P R E V E N T I V E O R A L H E A LT H C A R E A N D O L D E R P E O P L E

ARTICLE
ABSTRACT
The aim was to study the determinants of preventive oral health care need among community-dwelling old people. The study population consisted of 165 participants, a subpopulation in the Geriatric Multidisciplinary Strategy for Good Care of Elderly People (GeMS) study. Fifty-five percent of the edentate participants with full dentures and 82% of the dentate had a need for preventive oral health care. In the total study population, the need for preventive care was associated with co-morbidity (measured by means of the Modified Functional Co-morbidity Index) odds ratios (OR) 1.2 (confidence intervals [CI] 1.01.5), being pre-frail or frail, OR 2.5 (CI 1.25.1), presence of natural teeth, OR 4.8 (CI 2.210.4), and among dentate participants, the use of a removable partial denture, OR 12.8 (CI 1.4114.4). Primary care clinicians should be aware of the high need for preventive care and the importance of nonoral conditions as determinants of preventive oral health care need.

Determinants for preventive oral health care need among community-dwelling older people: a population-based study
Kaija Komulainen, DDS;1,2,5* Pekka Ylstalo, DDS, PhD;3,4 Anna-Maija Syrjl, DDS, PhD;3,8 Piia Ruoppi, DDS;5 Matti Knuuttila, DDS, PhD;3 Raimo Sulkava, MD PhD;6,7 Sirpa Hartikainen, MD, PhD1,2
Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland; 2Clinical Pharmacology and Geriatric Pharmacotherapy Unit, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; 3Department of Periodontology, Institute of Dentistry, University of Oulu, Finland; 4Institute of Dentistry, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; 5Social and Health Centre of Kuopio, Finland; 6 Institute of Public Health and Clinical Nutrition, Division of Geriatrics, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; 7Department of Neurology, Kuopio University Hospital, Kuopio, Finland; 8Oulu Health Centre, Oulu, Finland. *Corresponding author e-mail: kaija.komulainen@uef.fi Spec Care Dentist 34(1): 19-26, 2014
1Research

KEY WORDS: preventive oral health

care, older people

Introd u ct ion

Good oral health is related to general health and the quality of life, which emphasizes the importance of retaining good functional dentition.1,2 Longitudinal studies have shown that good oral health and retention of ones own natural teeth is possible with effective oral self-care and regular use of dental health care services.3,4 However, according to previous studies, older people use dental health care services infrequently and in a symptom-based manner.5,6 Earlier studies have shown that preventive oral health care measures lead to better oral health also among old people.7 From this point of view it is surprising that those older adults who use dental services have ongoing dental treatment needs.8 Whether this is due to a lack of preventive oral health care, including oral self-care and maintenance care, or the complexity of dental treatment among old people is not known. It has also been shown that functional and cognitional disabilities are reasons why older people may have special needs for preventive oral care.9,10 This means that successful implementation of preventive care requires recognition of the diversity and heterogeneity of the older population.11 However, implementation of preventive oral health care can be complicated by social and economic situations as well as deeply rooted traditions of restorative oral health care.12,13 To date, there is information on the supply of preventive dental care services,14,15 but information on the need for preventive dental care and its determinants among the community-dwelling older people is scarce. In order to be able to optimally allocate preventive oral health care to people of high age, it is important to identify factors associated with preventive oral health care need. The purpose of this study was to analyze the determinants of preventive oral health care need in a population of communitydwelling people aged 75 years or over.

2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12021

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Mater ial and me tho ds

Study design and participants
This study (Oral Health GeMS) is based on a subpopulation of participants in a population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study aimed at preventing disability and maintaining autonomy in older people. The original sample (n = 1,000) of the parent GeMS study was a random sample of all persons aged 75 years living in the city of Kuopio, Finland, on the first of November, 2003. In the parent GeMS study, computer-generated random numbers were used to randomize 500 people into an intervention group and 500 into a control group. For the Oral Health GeMS study, the intervention group of the parent GeMS study was further randomized into oral health intervention (n = 250) and control (n = 250) groups. This study was based on 165/250 (n = 44 refused, n = 19 died, n = 21 were institutionalized, n = 1 moved) community-dwelling older persons in the oral health intervention group whose oral status was recorded and whose need for preventive oral health care was assessed. The main reasons for refusing were having no teeth or tiredness. The parent GeMS study is described in more detail by Tikkanen et al.16 and the Oral Health GeMS, by Komulainen et al.17

Data collection
In this study, information was collected about nonoral health, oral health, medications, use of health care services, and socio-demographic background. Two study nurses performed a structured interview on health status, use of social and health care services, and sociodemographic factors. An overall medical geriatric assessment was conducted by two study physicians who were specializing in geriatrics.

