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Total Tooth Loss Among Persons Aged Greater Than or Equal to 65 Years -- Selected States, 1995-1997

Loss of all natural permanent teeth (edentulism) substantially reduces quality of life, self-image, and daily functioning (1). Although loss of teeth results from oral diseases such as dental caries and periodontitis, it also reflects patient and dentist attitudes, availability and accessibility of dental care, and the prevailing standard of care (2). One of the national health objectives for 2000 is to reduce to no more than 20% the proportion of persons aged greater than or equal to 65 years who have lost all their natural teeth (objective 13.4) (3). Edentulism has been declining in the United States since the 1950s (2), but few state-specific data are available on adult tooth loss. To estimate the prevalence of edentulism among persons aged greater than or equal to 65 years, CDC analyzed data from the 46 states that participated in the oral health module of the 1995-1997 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the findings from this analysis, which indicate a large state-specific variation in edentulism and that many states have not yet achieved the national health objective for preventing total tooth loss.

BRFSS is a state-based, random-digit-dialed telephone survey of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years. During 1995-1997, 46 states administered the optional oral health module during at least 1 year. Participants were asked how many of their permanent teeth were removed because of tooth decay or gum disease. Of the 28,979 persons aged greater than or equal to 65 years who were asked this question, 27,736 (95.7%) responded. Edentate persons were those who reported having lost all their teeth. Data were aggregated and weighted according to state population estimates, and prevalence estimates and standard errors were calculated using SUDAAN (4). To increase the precision of prevalence estimates within age groups, data from multiple years were aggregated for states that administered the BRFSS oral health module during greater than 1 year.

The prevalence of edentulism among persons aged greater than or equal to 65 years ranged from 13.9% (Hawaii) to 47.9% (West Virginia) (Table_1). In five states (Arizona, California, Hawaii, Oregon, and Wisconsin), less than 20% of persons were edentate; in three states (Kentucky, Louisiana, and West Virginia), greater than 40% were edentate.

In 1997, edentulism was more common among persons aged greater than or equal to 75 years (26.7%) than among those aged 65-74 years (22.9%) (Table_2). Edentulism was more prevalent among persons with less than a high school education (42.1%) than among those with more education (10.1%-25.1%); among those without dental insurance (27.0%) than among those who had insurance (18.3%); among non-Hispanic blacks (31.9%) than among Hispanics (18.2%) and non-Hispanic whites (24.1%); and among current every day cigarette smokers (41.3%) than among occasional smokers (28.9%), former smokers (25.7%), or persons who had never smoked (19.9%).

Reported by: State Behavioral Risk Factor Surveillance System coordinators. Surveillance, Investigations, and Research Br, Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that most states have not yet achieved the national health objective for edentulism prevention. However, edentulism among older persons probably reflects total tooth loss that occurred many years earlier. Because younger birth cohorts seem less likely than persons born earlier in the 20th century to lose all their teeth (2), the prevalence of edentulism among persons aged greater than or equal to 65 years will probably continue to decline in succeeding birth cohorts.

Dental caries and its complications are the primary reasons for tooth extraction for persons of all ages (2). Dental caries is largely preventable, and community water fluoridation remains the most effective and cost-effective prevention method (5). The destruction of tooth-supporting structures from advanced periodontitis is also a substantial etiologic factor for tooth loss (6).

The approximately fourfold range in total tooth loss among states and sociodemographic variations in edentulism supports the contention that total tooth loss is not an inevitable consequence of aging. Changes in attitudes toward dentistry, advancements in dental restorative technologies, periodontal treatment, and effectiveness of water fluoridation and other preventive measures have helped ensure tooth retention.

The association between edentulism and educational attainment may reflect differences in access to preventive and restorative dental services and attitudes toward oral health. Racial/ethnic differences in the prevalence of edentulism may reflect varying disease experiences, cultural differences in attitudes toward oral health and dentistry, or socioeconomic status, which can influence use of dental care and type of treatment received. In addition, the higher prevalence of total tooth loss among persons without dental insurance than among those with dental insurance may, in part, result from reduced use of preventive and restorative dental services (7). However, dental insurance in the United States is almost entirely employment-based, and Medicare does not cover most dental procedures; therefore, relatively few persons aged greater than or equal to 65 years have dental insurance.

Cigarette smoking is a risk factor for adult periodontitis and tooth loss (8). The higher prevalence of edentulism among current smokers may be directly related to the adverse effects of smoking on periodontal health. Cigarette smoking among adults in the United States is concentrated among persons with low levels of education and income (9), and its association with edentulism may reflect some degree of confounding of the association between low socioeconomic status and edentulism. However, the association between cigarette smoking and tooth loss remained after controlling for level of education (CDC, unpublished data, 1999).

The findings in this report are subject to at least two limitations. First, because BRFSS is administered as a telephone survey, only persons with telephones are represented. Second, results are based on self-reported data that have not been validated. However, previous studies have documented strong agreement between self-reported and clinically assessed total tooth loss (10).

