satisfaction with chewing ability in a diverse sample of dentate adults

Journal of Oral Rehabilitation 1998 25; 15–27

Satisfaction with chewing ability in a diverse sample ofdentate adultsG . H . G I L B E R T, U . F O E R S T E R & R . P. D U N C A N Claude D. Pepper Center for Research on Oral Healthin Aging, University of Florida, Gainesville, FL, U.S.A.

SUMMARY The Florida Dental Care Study (FDCS) is a

longitudinal study of changes in oral health, which

included at baseline 873 subjects who had at least

one tooth, were 45 years or older, and who

participated for an interview and clinical

examination. Two objectives of the FDCS were to:

(i) describe satisfaction with chewing ability in a

diverse sample of dentate adults; and (ii) quantify

the associations between satisfaction with chewing

ability and other measures of oral health.

Approximately 16% of subjects reported that they

were dissatisfied or very dissatisfied with their

Introduction

Recognizing that there is more to health than the lackof disease, during the past few decades measures ofhealth status have progressed from those based solelyon mortality or disease to those that include self-reported social, psychological, functional, andbehavioural measures of health status (Ware, 1995). Itis clear that self-reported data from patients can provideinformation important to the evaluation of theeffectiveness of health care, and that this informationis typically reliable and valid (Patrick & Deyo, 1989;Ware et al., 1995; McDowell & Newell, 1996). Progressin the use of self-reported health outcomes in the oralhealth field has lagged developments in measurementof general health status, and the need for further workin oral health measurement is clear, as is its applicationto improve the evaluation of the effectiveness of nearlyall aspects of dental care (Antczak-Bouckoms, 1995;

© 1998 Blackwell Science Ltd 15

chewing ability. Bivariate and multivariate resultsprovided consistent evidence of the constructvalidity of a proposed multi-dimensional model ofsatisfaction with chewing ability. Multiple regressionanalysis suggested that dissatisfaction with chewingability was independently associated with 12 specificclinical and self-reported measures of oral disease/tissue damage, pain, functional limitation, anddisadvantage. The self-reported measures of oralhealth and the proposed model of satisfaction withchewing ability improve our understanding of thisimportant oral health outcome in diversepopulation groups.

Bader & Shugars, 1995). Information on the multiple

dimensions of oral health status is emerging, however,

and suggests that the self-reported measures of oral

health are more informative of how oral disease affects

the daily lives of individuals and populations, whosequality of life is, after all, the predominant reason forthe existence of dental care (Atchison & Dolan, 1990;Gilbert, Heft & Duncan, 1993; Strauss & Hunt, 1993;Locker & Miller, 1994; Slade & Spencer, 1994; Hunt,Slade & Strauss, 1995).

One of the most important of these self-reported oralhealth outcomes is satisfaction with chewing ability.Herein we describe satisfaction with chewing ability ina community-based, representative sample of dentateadults from the Florida Dental Care Study (FDCS). Themost important advantages of this sample were that itincluded: (i) subjects without regard to whether theysought dental care regularly; and (ii) adults from adiverse array of backgrounds. The overall objective of

16 G . H . G I L B E R T et al.

the FDCS was to develop a risk assessment model of

longitudinal oral health outcomes. The objectives for

the analyses in this report were to: (i) describe

satisfaction with chewing ability in a diverse sample of

dentate middle-aged and older adults; and (ii) quantify

the associations between satisfaction with chewing

ability and other measures of oral health, namely, self-

rated and clinically derived measures of oral disease/

tissue damage, oral pain, oral functional limitation and

oral disadvantage.

Materials and methods

Sampling methods and subject recruitment

The goal of the sampling design was to ensure that a

large number of persons at a hypothesized increased

risk for oral health decrements would be included for

the FDCS sample at baseline. Hypothesized high-risk

groups of special interest were black people, residents

of rural areas, persons who were 45 years old or older,

and the poor, who were defined as being below the

U.S. poverty level (U.S. Bureau of the Census, 1992).

Only subjects with at least one remaining natural tooth

were included in the sample.

A telephone screening methodology was used to

identify a random sample of 3998 subjects in households

with telephone(s) who resided in one of four counties

in north Florida and who had at least one remaining

natural tooth. A disproportionate stratified random

sample of 1800 dentate subjects was selected for further

study from the pool of 3998 subjects. Eight hundred

and seventy-three of these subjects participated, 707

were contacted but refused, and 125 were unreachable,

usually because of disconnected telephone service.

Ninety-five subjects were subsequently judged

ineligible. We previously assessed the potential for bias

in the sample; participation by the 873 subjects resulted

in a sample of only modest bias with respect to the

population of interest (for other methodologic details,

see Gilbert et al., 1997a).

