717406

research-article2017
SJP0010.1177/1403494817717406H. Olofsson et al.Edentulism in people 65 and older

Scandinavian Journal of Public Health, 19

Original article

Association between socioeconomic and health factors and edentulism

in people aged 65 and older a population-based survey

HANNA OLOFSSON*, EVA LENA ULANDER*, YNGVE GUSTAFSON

& CARL HRNSTEN

Department of Community Medicine and Rehabilitation, Geriatric Medicine, Ume University, Sweden

Abstract
Aims: To study edentulism and use of dental services in a population-based sample of people aged 65 years and older from
northern Sweden and western Finland. Methods: In 2010, people aged 65, 70, 75 and 80 years who were living in one of 32
municipalities in northern Sweden and western Finland were invited to answer a questionnaire as part of the Gerontological
Regional Database (GERDA) study (n = 6099). The questionnaire contained items related to socioeconomic status, general
health and edentulism. Results: The prevalence of edentulism was 34.9% in Finland, compared with 20.6% in Sweden
(p < 0.001), 31.9% in rural areas, compared with 20.9% in urban areas (p < 0.001), and 25% overall. The prevalence of
edentulism rose from 17.8% in 65-year-olds, 23.8% in 70-year-olds, 33.5% in 75-year-olds and 37.3% in 80-year-olds
(p < 0.001), and was 23.8% in women, compared with 27% in men (p < 0.001). In multivariate models, edentulism was
associated with lower educational level (odds ratio (OR) 2.87, 95% confidence interval (CI) 2.313.58), low income level
(OR 1.7, CI 1.091.47), residence in a rural area (OR 1.43, CI 1.231.66), male sex (OR 1.30, CI 1.121.52), dependence
in instrumental activities of daily living (OR 1.48, CI 1.251.74), social isolation (OR 1.52, CI 1.171.98) and poor self-
experienced health (OR 1.38, CI 1.171.62). Conclusions: One-quarter of the total sample was edentulous, with a
higher prevalence of edentulism in Finland than in Sweden and in rural than in urban areas. Edentulism was
associated with socioeconomic, psychological and health-related factors. These findings could be used to inform
preventive measures and identify people aged 65 years and older who are in need of oral care.

Key Words: Epidemiology, dental health survey, dental care for older people, edentulous mouth, educational level

Introduction
The prevalence of edentulism decreased from 51% to
12% among 70-year-olds in Gothenburg, Sweden
between 1971 and 1992 [1] and decreased from 53.3
% to 35.7% in Ume, Sweden, between 1981 and
1990 [2]. Similar decreases in edentulism prevalence
have been found in other large population-based
studies from Sweden [3, 4] and other countries [5, 6].
The prevalence of removable denture use has
decreased over the years [1, 2, 7] but the prevalence
of dental implants seems to be growing [1, 5, 8].
The trend towards decreasing edentulism has bene-
fited older people by improving chewing ability, oral
function and self-esteem [1, 4, 9]. The utilization of
dental care among elderly people has increased over
time as well [10, 11]. Despite the recent decrease in
edentulism, a substantial number of people live with
edentulism and are in need of dental care.
With increasing age, there is a corresponding
increase in the factors that increase the risk of losing
teeth due to periodontal disease and caries [5, 12,

Correspondence: Carl Hrnsten, Department of Community Medicine and Rehabilitation, Geriatrics, Ume University, SE 901 85, Ume, Sweden. E-mail:
carl.hornsten@umu.se

*The first two authors contributed equally to the manuscript.