Public health strategies to prevent edentulism include maintenance of optimal levels of fluoride in community water supplies, oral health promotion for all age groups, and expansion of dental insurance coverage, particularly for older persons. Other preventive measures include the appropriate use of fluoride-containing or antibacterial agents such as dentifrices, topical gels, mouth rinses, and varnishes. In addition, improved access to clinical dental services and expanded community tobacco-control activities can help prevent total tooth loss.

References

  1. Gift HC, Redford M. Oral health and the quality of life. Clin Geriatr Med 1992;8:673-83.

  2. Burt BA, Eklund SA. Dentistry, dental practice, and the community. 5th ed. Philadelphia: WB Saunders Co., 1999.

  3. US Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991. DHHS publication no. (PHS)91-50212.

  4. Shah BV, Barnwell BG, Bieler GS. SUDAAN: software for the analysis of correlated data. User's manual, release 7.00. Research Triangle Park, North Carolina: Research Triangle Institute, 1996.

  5. Ripa LW. A half-century of community water fluoridation in the United States: review and commentary. J Public Health Dent 1993;53:17-44.

  6. Ong G. Periodontal disease and tooth loss. Int Dent J 1998;48:233-8.

  7. Bailit H, Newhouse J, Brook R, et al. Does more generous dental insurance coverage improve oral health? J Am Dent Assoc 1985;110:701-7.

  8. Christen AG, McDonald JL, Christen JA. The impact of tobacco use and cessation on nonmalignant and precancerous oral and dental diseases and conditions. Indianapolis: Indiana University School of Dentistry, 1991.

  9. Escobedo LG, Peddicord JP. Smoking prevalence in US birth cohorts: the influence of gender and education. Am J Public Health 1996;86:231-6.

  10. Douglass CW, Berlin J, Tennstedt S. The validity of self-reported oral health status in the elderly. J Public Health Dent 1991;51:220-2.



    Table_1
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    TABLE 1. Percentage of persons aged >=65 years who reported having lost all their
    natural teeth, by state and age group -- United States, Behavioral Risk Factor
    Surveillance System, 1995-1997*
    ===========================================================================================
                         65-74 years         >=75 years           Total
                       ----------------   ----------------   ----------------
    State               %     (95% CI+)    %     (95% CI)     %     (95% CI)
    -------------------------------------------------------------------------
    Alabama&@          35.3   (+/- 4.9)   37.2   (+/- 6.3)   36.0   (+/- 3.9)
    Alaska&            24.4   (+/-17.8)   28.5   (+/-16.1)   25.1   (+/-14.7)
    Arizona&**         17.6   (+/- 4.3)   19.9   (+/- 5.1)   18.5   (+/- 3.3)
    Arkansas&          32.1   (+/- 6.7)   50.1   (+/- 8.0)   39.2   (+/- 5.3)
    California&@       14.9   (+/- 2.9)   18.4   (+/- 3.7)   16.2   (+/- 2.4)
    Colorado@          20.6   (+/- 7.1)   28.1   (+/- 8.4)   23.0   (+/- 5.5)
    Connecticut**      22.3   (+/- 6.9)   22.3   (+/- 8.0)   22.3   (+/- 5.1)
    Florida@           20.2   (+/- 3.9)   24.2   (+/- 4.5)   21.9   (+/- 2.9)
    Georgia&           36.2   (+/- 5.5)   35.8   (+/-10.0)   36.1   (+/- 4.9)
    Hawaii**           12.1   (+/- 5.1)   17.4   (+/- 8.2)   13.9   (+/- 2.3)
    Idaho&@            25.9   (+/- 3.5)   32.7   (+/- 4.3)   28.7   (+/- 2.7)
    Illinois&**        27.2   (+/- 5.7)   30.2   (+/- 7.4)   28.3   (+/- 4.5)
    Indiana&@**        26.7   (+/- 3.5)   32.0   (+/- 4.1)   28.8   (+/- 2.7)
    Iowa&              28.1   (+/- 4.7)   38.8   (+/- 5.5)   32.7   (+/- 3.5)
    Kansas**           28.7   (+/- 6.3)   36.1   (+/- 7.3)   31.8   (+/- 4.7)
    Kentucky**         40.0   (+/- 6.7)   50.6   (+/- 8.0)   44.0   (+/- 5.3)
    Louisiana**        38.6   (+/- 7.6)   51.7   (+/- 9.4)   43.0   (+/- 6.1)
    Maine&             35.7   (+/- 8.2)   41.3   (+/-10.6)   37.8   (+/- 6.5)
    Maryland@          27.2   (+/- 7.3)   32.7   (+/-10.8)   29.2   (+/- 6.1)
    Massachusetts&     19.5   (+/- 5.9)   27.1   (+/- 8.6)   22.0   (+/- 4.9)
    Michigan**         22.1   (+/- 5.9)   17.7   (+/- 6.5)   20.6   (+/- 4.5)
    Mississippi@       30.1   (+/- 7.1)   44.2   (+/- 9.4)   35.3   (+/- 5.9)
    Missouri@          27.0   (+/- 6.5)   35.5   (+/- 7.8)   30.4   (+/- 4.9)
    Montana&@**        28.5   (+/- 3.9)   33.3   (+/- 4.7)   30.4   (+/- 2.9)
    Nebraska**         26.8   (+/- 5.7)   34.7   (+/- 6.7)   30.0   (+/- 4.3)
    Nevada@**          23.3   (+/- 7.1)   26.4   (+/-10.0)   24.1   (+/- 5.9)
    New Hampshire**    27.7   (+/- 7.6)   26.7   (+/- 9.4)   27.4   (+/- 5.9)
    New Jersey@**      20.7   (+/- 3.7)   23.7   (+/- 4.5)   21.8   (+/- 2.9)
    New Mexico@        20.0   (+/- 5.9)   27.4   (+/- 7.6)   22.7   (+/- 4.7)
    New York&@**       22.5   (+/- 3.7)   31.7   (+/- 5.7)   26.0   (+/- 3.3)
    North Dakota&      25.1   (+/- 5.9)   43.9   (+/- 7.1)   32.5   (+/- 4.7)
    Ohio&@             24.7   (+/- 4.1)   28.5   (+/- 5.7)   26.1   (+/- 3.3)
    Oklahoma**         31.9   (+/- 5.3)   45.9   (+/- 7.8)   36.2   (+/- 4.3)
    Oregon&            15.6   (+/- 4.1)   18.0   (+/- 5.1)   16.5   (+/- 3.1)
    Pennsylvania**     26.5   (+/- 4.3)   38.1   (+/- 6.5)   30.2   (+/- 3.5)
    Rhode Island&      24.0   (+/- 6.7)   28.2   (+/- 8.0)   25.6   (+/- 5.1)
    South Dakota**     27.2   (+/- 5.7)   40.7   (+/- 6.3)   33.2   (+/- 4.1)
    Tennessee@         33.6   (+/- 5.9)   38.0   (+/- 7.1)   35.3   (+/- 4.5)
    Texas&**           23.6   (+/- 5.3)   26.6   (+/- 6.7)   24.7   (+/- 4.1)
    Utah&@**           18.2   (+/- 3.5)   29.1   (+/- 4.5)   22.8   (+/- 2.7)
    Vermont&           30.7   (+/- 6.3)   41.1   (+/- 7.6)   34.8   (+/- 4.9)
    Virginia&@**       20.6   (+/- 3.7)   31.5   (+/- 6.3)   24.1   (+/- 3.3)
    Washington&        17.4   (+/- 4.9)   28.6     (+ 6.7)   21.5   (+/- 3.9)
    West Virginia@     44.2   (+/- 6.1)   54.3   (+/- 7.3)   47.9   (+/- 4.7)
    Wisconsin&         15.1   (+/- 5.1)   26.9   (+/- 7.8)   19.4   (+/- 4.3)
    Wyoming&           24.8   (+/- 5.7)   43.2   (+/- 8.2)   31.5   (+/- 4.7)
    -------------------------------------------------------------------------
     * n=27,736. For states in which data were collected in 1 year, analysis was conducted by
       aggregating data for multiple years.
     + Confidence interval.
     & 1995.
     @ 1997.
    ** 1996.
    ===========================================================================================
    