Data collected in the parent GeMS study

Educational level was asked by the study nurse and classified according to years of completion of a school: lower-level com-

prehensive school or less (06 years) and upper-level secondary school or occupational education (7 years or more). Self-reported health was measured on a five-point scale, as a part of the interview, and categorized into two categories: good or excellent vs. moderate, poor, or very poor. Each participants co-morbidities were scored according to a modified version of the Functional Comorbidity Index (FCI).18 The FCI has been shown to predict physical function in older people. In this study, diagnoses that were included were rheumatoid arthritis and other inflammatory connective tissue diseases, osteoporosis, diabetes, chronic asthma or chronic obstructive pulmonary disease, coronary artery disease, heart failure, myocardial infarction, stroke, depression, visual impairment, hearing impairment, Parkinson s disease or multiple sclerosis, and obesity (body mass index > 30).19,20 The presence of each of these 13 conditions gave one score, with a higher FCI sum representing greater co-morbidity. Self-reported diagnoses were complemented with data obtained from the Special Reimbursement Registers maintained by the Social Insurance Institution of Finland, by a clinical examination by a physician, and from medical records of Kuopio University Hospital and Kuopio Health Center. Frailty status, used in our study, was defined according to the five frailty criteria used in the Cardiovascular Health Study (CHS):21 weight loss ( 5% of body weight in the previous year), weakness (the lowest quintile for hand grip strength, adjusted for gender), low energy (based on the answer given in the context of the self-report Geriatric Depression Scale [GDS]), slowness (the time needed to walk 10 meters, adjusted for gender), and low physical activity (a modified version of the six-graded Grimby scale22). The participants were frail if at least 3/5 of the criteria were realized, pre-frail if 12/5 domains were fulfilled, and robust if no criteria were found. A study nurse assessed cognitive capacity using the Mini-Mental State

Examination (MMSE) screening test23 to test various cognitive functions (arithmetic, memory, orientation) with a 30-point questionnaire. The maximum score was 30, meaning good cognitive capacity, whereas 24 or below meant impaired capacity.24 Functional ability was evaluated using the 8-point Instrumental Activities of Daily Living (IADL) screening instrument.25 The measure included questions on using the telephone, grocery shopping, preparation of meals, housekeeping, doing the laundry, mode of transport, taking care of medication, and managing money. The scale was dichotomized as having significant difficulties in one or more daily tasks (IADL 07) vs. having no difficulties in any of the daily tasks (IADL 8). Nutritional status was determined by a study nurse using the Mini Nutritional Assessment (MNA) test,26 which has sensitivity and validity for an older population. The short version (MNASF)26 used in this study consists of six questions in different domains of nutritional well-being taken from the full MNA, including eating problems, weight loss, mobility, neuropsychological problems, acute illness or stress, and body mass. The total scores of the MNA-SF screening test ranged from 0 to a maximum score of 14 points; 11 or fewer points were classified as malnourished or at risk of it. Information on drug use was obtained through an interview and verified from prescriptions and drug containers. Classification of polypharmacy statussix drugs or more taken on a regular basiswas based on the definition by Jyrkk et al.27

Data collected in the Oral Health GeMS study

Clinical oral examination was done by two dentists. The clinical oral examination involved registration of the condition of the periodontium, teeth, removable dentures, and mucosa, as well as saliva collection, and it was performed by one of two experienced dentists in a primary care setting at the dental clinic of the social and health center of Kuopio or in the persons home. Information on

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oral self-care habits and use of dental health care services was obtained by means of an interview during the same visit. The clinical oral examination was performed in a standardized manner, based on written instructions. The examiners were trained by having them together examine and assess the need for preventive care of seven study participants before the survey. The oral examinations were done in adjacent rooms and the examiners had the possibility to consult each other in interpreting clinical findings and assessing the need for preventive oral health care. Because of the high age of the participants and the length of the examination (one hour), no repeated or parallel examinations were done to assess repeatability within examiners or concordance between examiners.