Date received 23 September 2016; reviewed 2 April 2017; accepted 8 May 2017

Author(s) 2017
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2 H. Olofsson et al.
13]. Thus, it is especially important to maintain good
oral hygiene and oral health as people age. The cor-
relation between edentulism and general health is
complex. Diabetes may increase an adults risk of
developing periodontal disease and dry mouth [14
16]. Cognitive impairment may increase the risk of
losing teeth and chewing ability [1618]. Conversely,
edentulism may lead to cardiovascular disease or
stroke, which, in turn, may aggravate cognitive
impairment [17, 19, 20]. Edentulism is also associ-
ated with poor quality of life [21].
In addition to health factors, socioeconomic and
demographic factors have been associated with eden-
tulism and the use of dental care [11, 22]. Low edu-
cational level, low income and residence in a rural
area are associated with not visiting a dental facility
and with edentulism [11, 2227]. Some older studies
found that there were more edentulous women than
men, but more recent studies do not show this differ-
ence based on sex [1, 2, 13, 28]. Prevalence of eden-
tulism differs between countries [29] and probably
by region within countries as well [1, 2].
The increasing number of people who retain their
own teeth as they age means that more people will be
at risk of developing periodontal disease and caries in
the future [7]. The rapid increase in the elderly popu-
lation as a result of medical advances and increased
prosperity may make this change even more pro-
nounced [30]. Elderly people have increased preva-
lence of several risk factors thought to lead to
edentulism. Thus, a demographic shift towards a
larger proportion of elderly people in the population
might have extensive effects on oral health.
Furthermore, many studies of edentulism are dated.
In light of this background, it is important to
investigate which factors are associated with edentu-
lism and the extent of edentulism in the current set-
ting. This information would be useful for developing
future strategies for dental care prevention.
The primary aim of this study was to describe the
prevalence of edentulism and the uses of removable
dentures, dental implants and dental services in a rep-
resentative sample of people aged 65 years or older in
northern Sweden and western Finland. The second-
ary aim was to investigate which socioeconomic and
health risk factors are associated with edentulism and
use of dental services in these populations.
Materials and methods
Setting
This study is based on the GERDA study [31], a pop-
ulation-based study of people aged 65, 70, 75 and 80
years old and living in one of 15 municipalities in
Vsterbotten, Sweden, or one of 17 municipalities in
sterbotten, Finland. The study and data collection
were carried out in 2010. The project was approved
by the Regional Ethics Review Board of Ume (Dnr
05-084/2010-220-320).
Participants
Of the 10,696 people aged 65, 70, 75 and 80 years to
whom the GERDA questionnaire was sent, 6838
responded (63.9% response rate). The response rate
was 70.7% (3799/5426) in Sweden and 58.0%
(3059/5270) in Finland. Those who answered yes or
no to the question Do you mainly have your own
permanent teeth left? were selected for inclusion in
this study, giving a final sample size of 6099 people.
Procedures
The survey was randomly mailed to every third per-
son in the urban municipalities of Skellefte and
Ume, to every second person in the urban munici-
pality of Vaasa, and to every person in the other
municipalities, for the investigated age groups, based
on records from the Swedish Tax Agency and the
Finish Population Register Centre. A second copy of
the questionnaire was sent 1 month after the first
mailing as a reminder to those who had not responded.
A returned survey from the participant was consid-
ered to indicate consent to participate in the study.
Definition of edentulism
The survey posed the following questions, which
could be answered with yes or no:
Do you mainly have your own permanent teeth
left?
Do you wear dentures?
Do you have dental implants?
Have you visited a dentist in the preceding year?
Edentulism was defined as a no response to the
question about mainly having ones own permanent
teeth left.
Diagnosis and definitions
Sociodemographic information regarding sex, domi-
cile, economy, education and living situation was col-
lected from all participants. Educational level was
categorized by number of years of school attended
and dichotomized as a higher educational level (9
years) or a lower educational level (<9 years).
Information about economy was elicited by the ques-
tion Do you make ends meet? The answer options
 Edentulism in people 65 and older 3
Table I. Prevalence of edentulism, denture use, dental implants and not having visited a dentist in the preceding year.

Edentulous Wearing denture Dental implants Total n Not visited a dentist Total n
n = 2348 (25.3) n = 2204 (23.4) n = 1271 (13.5) (preceding year)
n = 2215 (23.8)

n (%) n (%) n (%) n (%)