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    Table_2
    Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
    
    TABLE 2. Percentage of persons aged >=65 years who reported having lost all their
    natural teeth, by selected characteristics -- United States, Behavioral Risk Factor
    Surveillance System, 1997*
    ==============================================================================================
                                                     Edentate
                                         Sample  -----------------
    Characteristic                        size+   %      (95% CI&)
    --------------------------------------------------------------
    Sex
      Men                                 3420   23.6    (+/- 2.0)
      Women                               6282   24.9    (+/- 1.6)
    
    Age group (yrs)
      65-74                               5646   22.9    (+/- 1.6)
       >=75                               4056   26.7    (+/- 2.0)
    
    Education level
      Less than high school graduate      2437   42.1    (+/- 2.9)
      High school graduate                3391   25.1    (+/- 2.2)
      Some college                        2166   17.1    (+/- 2.2)
      College graduate                    1662   10.1    (+/- 2.0)
    
    Dental insurance status
      Insured                             2670   18.3    (+/- 2.0)
      Uninsured                           6855   27.0    (+/- 1.4)
    
    Race/Ethnicity
      Non-Hispanic white                  8539   24.1    (+/- 1.2)
      Non-Hispanic black                   641   31.9    (+/- 5.1)
      Hispanic                             352   18.2    (+/- 5.3)
      Other@                               134   26.2    (+/-12.5)
    
    Cigarette smoking status
      Current, every day                   919   41.3    (+/- 4.5)
      Current, some days                   215   28.9    (+/- 8.0)
      Former                              3551   25.7    (+/- 2.0)
      Never                               4983   19.9    (+/- 1.6)
    
    Total                                 9702   24.4    (+/- 1.2)
    --------------------------------------------------------------
    * Includes respondents in Alabama, California, Colorado, Florida, Idaho, Indiana, Maryland,
      Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Tennessee,
      Texas, Utah, Virginia, and West Virginia.
    + Numbers may not add to total because of missing data.
    & Confidence interval.
    @ Numbers for races other than black and white were too small for meaningful analysis.
    ==============================================================================================
    

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