Interview and clinical examination methods

Subjects attended for a baseline in-person interview,

which was followed immediately by a clinical dental

examination. The baseline field phase began in August,

1993 and ended in April, 1994. The interview was

administered by trained interviewers and typically lasted

© 1998 Blackwell Science Ltd, Journal of Oral Rehabilitation 25; 15–27

30 min. We have previously described the examination

protocol, clinical diagnostic criteria, quantified

interexaminer reliability for the clinical examination,

and quantified test–retest reliability of questions from

the baseline interview, all of which we judged to be

satisfactory (Gilbert et al., 1996; Ringelberg et al., 1996;

Dolan et al., 1997; Gilbert et al., 1997a).

A model of oral health that structured our analyses

To aid in identifying which factors to consider as

determinants of satisfaction with chewing ability, and

to structure our subsequent regression analysis, we

adapted a model of oral health to the chewing

satisfaction context (Fig. 1). This structure of oral health

(oral disease/tissue damage, pain, functional limitation,

and disadvantage) and satisfaction with chewing ability

was conceptualized by adapting with revision the work

of Locker (1988) and Johnson and Wolinsky (1993). The

model posits a sequential causal process that involves

specific antecedents and consequents, and parallels

strongly the biomedical conception of the natural history

of disease (Johnson & Wolinsky, 1993). In the

terminology that we have adopted, ‘oral disease/tissue

damage’ refers to disorder at the organic level, such as

active disease, a metabolic disorder, an anatomical

defect, or tissue loss. Its definition is confined to the

context of a single individual. ‘Pain’ can be experienced

in response to disease and tissue damage, whether

physical or psychological, such as the pain experienced

with toothaches caused by dental caries. ‘Oral functional

limitation’ denotes physical or psychological

dysfunction, such as an inability to chew food well. Its

definition is likewise confined to the context of a

single individual. ‘Oral disadvantage’ denotes a social

or societal state in which persons affected by disease,

tissue damage, pain, and/or functional limitation do

not perform normal social roles, such as interpersonal

contacts or employment. ‘Satisfaction with chewing

ability’ is the patient’s overall assessment of his or

her chewing ability, which may be influenced by oral

disease, tissue damage, pain, functional limitation, and/

or disadvantage.

Oral functional limitation and oral disadvantage

reflect whether or not specific behaviours have been

exhibited, such as whether persons have actually

avoided chewing certain foods. However, satisfaction

with chewing ability is entirely subjective, because it is

unobservable as behaviour. Nonetheless, satisfaction

S AT I S FA C T I O N W I T H C H E W I N G A B I L I T Y A M O N G D E N TAT E A D U LT S 17

Fig. 1. Conceptual model of chewing satisfaction specifying relations between oral health constructs.

with health and health-related function is of interest in

its own right because of its ability to predict health care

use, as well as its importance to the assessment of the

quality and effectiveness of health care (Mossey &

Shapiro, 1982; Idler & Angel, 1990; Wolinsky &

Johnson, 1991, 1992). Additionally, using subjective

ratings helps us understand what oral diseases,

conditions, and quality of life impacts are used by

patients to assess their own health and function, and

helps us infer what health decrements should be

targeted for dental care and public health interventions.

As an example from Fig. 1, consider the circumstance

of a person who has severely loose teeth, a significant

number of missing teeth, and a maxillary full denture

that is slightly fractured, exposing a sharp acrylic edge

(examples of measures of the disease/tissue damage

construct). The loose teeth, missing teeth, and defective

prosthesis may lead to pain during chewing (an example

of a measure of the oral pain construct in Fig. 1). These

missing teeth, loose teeth, and pain on chewing then

lead to difficulty chewing certain foods (an example of

a measure of functional limitation in Fig. 1), which in

turn leads to the avoidance of eating with others

because of that chewing difficulty (an example of oral

disadvantage in Fig. 1). Oral disease, tissue damage,

pain, functional limitation and disadvantage can then

affect the individual’s satisfaction with chewing ability.

Parenthetically, this ‘progression’ from disease and

tissue damage to the functional, behavioural, and social

aspects of health is not always a progression from

identifiable biologic causes; that is, psychosocial

manifestations of health decrements may not always

have identifiable biologic components (for example, as


Dworkin, von Korff & LeResche (1992) have discussed

in their biopsychosocial model of chronic pain). Because

of this possibility, we test the effects of selected

sociodemographic factors that may serve as proxies for

these possible psychologic effects (described later).

Our analysis of cross-sectional data in this report

relies upon this proposed temporal ordering of

antecedents and consequents to make inferences about

the validity of the proposed model. As the FDCS

progresses longitudinally, it will be possible to test

the predictive validity of the model. Additionally, we

hypothesize that some ‘consequent’ constructs can

themselves affect ‘antecedent’ constructs over time; for

example, the development of a functional limitation

(such as a decline in chewing ability) may ultimately

lead to disease/tissue damage (such as dental caries)

because of a change in diet. However, these pathways

of reciprocal causation cannot be tested in our cross-

sectional design.