Sex
Men 1195 (27.0)** 1067 (24.1) 595 (13.5) 4419 1051 (24.0) 4378
Women 1189 (23.8) 1137 (22.7) 676 (13.5) 5000 1163 (23.5) 4941
Age
65 677 (17.8)** 608 (16.0)** 479 (12.6) 3803 723 (19.1)** 3786
70 556 (23.8) 508 (21.7) 330 (14.1) 2341 516 (22.3) 2313
75 626 (33.5) 590 (31.6) 274 (14.7) 1867 514 (27.9) 1844
80 525 (37.3) 498 (35.4) 188 (13.4) 1408 461 (33.5) 1376
Domicile
Rural 1199 (31.9)** 1184 (31.5)* 464 (12.4)* 3757 1115 (30.1)** 3706
Urban 1185 (20.9) 1020 (18.0) 807 (14.3) 5662 1099 (19.6) 5613
Country
Sweden 1295 (20.6)** 1045 (16.6)** 926 (14.7)** 6301 1116 (18.6)** 6255
Finland 1089 (34.9) 1159 (37.2) 345 (11.1) 3118 1048 (34.2) 3064

*p < 0.05, ** p < 0.001 (chi-square tests). The epidemiological data in this table were weighted.

were with no difficulties, some difficulties, rather
difficult or very difficult, with the two latter answers
being considered indicative of a low income level. A
question of living situation was dichotomized as liv-
ing alone or not living alone. Participants answered
yes or no to questions about their medical history
(diabetes, stroke, myocardial infarction and high
blood pressure). A question about self-experienced
health from the Swedish version of the SF-36 was
dichotomized as good self-experienced health or
poor self-experienced health.
The four-item version of the Geriatric Depression
Scale was used as a measure of depression. This scale
has a high sensitivity and is useful in detecting depres-
sion among old people [32]. Questions about per-
sonal activities of daily living (P-ADLs), instrumental
activities of daily living (I-ADLs), loneliness and
social activity were asked. Participants who were
unable to shower independently were considered as
dependent in P-ADLs. Participants who were unable
to clean their home, shop for food or cook indepen-
dently were considered as dependent in I-ADLs.
A question about loneliness (Do you suffer from
loneliness?) was answered with either yes or no.
Participants were asked about outdoor activity; not
having been outdoors for a week was classified as no
activity outdoors. Participants were asked about
social contact; if they never had any contact with
neighbours or friends, they were classified as socially
isolated.
Statistics
The IBM SPSS Statistics 22 package was used for
statistical analyses. Univariate comparisons between
proportions were analysed using the Pearson chi-
square test. Comparisons between means were per-
formed with Students t test. Participants with
missing responses to the questions Do you wear
dentures? and Do you have dental implants?, who
also answered yes to the question Do you have
mainly your own permanent teeth left? were catego-
rized as having answered no to the questions about
dental implants and dentures.
In the epidemiologic presentation (Table I), prev-
alence figures were weighted to make the data more
representative in the selected age groups in
Vsterbotten, Sweden, and sterbotten, Finland.
Weighting was performed by counting the number of
participants in Ume and Skellefte (Sweden) thrice
and the number of participants in Vasa (Finland)
twice. Factors associated with the dependent variable
in univariate analyses were tested in multivariate
logistic regression analyses. Results from the logistic
regression analyses were presented as odds ratios
(ORs) and 95% confidence intervals (CIs). A signifi-
cance level of p < 0.05 was used.
Results
Epidemiology
In the total sample, 27.0% of men were edentulous
compared with 23.8 % of women (p < 0.001) (Table
I), resulting in a 25.3% prevalence overall. Nearly one-
quarter of 70-year-olds were edentulous. Among
70-year-olds, 20.1% of Swedes and 32.5% of Finns
were edentulous (p < 0.001). Men and women had
similar rates of edentulism in Sweden and Finland.
Among 70-year-old Swedes, 21.9% of men and 18.5%
4 H. Olofsson et al.
Table II. Factors associated with edentulism and denture use in univariate analyses.

