.5%) (24.8%) years (2753) 20 to 23.9 26.1 1239 1700 3724 2906 404 531 1625 29 (2.7) (7.0) (1387) (28.7%) (63.0) (49.1%) (6.8%) (9.0%) (27.5%) years (5915) 30 to 34.0 26.6 1425 439 1052 761 141 270 245 39 (2.8) (7.1) (1618) (31.1%) (74.6) (54.0%) (10.0%) (19.1%) (17.4%) years (1410) 40 to 45.7 25.6 1737 761 464 342 58 180 65 59 (4.0) (7.0) (1974) (54.0%) (82.4) (60.7%) (10.3%) (32.0%) (11.5%) years (563) ANOVA <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 /χ² P‐ Value

107

Table 15. Age Group Analysis – Severity of Treatment Requirement

AGE MEAN (SD) GROUP EMERGENCY PREVENTIVE RESTORED ROOT PERIODONTAL EXTRACTION VISITS PROCEDURES SURFACES CANALS PROCEDURES All Age 1.7 5.0 7.5 1.8 1.9 2.4 Groups (1.3) (3.0) (8.4) (1.1) (1.7) (1.5) 16 to 19 1.7 4.1 6.4 1.7 1.3 2.6 years (1.2) (2.1) (7.4) (0.9) (0.6) (1.3) 20 to 29 1.7 4.8 7.6 1.9 1.6 2.4 years (1.2) (2.7) (8.8) (1.1) (1.1) (1.4) 30 to 39 1.8 6.0 7.9 1.8 2.1 2.1 years (1.4) (3.6) (8.2) (1.0) (1.9) (2.2) 40 to 59 1.8 7.0 8.1 1.4 2.7 1.4 years (1.7) (4.6) (7.6) (0.7) (2.6) (0.8) ANOVA .624 <.001 <.001 .013 <.001 <.001 P-Value

108

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

Mean (SD) Prevalence Count (%) Age Months Treatment Emergency Preventive Restoration Root Periodontal Extraction In Cost ‐ $ Visit Canal Service All Members (10641) NCM 24.7 25.9 1268 2515 5236 4167 629 892 2292 (8547) (6.6) (7.0) (1401) (29.4%) (61.3) (48.8%) (7.4%) (10.4%) (26.8%) Officer 26.4 25.7 1044 462 1373 797 90 185 325 (2094) (8.7) (7.0) (1378) (22.1%) (65.6) (38.1%) (4.3%) (8.8%) (15.5%) T‐Test/χ² <.001 .056 < .001 < .001 <.001 < .001 < .001 .029 .001 P‐value 16‐19 Years (2753) NCM 18.8 25.4 1051 534 1016 780 102 89 578 (2081) (0.7) (7.0) (1152) (25.7%) (48.8%) (37.5%) (4.9%) (4.3%) (27.8%) Officer 18.8 25.3 773 120 353 175 14 7 104 (672) (0.7) (6.6) (786) (17.9%) (52.5%) (26.0%) (2.1%) (1.0%) (15.5%) T‐Test/χ² <.001 .662 < .001 <.001 .095 <.001 .002 <.001 .001 P‐value 20 – 29 Years (5915) NCM 23.8 26.1 1275 1531 3152 2576 374 462 1474 (5057) (2.7) (7.0) (1380) (30.3%) (62.3%) (50.9%) (7.4%) (9.1%) (29.1%) Officer 25.0 25.8 1028 169 572 330 30 69 151 (858) (2.6) (7.3) (1413) (19.7%) (66.7%) (38.5%) (3.5%) (8.0%) (17.6%) T‐Test/χ² <.001 .270 <.001 <.001 .015 <.001 <.001 .300 <.001 P‐value 30 – 39 Years (1410) NCM 33.8 26.6 1486 329 763 575 112 201 191 (1036) (2.8) (7.0) (1690) (31.8%) (73.6%) (55.6%) (10.8%) (19.4%) (18.5%) Officer 34.4 26.5 1256 109 289 186 29 68 53 (374) (2.8) (7.1) (1389) (29.1%) (77.3%) (49.7%) (7.8%) (18.2%) (14.2%) T‐Test/χ² .001 .749 .010 .344 .167 .053 .090 .601 .061 P‐value 40 ‐59 Years (563) NCM 45.4 26.0 1776 120 305 236 41 139 48 (373) (3.8) (7.1) (1794) (32.2%) (81.8%) (63.3%) (11.0%) (37.3%) (12.9%) Officer 46.5 24.8 1661 64 159 106 17 41 17 (8.9%) (190) (4.4) (6.7) (2290) (33.7%) (83.7%) (55.8%) (8.9%) (21.6%) T‐Test/χ² .004 .051 .513 .717 .573 .086 .450 < .001 .169 P‐value

109

Table 17. NCM and Officers – Severity of Treatment Requirement

Mean (SD) Emergency Preventive Restored Root Periodontal Extractions Visits Procedures Surfaces canals Procedures 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‐ .101 .119 < .001 .257 .156 .122 value 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‐ .734 <.001 < .001 .304 .490 .822 value 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‐ .004 .018 <.001 .866 .605 .882 value 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‐ .004 .987 .033 .065 .710 .184 value 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‐ .111 .488 .082 .011 .872 .828 value

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 Treatment Emergency Preventive Restoration Root Periodontal Extraction In Cost ‐ $ Visit Canal Service All Members (8547) Male 24.3 26.1 1258 2105 4360 3569 526 716 2049 (7320) (6.3) (6.9) (1394) (28.8%) (59.6%) (48.8%) (7.2%) (9.8%) (28.0%) Female 27.3 26.0 1326 410 876 598 103 176 243 (1227) (7.5) (7.0) (1447) (33.4%) (71.4%) (48.7%) (8.4%) (14.3%) (19.8%) T‐Test/ χ² <.001 .527 .113 .001 <.001 .990 .133 <.001 <.001 P‐value 16‐19 Years (2081) Male 18.8 25.4 1034 465 907 705 87 75 530 (1905) (0.7) (7.0) (1132) (24.4%) (47.6%) (37.0%) (4.6%) (8.0%) (27.8%) Female 18.9 25.4 1237 69 (39.2%) 109 75 15 14 48 (176) (0.7) (6.5) (1334) (61.9%) (42.6%) (8.5%) (3.9%) (27.3%) T‐Test/ χ² .325 .940 .025 <.001 <.001 .142 .020 .012 .876 P‐value 20 – 29 Years (5057) Male 23.6 26.1 1282 1308 2658 2247 323 381 1322 (4357) (2.6) (7.0) (1398) (30.0%) (61.0%) (51.6%) (7.4%) (8.7%) (30.3%) Female 24.4 26.1 1231 223 494 329 51 81 152 (700) (2.8) (7.0) (1264) (31.9%) (70.6%) (47.0%) (7.3%) (11.6%) (21.7%) T‐Test/ χ² <.001 .950 .327 .326 <.001 .025 .905 .016 < .001 P‐value 30 – 39 Years (1036) Male 33.7 26.7 1541 248 571 443 89 157 159 (783) 92.8) (7.0) (1731) (31.7%) (72.9%) (56.6%) (11.4%) (20.1%) (20.3%) Female 34.1 26.5 1316 81 192 132 23 45 33 (253) (2.8) (7.2) (1543) (32.1%) (75.9%) (52.4%) (9.1%) (17.8%) (13.0%) T‐Test/ χ² .053 .739 .051 .889 .352 .244 .320 .429 .010 P‐value 40 ‐59 Years (373) Male 45.6 26.4 1625 84 224 174 27 103 38 (275) (3.8) (7.1) (1615) (30.5%) (81.5%) (63.3%) (9.8%) (37.5%) (13.8%) Female 44.8 25.9 2199 36 81 62 14 36 10 (98) (3.6) (7.1) (2174) (36.7%) (82.7%) (63.3%) (14.3%) (36.7%) (10.2%) T‐Test/ χ² .089 .549 .006 .260 .792 .999 .225 .899 .359 P‐value

111

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

Mean (SD) Emergency Preventive Restored Root Periodontal Extractions Visits Procedures Surfaces canals Procedures 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‐ .040 <.001 .233 .181 .762 .007 value 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‐ .021 .366 .782 .603 .771 .528 value 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‐ .177 .006 .122 .151 .769 .164 value 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‐ .852 .335 .014 .778 .512 .119 value 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‐ 1.000 .088 .033 .601 .857 .471 value

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 Treatment Emergency Preventive Restoration Root Periodontal Extraction In Cost ‐ $ Visit Canal Service All Members (2094) Male 26.0 25.7 1009 358 1049 612 75 147 270 (1663) (8.1) (6.8) (1267) (21.5%) (63.1) (36.8%) (4.5%) (8.8%) (16.2%) Female 26.5 25.6 1181 104 324 185 15 38 55 (431) (8.9) (7.0) (1182) (24.1%) (75.2) (42.9%) (3.5%) (8.8%) (12.8%) T‐Test/ χ² .314 .848 .054 .246 <.001 .020 .348 .988 .076 P‐value 16‐19 Years (672) Male 18.3 25.7 749 91 261 126 9 6 84 (526) (0.7) (6.6) (793) (17.3%) (49.6%) (24.0%) (1.7%) (1.1%) (16.0%) Female 18.2 25.1 858 29 92 49 5 1 20 (146) (0.6) (6.5) (753) (19.9%) (63.0%) (33.6%) (3.4%) (0.7%) (13.7%) T‐Test/ χ² .046 .290 .140 .474 .004 .019 .200 .631 .502 P‐value 20 – 29 Years (858) Male 24.8 25.9 987 130 441 254 27 54 125 (687) (2.60 (7.4) (1230) (18.9%) (64.2%) (37.0%) (3.9%) (7.9%) (18.2%) Female 25.3 25.5 1193 39 131 76 3 15 26 (171) (2.7) (7.0) (1982) (22.8%) (76.6%) (44.4%) (1.8%) (8.8%) (15.2%) T‐Test/ χ² .042 .503 .088 .253 .002 .206 .187 .005 <.001 P‐value 30 – 39 Years (374) Male 34.4 26.4 1206 86 213 143 25 51 48 (291) (2.9) (7.3) (1243) (29.6%) (73.2%) (49.1%) (8.6%) (17.5%) (16.5%) Female 34.5 26.6 1430 23 76 43 4 17 5 (83) (2.6) (6.8) (1809) (27.7%) (91.6%) (51.8%) (4.8%) (20.5%) (6.0%) T‐Test/ χ² .819 .842 .197 .745 <.001 .668 .257 .538 .016 P‐value 40 ‐59 Years (190) Male 46.8 22.8 1600 51 134 89 14 36 13 (159) (4.4) (6.5) (2174) (32.1%) (84.3%) (56.0%) (8.8%) (22.6%) (8.2%) Female 44.9 25.2 1972 13 25 17 3 5 4 (31) (3.9) (6.7) (2831) (41.9%) (80.6%) (54.8%) (9.7%) (16.1%) (12.9%) T‐Test/ χ² .030 .073 .410 .288 .617 .907 .876 .420 .399 P‐value