Outcome variable
Our outcome variable was need for preventive care, which was assessed by the dentist in connection with the clinical oral examination and the interview. The need for preventive oral health care was based on an assessment of health status and a comprehensive assessment of oral status. If the participants had any of following, she/he fulfilled the criterion: poor oral or denture hygiene, signs of mucosal or gingival inflammation (presence of mucosal lesions, gingivitis, calculus, or deepened periodontal pockets), caries activity (cariological status in relation to treatment history), subjective symptoms of dry mouth (xerostomia), or objective low saliva secretion. Information on oral hygiene, oral health, and oral health behavior was obtained from the clinical oral examination and health interview. Oral hygiene among dentate subjects was measured by means of the presence of dental plaque, which was visually examined on the buccal and/or palatal/lingual surfaces of each tooth. Oral hygiene was considered good if there was dental plaque on 020% of all teeth vs. poor if there was dental plaque on more than 20% of all teeth. Denture hygiene was measured using a modified version of the

Ambjrnsen28 method and was categorized as good (minimal or no denture plaque) vs. moderate or poor (denture plaque detected by scraping with a blunt instrument or visible denture plaque). The presence of gingivitis was based on visual examination and recorded as presence of redness and/or edema on the buccal and/or lingual/palatal side of the gingiva of each tooth. Presence of deepened periodontal pockets (4 mm or more) and calculus were recorded during probing (WHO periodontal probe) at two sites: the mesiobuccal and distopalatal/ distolingual surfaces of each tooth. Dental caries was examined on each surface of every tooth and recorded as crown caries (caries had reached the dentin layer of the clinical crown), root caries (softened root surface), crown and root caries, or carious dental radix. Dental caries was recorded at tooth level; a tooth was defined as carious if any of the above-mentioned criteria were fulfilled on any surface of the tooth. Xerostomia (i.e., subjective feeling of dry mouth) and hyposalivation (reduced salivary flow rate) were based on subjective symptoms and objective saliva rate, respectively. Salivary flow rate was measured before the clinical oral examination. The subjects were asked to abstain from eating and drinking for one hour before the measurement. Unstimulated and stimulated saliva flow rate were measured using the draining method. Salivary flow rate measurements in the GeMS study are described in more detail by Syrjl et al.29` Mucosal lesions were examined on the mucosal membranes, palate, tongue, tissues under the tongue, gingiva, and alveolar ridges. The findings were classified by their location, color, and surface structure. The presence of mucosal findings was recorded according to whether they needed a follow-up (yes vs. no). Presence of denture stomatitis was based on whether there was smooth or nodular redness in the oral mucosa in the context of the removable denture. Toothbrushing frequency was asked and categorized as follows: toothbrushing at least twice a day vs. less. Toothpaste use and interdental cleaning

was categorized likewise into two categories: use of toothpaste at least twice a day vs. less, and use of toothpicks and interdental floss or a brush at least once a day vs. less. In denture cleaning, the classification was cleaning the denture at least twice a day and using a denture cleaning agent daily. The frequency of consumption of sugar products, sweet rolls, juice or other soft drinks, and candy was also asked. Time since the last dental visit was asked, and included visits to a dental technician, a dental hygienist, and/or a dentist in public and/or private dental care. The visitation frequency was classified as in the previous year vs. less frequently. Regular dental check-ups meant visits to dental care for a check-up at regular, given intervals, which were mainly once a year or once in 2 years. Characteristics related to the sociodemographic, health, and oral status and the dental health care service use of the study participants are described according to preventive oral health care need (Table 1).

Statistical method
Odds ratios (OR) with 95% confidence intervals (CI) were estimated using logistic regression models. The models were adjusted for age, education, and gender. The data were analyzed using the Statistical Package for Social Sciences (SPSS 14.0 software for Windows, Chicago, IL, USA).

Ethics
All the participants were offered standard dental care, including relief of oral pain and restorative, prosthetic, and surgical treatment, when indicated. Written informed consent was obtained from the study participants, or in a case of problems with communication or the participants memory, from a family member of the participant. The study protocol was approved by the Research Ethics Committee of the Hospital District of Northern Savo, as required by Finnish legislation.