Having their Edentulous p Wearing Not wearing p

own teeth left denture denture

n (%) n (%) n (%) n (%)

Men 1992 (45.5) 867 (49.5) 0.010 812 (48.2) 2047 (46.4) 0.185
Poor self-experienced health 1330 (30.7) 792 (45.4) <0.001 768 (45.8) 1354 (30.8) <0.001
Low income level 1503 (36.7) 759 (45.9) <0.001 743 (46.6) 1519 (36.6) <0.001
Living in rural area 2558 (59.8) 1199 (68.4) <0.001 1184 (70.4) 2573 (58.3) <0.001
Diabetes 483 (11.9) 259 (15.6) <0.001 255 (16.1) 487 (11.8) <0.001
High blood pressure 2181 (52.0) 936 (54.9) 0.044 908 (55.5) 2209 (51.8) 0.010
Myocardial infarction 323 (8.1) 187 (11.3) <0.001 190 (12.0) 320 (7.9) <0.001
Stroke 266 (6.5) 139 (8.3) 0.014 129 (8.0) 276 (6.6) 0.059
Living alone 1032 (23.9) 510 (29.5) <0.001 473 (28.4) 1069 (24.5) 0.002
Depression 277 (7.3) 168 (11.2) <0.001 161 (11.1) 284 (7.4) <0.001
Lower educational level 3246 (76.2) 1574 (92.0) <0.001 1540 (93.7) 3280 (75.8) <0.001
Dependent in I-ADLs 1174 (28.0) 732 (44.0) <0.001 695 (43.4) 1211 (28.5) <0.001
Dependent in P-ADLs 236 (5.5) 133 (7.7) 0.001 119 (7.1) 250 (5.7) 0.037
Experiencing loneliness 341 (8.2) 210 (12.5) <0.001 191 (11.8) 360 (8.5) <0.001
No activity outdoors 87 (2.0) 47 (2.8) 0.094 40 (2.4) 94 (2.2) 0.552
Socially isolated 271 (6.5) 145 (8.8) 0.002 144 (9.1) 272 (6.4) 0.001
Living in Finland 1659 (38.2) 957 (54.6) <0.001 1018 (60.5) 1598 (36.2) <0.001
mean sd mean sd mean sd mean sd
Age 69.84 5.27 72.12 5.6 <0.001 72.15 5.6 69.86 5.28 <0.001

I-ADLs: instrumental activities of daily living; P-ADLs: personal activities of daily living; sd: standard deviation.

of women were edentulous (p = 0.085). Among
70-year-old Finns, 35.6 % of men and 29.6 % of
women were edentulous (p = 0.091). Among 70-year-
olds in Ume, Sweden, 15.0% of men and 16.3% of
women were edentulous (p = 0.656). Among 75-year-
old Swedes, 28.1 % were edentulous, compared with
44.0 % of Finns in the same age group (p < 0.001).
The prevalence of edentulism increased with age
(p < 0.001), as did the rates of denture use (p <
0.001) and no dental visit in the preceding year (p <
0.001). The prevalence of edentulism (p < 0.001)
and denture use (p < 0.05) was higher among people
living in rural areas, who did not visit a dentist as
often as people living in urban areas (p < 0.001). The
prevalence of dental implants was higher among peo-
ple living in urban areas than in people living in rural
areas (p < 0.05) (Table I).
Prevalences of edentulism (p < 0.001) and denture
use (p < 0.001) were higher in Finland than in
Sweden, but dental implants were more common in
Sweden (p < 0.001). Finnish respondents were less
likely than Swedish respondents to have visited a den-
tist during the preceding year (p < 0.001) (Table I).
Factors associated with edentulism
In univariate analyses, edentulism was associated
with living in a rural area (p < 0.001), male sex (p =
0.010), increasing age (p < 0.001), low income level
(p < 0.001), lower educational level (p < 0.001),
poor self-experienced health (p < 0.001), diabetes (p
< 0.001), depression (p < 0.001), myocardial infarc-
tion (p < 0.001), high blood pressure (p = 0.044),
stroke (p = 0.014) living alone (p < 0.001), social
isolation (p = 0.002), loneliness (p < 0.001), depend-
ence in I-ADLs (p < 0.001) and P-ADLs (p = 0.001)
(Table II).
Denture use was associated with living in a rural
area (p < 0.001), increasing age (p < 0.001), low
income level (p < 0.001), lower educational level (p
< 0.001), poor self-experienced health (p < 0.001),
diabetes (p < 0.001), depression (p < 0.001), myo-
cardial infarction (p < 0.001), high blood pressure
(p = 0.010), living alone (p = 0.002), social isolation
(p = 0.001), loneliness (p < 0.001) and dependence
in I-ADLs (p < 0.001) and P-ADLs (p = 0.037)
(Table II).
Not having visited a dentist during the preceding
year was associated with edentulism (p < 0.001),
denture use (p < 0.001), lower dental implant use (p
< 0.001), living in a rural area (p < 0.001), increasing
age (p < 0.001), low income level (p < 0.001), lower
educational level (p < 0.001), poor self-experienced
health (p < 0.001), diabetes (p < 0.001), depression
(p = 0.014), myocardial infarction (p < 0.001), high
blood pressure (p < 0.001), living alone (p < 0.001),
social isolation (p < 0.001), loneliness (p < 0.001),
dependence in I-ADLs (p < 0.001) and in P-ADLs
 Edentulism in people 65 and older 5
Table III. Factors associated with not having visited a dentist in the preceding year in univariate analyses.