113

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

Mean (SD) Emergency Preventive Restored Root Periodontal Extractions Visits Procedures Surfaces canals Procedures 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‐ .227 .046 .981 .454 .320 .406 value 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‐ .118 .094 .879 .884 .009 .488 value 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‐ .570 .003 .354 .825 .093 .494 value 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‐ .962 .174 .373 .445 .211 .249 value 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‐ .072 .842 .586 .155 .072 .292 value

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 Treatment Emergency Preventive Restoration Root Periodontal Extraction In Cost ‐ $ Visit Canal Service All Members (10641) English 25.0 26.4 1201 2134 4866 3698 530 792 1870 (8025) (7.0) (7.0) (1388) (26.6%) (60.6) (46.1%) (6.6%) (9.9%) (23.3%) French 25.1 25.8 1295 843 1743 1266 189 285 747 (2616) (7.1) (7.0) (1433) (32.2%) (66.6) (48.4%) (7.2%) (10.9%) (28.6%) T‐Test/ χ² .540 <.001 .004 < .001 <.001 .039 .272 .131 <.001 P‐value 16‐19 Years (2753) English 18.8 25.2 974 476 981 695 87 71 476 (2041) (0.7) (6.9) (1073) (23.3%) (48.1%) (34.1%) (4.3%) (3.5%) (23.3%) French 18.5 25.7 1010 178 388 260 29 25 206 (712) (0.9) (6.8) (1103) (25%) (54.5%) (36.5%) (4.1%) (3.5%) (28.9%) T‐Test/ χ² <.001 .119 .437 .365 .003 .234 .828 .967 .003 P‐value 20 – 29 Years (5915) English 23.9 25.9 1208 1211 2777 2201 298 380 1176 (4522) (2.7) (7.0) (1357) (26.8%) (61.4%) (48.7%) (6.6%) (8.4%) (26.0%) French 24.1 26.5 1340 489 947 705 106 151 449 (1393) (2.7) (7.0) (1477) (35.1%) (68.0%) (50.6%) (7.6%) (10.8%) (32.2%) T‐Test/ χ² .034 .010 .003 <.001 <.001 .206 .187 .005 <.001 P‐value 30 – 39 Years (1410) English 34.0 26.4 1402 304 750 543 99 204 169 (1022) (2.8) (7.1) (1641) (29.8%) (73.4%) (53.2%) (9.7%) (20.0%) (16.6%) French 33.9 26.9 1487 134 302 218 42 65 75 (388) (2.8) (6.9) (1528) (34.5%) (77.8%) (56.2%) (10.8%) (16.8%) (19.3%) T‐Test/ χ² .395 .274 .377 .085 .086 .312 .528 .168 .218 P‐value 40 ‐59 Years (563) English 45.9 25.1 1713 142 358 259 46 136 48 (440) (4.1) (7.1) (1985) (32.3%) (81.4%) (58.9%) (10.5%) (30.9%) (10.9%) French 45.1 27.1 1823 42 106 83 12 44 17 (123) (3.8) (7.1) (1940) (34.1%) (86.2%) (67.5%) (9.8%) (35.8%) (13.8%) T‐Test/ χ² .064 .005 .586 .695 .215 .084 .822 .307 .372 P‐value

115

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

Mean (SD) Emergency Preventive Restored Root Periodontal Extractions Visits Procedures Surfaces canals Procedures 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‐ .152 .002 .002 .013 .637 .037 value 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‐ .114 .555 .512 .626 .775 .352 value 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‐ .143 .001 .010 .035 .682 .076 value 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‐ .368 .113 .017 .446 .320 .559 value 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‐ .901 .400 .880 .368 .884 .828 value

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 Treatment Emergency Preventive Restoration Root Periodontal Extraction In Cost ‐ $ Visit Canal Service All Members (10641) Canada 24.8 26.0 1211 2767 6167 4644 660 958 2767 (9960) (6.9) (7.0) (1372) (27.8%) (61.9) (46.6%) (6.6%) (9.6%) (27.8%) Foreign 28.5 25.1 1406 210 442 320 59 119 210 (681) (9.2) (7.0) (1743) (30.8%) (64.9) (46.9%) (8.7%) (17.5%) (30.8%) T‐Test/ χ² <.001 .001 .003 .086 .120 .854 .040 <.001 .086 P‐value 16‐19 Years (2753) Canada 18.7 25.4 983 624 1302 920 112 89 642 (2624) (0.8) (6.9) (1086) (23.8%) (49.6%) (35.1%) (4.3%) (3.4%) (24.5%) Foreign 18.6 25.2 986 30 67 (51.9%) 35 4 7 40 (31%) (129) (0.7) (7.0) (963) (23.3%) (27.1%) (3.1%) (5.4%) T‐Test/ χ² .366 .812 .972 .891 .607 .065 .519 .219 .093 P‐value 20 – 29 Years (5915) Canada 23.9 26.1 1229 1604 3524 2749 374 491 1536 (5597) (2.7) (7.0) (1356) (28.7%) (63.0%) (49.1%) (6.7%) (8.8%) (27.4%) Foreign 24.4 24.6 1424 96 200 157 30 40 89 (318) (2.7) (6.9) (1854) (30.2%) (62.9%) (49.4%) (9.4%) (12.6%) (28.0%) T‐Test/ χ² .001 <.001 .065 .557 .980 .929 .058 .021 .833 P‐value 30 – 39 Years (1410) Canada 33.9 26.7 1415 390 957 695 125 237 217 (1274) (2.8) (7.0) (1584) (30.6%) (75.1%) (54.6%) (9.8%) (18.6%) (17.0%) Foreign 35.0 25.3 1527 48 95 66 16 32 27 (136) (2.9) (7.4) (1914) (35.6%) (69.9%) (48.9%) (11.9%) (23.7%) (20.0%) T‐Test/ χ² <.001 .028 .440 .238 .180 .209 .453 .152 .386 P‐value 40 ‐59 Years (563) Canada 45.8 25.5 1738 149 384 280 49 141 53 (465) (4.1) (7.0) (2003) (32%) (82.6%) (60.2%) (10.5%) (30.3%) (11.4%) Foreign 45.6 26.2 1731 35 80 (81.6%) 62 9 39 12 (98) (3.7) (7.0) (1837) (35.7%) (63.3%) (9.2%) (39.8%) (12.2%) T‐Test/ χ² .663 .357 .974 .481 .823 .574 .689 .068 .812 P‐value

117

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

Mean (SD) Emergency Preventive Restored Root Periodontal Extractions Visits Procedures Surfaces canals Procedures 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‐ .640 .019 < .001 .319 .012 .172 value 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‐ .402 .534 .296 .349 .235 .109 value 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‐ .496 .158 .158 .094 .134 .761 value 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‐ .161 .302 .129 .835 .763 .523 value 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‐ .927 .428 .612 .538 .846 .263 value

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 Months Total Emergency Preventive Restorations Root Periodontal Extractions Mean in cost Visits Procedures Canals Procedures Service $ BC 25.1 26.3 1250 186 530 388 54 118 191 (878) (7.6) (6.8) (1573) (21.2%) (60.4%) (44.2%) (6.2%) (13.4%) (21.8%) AB 24.4 26.3 1208 148 442 334 38 82 137 (693) (6.2) (7.2) (1315) (21.4%) (63.8%) (48.2%) (5.5%) (11.8%) (19.8%) SK 24.7 26.4 1330 42 123 108 17 21 48 (181) (6.7) (7.0) (1316) (23.2%) (68.0%) (59.7%) (9.4%) (11.6%) (26.5%) MB (329) 25.6 26.4 1238 88 232 167 16 40 97 (7.1) (6.9) (1230) (26.7%) (70.5%) (50.8%) (4.9%) (12.2%) (29.5%) ON (3759) 24.8 25.8 1148 1035 2156 1609 227 318 861 (6.9) (6.9) (1351) (27.5%) (57.4%) (42.8%) (6.0%) (8.5%) (22.9%) QC (2484) 24.6 26.5 1283 804 1600 1191 185 256 739 (6.7) (6.9) (1416) (32.4%) (64.4%) (47.9%) (7.4%) (10.3%) (29.8%) NB 25.2 26.5 1263 231 419 349 58 48 177 (663) (6.7) (7.2) (1390) (34.8%) (63.2%) (52.6%) (8.7%) (7.2%) (26.7%) NS (957) 26.1 26.2 1205 251 611 465 69 110 194 (7.7) (6.9) (1376) (26.2%) (63.8%) (48.6%) (7.2%) (11.5%) (20.3%) PE 24.4 25.8 1196 22 48 33 5 6 23 (83) (7.6) (7.3) (1192) (26.5%) (57.8%) (39.8%) (6.0%) (7.2%) (27.7%) NL 23.8 26.2 1392 62 144 115 22 21 67 (233) (6.7) (6.7) (1860) (26.6%) (61.8%) (49.4%) (9.4%) (9.0%) (28.8%) Missing 29.5 19.4 1379 108 304 115 28 57 83 (381) (9.6) (4.9) (1443) (28.3%) (79.8%) (49.3%) (7.3%) (15%) (21.8%) TOTAL 25.1 25.9 1224 2977 6609 4964 719 1077 2617 (7.1) (7.0) (1400) (28.0%) (62.1%) (46.6%) (6.8%) (10.1%) (24.6%) ANOVA/χ² <.001 <.001 .004 <.001 <.001 <.001 .046 <.001 <.001 P‐value

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 Preventive Restorations Root Periodontal Extractions Visits Procedures Canals Procedures 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 .078 <.001 .012 .272 .117 .141 p‐value

