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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 13  |  Issue : 4  |  Page : 183-189

Oral health-related quality of life of institutionalized elderly in Satara District, India


1 Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India
2 Department of Oral Pathology & Microbiology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India
3 Department of Community Medicine, Krishna Institute of Medical Sciences, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India

Date of Web Publication16-Apr-2019

Correspondence Address:
Dr. K M Shivakumar
Public Health Dentistry, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed to be University, Malkapur, Satara (Dist.,), Karad - 415 110, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_36_17

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  Abstract 


Context: Almost in every country, the proportion of people aged over 60 years is growing rapidly than any other age group as a result of both longer life expectancy and declining fertility rates. Aims: The aim of this study is to assess the oral health status, oral health-related quality of life (OHRQoL), and the dental care utilization of institutionalized and homebound elderly in Satara district, India. Materials and Methods: A descriptive cross-sectional study was conducted among the 150 institutionalized elderly participants of Satara district. Type 3 clinical examination was done to detect dental caries, missing tooth, periodontal diseases, and any other oral findings followed by interview with elderly patients. A questionnaire was administered to assess OHRQoL according to the Geriatric Oral Health Assessment Index (GOHAI), dental visiting pattern, and sociodemographic and self-perceived oral health status of elderly. The descriptive and analytic statistics were used to analyze the data; Chi-square test or Fisher's exact test was performed to determine the prevalence of poor OHRQoL by independent variables. Results: Poor OHRQoL according to GOHAI was observed among 64.7% of the men and 67.1% of the women, and there was no statistically significant difference observed. In community periodontal index, 42.6% of men and 36.6% of women had all sextants excluded, and of those remaining, 95.6% of men and 96.3% of women needed one or other periodontal treatment. Regarding decayed, missing, and filled teeth index, mean was 22.5 in men and 24.2 in women. Conclusion: Institutionalized elderly with 65 years and older showed higher prevalence of poor oral health status and unmet needs for dental care that were associated with poor OHRQoL. Therefore, it is necessary to improve health and social importance of oral health care for elderly.

Keywords: Elderly, Geriatric Oral Health Assessment Index, oral health-related quality of life, self-perception


How to cite this article:
Shivakumar K M, Patil S, Kadashetti V, Raje V. Oral health-related quality of life of institutionalized elderly in Satara District, India. J Datta Meghe Inst Med Sci Univ 2018;13:183-9

How to cite this URL:
Shivakumar K M, Patil S, Kadashetti V, Raje V. Oral health-related quality of life of institutionalized elderly in Satara District, India. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2019 Jul 20];13:183-9. Available from: http://www.journaldmims.com/text.asp?2018/13/4/183/256209




  Introduction Top


There is an increase in population older than 65 years is very much widely discussed social implications in different sectors particularly in health-related sectors.[1],[2] Almost in every country, the proportion of people aged over 60 years is growing rapidly than any other age group as a result of both longer life expectancy and declining fertility rates.[3],[4]

Globally, poor oral health among elderly people has seen with high level of tooth loss, dental caries experience, high prevalence rates of periodontal disease, xerostomia, and oral precancer/cancer.[3],[5] India has around 100 million elderly at present, and the number is expected to increase to 323 million, constituting 20% of the total population, by 2050.[3],[6] Many of the older adults face special health challenges such as degenerative, physical, mental, and cognitive diseases and are at constant risk of noncommunicable cerebral and cardiovascular diseases and communicable diseases.[3] The negative impact of poor oral health conditions on daily life is particularly significant among elderly population which worsens the oral health by not only affecting chewing function and therefore nutrition but also general health. Malnutrition in the elderly has an evident impact on their general health and hence affecting the quality of life. Some reports show that extensive tooth loss and poor oral health have an impact on food choice and on the intake of key nutrients, causing various nutritional problems.[3],[5],[7]