Visited a dentist in the Not visited a dentist p

preceding year (preceding year)

n (%) n (%)

Edentulous 686 (15.6) 1031 (63.3) <0.001

Wearing denture 663 (15.1) 993 (61.0) <0.001
Dental implants 659 (15.0) 122 (7.5) <0.001
Men 2053 (46.7) 774 (47.5) 0.556
Poor self-experienced health 1388 (31.7) 700 (43.1) <0.001
Low income level 1527 (36.8) 704 (45.7) <0.001
Living in rural area 2591 (58.9) 1115 (68.5) <0.001
Diabetes 488 (11.8) 240 (15.7) <0.001
High blood pressure 2182 (51.2) 894 (56.5) <0.001
Myocardial infarction 329 (8.1) 171 (11.2) <0.001
Stroke 288 (6.6) 142 (8.0) 0.063
Living alone 1008 (23.1) 507 (31.5) <0.001
Depression 298 (7.8) 141 (9.9) 0.014
Lower educational level 3332 (77.3) 1422 (89.5) <0.001
Dependent in I-ADLs 1226 (28.9) 649 (41.9) <0.001
Dependent in P-ADLs 241 (5.5) 120 (7.4) 0.006
Experiencing loneliness 345 (8.2) 195 (12.6) <0.001
No activity outdoors 84 (2.0) 47 (3.0) 0.020
Socially isolated 269 (6.4) 143 (9.4) <0.001
Living in Finland 1682 (38.3) 890 (54.7) <0.001
mean sd mean sd
Age 70.01 5.31 71.67 5.67 <0.001

I-ADLs: instrumental activities of daily living; P-ADLs: personal activities of daily living; sd: standard deviation.

(p = 0.006) and lack of outdoor activity (p = 0.020).
(Table III).
In multivariate analyses (Table IV), edentulism
was independently associated with male sex, having
poor self-experienced health, low income level, liv-
ing in a rural area, lower educational level, depend-
ence in I-ADLs, social isolation and increasing age.
Denture use was independently associated with
poor self-experienced health, low income level, liv-
ing in a rural area, lower educational level, depend-
ence in I-ADLs, social isolation and increasing age.
Not having visited a dentist during the preceding
year was independently associated with edentulism,
denture use, living in a rural area, living alone and
social isolation. Having dental implants was also
associated with more frequent dental visits (p <
0.001).
There was a higher prevalence of dental implant
use in Sweden (14.8%) than in Finland (10.4%) (p <
0.001) (Table V). Among people with dental implants,
76.6% had a lower educational level, compared with
81.4% of people without implants (p < 0.001).
Compared with men, women more often reported
low income level (p < 0.001) and poor self-experi-
enced health (p < 0.001); however, fewer women
were edentulous (p < 0.01). Men reported more
dependence in I-ADLs than did women (Table V).
Compared with Swedes, more Finns were edentu-
lous (p < 0.001), living in rural areas (p < 0.001), had
a low educational level (p < 0.001) or diabetes (p =
0.009), were socially isolated (p < 0.001) and experi-
enced loneliness (p = 0.007) (Table V).
Discussion
We found a low prevalence of edentulism in Sweden
compared with the prevalence reported from previ-
ous studies in the same Swedish geographical areas
[2]. There were large geographical differences in
edentulism prevalence between urban and rural
areas, and between Sweden and Finland. Edentulism
was independently associated with lower educational
level, low income level, living in a rural area, male
sex, dependence in I-ADLs, social isolation and poor
self-experienced health.
In 2000, a study in Gothenburg reported a 7%
prevalence of edentulism in 70-year-olds [1]. We
found a 20.1% prevalence of edentulism in
Vsterbotten 10 years later in the same age group.
However, results from a study using a representative
sample of Swedes in 2000 showed a prevalence of
edentulism ranging from 25% to 30% in people aged
65 to 76 years [3]. Our finding that 31.9% of people
living in rural areas and 20.9% of people living in
6 H. Olofsson et al.
Table IV. Factors associated with edentulism, denture use and not having visited a dentist in the preceding year in multivariate analyses.