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 Months Total Emergency Preventive Restorations Root Periodontal Extractions Mean in cost Visits Procedures Canals Procedures Service $ BC 18.7 25.7 1005 46 107 81 7 12 58 (240) (0.7) (7.0) (1184) (19.2%) (44.6%) (33.8%) (2.9%) (5.0%) (24.2%) AB 18.8 25.7 1133 37 96 67 10 10 47 (191) (0.6) (7.3) (1270) (19.4%) (50.3%) (35.1%) (5.2%) (5.2%) (24.6%) SK 18.8 25.8 839 8 27 23 2 4 8 (51) (0.7) (6.9) (792) (15.7%) (52.9%) (45.1%) (3.9%) (7.8%) (15.7%) MB 18.7 26.4 1045 15 36 29 1 0 20 (66) (0.7) (7.0) (987) (22.7%) (54.5%) (43.9%) (1.5%) (0%) (30.3%) ON 18.7 25.0 920 228 452 292 31 25 216 (967) (0.7) (6.8) (1023) (23.6%) (46.7%) (30.2%) (3.2%) (2.6%) (22.3%) QC 18.4 25.6 1016 180 383 258 30 24 214 (713) (0.9) (6.8) (1116) (25.2%) (53.7%) (36.2%) (4.2%) (3.4%) (30.0%) NB 18.8 26.5 1002 38 74 58 9 7 31 (136) (0.6) (7.1) (893) (27.9%) (54.4%) (42.6%) (6.6%) (5.1%) (22.8%) NS 18.8 25.4 858 54 117 83 11 6 44 (238) (0.6) (6.7) (850) (22.7%) (49.2%) (34.9%) (4.6%) (2.5%) (18.5%) PE 18.7 24.6 831 8 8 8 1 0 8 (25) (0.7) (7.4) (1050) (32.0%) (32.0%) (32.0%) (4.0%) (0%) (32.0%) NL 18.6 26.1 1355 26 48 40 13 7 24 (90) (0.6) (6.5) (1512) (28.9%) (53.3%) (44.4%) (14.4%) (7.8%) (26.7%) Missing 19.0 19.6 1100 14 21 16 1 1 12 (36) (0.7) (5.3) (1126) (38.9%) (58.3%) (44.4%) (2.8%) (2.8%) (33.3%) Total 18.7 25.4 983 654 1369 955 116 96 682 (0.8) (6.9) (1081) (23.8%) (49.7%) (34.7%) (4.2%) (3.5%) (24.8%) ANOVA/χ² <.001 <.001 .009 .104 .069 .009 .001 .045 .006 P‐value

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 Preventive Restorations Root Periodontal Extractions Visits Procedures Canals Procedures 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 .296 .163 .038 .876 .755 .434 P‐value

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 Months Total Emergency Preventive Restorations Root Periodontal Extractions Mean in Cost Visits Procedures Canals Procedures Service BC 23.5 26.3 1290 102 287 217 32 55 109 (463) (2.6) (6.6) (1614) (22.0%) (62.0%) (46.9%) (6.9%) (11.9%) (23.5%) AB 23.9 26.4 1180 86 264 204 22 44 79 (397) (2.7) (7.2) (1288) (21.7%) (66.5%) (51.4%) (5.5%) (11.1%) (19.9%) SK 24.0 26.6 1477 25 69 65 10 9 35 (99) (2.8) (7.2) (1342) (25.3%) (69.7%) (65.7%) (10.1%) (9.1%) (35.4%) MB 24.0 26.3 1320 53 141 104 11 23 66 (196) (2.6) (7.1) (1357) (27.0%) (71.9%) (53.1%) (5.6%) (11.7%) (33.7%) ON 23.9 26.0 1164 601 1251 981 126 160 556 (2172) (2.7) (6.9) (1376) (27.7%) (57.6%) (45.2%) (5.8%) (7.4%) (25.6%) QC 24.0 26.6 1329 474 878 678 105 142 442 (1330) (2.7) (7.1) (1441) (35.6%) (66.0%) (51.0%) (7.9%) (10.7%) (33.2%) NB 24.0 26.6 1242 143 251 219 38 24 122 (402) (2.7) (7.2) (1112) (35.6%) (62.4%) (54.5%) (9.5%) (6.0%) (30.3%) NS 24.2 26.5 1220 129 321 255 36 50 117 (493) (2.8) (7.0) (1257) (26.2%) (65.1%) (51.7%) (7.3%) (10.1%) (23.7%) PE 23.4 26.7 1213 9 31 20 2 4 13 (46) (2.2) (7.1) (1106) (19.6%) (67.4%) (43.5%) (4.3%) (8.7%) (28.3%) NL 23.8 26.3 1403 27 65 56 7 3 37 (107) (2.4) (6.9) (2192) (25.2%) (60.7%) (52.3%) (6.5%) (2.8%) (34.6%) Missing 24.2 19.5 1222 51 166 107 15 17 49 (210) (2.8) (5.1) (1075) (24.3%) (79.0%) (51.0%) (7.1%) (8.1%) (23.3%) Total 24.0 26.0 1239 1700 3724 2906 404 531 1625 (5915) (2.7) (7.0) (1388) (23.8%) (63.0%) (49.1%) (6.8%) (9.0%) (27.5%) ANOVA/ .005 <.001 .046 <.001 <.001 <.001 .166 .001 <.001 χ² P‐value

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 Preventive Restorations Root Periodontal Extractions Visits Procedures Canals Procedures 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 .458 .001 .040 .877 .736 .021 P‐value

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 Months Total Emergency Preventive Restorations Root Periodontal Extractions Mean in cost Visits Procedures Canals Procedures Service BC 33.8 27.6 1382 21 86 62 13 25 19 (113) (2.6) (6.5) (1783) (18.6%) (76.1%) (54.9%) (11.5%) (22.1%) (16.8%) AB 33.8 26.7 1347 19 64 50 3 24 10 (84) (2.7) (7.5) (1386) (22.6%) (76.2%) (59.5%) (3.6%) (28.6%) (11.9%) SK 33.9 26.6 1652 5 20 14 3 7 4 (23) (2.6) (6.9) (1789) (21.7%) (87.0%) (60.9%) (13.0%) (30.4%) (17.4%) MB 34.0 27.8 1090 15 39 24 2 11 9 (50) (3.1) (6.2) (780) (30.0%) (78.0%) (48.0%) (4.0%) (22.0%) (18.0%) ON 34.0 26.7 1338 141 305 223 52 75 68 (437) (2.9) (7.2) (1534) (32.3%) (69.8%) (51.0%) (11.9%) (17.2%) (15.6%) QC 33.8 27.4 1538 116 261 190 38 60 70 (344) (2.7) (6.7) (1615) (33.7%) (75.9%) (55.2%) (11.0%) (17.4%) (20.3%) NB 33.8 26.6 1590 42 72 61 9 12 21 (99) (2.6) (7.3) (2079) (42.4%) (72.7%) (61.6%) (9.1%) (12.1%) (21.2%) NS 34.2 26.5 1503 49 120 86 16 31 29 (158) (2.9) (7.0) (1750) (31.0%) (75.9%) (54.4%) (10.1%) (19.6%) (18.4%) PE 33.7 23.6 1189 3 3 2 1 0 1 (6) (3.7) (8.1) (935) (50.0%) (50.0%) (33.3%) (16.7%) (0%) (16.7%) NL 33.6 26.4 1373 7 21 12 1 8 5 (26) (2.2) (6.6) (1655) (26.9%) (80.8%) (46.2%) (3.8%) (30.8%) (19.2%) Missing 34.7 18.9 1371 21 61 37 3 17 9 (70) (3.0) (4.1) (1495) (30.0%) (87.1%) (52.9%) (4.3%) (24.3%) (12.9%) Total 33.9 26.6 1425 439 1052 761 141 270 245 (1410) (2.8) (7.1) (1618) (31.1%) (74.6%) (54.0%) (10.0%) (19.1%) (17.4%) ANOVA/ .482 <.001 .683 .024 .083 .626 .249 .065 .717 χ² P‐value

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 Preventive Restorations Root Periodontal Extractions Visits Procedures Canals Procedures 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 .699 .004 .070 .701 .044 .477 P‐value

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 Months Total Emergency Periodontal Restorations Root Periodontal Extractions Mean in cost Visits Procedures Canals Procedures Service BC 45.6 25.8 1645 17 50 28 2 26 5 (62) (3.7) (6.9) (2018) (27.4%) (80.6%) (45.2%) (3.2%) (41.9%) (8.1%) AB 45.9 26.0 1862 6 18 13 3 4 1 (21) (3.8) (6.6) (1761) (28.6%) (85.7%) (61.9%) (14.3%) (19.0%) (4.8%) SK 44.9 28.4 1721 4 7 6 2 1 1 (8) (3.6) (6.2) (1479) (50.0%) (87.5%) (75.0%) (25.0%) (12.5%) (12.5%) MB 46.3 25.0 1481 5 16 10 2 6 2 (17) (4.3) (6.1) (1544) (29.4%) (94.1%) (58.8%) (11.8%) (35.3%) (11.8%) ON 45.7 26.4 1709 65 148 113 18 58 21 (183) (3.9) (6.9) (1789) (35.5%) (80.9%) (61.7%) (9.8%) (31.7%) (11.5%) QC 44.7 27.5 1702 34 78 65 12 30 13 (97) (3.7) (6.8) (1876) (35.1%) (80.4%) (67.0%) (12.4%) (30.9%) (13.4%) NB 46.5 24.9 1704 8 22 11 2 5 3 (26) (4.6) (6.8) (3005) (30.8%) (84.6%) (42.3%) (7.7%) (19.2%) (11.5%) NS 45.6 26.1 1622 19 53 41 6 23 4 (68) (4.2) (6.8) (2201) (27.9%) (77.9%) (60.3%) (8.8%) (33.8%) (5.9%) PE 46.7 26.0 2589 2 6 3 1 2 1 (6) (5.4) (8.6) (1746) (33.3%) (100%) (50.0%) (16.7%) (33.3%) (16.7%) NL 45.2 25.7 1655 2 10 7 1 3 1 (10) (2.1) (8.4) (1143) (20.0%) (100%) (70.0%) (10.0%) (30.0%) (10.0%) Missing 47.0 19.4 2050 22 56 45 9 22 13 (65) (4.3) (5.0) (2215) (33.8%) (86.2%) (69.2%) (13.8%) (33.8%) (20.0%) Total 45.7 25.6 1737 761 464 342 58 180 65 (563) (4.0) (7.0) (1974) (54.0%) (82.4%) (60.7%) (10.3%) (32.0%) (11.5%) ANOVA/ .134 <.001 .965 .920 .660 .131 .666 .614 .543 χ² P‐value

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 Periodontal Restorations Root Periodontal Extractions Visits Procedures Canals Procedures 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 .832 .035 .194 .581 .875 .434 P‐value

128

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

MEAN (SD) PREVALENCE COUNT (%) AGE MONTHS TREATMENT EMERGENCY PREVENTIVE RESTORATIONS ROOT PERIODONTAL EXTRACTIONS IN COST VISITS PROCEDURES CANALS PROCEDURES SERVICE $ Tobacco 24.8 27.3 1686 411 816 772 114 178 396 Users (1160) (6.0) (6.8) (1658) (35.4%) (70.3%) (66.6%) (9.8%) (15.3%) (34.1%) Non 25.4 27.5 1451 635 1600 1136 160 295 570 Tobacco Users (7.6) (6.8) (1533) (29.4%) (74.1%) (52.6%) (7.4%) (13.7%) (26.4%) (2158)

T‐ .007 .590 <.001 <.001 .019 <.001 .016 .188 <.001 Test/χ² P‐Value

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 PREVENTIVE RESTORATIONS ROOT PERIODONTAL EXTRACTIONS VISITS CANALS PROCEDURES Tobacco 1.8 3.6 8.4 1.8 1.8 2.5 Users (1.3) (3.4) (9.6) (0.9) (1.4) (1.4)

Non 1.8 3.9 6.9 1.8 1.9 2.5 Tobacco (1.4) (3.6) (7.2) (0.9) (1.6) (1.3) Users

T-Test .584 .017 <.001 .662 .107 .516 P-Value

130

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

Age PSR Score Prevalence Count (%) Mean (SD) 0 1 2 3 4 All Members with PSR 13 (0.2%) 231 (3.3%) 3981 (57.7%) 2187 486 (7.0%) Score 25.6 (7.4) (31.7%) (6898)

Male (5738) 25.3 (7.3) 11 (0.2%) 161 (2.8%) 3231(56.3%) 1894 441 (7.7%) (33.0%) Female (1160) 27.4 (7.9) 2 (0.2%) 70 (6.0%) 750 (64.7%) 293 (25.3%) 45 (3.9%) T-Test Chi-square P-Value <.001 P value <.001

NCM (5579) 25.3 (6.9) 10 (0.2%) 151 (2.7%) 3213 (57.6%) 1819 386 (6.9%) (32.6%) Officer (1319) 27.2 (9.0) 3 (0.2%) 80 (6.1%) 768 (58.2%) 368 (27.9%) 100 (7.6%) T-Test Chi-square P-Value <.001 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 25.9 (7.9) 1 (0.1%) 61 (3.6%) 993 (58.5%) 511 (30.1%) 131 (7.7%) (1697) T-Test Chi-square P-Value <.001 P 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.