R es ul t s

Fifty-five percent of the edentate participants, who all had full dentures, and

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Table 1. Characteristics of study population by need for preventive oral health care, stratified by being dentate or being edentate.
All n = 165 Socio-demographic factors Age, mean, (SD)a Gender, female,% (n/all) Education, 7 years,% (n/all) Health-related factors Self-reported health -moderate/poor% (n/all) Co-morbidity FCIb, score 013, mean (SD)a Frailty status, score 05 Pre-frail and frail, score 14,% (n/all) Cognitive ability MMSEc, impaired, score 24,% (n/all) Functional ability IADLd, impaired, score < 8,% (n/all) Malnutrition or risk of it, MNAe, score 11,% (n/all) Polypharmacy, 6 regular drugs,% (n/all) Oral-status-related factors Feeling of dry mouth,% (n/all) No unstimulated saliva secretion% (n/all) Regular dental check-ups,% (n/all) Time since last dental visit < 1 year,% (n/all) Poor dental /denture hygiene% (n/all) Presence of a removable partial denture % (n/dentate) Mean number of teeth, (SD)a
aStandard bFunctional

Need dentate n = 63 80.6 (3.4) 76.2 (48/63) 53.2 (33/62) 63.5 (40/63) 2.9 (1.9) 59.7 (37/62) 14.3 (9/63) 46.8 (29/62) 19.0 (12/63) 38.1 (24/63) 60.3 (38/63) 30.6 (19/62) 47.6 (30/63) 57.1 (36/63) 84.1 (53/63) 98.1 (28/29) 13.2 (8.0)

No need dentate n = 14 79.4 (2.8) 64.3 (9/14) 53.8 (7/13) 50.0 (7/14) 2.4 (1.3) 38.5 (5/13) 14.3 (2/14) 42.9 (6/14) 7.1 (1/14) 35.7 (5/14) 42.9 (6/14) 23.1 (3/13) 71.4 (10/14) 84.6 (11/13) 42.9 (6/14) 1.9 (1/29) 14.4 (8.6)

Need edentate n = 48 82.9 (5.5) 79.2 (38/48) 31.1 (14/45) 66.0 (31/47) 3.2 (1.8) 72.7 (32/44) 37.5 (18/48) 61.7 (29/47) 31.3 (15/48) 45.8 (22/48) 41.7 (20/48) 44.4 (20/45) 6.3 (3/48) 14.6 (7/46) 64.6 (31/48)

No need edentate n = 40 81.2 (4.0) 75.0 (30/40) 30.8 (12/39) 52.5 (21/40) 2.4 (1.7) 40.5 (15/37) 12.5 (5/40) 48.7 (19/39) 17.5 (7/40) 35.0 (14/40) 35.0 (14/40) 23.1 (9/39) 2.5 (1/40) 12.5 (5/40) 30.0 (12/40)

81.3 (4.3) 75.8 (125/165) 41.5 (66/159f) 60.4 (99/164g) 2.8 (1.8) 57.1 (89/156h) 20.4 (34/165) 51.2 (83/162i) 21.2 (35/165) 39.5 (65/165) 47.3 (78/165) 32.1 (51/159 ) 27.5 (44/165) 36.3 (59/163 ) 37.7 (29/77) 13.4 (8.1)
j f

deviation, Co-morbidity Index modified, State Examination, dInstrumental Activities of Daily Living. eMini Nutritional Assessment. Missing data, n = 6f, n = 1g, n = 9h, n = 3i, n = 2j.

cMini-mental

82% of the dentate had a need for preventive oral health care. Among the subjects who used a partial removable denture, the proportion of those who were in need of preventive oral health care was 97% (Table 1). Health-related problems were more common among edentate participants with full dentures than among dentate participants (Table 1). The use of dental health care services was uncommon among participants with full dentures (Table 1). In the whole study population the need for preventive oral health care associated with high age and co-morbidity and being frail or pre-frail. The adjusted odd ratios were for age, used as a continu-

ous variable, OR 1.1 (CI 1.01.2), for the modified functional co-morbidity index, FCI (used as a continuous variable with 13 morbidities), OR 1.2 (CI 1.01.5), for being frail or pre-frail vs. robust, OR 2.5 (CI 1.25.1), and for the presence of natural teeth vs. edentulous, OR 4.8 (CI 2.210.4) (Table 2). When we stratified the data according to dentate status, the results showed that among the edentate participants frailty status, co-morbidity, and impaired cognition were associated with preventive oral health care need (Table 3). Among the dentate participants, co-morbidity and frailty status were more weakly associated with need for preven-

tive oral health care than among the edentate participants. Among the dentate participants the use of a removable partial denture, OR 12.8 (CI 1.4114.4), but not impaired cognition or functioning, was associated with the need for preventive oral health care (Table 3).