Edentulous p Wearing denture p Not visited a dentist p

OR (95% CI) OR (95% CI) (preceding year)
OR (95% CI)

Edentulous 4.12 (3.195.32) <0.001

Wearing denture 2.68 (2.073.46) <0.001
Dental implants 0.45 (0.340.60) <0.001
Men 1.30 (1.121.52) 0.001
Poor self-experienced health 1.38 (1.171.62) <0.001 1.23 (1.101.52) 0.002 1.10 (0.911.33) 0.310
Low income level 1.70 (1.091.47) 0.002 1.33 (1.151.55) <0.001 1.15 (0.971.36) 0.108
Living in rural area 1.43 (1.231.66) <0.001 1.64 (1.401.91) <0.001 1.24 (1.051.48) 0.013
Diabetes 0.96 (0.761.20) 0.705 0.97 (0.771.22) 0.787 1.14 (0.891.46) 0.302
High blood pressure 0.93 (0.801.08) 0.364 0.98 (0.851.14) 0.809 1.12 (0.951.33) 0.172
Myocardial infarction 0.88 (0.671.16) 0.367 1.09 (0.841.42) 0.511 0.97 (0.711.30) 0.819
Stroke 1.19 (0.881.61) 0.253
Living alone 1.15 (0.961.37) 0.126 1.03 (0.861.24) 0.786 1.52 (1.251.84) <0.001
Depression 1.19 (0.911.57) 0.210 1.13 (0.851.49) 0.399 0.85 (0.611.17) 0.325
Lower educational level 2.87 (2.313.58) <0.001 3.95 (3.095.04) <0.001 1.80 (0.941.46) 0.151
Dependent in I-ADLs 1.48 (1.251.74) <0.001 1.49 (1.271.75) <0.001 1.16 (0.961.40) 0.115
Dependent in P-ADLs 1.03 (0.761.4) 0.842 0.94 (0.691.28) 0.697 1.22 (0.861.73) 0.274
Experiencing loneliness 1.11 (0.851.44) 0.445 1.01 (0.771.33) 0.923 1.14 (0.841.53) 0.407
Socially isolated 1.52 (1.171.98) 0.002 1.54 (1.182.01) 0.001 1.36 (1.011.83) 0.044
No activity outdoors 1.13 (0.602.11) 0.715
Age (per year) 1.07 (1.061.09) <0.001 1.07 (1.051.08) <0.001 1.01 (0.991.03) 0.224

Results are presented odds ratios (ORs) with 95% confidence intervals (CIs). Logistic regression models were used. Only variables that
were significantly associated with their respective outcomes were included in the multivariate analyses. I-ADLs: instrumental activities of
daily living; P-ADLs: personal activities of daily living.

Table V. Characteristics of the study sample in total, in women compared with men, and in Sweden compared with Finland.