131

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

Age Prevalence Count (%) Severity Mean (SD) Mean (SD) Preventive Periodontal Preventive Periodontal Procedures Procedures Procedures Procedures PSR 0 through 3 25.4 (7.1) 5241 (81.7%) 773 (12.1%) 5.1 (3.0) 1.7 (1.6) (6412) PSR 4 29.3 (9.7) 397 (81.7%) 189 (38.9%) 6.4 (4.3) 2.8 (2.3) (486) PSR Undetermined 24.0 (6.4) 971 (25.9%) 115 (3.1%) 4.0 (2.1) 1.5 (1.0) (3743) ANOVA Chi‐Square Chi‐Square ANOVA ANOVA P value P value <.001 P value <.001 P value <.001 P value <.001 <.001

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 Diagnostic Procedure) 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 2007/2008 CF Recruit Population Statistics Canada*

Total Male Female Total Male Female Age Persons in Persons in Persons in Persons Persons Persons Group thousands thousands thousands (% of group (% of (% of (% of group (% of (% of group) total) group) group) total) group) Total 21,553.1 10,854.5 17,007.4 10,641 8983 1658 15 ‐ 59 (100%) (50.4%) (49.6%) (100.0%) (84.4%) (15.6%) 15 to 19 2,252.1 1,153.3 1,098.8 2753 2431 322 (10.4%) (51.2%) (48.8%) (25.9%) (88.3%) (11.7%) 20 to 24 2,321.4 1,192.6 1,128.9 3923 3437 486 (10.8%) (51.4%) (48.6%) (36.9%) (87.6%) (12.4%) 25 to 29 2,347.9 1,185.6 1,162.3 1992 1607 385 (10.9%) (50.5%) (49.5%) (18.7%) (80.7%) (19.3%) 30 to 34 2,261.7 1,131.7 1,130.0 913 701 212 (10.5%) (50.0%) (50.0%) (8.6%) (76.8%) (23.2%) 35 to 39 2,303.0 1,160.6 1,142.4 497 373 124 (10.7%) (50.4%) (49.6%) (4.7%) (75.1%) (24.9%) 40 to 44 2,484.7 1,251.8 1,232.9 281 204 77 (11.5%) (50.4%) (49.6%) (2.6%) (72.6%) (27.4%) 45 to 49 2,790.1 1,402.8 1,387.3 184 146 38 (12.9%) (50.3%) (49.7%) (1.7%) (79.3%) (20.7%) 50 to 54 2,575.4 1,282.9 1,292.5 87 74 13 (11.9%) (49.8%) (50.2%) (0.8%) (85.1%) (14.9%) 55 to 59 2,216.8 1,093.2 1,123.6 11 10 1 (10.3%) (49.3%) (50.7%) (0.1%) (90.9%) (9.1%) *Ottawa Canada. Statistics Canada (2009). Population by sex and age group. Retrieved 19 Jul 2010: http://www40.statcan.gc.ca/l01/cst01/demo10a-eng.htm

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 25,664,220 Total Number of 10641 15 years and over recruits

Less than University 19,872,305 (77.4%) NCMs 8547 (80.3%) certificate or diploma

University certificate 5,791,915 (22.6%) Officers 2094 (19.7%) or diploma and above

*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

Demographic Comparison

Statistics Canada 2006 2007 & 2008

Census Data* 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%)

* 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

136

Table 44. Demographic comparison of Canadian population most spoken language and recruit first language as reported at enrolment.

Demographic Comparison

Statistics Canada 2006 2007 & 2008 Census Data* CF Recruit Population

First Language Most common language As reported at spoken at home 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%)

* 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])

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 Months Treatment Emergency Restorations Root Periodontal Extractions (SD) In Cost (SD) Visits Count (%) Canals Procedures Service Count (%) Count Count (%) Count (%) (SD) (%) In 22.5 26.0 $1146 1513 2481 315 425 1474 Census (3.3) (7.0) (1302) (26.7%) (43.8%) (5.6%) (7.5%) (26.0%) Tract (5670) Not In 21.8 25.5 $1180 841 1380 205 202 833 Census (3.3) (7.1) (1305) (28.1%) (46.0%) (6.8%) (6.7%) (27.8%) Tract (2998) χ2 test, <.001 .003 .266 .173 .043 .017 .195 .073 T-test p-value

138

Table 46. Census tract population descriptive statistics

Descriptive Statistics Age CT CMA/CA Above/Below Above Treatment Income Income CMA/CA CMA/CA Cost Mean Median Median % Mean (SD) Count (%) $Mean (SD) (SD) $Mean $Mean [Range] [Range] (SD) (SD) All 22.5 28388 27305 4.02% (22.0) 3201 1146 Members (3.32) (6484.7) (2482.0) [-62 to 114] (56.5%) (1302.8) [16.7-29.9] (5670) Officers 22.3 29619 27551 7.5% 689 913 (1275.0) (1119) (3.85) (7077.2) (2528.9) (23.40) (61.6%) NCM (4551) 22.5 28084 27245 3.2% 2512 1204 (3.17) (6294.5) (2466.9) (21.55) (55.2%) (1303.3) T-Test/χ2 .060 <.001 <.001 <.001 <.001 <.001 test, p-value Officers Male (885) 22.3 29713 27603 7.6% 545 865 (3.77) (7033.5) (2550.4) (23.30) (61.6%) (1110.3) Female (234) 22.3 29265 27355 6.8% 144 1095 1755.5 (4.11) (7244.6) (2441.3) (23.70) (61.5%) T-Test/ χ2 .932 .398 .171 .638 .990 .058 test, p-value NCM Male 22.4 28091 27344 2.7% 2231 1206 (4041) (3.14) (6264.6) (2468.9) (21.38) (55.2%) (1307.4) Female 23.5 28035 27344 2.7% 281 1187 (510) (3.30) (6532.4) (2450.6) (21.90) (55.1%) (1271.5) T-Test/ χ2 <.001 .852 .335 .582 .962 .754 test, p-value First Language English 22.5 28747 27305 4.3% 3033 1112 (4264) (3.24) (6465.3) (2499.3) (21.83) (57.3%) (1263.1) French 22.5 27295 26272 4.1% 771 1250 (1406) (3.53) (6422.8) (2539.3) (22.90) (54.8%) (1411.8) T-Test/ χ2 .662 <.001 <.001 .947 .158 .001 test, p-value Birthplace Canada 22.5 28457 27305 4.3% 3033 1136 (5292) (3.30) (6427.4) (2499.3) (21.83) (57.3%) (1269.4) Foreign 22.8 27415 27306 0.2% 168 1289 (378) (3.56) (7178.1) (2228.2) (23.81) (44.4%) (1698.1) T-Test/ χ2 .064 .006 .998 .001 <.001 .086 test, p-value

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 Median Above Well TOTAL ANOVA Below -25% to >-7% to 7% to Above p-value <-25% -7% <7% 25% >25% Count (%) 492 1299 1410 1571 898 5670 n/a All Members (8.6%) (22.8%) (24.8%) (27.6%) (15.8%)

Officers 76 238 254 316 235 1119 n/a (6.8%) (21.3%) (22.7%) (28.2%) (21.0%) NCM 416 1061 1156 1255 663 4551 n/a (9.1%) (23.2%) (25.3%) (27.5%) (14.5%)

Age Mean 23.3 22.9 22.5 22.3 21.8 22.5 <.001 (SD) (3.26) (3.30) (3.32) (3.26) (3.33) (3.32) All Members Officers 23.6 23.0 22.5 22.2 21.1 22.3 <.001 (3.30) (3.83) (3.91) (3.86) (3.65) (3.85) NCM 23.3 22.8 22.4 22.3 22.1 22.6 .004 (3.26) (3.17) (3.17) (3.08) (3.17) (3.17) T-test, p- .392 .567 .815 .703 .001 .060 value

Months in 25.9 26.3 26.1 25.9 25.5 26.0 .131 Service (7.02) (7.00) (6.91) (6.98) (6.82) (6.95) Mean(SD) All Members Officers 24.1 26.6 26.3 25.3 24.7 25.6 .004 (6.76) (7.05) (7.20) (6.88) (6.64) (6.97) NCM 26.1 26.3 26.1 26.1 25.9 26.1 .854 (7.04) (6.99) (6.84) (7.00) (6.87) (6.94) T test, p- .025 .456 .593 .073 .030 .042 value

140

Table 48. Census tract group prevalence of emergency visits

Prevalence Census Tract Median Income in Relation to CMA/CA Count (%) Well Below Median Above Well χ2 Below -25% to >-7% to 7% to Above TOTAL test <-25% -7% <7% 25% >25% (5670) p- (492) (1299) (1410) (1571) (898) value E M All Members 153 363 366 409 222 1513 E (5670) (31.1%) (27.9%) (26.0%) (26.0%) (24.7%) (26.7%) .077 R G N Officers 12/76 49/238 44/254 59/316 41/235 205/1119 .834 C (1119) (15.8%) (20.6%) (17.3%) (18.7%) (17.4%) (18.3%) Y

NCM 141/416 314/1061 322/1156 350/1255 181/663 1308/4551 .119 (4551) (33.9%) (29.6%) (27.9%) (27.9%) (27.3%) (28.7%)