At the individual and society levels, there is a myth that oral diseases and edentulousness are typical of aging.[1],[2],[8] On the other hand, aging and oral health should be analyzed taking into account the impact on quality of life. Thus, although historically oral health status was assessed by epidemiological surveys using objective clinical indicators, currently specific measures of oral health-related quality of life (OHRQoL) are also used.[1],[9],[10] The latter is the subjective interpretation that individuals make of their oral health taking into account previous experiences and the social, economic, cultural, and historical context in which they have lived[1],[11] The boundary of old age cannot be defined exactly because it does not have the same meaning in all societies. The Government of India adopted “National Policy on Older Persons” in January 1999. The policy defines “senior citizen” or “elderly” as a person who is the age of 60 years or above.[3],[4]

A study by Gift et al.[12] correlated (R2 = 0.22) the OHRQoL with current issues linked to social determinants of health such as external environmental factors such as place of residence (e.g., rural/urban and region or country of origin), access to health care, and individual characteristics such as oral health status, sex, and age and also with self reported health of teeth, gums, and dentures. The important findings of this study[12] were that the perception of general health and epidemiological indicators of oral health status had significant factors. Socioeconomic indicators did not contribute significantly in either regression, and the understanding components of overall perceptions of oral health move us closer to understanding oral health behaviors and OHRQoL. Our study helps us to know the picture of oral health status of elderly and helps to understand the associated factors which affect oral health outcomes directly and indirectly. These findings will help to provide appropriate care for this group. In India, geriatric oral health is neglected, especially in rural population. This is the first study of its kind in Satara district of western Maharashtra. This study will help in translating our research findings in practice.

Of the different tools for measuring the impact of oral health status on quality of life, the most one commonly used in the elderly, both individually and collectively, has been the Geriatric Oral Health Assessment Index (GOHAI). It has been proved useful as a predictor of the need for an oral examination at individual level.[1],[13] One of the benefits offered by public health services is the resolution of dental emergencies, primarily through extraction, but the current portfolio of services excludes recuperative dental care in adults and the elderly[1],[14]

Therefore, the aim of this study was to assess the oral health status, OHRQoL, and the dental care utilization of institutionalized and homebound elderly in Satara district, India.


  Materials and Methods Top


A descriptive cross-sectional study was conducted among the 150 institutionalized elderly participants of Satara district in India. There were six institutionalized elderly old age homes, and the permissions from the management of the old age home were obtained. Ethical approval was obtained from the Institutional Ethics Committee of Krishna Institute of Medical Sciences Deemed University. The study was conducted over a period of 2 years from December 15, 2013, to December 14, 2015. Informed consent was obtained from all the participants. List Old age homes in Satara district were obtained and old age homes were selected using systematic random sampling technique. A total of three old age homes were selected for the study. From selected old age home, 50 elderly participants were enrolled by simple random sampling technique.

A pilot study was conducted among 30 participants in one of the old age homes to assess the face, content, criterion validity, and reliability of the questionnaire. It was found to be satisfactory. Depending on the findings of the pilot study, the final sample size was determined to be 150 elderly in the age group 65 and above living in old age homes of Satara district. The elderly having systemic diseases, under medication, and those with cognitive decline who lacked understanding of the questionnaire were excluded from the study. During the visit to the centers, the principal investigator performed an oral examination which provided information on oral health followed by interview with the elderly patients to obtain data on sociodemographic issues and self-reported oral health, use of dental services, and OHRQoL.

We have assessed the OHRQoL using GOHAI. The GOHAI was consisted of 12 questions scored from 1 to 5 (total from 12 to 60 points) corresponding to worst (poor) and best (good) OHRQoL, respectively, which were dichotomized into poor (negative) in individuals with a score of <57 and good (positive) in those with ≥57.

A questionnaire as per GOHAI was administered to assess the OHRQoL, dental visiting pattern, and sociodemographic and self-perceived oral health status of elderly The questions covered three dimensions: (a) psychosocial (concern about oral health, self-image, and limited social contacts due to oral problems), (b) physical (eating, speaking, and swallowing), and (c) pain or discomfort associated with oral health.