Total n (%) Women Men p Sweden Finland p

n (%) n (%) n (%) n (%)

Edentulous 1752 (28.7) 885 (27.3) 867 (30.3) 0.010 795 (22.8) 957 (36.6) <0.001
Wearing denture 1683 (27.6) 871 (26.9) 812 (28.4) 0.185 665 (19.1) 1018 (38.9) <0.001
Dental implants 787 (12.9) 425 (13.1) 362 (12.7) 0.596 516 (14.8) 271 (10.4) <0.001
Not visited a dentist (preceding year) 1628 (27.0) 854 (26.7) 774 (27.4) 0.556 738 (21.4) 890 (34.6) <0.001
Poor self-experienced health 2122 (34.9) 1212 (37.5) 910 (31.9) <0.001 1129 (32.6) 993 (38.0) <0.001
Low income level 2262 (39.3) 1303 (42.9) 959 (35.4) <0.001 1320 (40.7) 942 (37.6) 0.015
Living in rural area 3757 (61.6) 1987 (61.3) 1770 (61.9) 0.641 2074 (59.5) 1683 (64.3) <0.001
Diabetes 742 (13.0) 350 (11.6) 392 (14.5) 0.001 398 (12.0) 344 (14.4) 0.009
High blood pressure 3117 (52.8) 1650 (52.8) 1467 (52.8) 0.933 1840 (54.0) 1277 (51.2) 0.31
Myocardial infarction 510 (9.0) 155 (5.2) 355 (13.3) <0.001 329 (10.1) 181 (7.5) 0.001
Stroke 405 (7.0) 178 (5.8) 227 (8.4) <0.001 285 (8.5) 120 (4.9) <0.001
Living alone 1542 (25.5) 1046 (32.6) 496 (17.6) <0.001 958 (27.8) 584 (22.6) <0.001
Depression 445 (8.4) 248 (8.9) 197 (7.9) 0.158 262 (8.7) 183 (8.1) 0.399
Lower educational level 4820 (80.2) 2535 (80.0) 2285 (81.6) 0.115 2577 (75.8) 2243 (87.3) <0.001
Dependent in I-ADLs 1906 (32.5) 737 (23.8) 1169 (42.5) <0.001 1085 (32.2) 821 (33.0) 0.503
Dependent in P-ADLs 369 (6.1) 179 (5.6) 190 (6.7) 0.070 236 (6.8) 133 (5.1) 0.007
Experiencing loneliness 551 (9.5) 341 (11.1) 210 (7.6) <0.001 285 (8.6) 266 (10.7) 0.007
No activity outdoors 134 (2.3) 79 (2.5) 55 (2.0) 0.167 88 (2.6) 46 (1.8) 0.046
Socially isolated 416 (7.1) 173 (5.6) 243 (8.9) <0.001 174 (5.2) 242 (9.8) <0.001

I-ADLs: instrumental activities of daily living; P-ADLs: personal activities of daily living.

urban areas had edentulism is consistent with find-
ings from earlier studies [22, 33]. There appear to be
vast geographical differences in edentulism in Sweden;
however, differences in study timeframes, definitions
of edentulism and presentations of age-specific results
complicate such comparisons. Additionally, we found
no overrepresentation of women, but actually a slightly
higher prevalence of edentulism among men overall,
consistent with the diminished sexual divide in eden-
tulism that has previously been reported [26, 27].

