Purpose
To examine self-reported oral health among adults aged 40 years and older with and without vision impairment.
Design
Cross-sectional, with a nationally representative sample.
Methods
We used publicly available data from the Oral Health Module, last administered in 2008, of the National Health Interview Survey. Outcome variables included fair/poor oral health status, mouth condition compared to others the same age, mouth problems (mouth sores, difficulty eating, dry mouth, bad breath, and/or jaw pain), teeth problems (toothache; broken/missing fillings or teeth; loose, crooked, or stained teeth; and/or bleeding gums), and lack of social participation. Using descriptive statistics and multivariate logistic regression, we examined the association ( P < .05) between vision impairment and oral health outcomes by age group, sociodemographics, and other explanatory variables.
Results
Our study sample included 12,090 adults; 12.8% of adults aged 40-64 years reported vision impairment, and among them, 44.5% reported fair/poor oral health status and 47.2% reported any mouth problems. Among adults aged ≥65 years, 17.3% reported vision impairment, of whom 36.3% reported fair/poor oral health status and 57.3% reported any mouth problems. There is a strong association between vision impairment and poorer oral health of adults; adults aged 40-64 years with vision impairment reported 90%-150% greater odds of oral health problems, including fair/poor oral health status, mouth problems, and teeth problems, compared to people without vision impairment.
Conclusions
Oral health disparities exist between adults with and without vision impairment. Targeted interventions are required to improve oral health in this vulnerable population.
In the United States, about 12.4 million people have blindness, vision impairment (VI), or uncorrected refractive error, and this number is projected to double by 2050. Multiple investigations have identified the association of VI with chronic conditions —especially stroke, depression, diabetes, poorer health and health-related quality of life, and increased risk of mortality. Some research has examined potential factors limiting oral health care access and has shown poor oral health among adults with VI. , However, little research has examined the oral health status of people with VI at the population level.
In 2000, the Surgeon General’s report, Oral Health in America, drew attention to oral health disparities among various groups and subpopulations. The report highlighted the lack of studies estimating oral health problems among people with disabilities. To better understand the oral health status of people with VI and to address the gap identified in the Surgeon General’s report, we examined the oral health module, last administered in 2008, of the National Health Interview Survey (NHIS) to determine self-reported oral health status of older adults with VI compared to adults without VI.
Methods
Data Source
The NHIS is a cross-sectional household interview survey that uses a multistage area probability design among the US noninstitutionalized civilian population. We used data from the Sample Adult Core and the Oral Health Module. Detailed information regarding the survey design, questionnaire, and implementation is available from http://www.cdc.gov/nchs/nhis/about_nhis.htm . The NHIS data are de-identified, publicly available, and exempt from institutional review board approval.
Outcome Variables
The Oral Health Module asked questions about dentate status (having at least 1 natural tooth or none) and oral health status: (1) overall oral health status , that is, perceived “condition of mouth and teeth” (very good, good, fair, or poor); and (2) condition of mouth and teeth relative to others of the same age (better, same, or not as good). In addition, the module included questions about the presence (yes or no) of the following mouth problems within the last 6 months: (1) jaw pain, (2) mouth sores, (3) difficulty eating or chewing, (4) bad breath, and (5) dry mouth. We classified a respondent as having a mouth problem if he or she answered yes to at least 1 of the questions, and as not having a mouth problem otherwise. Teeth-related questions were asked only of adults with teeth: (1) toothache or sensitive teeth, (2) bleeding gums, (3) crooked teeth, (4) broken or missing teeth, (5) stained or discolored teeth, (6) loose teeth not owing to an injury, and (7) broken or missing fillings. We classified a dentate respondent as having teeth problems if he or she answered yes to at least 1 of these 7 problems, and no problem otherwise.
Finally, a series of questions asked about social participation related to oral health or dental problems among those who reported at least 1 problem (“Did the problems with your mouth or teeth interfere with any of the following…your job or school, social activities such as going out or being with other people, or your usual activities at home”). We classified persons reporting problems with job/school, social activities, or home activities as lacking in participation .
Vision Impairment
VI was defined by a positive repose to the question: “Do you have any trouble seeing, even when wearing glasses or contact lenses?” This question in the NHIS is widely used in investigations regarding VI. Nonrespondents were excluded from the analysis.