The in-person interview and clinical examination

were used to obtain information about the broad range

of oral health measures (Table 1 and Appendix)

suggested by the model in Fig. 1. Self-reported items

were elicited by asking a series of closed-ended questions

that queried each item separately; that is, symptom

check-lists were not used. The actual wording of these

items is available from the authors upon request. Data

on ‘current oral disease/tissue damage’ were gathered

by direct clinical examination and by selected self-

reported items that queried whether the subject had

the disease/tissue damage at the time of the interview

and, for those who answered affirmatively, the duration

of that disease/tissue damage. The clinical examination


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recorded the presence and location of remaining teeth,

root fragments (defined as missing more than three-

quarters of the clinical crown), bulk restoration

fractures, fractured teeth involving the dental cusp and/

or incisal edges, and teeth that were severely mobile

(more than 2 mm buccolingual movement). Self-

reported measures of oral disease/tissue damage were

queried as listed in Table 1. ‘Oral pain’ was measured

by asking subjects to report its presence and duration;

these pain symptoms were then linked to the more

common dental diseases and conditions – dental decay

and denture soreness. It was not within the scope of

the FDCS to measure other types of orofacial pain, such

as neuropathic pain, pain of the temporomandibular

joint, etc. ‘Oral functional limitation’ was measured by

asking subjects: (i) current chewing ability, using with

minor revision (Foerster, Gilbert & Duncan, 1997) an

index of chewing ability proposed by Leake (1990);

and (ii) whether they had any difficulty speaking or

pronouncing words because of problems with their

teeth, mouths, or dentures, and the frequency of that

difficulty within the previous 6 months. ‘Oral

disadvantage’ that was relevant to chewing satisfaction

was measured with five questions that asked subjects

to report on whether mouth problems caused them

to avoid certain activities, and the frequency of that

disadvantage within the previous 6 months. Most of

these oral disadvantage items were adapted with some

revision from the work of Cushing, Sheiham & Maizels

(1986). Our previous report used factor analysis to

demonstrate the validity of the oral disadvantage

construct (Gilbert et al., 1997c). ‘Satisfaction with

chewing ability’ was measured using a single question

that asked subjects to rate their satisfaction as ‘very

satisfied’, ‘satisfied’, ‘dissatisfied’, or ‘very dissatisfied’.

As is evident from Table 1 and the preceding

paragraphs, multiple measures of each of the four

constructs of oral disease/tissue damage, pain,

functional limitation, and disadvantage were used. We

hypothesized differential effects on satisfaction with

chewing ability by individual measures of a given

construct. As an example, for the ‘oral disease/tissue

damage’ construct measured by 18 factors (which are

listed in Table 1), a given factor may have a larger

effect on satisfaction than one of the other factors. For

example, we hypothesized that the number of occluding

pairs of teeth and fixed prostheses would have a greater

influence on satisfaction than the number of bulk

restoration fractures, because, while the latter represents


a need for restorative treatment, it may not affect

chewing ability. Thus, we tested the effects on

satisfaction from the 18 individual measures separately,

rather than by creating an index or summated scale of

these measures.

Although not specified in Fig. 1, we also hypothesized

that the approach to dental care and certain

sociodemographic factors (age, sex, race, financial

status, rural/urban residence, level of formal education)

affect satisfaction with chewing ability. These factors

are not specified in Fig. 1 for simplicity of graphical

presentation. The approach to dental care was

determined by asking subjects whether they sought

dental care: (i) regularly; (ii) occasionally, but not

because of a specific dental problem; (iii) only when

they have a specific problem; or (iv) never. The first

two of these categories were subsequently combined, as

were the third and fourth of these categories. Financial

status was ascertained by two sets of questions. The

first set of questions asked about annual household

income and the number of persons residing in the

household, from which it was determined whether the

subject lived above or at/below the 100% poverty level

as defined by the U.S. Bureau of the Census (U.S.

Bureau of the Census, 1992). The second question

asked subjects about their ability to pay an unexpected

$500 dental bill, and provided three response categories:

(i) able to pay comfortably; (ii) able to pay, but with

difficulty; (iii) not able to pay the bill. ‘Ability to pay

an unexpected $500 dental bill’ was ultimately chosen

for the regression modelling (Table 6) because 50

subjects refused to provide answers that allowed

categorization by poverty status, compared to only three

subjects for the ‘ability to pay’ variable.

Statistical methods

Results were weighted using the sampling proportions

in order to reflect the population in the counties studied.

For example, although 35% of the sample of 873

subjects was poor, the weighted percentage was 16%

to reflect the percentage of 45- year-old or older persons

in these counties who were actually poor. The

demographic targets were taken from county-specific

and ZIP code-specific census data that detailed target

populations by age, gender, race, and poverty status

(U.S. Bureau of the Census. Unpublished special

tabulations for the University of Florida from the 1990

Census of Population & Housing for the U.S. & four

counties in north Florida, 1994).


Analyses were done using SAS (SAS System for

Windows®, Version 3·1, SAS Institute, 1989). Comments

about statistical significance refer to probabilities of less

than 0·05. The chi-squared and Mantel–Haenszel chi-

squared trend tests were used for bivariate comparisons

when variables were nominal or ordinal, respectively.