The independent variables were as follows: (a) individual characteristics: sex, age grouped in 65–74 and ≥75 years; educational attainment grouped as “educated” (primary education and over) or “no education” (less than primary education); (b) oral health behavior: time since last visit to the dentist grouped into 1 year or less, >1 year; (c) subjective oral health: subjective oral health conditions (self-reported) such as the existence of any teeth problems (yes/no), any gum problems (yes/no), and opinion about their own teeth, gums, and/or dentures categorized as yes (fair, poor, or very poor) and no (good or excellent); and (d) objective oral health was measured by the principal investigator using Type 3 clinical examination by following the criteria of the World Health Organization for oral health surveys.[15] The oral health assessment form 1997 was used to assess oral health status and treatment needs of elderly: using upper and lower dentures (yes/no); needing upper and lower denture as technical and professional criteria (yes/no), defining prosthetic rehabilitation required if tooth loss affects the esthetics and/or functionality; and needing periodontal treatment according to the community periodontal index (CPI) and sextant of the mouth showing the worst periodontal condition for each individual. CPI index was categorized as needing periodontal treatment: yes (bleeding, calculus, or pockets)/no (healthy people and those with all sextants excluded); decayed, missing, and filled teeth (DMFT) index defined as the sum of the number of DMFT and also categorized according to the mean, i.e., ≤23 and >23; edentulism defined as the total absence of natural teeth (yes/no) and also evaluated “functional edentulism” (the existence of <20 teeth).

The collected data were analyzed using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). The descriptive and analytic statistics were used to analyze the data.

Statistical analysis

descriptive analysis of the variables by sex and bivariate analysis, using Chi-square test or Fisher's exact test, was performed to determine the prevalence of poor OHRQoL as per GOHAI with a score of <57 (poor OHRQoL) and ≥57 (good OHRQoL) by independent variables. Adjusted Poisson regression bivariate analysis and multivariate models were used to obtain prevalence ratios (PR) and their respective confidence intervals at 95% to determine factors associated with poor OHRQoL.


  Results Top


[Table 1] shows the description of the variables by sex. In the present study, no variable showed statistically significant differences by sex other than their educational level. Poor OHRQoL according to GOHAI was observed among 64.7% of men and 67.1% of women, and there was no statistically significant difference observed. In the present study, more than 70.6% were older than 75 years; 60.3% of men and 78.1% of women had not completed primary education. Only 5.9% of men and 8.5% of women visited a dentist in the past year and 44.1% of men and 57.4% of women self-reported having a poor opinion about their own teeth, gums, or dentures. Regarding objective oral health status, wearing dentures was more frequent in women (42.7% upper and 39.0% lower dentures) than men (38.2% and 27.9%, respectively). Similarly, a greater percentage of men needed (58.9% upper and 73.5% lower) than women (51.2% upper and 58.5% lower), respectively. Over 72.1% of men and 75.6% of women were “functional edentulous.”
Table 1: Demography and profile of the institutionalized elderly

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[Table 2] showed that in terms of periodontal status, assessed using the CPI, 42.6% of men and 36.6% of women had all sextants excluded, and of those remaining, 95.6% of men and 96.3% of women needed one or other periodontal treatment. Regarding DMFT index, the mean was 22.5 in men and 24.2 in women, and in terms of its components, the average for decayed was 2.9 and 3.0, for missing 18.1 and 20.8, and for filled 0.5 in men and 0.4 in women, respectively. The average number of remaining teeth was 10.9 in men and 9.8 in women. No statistically significant difference has been observed between gender and the periodontal status and dental caries.
Table 2: Description of the community periodontal index and decayed, missing, and filled teeth index and number of remaining teeth of institutionalized elderly