χ2 test, p-value .002 .005 .001 .001 .003 <.001

141

Table 49. Census tract group mean treatment cost

Census Tract Median Income in Relation to CMA/CA Treatment Well Below Median Above Well One- COST $mean(SD) Below -25% to >-7% to 7% to Above TOTAL Way <-25% -7% <7% 25% >25% ANOVA p-value C O All Members (5670) 1331 1245 1153 1060 1044 1146 <.001 S (1477.3) (1469.1) (1344.1) (1076.6) 91218.90 (1302.8) T Officers (1119) 1131 1000 995 821 788 913 (1531.9) (1409.0) (1751.1) (772.80 (904.7) (1275.0) .081

NCM (4551) 1367 1300 1188 1120 1134 1204 .001 (1464.7) (1477.8) (1235.0) (1132.7) (1301.0) (1303.1)

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 95% CI p-value Ratio*

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 P-value estimate β

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 -2.44 .001 gain relative to CMA/CA median income)

R2= .083

144

Table 52. Census tract group prevalence of treatment requirement, stratified by rank class. Prevalence Census Tract Median Income in Relation to CMA/CA Count (%) Well Below Median Above Well χ2 Below -25% to - >-7% to 7% to Above TOTAL test <-25% 7% <7% 25% >25% (5670) p- (492) (1299) (1410) (1571) (898) value R E S All Members 234 630 625 650 342 2481 <.001 T (5670) (47.6%) (48.5%) (44.3%) (41.4%) (38.1%) (43.8%) O Officers 19/76 95/238 87/254 95/316 61/235 357/1119 R T (1119) (25.0%) (39.9%) (34.3%) (30.1%) (26.0%) (31.9%) .008 I NCM 215/416 535/1061 538/1156 555/1255 281/663 2124/4551 .001 O N (4551) (51.7%) (50.4%) (46.5%) (44.2%) (42.4%) (46.7%) χ2 test, p-value <.001 .003 <.001 <.001 <.001 <.001 R O O All Members 42 81 75 73 44 315 .012 T (5670) (8.5%) (6.2%) (5.3%) (4.6%) (4.9%) (5.5%) Officers 5/76 8/238 6/254 7/316 6/235 32/1119 .311 C A (1119) (6.6%) (3.4%) (2.4%) (2.2%) (2.6%) (2.9%) N NCM 37/416 73/1061 69/1156 66/1255 38/663 283/4551 .082 A L (4551) (8.9%) (6.9%) (6.0%) (5.3%) (5.7%) (6.2%) χ2 test, p-value .507 .042 .020 .022 .052 <.001 E X T All Members 149 364 363 390 208 1474 .015 R (5670) (30.3%) (28.0%) (25.7%) (24.8%) (23.2%) (26.0%) A Officers 11/76 35/238 42/254 55/316 33/235 176/1119 .813 C T (1119) (14.5%) (14.7%) (16.5%) (17.4%) (14.0%) (15.7%) I NCM 138/416 329/1061 321/1156 335/1255 175/663 1298/4551 .022 O N (4551) (33.2%) (31.0%) (27.8%) (26.7%) (26.4%) (28.5%) χ2 test, p-value .001 <.001 <.001 <.001 <.001 <.001 P E R All Members 50 119 94 100 62 425 .005 I (5670) (10.2%) (9.2%) (6.7%) (6.4%) (6.9%) (7.5%) O D Officers 6/76 17/238 10/254 16/316 12/235 61/1119 .481 O (1119) (7.9%) (7.1%) (3.9%) (5.1%) (5.1%) (5.5%) N T NCM 44/416 102/1061 84/1156 84/1255 50/663 364/4551 .022 A (4551) (10.6% (9.6%) (7.3%) (6.7%) (7.5%) (8.0%) L 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 Census Tract Median Income in Relation to CMA/CA Count (%) Well Below Median Above Well χ2 Below ‐25% to >‐7% to 7% to Above TOTAL test <‐25% ‐7% <7% 25% >25% (5670) p‐ (492) (1299) (1410) (1571) (898) value R All Members (5670) 234 630 625 650 342 2481 E (47.6%) (48.5%) (44.3%) (41.4%) (38.1%) (43.8%) <.001 S T 16 ‐19 yrs (1631) 30/101 116/303 141/407 147/482 97/338 531/1631 O (29.7%) (38.3%) (34.6%) (30.5%) (28.7%) (32.6%) .063 R 20 – 29 yrs (4039) 204/391 514/996 484/1003 503/1089 245/560 1950/4039 .010 T (52.2%) (51.6%) (48.3%) (46.2%) (43.8%) (48.3%) I O χ2 test, p‐value <.001 <.001 <.001 <.001 <.001 <.001 N R All Members (5670) 42 81 75 73 44 315 O (8.5%) (6.2%) (5.3%) (4.6%) (4.9%) (5.5%) .012 O T 16 ‐19 yrs (1631) 4/101 16/303 13/407 15/482 10/338 58/1631 (4.0%) (5.3%) (3.2%) (3.1%) (3.0%) (3.6%) .484 C 20 – 29 yrs (4039) 38/391 65/996 62/1003 58/1089 34/560 257/4039 .049 A (9.7%) (6.5%) (6.2%) (5.3%) (6.1%) (6.4%) N A χ2 test, p‐value .065 .432 .024 .055 .036 <.001 L E All Members (5670) 149 364 363 390 208 1474 .015 X (30.3%) (28.0%) (25.7%) (24.8%) (23.2%) (26.0%) T R 16 ‐19 yrs (1631) 38/101 80/303 93/407 112/482 75/338 398/1631 A (37.6%) (26.4%) (22.9%) (23.2%) (22.2%) (24.4%) .017 C 20 – 29 yrs (4039) 111/391 284/996 270/1003 278/1089 133/560 1076/4039 .238 T 28.4%) (28.5%) (26.9%) (25.5%) (23.8%) (26.6%) I O χ2 test, p‐value <.072 <.474 <.113 <.332 <.591 <.082 N P All Members (5670) 50 119 94 100 62 425 .005 E R (10.2%) (9.2%) (6.7%) (6.4%) (6.9%) (7.5%) I 16 ‐19 yrs (1631) 6/101 14/303 10/407 13/482 15/338 58/1631 .206 O (5.9%) (4.6%) (2.5%) (2.7%) (4.4%) (3.6%) D O 20 – 29 yrs (4039) 44/391 105/996 84/1003 87/1089 47/560 367/4039 .121 N (11.3%) (10.5%) (8.4%) (8.0%) (8.4%) (9.1%) T A χ2 test, p‐value .115 .002 <.001 <.001 .024 <.001 L E All Members (5670) 153 363 366 409 222 1513 M (31.1%) (27.9%) (26.0%) (26.0%) (24.7%) (26.7%) .077 E R 16 ‐19 yrs (1631) 27/101 81/303 93/407 100/482 66/338 367/1631 G (26.7%) (26.7%) (22.9%) (20.7%) (19.5%) (22.5%) .150 E 20 – 29 yrs (4039) 126/391 282/996 273/1003 309/1089 156/560 1146/4039 .475 N (32.2%) (28.3%) (27.2%) (28.4%) (27.9%) (28.4%) C Y 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 Census Tract Median Income in Relation to CMA/CA Mean (SD) Well Below Median Above Well ANOVA Below ‐25% >‐7% to 7% to Above TOTAL p‐value <‐25% to ‐7% <7% 25% >25% R All Members 8.1 7.5 7.4 6.5 7.2 7.3 .104 E S (9.37) (9.75) (9.34) (7.15) (7.74) (7.73) T Officers 5.4 6.0 6.2 4.6 4.4 5.4 .303 O R (6.06) (6.92) (8.73) (4.14) (4.52) (6.44) T NCM I 8.3 7.8 7.7 6.8 7.8 7.6 .222 O (9.58) (10.15) (9.43) (7.50) (8.20) (8.20) N T‐test, p‐value .194 .104 .168 <.001 <.001 <.001 * R All Members 2.1 1.8 1.8 1.91 1.77 1.85 .498 O O (1.97) (0.99) (0.90) (1.08) (0.94) (1.16) T Officer 1.8 2.0 1.5 1.7 1.8 1.8 .828 (0.83) (1.07) (0.55) (0.49) (0.75) (0.75) C A NCM 2.2 1.7 1.8 1.9 1.8 1.9 .431 N (2.08) (0.99) (0.92) (1.12) (0.97) (1.20) A L T ‐ test, p‐value .706 .463 .399 .602 .867 .710 E All Members 2.5 2.4 2.55 2.5 2.4 2.4 .556 X T (1.42) (1.39) (1.44) (1.37) (1.28) (1.38) R Officer 3.3 2.1 2.7 2.3 2.5 2.4 .130 A C (1.55) (1.16) (1.91) (1.29) (1.37) (1.48) T NCM 2.4 2.4 2.5 2.5 2.4 2.4 .754 I (1.40) (1.41) (1.37) (1.37) (1.27) (1.37) O N T ‐ test, p‐value .055 .322 .313 .348 .609 .805 P All Members 2.0 1.6 1.5 1.3 1.5 1.5 E R (1.60) (1.13) (1.08) (0.67) (1.11) (1.11) .025 I O Officer 3.3 1.9 1.6 1.3 1.1 1.7 .010 D (2.33) (1.79) (0.69) (0.60) (0.28) (1.37) O NCM 1.8 1.5 1.5 1.3 1.6 1.5 .256 N T (1.41) (0.98) (1.12) (0.68) (1.21) (1.06) A T ‐ test, p‐value .166 .428 .803 .910 .167 .410 L E All Members 1.9 1.6 1.7 1.7 1.6 1.7 .136 M (1.6) (1.1) (1.1) (1.1) (1.1) (1.2) E R Officer 1.9 1.5 1.6 1.7 1.5 1.6 .594 G (1.7) (0.9) (0.9) (1.1) (0.8) (1.1) E NCM 1.9 1.7 1.7 1.7 1.6 1.7 .257 N (1.6) (1.1) (1.2) (1.1) (1.1) 1.2 C Y T ‐ test, p‐value .985 .324 .495 .800 .475 .278

147

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

Treatment All treatment Data DentIS Data Blue Cross Data Category Procedures Total Procedures Cost Procedures Cost Cost $ $ $ Diagnostic 72173 4667012 69705 4517692 2468 149320 % of Total Sum 48.1% 34.5% 51.3% 42.5% 17.5% 5.1%

(Emergency (5650) (673342) (5583) (668577) (67) (3766) Procedure) (3.8%) (5.0%) (4.1%) (6.3%) (0.5%) (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 1.2% 5.7% 1.0% 3.6% 3.3% 13.6%

(Root Canals (1386) (725535) (1008) (368485) (378) (357050) completed) (0.9%) (5.4%) (7.2%) (3.5%) (2.7%) (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 6.6% 14.6% 4.7% 9.1% 24.8% 34.5%