For stratified analyses, the Cochran–Mantel–Haenszel

general association test was used. Logistic regression

(LOGISTIC procedure, SAS) was used to test differences

multivariately. Although the outcome of interest,

satisfaction with chewing ability, was ascertained by

response to a four-point ordinal scale, preliminary

logistic regression analyses indicated that the parallel

lines assumption (‘proportional odds’ assumption) that

is required in SAS for logistic regression of ordinal data,

was violated. Consequently, we pooled persons who

responded ‘very dissatisfied’ with those who responded

‘dissatisfied’. The outcome then became a three-point

ordinal scale, and the parallel lines assumption was

then no longer violated. Multicollinearity was measured

using a procedure described by Belsley, Kuh & Welsch

(1980). Several explanatory covariates introduced

problems with multicollinearity. Only when ‘sore

denture’ and ‘broken denture’ were combined into one

variable; when ‘toothache pain’ and ‘abscessed tooth’

were combined into one variable; and when ‘broken

tooth or broken cap’ and ‘loose cap or bridge’ were

combined into one variable, was the problem with

multicollinearity eliminated, and these combined

variables were the ones used in the regression in Table 6

(for exact coding of these variables, see Appendix).

Some of these recoded variables combined measures of

oral disease/tissue damage with measures of oral pain;

this was necessary for the stated empirical reasons, not

for theoretical reasons.

Model fit was assessed using the association between

predicted probabilities and observed responses. This

association is calculated by determining the number of

times concordant, discordant, and tied pairs occur based

on predictions from the logistic model. A pair of

responses from two different subjects is said to be

concordant (discordant) if the larger response has a

higher (lower) predicted event probability than the

smaller response.

Results

Although relevant to satisfaction with chewing ability,

we have previously described the sociodemographic


characteristics of the FDCS sample and its prevalence

of oral disease/tissue damage, oral pain, oral functional

limitation, and oral disadvantage (Gilbert et al., 1996,

1997a,b,c; Ringelberg et al., 1996; Dolan et al., 1997;

Foerster et al., 1997). Consequently, we do not repeat

them here.

Prevalence of dissatisfaction with chewing ability

Approximately 46% of subjects reported that they were

‘very satisfied’ with their chewing ability, 39% said

‘satisfied’, 11% said ‘dissatisfied’, and 4% said ‘very

dissatisfied’. Table 2 presents associations between

satisfaction with chewing ability and approach to dental

care, as well as selected sociodemographic factors.

Dissatisfaction with chewing ability was much more

prevalent in subjects who reported that they attend a

dentist only when they have a problem, compared to

those who said they attend whether or not they have

a problem. Age group, sex, and rural/urban area of

residence were not associated with dissatisfaction at the

bivariate level. Black and poor persons were more likely

to be dissatisfied with their chewing ability, as were

persons with lower levels of formal education.

Association between dissatisfaction and other aspects of oral

health

Table 3 shows the prevalence of dissatisfaction, stratified

by clinical measures of current oral disease/tissue

damage. There was no dissatisfaction with chewing

ability in persons who had 15 or 16 occluding pairs of

teeth or fixed prosthetic replacements. An occluding

pair was defined as having a maxillary tooth or fixed

prosthetic replacement (i.e. a pontic, cantilever, or

implant) that opposed a mandibular tooth or fixed

prosthetic replacement. Dissatisfaction was highest in

those who only had 1–7 occluding pairs. Dissatisfaction

was also associated with the number of severely mobile

teeth and the number of retained root fragments, but

was not associated with the number of teeth with cusp/

incisal edge fractures or the number of teeth with bulk

restoration fractures.

Table 4 shows the prevalence of dissatisfaction,

stratified by self-reported measures of current oral

disease/tissue damage. Dissatisfaction with chewing

ability was more common in subjects who reported that

they had an abscessed tooth, one or more loose teeth,

a broken tooth or broken cap, a loose cap or bridge,

infected and/or sore gums, a problem with food catching


Table 2. Satisfaction with chewing ability for the sample overall,

and by approach to dental care and selected sociodemographic

characteristics

Characteristic (weighted n) % subjects who were

dissatisfied or very

dissatisfied with their

chewing ability

All subjects (872) 16

missing (1)

Approach to dental care

Never go or go only when have a 27*

problem (400)

Go to a dentist whether or not 6

have a problem (474)

Missing (0)

Age group

45–64 years old (513) 16†

65 1 years old (361) 15

missing (0)

Sex

Female (491) 16†

Male (383) 16

Missing (0)

Race and poverty status

Poor Black (75) 36 *

Poor White (57) 35

Non-poor Black (133) 17

Non-poor White (553) 10

Missing (55)

Ability to pay an unexpected $500

dental bill

Not able to pay the bill (122) 40 *

Able to pay, but with difficulty (342) 18

Able to pay comfortably (406) 7

Missing (3)

Area of residence

Rural (436) 17†

Urban (437) 15

Missing (0)

Highest level of formal education

Did not graduate from high school (184) 29*

Graduated from high school (689) 12

Missing (1)

*P , 0·05; statistical significance was tested using the chi-squared

test, the Mantel–Haenszel chi-squared trend test, and the Cochran–

Mantel–Haenszel general association test.†, not statistically significant.