D is cus s ion

This study showed that in this community-dwelling population of people aged 75 or more, four out of five of the dentate subjects and half of the edentulous study participants had a need for preventive oral health care. Besides the fact that the need for preventive care was

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Table 2. All participants, association between socio-demographic and health factors, and need for preventive care unadjusted and adjusted odds ratios (OR).
Need for preventive care OR (95% CI) Socio-demographic factors Age, Continuous Gender Male Female Education 7 years <7 years Health factors Self-reported health Good/excellent Moderate/poor/very poor Co-morbidity FCIb (Modified, Continuous) Frailty status Robust Pre-frail, frail Cognitive ability (MMSEc score) Good cognition Impaired cognition (24) Functional ability (IADLd score) Good function Impaired function (<8) Nutrition (MNAe score) Good nutrition Malnutrition or risk of it (11) Regular drugs No polypharmacy Polypharmacy (6) Presence of natural teeth No Yes
aAdjusted

Adjusteda OR (95% CI) 1.1 (1.01.2) 1 1.3 (0.62.8) 1 0.7 (0.41.4)

1.1 (1.0 1.1) 1 1.3 (0.62.8) 1 0.7 (0.41.5)

1 1.7 (0.93.3) 1.2 (1.01.5) 1 2.8 (1.45.6) 1 2.2 (0.85.3) 1 1.2 (0.82.7) 1 1.8 (0.84.4) 1 1.3 (0.72.6) 1 3.6 (1.87.7)

1 1.8 (0.93.5) 1.2 (1.01.5) 1 2.5 (1.25.1) 1 2.3 (0.95.6) 1 1.3 (0.62.5) 1 1.8 (0.74.3) 1 1.2 (0.62.5) 1 4.8 (2.210.4)

for age (continuous), gender, and education (continuous). bFunctional Co-morbidity Index, cMini-mental State Examination, dInstrumental Activities of Daily Living, eMini Nutritional Assessment.

associated with being dentate and having a removable partial prosthesis, it was also associated with nonoral conditions such as high co-morbidity and being frail or pre-frail.

In this study population, nearly half of the study subjects had no natural teeth, and this high proportion of edentate participants reduced the overall need for preventive oral health care, but it was

surprising that also among edentulous participants about half of the participants had a need for preventive oral health care. Among the edentulous participants the most important determinants and possible underlying reasons for preventive oral health care need were frailty status, co-morbidities, and impaired cognition. On the other hand, among the dentate participants the most important determinants were the presence of partial dentures and irregular dental visits, but unexpectedly not the number of own natural teeth. The role of nonoral conditions was less important than among the edentate participants. Almost all the dentate participants with a partial denture and 55% of edentate participants, who all had full dentures, had preventive oral health care need. This high need, especially among the dentate, is most likely related to inability to maintain good oral hygiene. This high need can be contrasted to regular use of dental care services, which in this population was quite low52% among the dentate and 5% among the edentulous. This discrepancy between need and use suggests that there is a gap between the use of dental health care services and the need for dental care, both among dentate subjects and edentate subjects. The results can be interpreted in other way, too. The fact that preventive care need was not associated with a high number of teeth, which, together with the finding that need for preventive care is associated with nonoral condition, may indicate that maintaining good oral health and oral health behavior through life is possible unless disturbed by diseases or disabilities, as suggested earlier by Vilstrup et al.30 If poor nonoral health is truly the underlying reason for poor oral self-care and subsequent need also for preventive health care, it would mean that the current situation is somewhat paradoxical, because old people with impaired health are the most irregular and infrequent users of dental health care services. It has been observed earlier that the complexity of dental care increases as people live longer and retain their natural