(Extractions) (8133) (1798528 (4797) (855768) (3336) (942760) (5.4%) ) (3.5%) (8.0%) (23.6%) (32.3%) (13.3%) 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 7-12 13-18 19 -24 25-30 31-36 Total

Months Months Months Months Months months S Valcartier 2551 3628 5006 3245 1648 633 16,711 P 5.6% 12.1% 14.9% 14.7% 11.9% 13.8% 11.1% E Edmonton 919 2053 4284 3934 2439 637 14,266 C 2.0% 6.9% 12.7% 17.9% 17.6% 13.8% 9.5% I Petawawa 841 1416 3570 2621 1915 887 11,350 A L 1.8% 4.7% 10.9% 11.9% 13.8% 19.3% 7.6% T Halifax 2107 1780 2466 1616 1142 348 9460 Y 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% M Borden 6158 4826 3336 875 430 112 15,737 I 13.4% 16.1% 9.9% 4.0% 3.1% 2.4% 10.5% D Gagetown 3226 3552 2983 1824 899 267 12,751 S 7.0% 11.9% 8.9% 8.3% 6.5% 5.8% 8.5% I Kingston 2570 1554 2519 951 1087 118 8799 Z 5.6% 5.2% 7.5% 4.3% 7.8% 2.6% 4.8% E 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 St Jean 19,227 1691 787 451 156 72 22,384 M 41.9% 5.7% 2.3% 2.0% 1.1% 1.6% 14.9% A Shilo 425 1075 1109 566 249 97 3521 L .9% 3.6% 3.3% 2.6% 1.8% 2.1% 2.3% L Wainwright 1078 1189 458 240 97 65 3127

2.3% 4.0% 1.4% 1.1% .7% 1.4% 2.1% D E Greenwood 429 335 486 437 340 100 2127 T .9% 1.1% 1.4% 2.0% 2.5% 2.2% 1.4% A Toronto 654 398 352 215 116 60 1795 C 1.4% 1.3% 1.0% 1.0% .8% 1.3% 1.2% H Bagotville 225 297 329 393 281 96 1621 M .5% 1.0% 1.0% 1.8% 2.0% 2.1% 1.1% E Moose Jaw 180 244 261 225 124 57 1091 N .4% .8% .8% 1.0% .9% 1.2% .7% T Comox 153 149 335 263 119 51 1070 .3% .5% 1.0% 1.2% .9% 1.1% .7% North Bay 311 273 193 140 81 5 1003 .7% .9% .6% .6% .6% .1% .7% Longue-Pointe 365 183 124 99 86 38 895 .8% .6% .4% .4% .6% .8% .6% Gander 456 172 95 73 51 12 859 1.0% .6% .3% .3% .4% .3% .6% Preserver 6 80 109 62 34 22 313 .0% .3% .3% .3% .2% .5% .2% Goose Bay 42 3 86 36 39 6 212 .1% .0% .3% .2% .3% .1% .1% Total 45,917 29,910 33,699 22,000 13,875 4602 150,003 100.0% 100.0% 100% 100.0% 100% 100 % 100 %

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Table 57. Detachment workload impact – Total procedures and cost Detachment Total Procedures DentIS (In-Service) Procedures Blue Cross (Out-Service) Procedures % Count Cost $ % Count Cost $ % Count Cost $ (% row) (% row) S Valcartier 11.1 16,711 1,540,260 11.4 15,468 1,261,121 8.8 1243 279,139 P (92.6%) (7.4%) E Edmonton 9.5 14,266 1,584,023 8.6 11,698 964,608 18.2 2658 619,415 C (82.0%) (18.0) I Petawawa 7.6 11,350 1,102,115 7.4 10,019 752,138 9.4 1331 349,977 A (88.3%) (11.7) L Halifax 6.3 9460 815,967 6.4 8662 638,290 5.7 798 177,677 T (91.6%) (8.4%) Y Esquimalt 5.4 8105 798,911 5.1 6874 572,128 8.7 1231 226,784 (84.8%) (15.2) Ottawa 3.2 4825 489,630 3.2 4366 409,318 3.3 459 80,312 (90.5%) (9.5%) Spec Sub total 43.1 64,717 6,330,906 42.1 57,087 4,597,603 54.1 7630 1,733,304 (88.2%) (11.8) M Borden* 10.5 15,737 1,356,231 10.8 14,677 1,153,460 7.5 1060 202,771 I (93.3%) (6.7%) D Gagetown 8.5 12,751 1,136,929 8.3 11,313 940,138 10.2 1438 196,791 S (88.7%) (11.3%) I Kingston** 5.9 8799 691,577 6.0 8120 540,311 4.8 679 151,266 Z (92.3%) (7.7%) E Trenton*** 2.0 3064 275,870 1.9 2541 156,596 3.7 523 119,273 (82.9%) (17.1) Winnipeg* 2.0 2968 232,319 2.0 2703 195,810 1.9 265 36,508 (91.1%) (8.9%) Cold Lake 1.3 1949 152,342 1.3 1800 117,768 1.1 149 34,574 (92.4%) (7.6%) Mid Sub total 30.2 45,268 3,845,268 30.3 41,151 3,104,083 29.2 4114 741,183 (90.9%) (9.1%) S St Jean 14.9 22,384 1,888,182 16.0 21,775 1,766,777 4.3 609 121,406 M (97.2%) (2.8%) A Shilo 2.3 3521 289,359 2.3 3166 212,815 2.5 355 76,544 L (90.0%) (10.0) L Wainwright 2.1 3127 271,130 2.3 3060 257,012 .5 67 14,118 (97.9%) (2.1%) D Toronto 1.2 1795 161,531 1.2 1657 135,101 1.0 138 26,431 E (92.3%) (7.7%) T Bagotville 1.1 1621 147,160 1.0 1409 100,789 1.5 212 46,370 A (86.9%) (13.1) C Greenwood 1.4 2127 169,438 1.4 1928 122,424 1.4 199 47,014 H (90.6%) (9.4%) M Moose Jaw .7 1091 97,790 .6 843 54,505 1.8 248 43,284 E (77.3%) (22.7) N Comox .7 1070 96,488 .7 975 74,437 .7 95 22,051 T (91.1%) (8.9%) North Bay .7 1003 69,173 .7 933 59,211 .5 70 9962 (93.0%) (7.0%) Longue-Pointe .6 895 64,761 .7 895 64,761 0 0 0 (100%) (0%) Gander .6 859 79,503 .4 498 41,710 2.6 361 37,793 (58.0%) (43.0) Goose Bay .1 212 15,285 .2 205 14,188 .0 7 1097 (96.7%) (3.3%) Preserver .1 313 18,947 .2 313 18,947 0 0 0 (100%) (0%) Small Sub total 26.7 40,018 3,368,747 27.7 37,649 2,922,677 16.8 2361 446,070 (94.1%) (5.9%) Total 100 150,003 13,544,921 100 135,898 10,624,366 100 14,105 2,920,556 (90.6%) (9.4%)

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Table 58. Detachment workload by treatment category

DETACHMENT Emerg Oral Misc Prostho Diag Pr visit Prev Pr Resto Pr Endo Pr Perio Pr Surgery Ortho S Valcartier 5905 734 4994 3121 235 227 1410 698 121 P 8.2% 13.0% 14.3% 13.6% 13.0% 10.6% 14.3% 13.6% 11% E Edmonton 5157 249 3697 2991 116 254 1252 732 67 C 7.1% 4.4% 10.6% 13.0% 6.4% 11.9% 12.7% 14.2% 6.3% I Petawawa 4803 574 2687 1900 171 104 1136 431 118 A L 6.7% 10.2% 7.7% 8.3% 9.5% 4.9% 11.5% 8.4% 11.1% T Halifax 3472 179 3449 1247 86 149 547 363 147 Y 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% M Borden 8225 746 2428 2383 259 351 1374 581 136 I 11.4% 13.2% 7.0% 10.4% 14.4% 16.4% 14.0% 11.3% 12.8% D Gagetown 5494 826 3406 2238 196 102 875 378 62 S 7.6% 14.6% 9.8% 9.8% 10.9% 4.8% 8.9% 7.4% 5.8% I Kingston 5122 385 2013 865 74 57 403 230 35 Z 7.1% 6.8% 5.8% 3.8% 4.1% 2.7% 4.1% 4.5% 3.3% E Trenton 1258 114 979 428 40 117 115 111 16 1.7% 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 42 1.4% 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 11 1.2% 1.8% 1.8% .9% .9% 3.5% .8% 1.3% 1.0% S St Jean 18,883 795 610 1734 221 52 532 288 64 M 26.2% 14.1% 1.7% 7.6% 12.3% 2.4% 5.4% 5.6% 6.0% A Shilo 1173 101 1129 715 56 31 256 148 13 L 1.6% 1.8% 3.2% 3.1% 3.1% 1.5% 2.6% 2.9% 1.2% L Wainwright 1217 183 596 777 58 90 246 124 17

1.7% 3.2% 1.7% 3.4% 3.2% 4.2% 2.5% 2.4% 1.6% D E Toronto 875 43 493 221 15 17 103 50 21 T 1.2% .8% 1.4% 1.0% .8% .8% 1.0% 1.0% 2.0% A Bagotville 635 63 436 245 19 51 116 63 56 C .9% 1.1% 1.2% 1.1% 1.1% 2.4% 1.2% 1.2% 5.3% H Moose Jaw 360 3 397 187 10 16 73 43 5 M .5% .1% 1.1% .8% .6% .7% .7% .8% .5% E Greenwood 824 83 772 292 16 31 93 78 21 N 1.1% 1.5% 2.2% 1.3% .9% 1.5% .9% 1.5% 2.0% T Gander 388 11 155 211 9 8 60 16 12 .5% .2% .4% .9% .5% .4% .6% .3% 1.0% Comox 480 8 237 204 12 33 64 29 11 .7% .1% .7% .9% .7% 1.5% .7% .6% 1.0% North Bay 384 28 410 128 6 6 32 24 13 .5% .5% 1.2% .6% .3% .3% .3% .5% 1.2% Goose Bay 81 6 70 35 3 5 8 6 4 .1% .1% .2% .2% .2% .2% .1% .1% .4% Longue-Pointe 390 62 324 128 9 13 16 9 6 .5% 1.1% .9% .6% .5% .6% .2% .2% .5% Preserver 165 6 73 53 1 7 5 9 0 .2% .1% .2% .2% .1% .3% .1% .2% 0% Total 72,173 5650 34,915 22,932 1802 2137 9841 5139 1063 100.0% 100.0% 100% 100.0% 100 % 100.0% 100.0% 100.0% 100%

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Table 59. Timeline for treatment delivery, by category (not including diagnostic services, other than emergency visits), in 6 month intervals following date of enrolment