Some sample sizes do not add to 873 because of weighted rounding.

in their teeth and/or denture(s), a broken filling, or

reported that they did not wear their mandibular partial

denture. With these bivariate comparisons, there were

no statistically significant associations between


Table 3. Satisfaction with chewing, by clinical measures of oral

disease/tissue damage

Clinical measure of oral % subjects who were

disease/tissue damage (weighted n) dissatisfied or very

dissatisfied with their

chewing ability

Number of occluding pairs of teeth

15–16 (36) 0*

11–14 (423) 4

8–10 (155) 23

1–7 (148) 38

0 (110) 24

Missing (2)

Number of root fragments

0 (779) 12*

1 (42) 35

2 or more (47) 56

Missing (6)

Number of severely mobile teeth

0 (718) 11*

1 (69) 34

2 or more (76) 41

Missing (10)

Number of teeth with bulk fractures

0 (730) 16†

1 (107) 10

2 or more (27) 20

Missing (9)

Number of teeth with cusp fractures

0 (745) 16†s

1 (91) 13

2 or more (27) 15

Missing (10)

*P , 0·05; statistical significance tested using the Mantel–Haenszel

chi-squared trend test.†: not statistically significant.


dissatisfaction with chewing ability and reporting a dry

mouth, a broken denture, or wearing one’s maxillary

full denture or maxillary partial denture.

Table 5 shows the prevalence of dissatisfaction with

chewing ability, stratified by self-reported measures of

current oral pain, current and/or recent functional

limitation, and current and/or recent oral disadvantage.

Dissatisfaction was significantly associated with each of

these self-reported oral health decrements.

Multivariate findings

A multiple logistic regression was done to identify

independent determinants of satisfaction with chewing


Table 4. Satisfaction with chewing, by self-reported measures oforal disease/tissue damage

Self-reported measure of oral % subjects who weredisease/tissue damage (weighted (n) dissatisfied or very

dissatisfied with theirchewing ability

Has an abscessed toothYes (22) 60*No (835) 14Missing (16)

Has a broken tooth or broken capYes (178) 34*No (684) 11Missing (12)

Has a broken denture‡

Yes (30) 26†

No (180) 19Missing (NA)

Has a loose cap or bridgeYes (10) 51*No (861) 15Missing (2)

Has a loose toothYes (115) 38*No (747) 12Missing (11)

Has a broken fillingYes (130) 29*No (722) 14Missing (21)

Has infected/sore gumsYes (102) 36*No (765) 13Missing (6)

Has a dry mouthYes (190) 20†

No (678) 15Missing (5)

Problem with food catching withinprevious 6 months

Yes (622) 18*No (249) 12Missing (3)

Has & wears a maxillary full denture §

Yes (80) 21†

No (9) 40Missing (0)

Has and wears a maxillary partialdenture 1

Yes (99) 22†

No (43) 30Missing (NA)

Has and wears a mandibularpartial denture **

Yes (119) 15 *No (68) 28Missing (NA)


ability. These determinants included the measures of

disadvantage, functional limitation, pain, and disease/

tissue damage that were shown in Table 1. An additional

interest was to determine if persons who reported

seeking dental care on a regular basis, and persons in

certain sociodemographic groups, reported more

satisfaction with chewing ability, with differences in

oral disadvantage, oral functional limitation, oral pain,

and oral disease/tissue damage taken into account.

Table 6 shows the results from the ordinal logistic

regression of satisfaction with chewing ability. At least

one measure from each oral health construct in Fig. 1

had a statistically significant direct effect on satisfaction

with chewing ability. With the other conditions taken

into account, reporting oral disadvantage, chewing

difficulties, speaking difficulty, a sore and/or broken

denture, a toothache and/or abscessed tooth, a broken

tooth and/or broken cap, a loose tooth, a broken filling,

a food catching problem, not wearing their maxillary full

denture if they had one, not wearing their mandibular

partial denture if they had one, and having fewer

occluding pairs of teeth, were all significantly associated

with more dissatisfaction with chewing ability. The odds

ratios in this model are interpretable as the increase in

the odds of moving up one level of satisfaction (e.g.

from ‘dissatisfied/very dissatisfied’ to ‘satisfied’, or from

‘satisfied’ to ‘very satisfied’) with an increase in one

level of the explanatory covariate. For example, moving

from five chewing difficulties to only four chewing

difficulties increased the odds of reporting a higher level

of satisfaction by 53% (odds ratio of 1·53).

*, P , 0·05; statistical significance tested using the chi-squared

test, except for ‘has & wears maxillary full denture’, for which

the one-tailed Fisher’s exact test was used.