Among 70-year-olds in Vsterbotten, there were
21.4% edentulous men and 35.7% edentulous
women in the city of Ume in 1990 [2], compared
with our results from 2010 study data showing 15.0%
edentulous men and 16.3% edentulous women in the
same city and age group.
Our findings of 28.1% edentulism in Sweden and
44.0% edentulism in Finland among 75-year-olds dif-
fers from a 1989 report showing a 23% prevalence of
edentulism in Gothenburg, Sweden, and a 58% preva-
lence in Jyvskyl, Finland [29]. Although the preva-
lence of edentulism may have decreased in Finland,
and the regional difference may have decreased, ear-
lier studies comparing Finland and Sweden were
made in the different geographical areas.
Our study showed that edentulism and denture
use were more common in Finland, whereas dental
implant use and dental visits were more common in
Sweden. These findings may reflect differences in
health insurance and reimbursement systems for
dental treatments between the two countries [34].
Public funding of dental care significantly decreases
inequity in dental health [35]. Sweden introduced
partial public coverage of dental care expenses in
1974, which was reduced somewhat in 1999, but still
probably had a large effect on edentulism. Meanwhile,
Finland introduced partial public coverage as late as
2002, which is not likely to have produced major
positive cohort effects in a survey collected in 2010.
Some previous study results indicated that women
visit the dentist more frequently than men [23, 24],
although another study found no differences between
men and women with respect to dental visits [11]. We
did not see a difference in dental visit frequency
between men and women. The prevalence of edentu-
lism in women may have decreased compared with
previous results [1, 2], possibly as a result of increased
sexual equality in access to and quality of health care.
However, women reported worse self-experienced
health and lower income levels than men in our study.
Consistent with previous findings, we found
strong multivariate correlations between edentulism
and educational level, income level and residence in
a rural area [4, 16, 2227], as well as an association
between social isolation and edentulism [36]. The
same risk factors were found to be associated with
denture use. Dental implant use was mainly associ-
ated with educational level. However, dental implant
prevalence was lower compared with the other pri-
mary study variables, suggesting that a larger sample
may have been needed to find the same associations.
The factors associated with not visiting a dentist
were partly different, with no apparent associations
with income level or educational level, but rural living
was associated with fewer dental visits. A previous
Edentulism in people 65 and older 7
Swedish study showed the decreasing effect of socio-
economic status on dental visits over time in repeated
surveys, but a significant association remained at the
last measurement point in 2000 [37]. Another Swedish
study showed educational level to be consistently asso-
ciated with dental visits from 1992 to 2011, with no
apparent attenuation of the association over time [11].
The association between rural living and fewer dental
visits in this study may be explained by the differences
in availability of dental clinics near participants
homes, travel distances to the nearest dental clinic,
and difficulty in accessing dental care for those with
impaired health. Edentulism, denture use, living alone
and social isolation were also associated with not visit-
ing a dentist. Edentulous people may not prioritize
dental visits or, alternatively, may not need regular
dental care. Conversely, not visiting the dentist may
lead to worse oral health and edentulism.
Previous studies have found that poor oral hygiene
and oral health are associated with cardiovascular
disease and stroke [16, 1920]. However, our results
do not show any significant association between
edentulism or denture use and cardiovascular dis-
ease. We found a correlation between dependence in
I-ADLs and edentulism. People who are dependent
in I-ADLs have a greater need for mobility services,
which may limit contact with dental care profession-
als. However, we did not find an association between
I-ADL dependency and not visiting a dentist.
Diabetes was not strongly associated with being
edentulous, despite previous reports that diabetes
increases adults risk of developing periodontal dis-
ease [14, 15].
One limitation of this study is that we used non-
specific questions to inquire about edentulism, den-
ture use and implants. People who answered yes to
the question about having dental implants could have
a single implant or an implant-supported denture;
these constructions differ markedly. Respondents
may have had difficulty in understanding the ques-
tion about denture use to include both partial and
full dentures. Questions about degree of edentulism
would be instructive in providing information about
chewing abilities. A previous analysis of survey non-
responders showed higher non-response rates among
older people than younger people, and slightly higher
non-response rates in rural than urban areas. The
non-response rate was higher in Finland than Sweden
overall, but the distribution of non-responders was
similar based on age groups and urban versus rural
areas [38]. These demographic features of non-
responders may have led to a slight underestimation
of the overall prevalence of edentulism. Strengths of
the study are the large number of participants, cover-
age of both urban and rural areas, and inclusion of
8 H. Olofsson et al.
Swedes and Finns. Thus, comparisons could be made
for these demographic parameters.
In conclusion, this study shows that edentulism is
more prevalent in Finland than in Sweden, and more
common in rural than in urban areas. The prevalence
of edentulism is likely to decrease with time, as
advances in dental care and health care may increase
the need for dental care among large numbers of
older people who keep their teeth and remain at risk
of developing periodontal disease. We found edentu-
lism in people aged 65 years and older to be associ-
ated with low educational level, low income level,
male sex, not visiting a dentist, residence in rural
areas and dependence in ADLs, social isolation and
experiencing poor health. These results identify
important factors associated with edentulism that
could be used to identify at-risk people who should
be offered preventive services, and to identify factors
important for intervention.
Conflict of interest
The authors declare that there is no conflict of
interest.
Funding
This work was supported by the Interreg IIIA
Kvarken-MittSkandia Program (20052007) and the
Bothnia-Atlantica Program, which were both funded
by the European Union, the European Regional
Development Fund and the Swedish Research
Council (grant number K2014-99X-22610-01-6).
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