Treatment TIMELINE Category 0-6 7-12 13-18 19 -24 25-30 31-36 Total Months Months Months Months Months Months Emergency 1488 1489 1217 841 472 143 5650 Visits 10.2% 7.7% 5.4% 5.6% 5.2% 4.6% 6.8% % of Total Sum 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 3.0% 2.4% 1.9% 1.9% 1.7% 1.5% 2.2%

(Root Canals (338 (356 (323 (214 (121 (34 (1386 completed) 2.3%) 1.8%) 1.4%) 1.4%) 1.3%) 1.1%) 1.7%) 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 10.4% 11.7% 13.3% 12.4% 10.7% 7.8% 11.8%

(Extractions) (1256 (1882 (2509 (1526 (790 (170 (8133 8.6%) 9.8%) 11.2%) 10.2%) 8.8%) 5.4%) 9.7%) Orthodontic 47 85 67 64 55 14 332 % of Total Sum .3% .4% .2% .4% .6% .4% .4% Miscellaneous 887 1129 1389 1002 569 163 5139 % of Total Sum 6.1% 5.9% 6.2% 6.7% 6.3% 5.2% 6.2% Total 14,616 19,256 22,490 14,978 9014 3132 83,480 % of Total Sum 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

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Table 60. Detachment impact of completed tooth extractions

Detachment Total Extractions DentIS (In-Service) Blue Cross (Out-Service) % Count Cost $ % Count Cost $ % Count Cost $ Procedure Procedure (% row) Procedure (% row) S Valcartier 14.1 1150 268,253 14.4 689 140,574 13.8 461 127,679 P (59.9%) (40.1%) E Edmonton 13.7 1114 334,160 10.1 486 105,548 18.8 628 228,612 C (43.6%) (56.4%) I Petawawa 10.8 878 213,089 9.0 432 80,511 13.4 446 132,578 A (49.2%) (50.8%) L Halifax 5.1 417 84,282 5.4 259 46,122 4.7 158 38,160 T (62.1%) (37.9%) Y Esquimalt 5.1 416 90,349 2.3 108 13,347 9.2 308 77,002 (26.0%) (74.0%) Ottawa 3.8 305 61,177 5.4 258 49,131 1.4 47 12,046 (84.6%) (15.4%) Spec Sub total 52.6 4280 1,051,310 46.6 2232 435,233 61.3 2048 616,077 (52.1%) (47.9%) M Borden* 14.0 1135 196,441 18.7 898 137,328 7.1 237 59,113 I (79.1%) (20.9%) D Gagetown 9.7 791 158,109 13.4 642 120,883 4.5 149 37,226 S (81.2%) (18.8%) I Kingston** 4.0 326 73,001 2.7 128 21,512 5.9 198 51,489 Z (39.3%) (60.7%) E Winnipeg* 1.8 148 25,927 2.2 106 16,057 1.3 42 9869 (71.6%) (28.4%) Trenton*** 1.1 91 22,210 .1 6 538 2.5 85 21,672 (6.6%) (93.4%) Cold Lake .7 57 15,631 .4 20 3284 1.1 37 12,347 (35.0%) (65.0%) Mid Sub total 31.3 2548 491,319 37.5 1800 299,602 22.4 748 119,717 (70.7%) (29.3%) S St Jean 5.5 451 84,857 7.4 353 56,997 2.9 98 27,860 M (78.3%) (21.7%) A Shilo 2.7 222 44,083 .8 38 4096 5.5 184 39,987 L (17.1%) (82.9%) L Wainwright 2.3 186 33,111 3.8 182 32,337 .1 4 775 (97.8%) (2.2%) D Toronto 1.1 92 19,007 1.4 68 12,082 .7 24 6924 E (73.9%) (26.1%) T Bagotville 1.1 93 19,752 .5 23 2967 2.1 70 16,785 A (24.7%) (75.3%) C Moose Jaw .8 64 16,687 .2 9 1119 1.6 55 15,568 H (14.0%) (86.0%) M Greenwood .8 62 14,716 .3 15 1547 1.4 47 13,169 E (24.2%) (75.8%) N Gander .6 52 10,242 .3 14 1689 1.1 38 8553 T (26.9%) (73.1%) Comox .5 43 7377 .5 26 2649 .5 17 4728 (60.5%) (39.5%) North Bay .3 25 3654 .5 25 3654 0 0 0 (100%) (0%) Goose Bay .1 5 861 .0 2 243 .1 3 618 (40%) (60.0%) Longue-Pointe .1 7 1236 .1 7 1236 0 0 0 (100%) (0%) Preserver .0 3 317 .1 3 317 0 0 0 (100%) (0%) Small Sub 15.9 1305 255,900 15.9 765 120,933 16.3 540 206,966 total (58.6%) (41.4%) Total 100% 8133 1,798,528 100% 4797 855,768 100% 3336 942,760 (59.0%) (41.0%)

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Table 61. Detachment impact of completed root canals Detachment Total Root Canals DentIS (In-Service) Blue Cross (Out-Service) % Count Cost $ % Count Cost $ % Count Cost $ Procedure Procedure (% row) Procedure (% row) S Petawawa 11.4 158 93,894 7.8 79 22,627 20.9 79 71,267 P (50.0% (50.0%) E Valcartier 10.6 147 58,346 13.9 140 54,079 1.9 7 4267 C (95.2%) (4.8%) I Edmonton 7.1 99 83,777 3.2 32 13,665 17.7 67 70,113 A (32.3%) (67.7%) L Esquimalt 6.3 87 55,222 6.3 64 28,459 6.1 23 26,763 T (73.6%) (26.4%) Y Halifax 4.7 65 37,654 3.1 31 11,442 9.0 34 26,212 (47.7%) (52.3%) Ottawa 2.3 32 20,489 1.7 17 6766 4.0 15 13,723 (53.1%) (46.9%) Sub total 42.4 588 349,382 36 363 137,038 59.6 225 212,344 (61.7%) (38.3%) M Borden* 15.4 214 93,842 17.9 180 61,758 9.0 34 32,084 I (84.1%) (15.9%) D Gagetown 10.9 151 75,001 13.1 132 55,588 5.0 19 19,413 S (87.4%) (12.6%) I Kingston** 4.8 66 35,312 4.4 44 15,296 5.8 22 20,016 Z (66.7%) (33.3%) E Trenton*** 1.9 27 25,370 0.2 2 495 6.6 25 24,875 (7.4%) (92.6%) Winnipeg* 1.4 20 9740 1.5 15 6877 1.3 5 2864 (75.0%) (25.0%) Cold Lake 0.6 9 5530 0.7 7 3570 0.5 2 1960 (77.8%) (22.2%) Sub total 35.0 487 244,795 37.8 380 143,584 28.2 107 101,211 (78.0%) (22.0%) S St Jean 12.4 172 55,075 15.7 158 42,450 3.7 14 12,624 M (91.8%) (8.2%) A Wainwright 3.0 42 18,534 3.9 39 16,028 0.8 3 2506 L (92.8%) (7.2%) L Shilo 2.4 33 15,474 2.7 27 10,124 1.6 6 5351 (81.8%) (18.2%) D Toronto 1.0 14 10,331 0.9 9 4503 1.3 5 5828 E (64.3%) (35.7%) T Bagotville 0.7 10 5871 0.8 8 3596 0.5 2 2275 A (80.0%) (20.0%) C Greenwood 0.7 10 6661 0.6 6 2992 1.1 4 3669 H (60.0%) (40.0%) M Gander 0.5 7 6330 0.3 3 2011 1.1 4 4318 E (42.9%) (57.1%) N Moose Jaw 0.4 6 4328 0 0 0 1.6 6 4328 T (0%) (100%) Comox 0.4 5 3786 0.4 4 2725 0.3 1 1061 (80.0%) (20.0%) North Bay 0.4 5 2587 0.4 4 1054 0.3 1 1533 (80.0%) (20.0%) Longue-Pointe 0.4 5 1696 0.5 5 1696 0 0 0 (100%) (0%) Goose Bay 0.1 1 495 0.1 1 495 0 0 0 (100%) (0%) Preserver 0.1 1 190 0.1 1 190 0 0 0 (100%) (0%) Sub total 22.6 311 131,358 26.2 265 87,863 12.2 46 (14.8%) 43,495 (85.2%) Total 1386 725,535 1008 368,485 378 357050 (72.7%) (27.3%) *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

155

Figure 1. 2007 and 2008 recruit population inclusion criteria

Figure 1. 14393 Members Enrolled 2007 & 2008 ‐ DHRIM

2373 Excluded –No Dental Data

12020 Records in DentIS Database

1379 Released from CF

10641 Members with Active Dental Records

5237 Enrolled in 2007 5404 Enrolled in 2008

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Figure 2. Recruit population residing in census tracts

Figure 2. 14393 Members Enrolled 2007 & 2008 ‐ DHRIM

2373 Excluded –No Dental Data

12020 Records in DentIS Database

1379 Released from CF

10641 Members with Active Dental Records

1973 were over the age of 30

2998 Did not Reside in a CT

5670 Members Residing in a CT Included in the Study

2816 Enrolled in 2007 2854 Enrolled in 2008

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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 1. Service 1. Service 2. Postal Code Number number 1. Postal Code

3. Date of Birth 2. Rank 2. Outsourced 2. CT Median 4. Gender 3. Treatment treatment Income 5. Place of Birth procedure codes (city, Province, codes 3. Treatment cost 3. CMA/CA country) 4. Treatment Median 6. Address at time of dates Income enrolment 5. Treatment cost 7. Enrollment date 8. First Language

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

Teeth and Roots Class Third Molars (unerupted, partially erupted, malposed)

1 Unerupted, partially erupted, or malposed third Unerupted, partially erupted, or molars are without historical, clinical, or malposed teeth or roots are without radiographic signs or symptoms of pathosis, historical, clinical, or radiographic signs and are NOT recommended for prophylactic or symptoms of pathosis, and are NOT removal. recommended for prophylactic removal.

2 Unerupted, partially erupted, or malposed third Unerupted, partially erupted, or molars are without historical, clinical, or malposed teeth or roots are without radiographic signs or symptoms of pathosis, historical, clinical, or radiographic signs but are recommended for prophylactic removal. or symptoms of pathos’s, but are recommended for prophylactic removal. NOTE: The presence of third molars, in communication with the oral cavity, which are NOTE: Buried roots with no associated unlikely to erupt into functional occlusion and pathology may be left in situ and have a history of repeated pericoronal infection, monitored. may preclude the dentally fit classification. Where the prognosis is unclear, individual occupational and operational commitments must be taken into consideration.

3 Unerupted, partially erupted, or malposed third Unerupted, partially erupted, or molars have historical, clinical, or radiographic malposed teeth or roots have historical, signs or symptoms of pathosis, and require clinical, or radiographic signs or removal. symptoms of pathosis, and require removal.