Missing values are not applicable (NA) in some cases because the

only subjects eligible for the cross-tabulation were those who

answered the question. Some sample sizes do not add to 873 or

the otherwise expected number because of weighted rounding.†, not statistically significant.‡, only includes persons who currently have and wear a removable

denture; n 5 211.§, only includes persons who upon clinical examination were

edentulous in the maxilla; n 5 89.1, only includes persons who reported ever having a maxillary

partial denture and who upon clinical examination had 1–15

teeth in the maxillary arch; n 5 143.**, only includes persons who reported ever having a mandibular

partial denture and who upon clinical examination had 1–15 teeth

in the mandibular arch; n 5 186.


Table 5. Satisfaction with chewing, by self-reported oral pain,

functional limitation, and oral disadvantage

Measure of self-reported oral % subjects who were

pain, functional limitation, dissatisfied or very

disadvantage (weighted n) dissatisfied with their

chewing ability

Oral pain

Toothache pain

Yes (100) 38*

No (772) 13

Missing (1)

Denture soreness†

Yes (43) 49*

No (168) 13

Missing (NA)

Functional limitation

Number of chewing index items can

chew

0 (4) 100 *

1 (20) 88

2 (38) 63

3 (40) 42

4 (92) 27

5 (663) 7

Missing (17)

Difficulty speaking or pronouncing

within the previous 6 months

Yes (84) 56*

No (788) 12

Missing (2)

Oral disadvantage within the previous

6 months

Avoided chewing hard things

Yes (222) 36*

No (651) 9

Missing (1)

Prevented from eating foods

Yes (137) 54*

No (735) 9

Missing (1)

Avoided eating with others

Yes (40) 65*

No (833) 14

Missing (1)

Kept from normal activities

Yes (43) 60*

No (829) 14

Missing (1)

Trouble sleeping

Yes (73) 49*

No (799) 13

Missing (1)


Discussion

Dissatisfaction with chewing ability in the FDCS was

prevalent, with about one in six persons being

dissatisfied or very dissatisfied. In conjunction with

our previous reports of oral disease/tissue damage,

functional limitation, and oral disadvantage from this

sample, we have documented a substantial burden

from oral diseases and conditions in a sample that is

representative (Gilbert et al., 1997a) of diverse groups

of dentate adults. Given that the FDCS sample excluded

persons with no teeth, this substantial burden is even

more salient.

This study documents, like quite a few other studies

(e.g. Kayser, 1981; Rosenoer & Sheiham, 1995), that

satisfaction and function are worse among persons with

few teeth. It also documents that dissatisfaction with

chewing is very low (only 4%) among persons with 11

or more teeth. We also observed in this sample higher

prevalences of dissatisfaction with chewing ability in

irregular dental attenders, black and poor persons. Given

the theoretical expectation, it is not surprising that these

groups also have the highest prevalence in almost

all the measures of oral disease/tissue damage, pain,

functional limitation, and disadvantage used in the

FDCS. However, in the multivariate models, irregular

attenders’, black and poor persons’ higher prevalence

of decrements accounted for their higher prevalence of

dissatisfaction with chewing ability. Therefore,

attendance, race, and poverty status were not

statistically significant in the multivariate models.

Understanding which factors are independently

associated with dissatisfaction with chewing ability is

important to understanding what aspects of oral health

are important to patients, as compared to what dentists

believe or assume is important. As we hypothesized,

oral disadvantage, which measures the impact of oral

health decrements on the daily lives of individuals,

was strongly associated with dissatisfaction. Difficulty

speaking and/or pronouncing words because of dental,

oral, or denture problems (an oral functional limitation)

* P , 0·05; statistical significance tested using the chi-squared test

and the Mantel-Haenszel chi-squared trend test.†, only includes subjects who currently have and wear a removable

denture; n 5 211; missing values are not applicable (NA) because

the only subjects eligible for the cross-tabulation were those who

answered the question.



Table 6. Ordinal logistic regression of satisfaction with chewing ability

Covariate Parameter Estimate Standard Error P Value Odds Ratio (95% CI)*

Intercept 1 –13·20 1·55 0·001 –

Intercept 2 –10·09 1·50 0·001 –

Oral disadvantage

Disadvantage † 0·17 0·04 0·001 1·19 (1·10, 1·28)

Functional limitation

Chewing difficulties † 0·42 0·12 0·001 1·53 (1·20, 1·95)

Speaking difficulty † 0·44 0·12 0·001 1·56 (1·24, 1·98)

Pain

Sore/broken denture † 0·62 0·30 0·039 1·86 (1·03, 3·35)

Toothache/abscess † 0·46 0·24 0·049 1·59 (1·00, 2·52)

Self-reported disease/tissue damage

Broken tooth/broken cap † 0·79 0·22 0·001 2·20 (1·42, 3·42)

Loose tooth † 0·78 0·27 0·004 2·17 (1·26, 3·75)

Broken filling † 0·63 0·25 0·011 1·87 (1·16, 3·03)

Infected/sore gums 0·39 0·27 0·156 1·47 (0·86, 2·52)

Dry mouth 0·25 0·20 0·214 1·28 (0·87, 1·90)

Food catching † 0·18 0·07 0·010 1·20 (1·04, 1·38)