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Table 3. Stratified analyses, dentate and edentate participants, and association between health-related factors and need for preventive care, adjusted odds ratios (OR).
Dentate Need, for preventive care Adjusteda OR (95% CI) Health-status-related factors Self-reported health Good/excellent Moderate/poor/very poor Co-morbidity FCIb (Modified, Continuous) Frailty status Robust Pre-frail, frail Cognitive ability (MMSEcscore) Good cognition Impaired cognition (24) Functional ability (IADLd score) Good function Impaired function (<8) Regular drugs No polypharmacy Polypharmacy (6) Nutrition (MNAe score) Good nutrition Malnutrition or risk of it (11) Oral-status-related factors Number of teeth (SD) Continuous Presence of a partial denture No Yes Time since last dental visit 1 year <1 year Regular dental check-up Yes No
a

Edentate Need for preventive care Adjusteda OR (95% CI)

1 1.6 (0.85.2) 1.1 (0.81.7) 1 2.5 (0.69.6) 1 0.8 (0.14.3) 1 1.0 (0.33.8) 1 1.0 (0.33.3) 1 2.1 (0.85.9) 1 1.0 (0.91.1) 1 12.8 (1.4114.4) 1 4.5 (0.824.7) 1 3.4 (0.814.7)

1 2.1 (0.85.2) 1.3 (1.01.6) 1 3.2 (1.2 8.3) 1 4.8 (1.515.7) 1 1.8 (0.74.1) 1 1.3 (0.43.8) 1 2.0 (0.75.8)

care. The underlying reasons for preventive care need were in most cases related to poor oral hygiene, which finding concurs with earlier observations where problems with plaque control have been observed when the conditions require both dental and prosthetic hygiene.31 On the other hand, it has also been shown that problems with plaque control can be overcome if partial denture wearers are regularly checked, motivated, and instructed.32 In this study, the need for preventive oral care and nonoral diseases among the edentate participants were observed. This means that problems with full dentures might serve as an indicator of underlying health problems, as observed earlier.33 In contrast, no such accumulation of health problems was observed among the dentate participants; in this group need was related to the regularity of dental care and the type of dental prosthesis.

Strengths and limitations

The strength of the current study was that it was conducted in real-life circumstances, in the primary dental care unit of a social and health center, mainly in the way standard dental care is carried out in Finland, taking into account the study protocol. This means the finding can be considered to represent the situation among older community-dwelling people at large. A limitation of our study was that there were not many dentate participants without preventive care need, which poses difficulties in the analyses and in the interpretation of results. As an example, we were not able to analyze the determinants for preventive oral health care need among participants with removable partial dentures. Another limitation was that the assessment of the need for preventive oral care may have been to some extent subject to subjective judgment, based on interviews and clinical findings, such as an abundant presence of dental and denture plaque, presence of gingivitis, calculus, and a subjective feeling of dry mouth or low salivary secretion, for example. But, however, the observed associations with expected determinantse.g. being

Adjusted for age (continuous), gender, and education (continuous). bFunctional Co-morbidity Index, cMini-mental State Examination, dInstrumental Activities of Daily Living, eMini Nutritional Assessment.

teeth.14 In this study population, dentate subjects had an average of 13 teeth and more than one-third of the dentate par-

ticipants had a removable partial denture, and all except one with a removable partial denture had a need for preventive

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dentate or having a removable prosthesisas well as other determinants, such as co-morbidity, frailty status, or impaired cognition among the edentate, were fairly strong.

Concluding remarks
The results of this study highlight a comprehensive approach to the conditions of old people. When providing good oral health care to older people, dental professionals should understand the complexity of the conditions of older people and assess their special needs and ability to undergo and respond to care.34-36 In this study a high need for preventive oral health care was observed among community-dwelling dentate older people, but the edentate older people with full dentures also had preventive oral health care need, which was associated with co-morbidity, being frail, and impaired cognition. Altogether, the findings of this study emphasize the importance of regular follow-ups of the oral health of all older people and that the quality and content of oral self-care must be checked and appropriate assistance given. In addition, all primary care clinicians should be aware of the importance of nonoral conditions as determinants of preventive oral health care need.

Ackn owledgeme nts

Thanks are due to dental nurses Ritva Lms and Leena Pitknen and nurses Anu Hnninen and Paula Iire for participating in the data collection. This study was financially supported by the Social Insurance Institute of Finland and the City of Kuopio. Research grants were received from the Finnish Dental Society.

C on f l ict of i nte re st
None

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