Covariates
Based on the findings of previous studies, covariates were sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic Asian, and other), education (<high school; high school or General Educational Diploma; some college; completed 4 years of college or more), family income (<$35,000, ≥$35,000), health insurance status at the time of survey (insured, uninsured), marital status (married/cohabitating; separated/widowed/divorced; single), employment status at the time of survey (yes/no), reported health status (excellent/very good/good, and fair/poor), smoking (nonsmoker, current smoker, past smoker), self-reported diagnosed diabetes (yes/no), last dentist visit (<1 year, 1-2 years, >2 years, none), and dental insurance status at the time of survey (insured, uninsured).
Statistical Analysis
We used Stata 14.1 statistical software (StataCorp LP, College Station, Texas, USA) to account for the complex sampling design of the NHIS. All data were weighted to produce prevalence estimates for the civilian, noninstitutionalized population of US residents aged ≥40 years. We described the characteristics of our study population, estimated crude prevalence, and used t tests to examine whether crude prevalence of conditions differed by presence of VI. Although all reported crude findings are significant at P < .05, we only report confidence intervals (CI) and P values in the tables. Because the association between oral health and quality of life among persons with VI can vary by age, we used separate logistic regression models for middle-aged adults (40-60 years) and older adults (≥65 years) to examine the association between VI and oral health status, mouth problems, teeth problems, participation, and condition of mouth and teeth relative to others of the same age, controlling for covariates. Furthermore, we conducted additional analysis to test whether the odds ratios (ORs) for those aged 40-64 years and for those aged ≥65 years were significantly different from each other. P values <.05 were considered statistically significant.
Results
Characteristics of Study Population
Among our study population of 12,090 participants, 63.1% were aged 40-64 years, and 12.8%, of these reported VI. Compared to those reporting no VI, middle-aged adults reporting VI were more likely to be women (59.8% vs 50.0%), have fair/poor health status (31.4% vs 12.2%), be current smokers (32.1% vs 20.9%), report diagnosed diabetes (18.6% vs 9.2%), have lower incomes (35.8% vs 22.0%), be single (37.5% vs 27.9%), be Non-Hispanic black (12.9% vs 10.8%), be less likely to be employed (62.6% vs 75.8%), and be more likely to have less than a high school education (18.2% vs 12.0%) ( Table 1 ).
| Total | Age 40-64 | Age 65+ | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Vision Impairment | Without Vision Impairment | P Value | Vision Impairment | Without Vision Impairment | P Value | |||||||
| N = 12,090 (100%) | N = 1082 (12.8%) | N = 7145 (87.2%) | N = 676 (17.3%) | N = 3187 (82.7%) | ||||||||
| % | 95% CI | % | 95% CI | % | 95% CI | % | 95% CI | % | 95% CI | |||
| Sex | <.0001 | .005 | ||||||||||
| Male | 47.0 | [45.9-48.1] | 40.2 | [36.8,43.7] | 50.0 | [48.6,51.4] | 36.7 | [32.8,40.9] | 43.5 | [41.4,45.7] | ||
| Female | 53.0 | [51.9-54.1] | 59.8 | [56.3,63.2] | 50.0 | [48.6,51.4] | 63.3 | [59.1,67.2] | 56.5 | [54.3,58.6] | ||
| Marital status | <.0001 | .014 | ||||||||||