Maxillary full denture † 1·21 0·42 0·004 3·35 (1·47, 7·66)

Maxillary partial denture 0·07 0·31 0·815 1·07 (0·59, 1·97)

Mandibular partial denture † 0·73 0·27 0·008 2·08 (1·21, 3·61)

Clinical disease/tissue damage

Occluding pairs † 0·11 0·03 0·001 1·12 (1·05, 1·19)

Root fragments 0·27 0·30 0·376 1·31 (0·72, 2·39)

Severely mobile teeth 0·04 0·12 0·734 1·04 (0·82, 1·32)

Bulk fractures 0·32 0·18 0·086 1·37 (0·96, 1·98)

Cusp fractures 0·30 0·18 0·096 1·35 (0·96, 1·92)

Sociodemographic

Approach to dental care 0·33 0·20 0·114 1·36 (0·93, 2·00)

Age group 0·11 0·17 0·510 1·12 (0·80, 1·55)

Sex 0·02 0·16 0·913 1·02 (0·74, 1·41)

Race 0·18 0·20 0·381 1·19 (0·80, 1·77)

Ability to pay $500 bill 0·24 0·14 0·077 1·27 (0·97, 1·66)

Area of residence 0·11 0·16 0·496 1·12 (0·81, 1·54)

Education 0·25 0·22 0·264 1·28 (0·83, 2·01)

* 95% confidence interval

n 5 795, –2 log likelihood chi-squared for covariates 5 441·2, 26 d.f., P , 0·0001; c 5 0·84; association of predicted probabilities and

observed responses: concordant 5 84%, discordant 5 15%, tied 5 1%.†, denote that the variable was statistically significant.

was also strongly associated, as was a multifarious array

of six measures of self-reported disease/tissue damage

and one clinical measure of the disease/tissue damage

construct. These results suggest that persons do use

multi-dimensional cues to evaluate their satisfaction

with chewing ability, with direct effects from each of

the dimensions of oral health as described in Fig. 1.

The multivariate model in Table 6 explicitly estimates

the magnitude of the effects specified in the model in

Fig. 1. Estimation using these models is important not

only to identify the key factors that act singly or in


combination with other factors to determine satisfaction

with chewing ability, but also to understand their

relative importance compared to other factors, as well

as the degree to which satisfaction with chewing ability

might be altered by dental care interventions. For

example, the models suggest that tooth loss is an

important determinant of satisfaction with chewing

ability, and consequently should be a focus of dental

health care expenditures. With regard to tooth loss,

these self-reported measures could be used to determine

the effectiveness and cost-effectiveness of replacing a


particular number of missing teeth with a removable

partial denture as compared to a fixed prosthetic bridge

or dental implants. These cost-effectiveness analyses

should provide guidance as to where resources should

be expended. The literature on dental care use provides

little information with regard to exactly what benefits

are derived from seeking dental care on a regular basis.

Regular dental care seekers seem to benefit by having

a smaller amount of active disease, but it is uncertain

to what extent future disease is prevented by regular

care (Bailit et al., 1985; Sheiham et al., 1985), and those

who attend regularly may suffer from unnecessary

repeated replacement of dental restorations (Elderton,

1985; Elderton et al., 1985). Including measures of oral

pain, oral functional limitation, oral disadvantage, and

satisfaction in dental care effectiveness research will

probably demonstrate benefits of dental care attendance

that use of disease/tissue damage measures alone would

obscure. The FDCS is currently planned for 48 months

of data gathering (now at the 42-month stage). With

the longitudinal data, we will be able to assess the

predictive validity of our proposed model of satisfaction

with chewing ability.

The ability of these measures to detect change in

groups longitudinally (with or without dental treatment

interventions), and more importantly, to detect change

within individuals, remains in question. Such ability

must be demonstrated in dental care effectiveness

research before these constructs can be considered

useful in that context. The ability of these self-reported

measures to predict utilization of care also needs

demonstration, although recent work by Kressin et al.

(1996) has shown promise in that regard. A longitudinal

description of how labile these measures are over time

is also needed; as the FDCS progresses longitudinally,

we will be able to make these descriptions.

It should be noted that the measures of oral pain,

oral functional limitation, oral disadvantage, and almost

all of the oral disease/tissue damage measures that were

used in the FDCS are measures of extent and duration,

not severity. The correlations between satisfaction with

chewing ability and the various oral health measures

may be larger if measures of severity are used. Thus,

we recommend further refinement to include gradations

of severity. As the use of these and similar oral health

outcome measures continues to evolve, an additional

methodologic issue that needs resolution if scales and

indices are adopted is the existence of floor and ceiling

effects. Measures or scales are said to have ceiling effects


when individuals who are scored as perfectly healthy

on the scale are identified as still having health problems.

Because these people are at the top of the scale, further

improvements in health will not be detected. The inverse

is true for floor effects. The distribution of the satisfaction

with chewing ability variable did have a preponderance

of ratings at the upper end of the scale, and from a

statistical point of view, would benefit from further

spread at the upper end of the scale.