Non-restorable teeth and functionless roots in communication with the oral cavity require extraction.

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Appendix 6. Example: Recruit dental experience while in training

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Appendix 7 The Advanced General Dentist Position Paper Background Prior to 1969 the CF had no dental specialists in the clinical disciplines, although as early as 1957 the requirement had been established for Public Health Dentists (PHD), the first of whom graduated in 1958. Training in clinical specialties was limited to short courses, four weeks to eight months in duration, during which dental officers learned many of the skills required to enable them to perform specific specialty treatment procedures.

In 1969, the CF produced its first clinical specialists. Two periodontists, one prosthodontist and one oral surgeon completed their training and were certified as specialists that year. From 1969 until the present the CFDS has produced a steady stream of dental specialist officers. The large majority of specialty training has historically been provided by the US Army Dental Corps (USADC); in recent years, due to lack of training positions at USADC installations, much of the specialty training has been undertaken at civilian institutions, both in Canada and the United States.

At the DGDS/Unit Commanders Conference of 1974, the CFDS set the establishment for specialists at six periodondists, five oral surgeons, two prosthodontists, four PHDs, and thirteen advanced general dentists (AGDs). The AGDs were to be trained exclusively in the US Army General Dentistry Residency, which is currently called the Advanced Educational Program Dentistry - 2yr. The current specialist establishment differs slightly, but still calls for thirteen AGDs.

Advanced General Dentistry Specialists

The Advanced General Dentist is the backbone of the CFDS dental specialist classification. The specialty is one of only two with a doctrinal operational role (OMFS is the other). AGDs deployed in the Gulf War and, more recently, during Op Athena. Since the AGD has advanced training in many of the dental specialties, doctrine recommends AGD deployment with large concentrations of troops in demanding conditions, as the AGDs are deemed better able to cope with the dental and oro-facial emergencies that might arise in these areas of operation, diminishing the requirement for patient evacuation. They have also undertaken advanced training in trauma management, including the closed reduction of facial fractures.

In most clinics where they are employed, the AGD coordinates and participates in effecting complex treatment plans, often involving other CFDS and civilian dental specialists. They also act as mentors to inexperienced dental officers, providing much needed and sought after guidance as these officers develop their clinical skills. Partly due to the variety of positions they can serve in, the CFDS tends to retain AGDs, and the availability of PG positions in this specialty has been a great incentive factor for dental officers to remain in the CFDS past their periods of obligatory service. AGDs have received the dental specialty allowance since the inception of DOSA/MOSA in the early 90s, and are currently compensated as dental specialist officers IAW CBI 204.217.

AGD specialist officers usually act as the first point of specialty referral, as their training in the dental specialties is extensive compared to undergraduate dental school. In most

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undergraduate programs the graduating dentist has been taught to recognize and manage conditions by referral to specialists; the AGD is taught to recognize and treat most conditions to the level of competency of a specialist. In the CFDS, the AGD is also used as a mentor in the Officer Clinical Specialty Courses, enjoying the same standing as the course director, who is usually a specialist in the discipline being taught. As we have no CFDS specialists in Endodontics, an AGD is employed as course director for the Clinical Endodontcs course. Since 1973, almost without exception, the CFDS has sent two dental officers on this very demanding post-graduate specialty program every year. The decision was taken in 1974 that every Dental Detachment with more than three dentists on staff should employ an AGD in order to minimize referrals to specialists. In addition, AGD specialist positions at CFDSS and the Directorate were established. The net result was intended to reduce the need for single discipline specialists, outside referrals and patient travel, with the added benefit of better patient care and less administrative burden on units.

History of the Advanced General Dentist Specialty

During the late 1950s and early 1960s, the USADC expanded its investment in graduate and post-graduate training in order to keep up with the trend toward specialization. They quickly realized that although large centers were well served by specialists, the majority of army installations were staffed by a small number of dentists and lacked most, if not all, of the specialist services. It was not economical to place three or four specialist officers, providing a limited scope of dentistry, in the smaller installations, as there was not enough treatment needs to challenge their skills and keep them fully occupied with clinical care. From an analysis of this situation a new concept evolved - that of an individual trained to a level that would free him/her of a reliance on specialists, a dentist who could manage the majority of cases that are normally referred to single discipline specialists for treatment. This dentist would be trained to a semi- specialty level in each major discipline.

A program was developed; the guidance given to the directors was to produce a dentist who could, at a minimum, function in these capacities:

Provide the full spectrum of dental treatment in order to treat at least 90% of the specialty needs of personnel in locations where specialists are not available. Act as the head of a group practice dental service, who provides technical supervision for both professional and auxiliary personnel. Command a dental unit in a mobile or static situation. Act as a treatment coordinator in cases in which a multidisciplinary approach is required and available specialists are geographically remote from one another Instruct in professional subjects at a sub-specialty level.

The programs were set up at select bases with a patient census of at least 50,000, and with at least one clinic large enough to house several specialty departments, to encourage consultation and cross training. The residents were to have access to a hospital with an accredited dental service, as the oral surgery portion of the training was to be conducted in a hospital setting. The minimal teaching staff was to include board certified (or eligible) specialists in oral surgery, fixed prosthodontics, removable prosthodontics,endodontics, periodontics, and either oral pathology or oral medicine. At bases where dependent care was authorized, it was desirable to

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have a pedodontist and orthodontist on staff. The first program was initiated in 1962; by 1969, five programs were running, producing 20 residents a year. For the most part, individuals selected for training had practiced dentistry for five or more years and had various degrees of experience in the separate disciplines. This principle is still in place today, with experienced clinicians competing for positions in this residency in order to enhance their clinical skills to the specialty level. In January 1970 the US Army Dental Corps began certifying qualified graduates of the AGD program as specialists, awarding them the same "B" prefix awarded to those clinical dental specialists who pass their American specialty board examination, and accorded them the same pay scale. They considered that the AGD residents had completed a concentrated two-year experience in which their education exceeds that required by some specialties.

Scope of AGD Training and Capabilities of AGD Graduates

A minimum curriculum was developed for each discipline in the program. With no attempt to be all-inclusive, and with the inclusion of some updated procedures, the following points highlight the objectives of training and the advanced capabilities of the AGD graduate, by discipline:

Oral Surgery - Perform any extraction, up to the most difficult impaction, that can be done intraorally Manage any complication that might reasonable result from an extraction procedure Perform closed reductions of the tooth bearing bones, and know when an open reduction is indicated Provide emergency treatment of acute maxillo-facial injuries Establish diagnoses of lesions of the oral regions

Periodontics - Establish a periodontal diagnosis, prognosis, and treatment plan. Understand the capabilities and limitations of the various treatment techniques available, and exercise judgment in choosing a conservative or surgical approach Be able to perform the basic periodontal surgical techniques Understand to role of occlusion in periodontics and be able to correct occlusal disharmonies Understand and emphasize the importance of patient education and motivation in the maintenance of periodontal health

Fixed prosthodontics Know enough about occlusion to locate the hinge axis, accurately mount diagnostic casts, and correct occlusal disharmonies Understand the contraindications as well as the indications for fixed prostheses Be able to design fixed appliances that not only restore missing structures, but preserve the existing ones Be able to prepare teeth for full crowns, partial veneers, or pin-type retainers, and know the advantages and disadvantages of each Know the advantages and disadvantages of the various impression materials, and be skilled in their use Be skilled enough in laboratory procedures to instruct laboratory personnel in the various techniques

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Be able to seat, adjust and finish a completed fixed partial denture

Removable prosthodontics - Develop a diagnosis and treatment plan based on oral anatomy, physiology, and biotechnical influences Thoroughly evaluate patients physically and psychologically, and anticipate problem areas Construct satisfactory complete denture for most patients with problems (including inadequate lower ridges, prognathic mandible or retrognathic maxilla, minimal intermaxillary space, tendency to gag, and so forth Design and construct all types of removable partial dentures. Thoroughly understand the use of the surveyor, and the benefits that often can be obtained by modification of remaining teeth. Design and construct surgical splints

Endodontics - Be able to accurately diagnose pulpal and periapical pathologic conditions Be fully competent in the treatment of endodontic emergencies, whether they are infectious or traumatic Have a broad knowledge of sterilization techniques and the chemotherapeutic agents and bacteriology involved Be experienced in the treatment of posterior as well as anterior teeth Be capable of performing any type of surgical endodontic procedure indicated

Oral medicine and pathology - Recognize congenital lesions Be able to make a differential diagnosis among the various soft tissue and bony lesions occurring in and around the oral cavity Be able to identify oral manifestations of systemic disease and make proper referrals Understand the hemorrhagic disorders, and arrange for their management when necessary Be competent in exfoliative cytology and, in conjunction with his surgical training, in biopsy techniques

Discussion These skills (and knowledge levels) far exceed those of the dentist in general practice, and are the same as those expected of specialists in each of the single clinical specialty disciplines. Since this minimum curriculum was developed, changes in the way dentistry is practiced, in particular the advent of the use of implants, have resulted in corresponding changes to the curriculum. Placement and restoration of dental implants is now part of the curriculum. In addition, all residents experience a rotation in anesthesiology as part of their program.

A more appropriate term might be "Comprehensive" dentist or "Advanced Comprehensive" dentist, since most treatment provided is well above the level of expertise of the undergraduate trained general dentist. Having undergone advanced education and training, to the level of single discipline dental specialists in the majority of specialty procedures, the presence of an AGD specialist reduces the need for single discipline specialists and civilian referrals in the CFDS. This greatly reduces patient time away from work and overall civilian treatment costs. The

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patient experiences a higher level of care than he/she would otherwise receive, especially in geographical areas under- serviced by single discipline specialists, and the administrative burden on units arranging patient travel is reduced. The title Advanced General Dentistry specialist perhaps does not do the discipline justice.

Summary The rationale for the existence and retention of the AGD specialist group is multidimensional and sound. The Medical and Dental MOSID advisors have agreed that there is simply no medical equivalent with which to compare due to the wide breadth of multidisciplinary knowledge and specifically multidiscipline hands-on procedural activity, and, they are required to be Board certified. There is a clear and compelling business case for having the AGD specialists because of this multidisciplinary capability.

Validation of the AGD specialist was done in the Treasury Board Pay review passed in 2000. It was ultimately included in the Compensation and Benefits Instruction 204.217 with the introduction of the new specialist pay field. It has effectively already met the highest level of outside scrutiny and survived. This should be considered a dead issue. The long-standing existence of this specialty is a significant retention factor for the CFDS and removal of same would create such a backlash from the dental officer corps that a mass exodus would be expected. Recovery from the subsequent dental officer manning shortage would be difficult or impossible to recover from.

The AGD specialists form the backbone of the CFDS, supporting both single discipline specialists and undergraduate trained general dentists alike. The perpetuation of this specialty discipline is essential to the successful future of the CFDS.

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