| Married/cohabitating | 67.3 | [66.2-68.4] | 62.5 | [58.9,65.9] | 72.1 | [70.9,73.4] | 52.1 | [47.3,56.8] | 58.6 | [56.5,60.7] | ||
| Single/separated/widowed/divorced | 32.7 | [31.6-33.8] | 37.5 | [34.1,41.1] | 27.9 | [26.6,29.1] | 47.9 | [43.2,52.7] | 41.4 | [39.3,43.5] | ||
| Race/ethnicity | .0007 | .564 | ||||||||||
| Non-Hispanic white | 74.9 | [73.8-76.0] | 72.9 | [69.7,75.8] | 73.0 | [71.6,74.4] | 79.4 | [75.9,82.5] | 80.3 | [78.7,81.9] | ||
| Non-Hispanic black | 10.4 | [9.6-11.1] | 12.9 | [10.7,15.6] | 10.8 | [9.9,11.7] | 9.8 | [7.7,12.3] | 8.2 | [7.1,9.5] | ||
| Hispanic | 10.0 | [9.3-10.7] | 9.5 | [7.7,11.7] | 11.3 | [10.4,12.2] | 6.5 | [4.8,8.7] | 7.2 | [6.3,8.2] | ||
| Non-Hispanic Asian | 3.8 | [3.5-4.2] | 2.7 | [1.8,4.0] | 4.1 | [3.6,4.7] | 3.3 | [2.1,5.1] | 3.6 | [2.9,4.5] | ||
| Non-Hispanic other | 0.9 | [0.7-1.1] | 2.0 | [1.2,3.4] | 1.0 | [0.7,1.2] | 1.1 | [0.5,2.5] | 0.7 | [0.5,1.1] | ||
| Education | <.0001 | .0003 | ||||||||||
| Less than HS | 15.7 | [14.8-16.6] | 18.2 | [15.4,21.3] | 12.0 | [10.9,13.0] | 30.8 | [26.8,35.0] | 22.3 | [20.6,24.0] | ||
| HS/GED | 29.3 | [28.3-30.3] | 29.2 | [26.0,32.7] | 27.7 | [26.4,29.0] | 29.7 | [25.8,34.0] | 34.0 | [32.1,35.9] | ||
| Some college | 27.3 | [26.3-28.3] | 29.7 | [26.5,33.0] | 28.8 | [27.5,30.0] | 23.1 | [19.4,27.3] | 22.9 | [21.2,24.6] | ||
| Completed 4 years college or more | 27.7 | [26.6-28.8] | 22.9 | [19.8,26.4] | 31.6 | [30.2,33.1] | 16.4 | [13.3,20.1] | 20.8 | [19.3,22.5] | ||
| Income | <.0001 | .0002 | ||||||||||
| <$35k | 30.6 | [29.5,31.8] | 35.8 | [32.4,39.3] | 22.0 | [20.8,23.1] | 56.7 | [52.3,61.0] | 47.9 | [45.8,50.1] | ||
| ≥$35k | 69.4 | [68.2,70.5] | 64.2 | [60.7,67.6] | 78.0 | [76.9,79.2] | 43.3 | [39.0,47.7] | 52.1 | [49.9,54.2] | ||
| Employed at time of survey | <.0001 | <.0001 | ||||||||||
| Yes | 58.3 | [57.2,59.5] | 62.6 | [59.2,65.9] | 75.8 | [74.6,77.0] | 52.1 | [47.3,56.8] | 58.6 | [56.5,60.7] | ||
| No | 41.7 | [40.5,42.8] | 37.4 | [34.1,40.8] | 24.2 | [23.0,25.4] | 47.9 | [43.2,52.7] | 41.4 | [39.3,43.5] | ||
| Health insurance status | .011 | .592 | ||||||||||
| Insured | 89.1 | [88.4-89.8] | 82.6 | [79.7,85.2] | 86.1 | [85.1,87.1] | 98.2 | [96.4,99.1] | 98.6 | [98.0,99.0] | ||
| Uninsured | 10.9 | [10.2-11.6] | 17.4 | [14.8,20.3] | 13.9 | [12.9,14.9] | 1.8 | [0.9,3.6] | 1.4 | [1.0,2.0] | ||
| Health status | <.0001 | <.0001 | ||||||||||
| Excellent/very good/good | 83.0 | [82.1-83.8] | 68.6 | [65.4,71.7] | 87.8 | [86.8,88.8] | 61.0 | [56.3,65.5] | 79.6 | [77.8,81.3] | ||
| Fair/poor | 17.0 | [16.2-17.9] | 31.4 | [28.3,34.6] | 12.2 | [11.2,13.2] | 39.0 | [34.5,43.7] | 20.4 | [18.7,22.2] | ||
| Diagnosed diabetes | <.0001 | <.0001 | ||||||||||
| Yes | 12.7 | [12.0-13.4] | 18.6 | [15.8,21.7] | 9.2 | [8.4,10.0] | 25.8 | [22.3,29.7] | 17.6 | [16.0,19.2] | ||
| No | 87.3 | [86.6-88.0] | 81.4 | [78.3,84.2] | 90.8 | [90.0,91.6] | 74.2 | [70.3,77.7] | 82.4 | [80.8,84.0] | ||
| Smoking status | <.0001 | .014 | ||||||||||
| Current smoker | 18.9 | [17.9-19.9] | 32.1 | [28.7,35.7] | 20.9 | [19.7,22.1] | 10.9 | [8.5,14.0] | 9.1 | [8.0,10.5] | ||
| Past smoker | 28.1 | [27.2-29.2] | 24.1 | [21.3,27.2] | 23.2 | [22.1,24.5] | 45.8 | [41.1,50.5] | 40.2 | [38.1,42.3] | ||
| Nonsmoker | 53.0 | [51.8-54.1] | 43.8 | [40.2,47.4] | 55.9 | [54.4,57.3] | 43.3 | [38.9,47.8] | 50.7 | [48.5,52.8] | ||
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