Acknowledgments

This investigation was supported by USPHS contract

DE-12587 and research grants DE-11020 and DE-00392.

Additional support was provided by funds from the

University of Florida. We acknowledge the contributions

of D.E. Antonson, T.A. Dolan, D.W. Legler, and M.L.

Ringelberg, who in addition to U. Foerster and G.H.

Gilbert, served as clinical examiners for the study. We

are also grateful to J.L. Earls and B.A. Ringelberg, who

served as regional coordinators for the baseline phase

of the study. The opinions and assertions contained

herein are those of the authors and are not to be

construed as necessarily representing the views of the

University of Florida or the National Institutes of Health.

The informed consent of all human subjects who

participated in this investigation was obtained after the

nature of the procedures had been explained fully.

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Appendix

Explanation of coding of variables in Table 6.

The outcome of interest (satisfaction with chewing

ability) was coded 0 5 dissatisfied or very dissatisfied;

1 5 satisfied; 2 5 very satisfied.

Coding of explanatory covariates

The scales of two variables (number of root fragments

and number of severely mobile teeth) were arbitrarily

inverted to make the odds ratio for that variable

exceed one.


Disadvantage: sum of scores of 5 variables that measuredavoidance of certain activities because of mouth/dentalproblems: (1) avoided chewing hard things; (2) beenprevented from eating foods would like to eat; (3)avoided eating with others; (4) trouble sleeping; (5)mouth pain/discomfort kept from doing normal dailyactivities. Each variable was coded with reference tofrequency of these behaviours: 1 5 very often withinprevious 6 months; 2 5 fairly often within previous 6months; 3 5 sometimes within previous 6 months; 4 5

at least once in adults lifetime, but never within previous6 months; 5 5 never in adult lifetime. The oraldisadvantage variable ranged from 5 to 25.Chewing difficulties: number items on Chewing Indexthat subject can chew (range of 0–5).Speaking difficulty: frequency that had difficultyspeaking or pronouncing any words because of problemswith teeth, mouth, or dentures; 1 5 very often inprevious 6 months; 2 5 fairly often in previous 6months; 3 5 sometimes in previous 6 months; 4 5

never in previous 6 months; 5 5 never have haddifficulty.Sore/broken denture: number of these problemscurrently has: (i) broken denture; (ii) sore denture. 0 5

both; 1 5 1 of the 2; 2 5 neither of the 2. Note thatthis recoded variable combines a measure of tissuedamage and a measure of pain.Toothache/abscess: number of these problems currentlyhas: (i) toothache or painful tooth; (ii) abscessed tooth.Variable coded as: 0 5 both; 1 5 1 of the 2; 2 5 neitherof the 2.Broken tooth/broken cap: number of these problemscurrently has: (i) broken tooth or a broken cap; (ii)loose cap or bridge. Variable coded as: 0 5 both; 1 5 1of the 2; 2 5 neither of the 2.Loose tooth: response to ‘Do you have a loose tooth?’.0 5 Yes; 1 5 No.Broken filling: response to ‘Do you have a brokenfilling?’. 0 5 Yes; 1 5 No.


Infected/sore gums: response to ‘Do you have infected

or sore gums?’. 0 5 Yes; 1 5 No.

Dry mouth: response to ‘Do you have infected or sore

gums?’. 0 5 Yes; 1 5 No.

Food catching: frequency in previous 6 months that

had trouble with food catching in teeth or dentures; 1 5

very often; 2 5 fairly often; 3 5 sometimes; 4 5 never.

Maxillary full denture: 1 5 has and wears a maxillary

full denture; 0 5 does not.

Maxillary partial denture: 1 5 has and wears a maxillary

partial denture; 0 5 does not.

Mandibular partial denture: 1 5 has and wears a

mandibular partial denture; 0 5 does not.

Occluding pairs: number of occluding pairs of natural

teeth or fixed pontics/cantilevers (range of 0–16).

Root fragments: number of remaining teeth that are root

fragments upon clinical examination. [scale inverted in

Table 6]

Bulk fractures: number of remaining teeth that have a

bulk restoration fracture upon clinical examination.

Cusp fractures: number of remaining teeth that have a

cusp or incisal edge fracture upon clinical examination.

Severely mobile teeth: number of remaining teeth that

are severely mobile upon clinical examination. [scale

inverted in Table 6]

Approach: approach to dental care; 0 5 never go to a

dentist or go only when have a problem; 1 5 go to a

dentist whether or not have a problem.

Age group: 0 5 45–64 years old; 1 5 65 years old

or older.

Sex: 0 5 female; 1 5 male.

Race: 0 5 black; 1 5 white.

Ability to pay $500 dental bill: 0 5 not able to pay the

bill; 1 5 able to pay, but with difficulty; 2 5 able to pay

comfortably.

Area of residence: 0 5 rural; 1 5 urban.

Education: highest level of formal education attained;

0 5 graduated high school; 1 5 did not.

satisfaction with chewing ability in a diverse sample of dentate adults

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