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[Table 3] showed that although women with higher educational level and those who visited a dentist during the previous year showed a greater prevalence of poor OHRQoL, according to the bivariate analysis, no sociodemographic related variables (e.g., sex PR 1.12 95% confidence interval [CI] 0.79–1.43) nor last visit to dentist (PR 0.95 95% CI: 0.59–1.29) was statistically significantly associated with poor OHRQoL (GOHAI). All subjective and only some objective oral health conditions (using upper denture PR 0.81 95% CI: 0.71–0.93, needing upper prostheses PR 1.37 95% CI: 1.07–1.79, and needing lower prostheses PR 1.41 95% CI: 1.09–1.77) were found to be associated to poor OHRQoL. Even though “functional edentulism” was not statistically significant in the bivariate analysis (PR 1.33 95% CI: 0.88–1.71), it was introduced in multivariate models due to its conceptual plausibility. Variables that explain the poor OHRQoL were “functional edentulism” and needing upper denture, independently when they were adjusted for each one of the subjective variables, except “functional edentulism” which was not statistically significant when adjusted for self-reporting gums.
Table 3: Prevalence (%) of poor oral health self-perception (measured by Geriatric Oral Health Assessment Index) and its associated factors

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  Discussion Top


The institutionalized elderly people in Satara district showed a higher prevalence of poor oral health and poor OHRQoL. Subjective oral health conditions, objective oral health conditions, needing upper denture, and “functional edentulism” explain the poor OHRQoL. Most of the study participants were almost ≥75 years' age group.

Our study population showed a high prevalence of poor objective oral health conditions. The studies conducted by Cornejo et al.[1] and Zuluaga et al.[9] showed a prevalence of edentulism of 32.95% and 33.8%, respectively. Another study[7] conducted in Spain found a lower prevalence of edentulism and DMFT index (22.8) in the institutionalized population. The prevalence of poor OHRQoL is also greater than that described by other studies[1],[9] for institutionalized elderly although our results were in consistent with these results.

However, several studies using GOHAI show a lower prevalence of poor OHRQoL in institutionalized elderly.[1],[11],[16],[17] The difference between our results and other studies not only corresponds to differences in objective oral health conditions but also to sociocultural factors, individual history and treatment of oral diseases, and access to dental care. Hence, many other life events and socially and culturally derived values also appear to affect an elderly person's perception of the impact of oral health and oral disease.[1],[18] Therefore, to describe the needs in the institutionalized population, in addition to the damage due to caries, periodontal disease, and edentulism, among other oral diseases, it would be necessary to assess their opinion using validated instruments such as GOHAI or OHIP.[19]

According to our study results, only 55.9% of men and 42.6% of women self-reported a poor opinion of teeth, gums, or dentures. However, when trying to measure such an opinion using GOHAI, we observed an increase in the prevalence of poor scores and that 80.8% of elderly self-reporting a poor opinion about their oral health conditions showed poor OHRQoL (GOHAI).

The esthetic, psychosocial, and cultural issues may have influenced the self-perception of the elderly tested in our study. Factors related with poor OHRQoL: Regarding the impact of poor OHRQoL, like in other studies, it was determined that the elderly were needing upper dentures and self-reported poor opinion about their teeth/gums/dentures.[1],[11] Furthermore, agreeing with Koltermann et al.,[20] OHRQoL was associated with “functional edentulism” as functional-edentulous elders had much worse scores in GOHAI than those with ≥20 remaining teeth. Therefore, our results are in concordant with other studies showing the importance of clinical oral health status on the quality of life for elderly.[7],[9] Some of the researches used the GOHAI as a predictor of objective oral health conditions in the institutionalized geriatric patients.[21] To meet the unmet needs for dental health care, it is proposed that good sensitivity when comparing with other indicators of OHRQoL. Hence, GOHAI can be used to assess OHRQoL in elderly and would contribute to detect and predict the need for the oral health care as well as for oral health diagnosis and planning services. Health-care utilization, measured as the prevalence of elderly who have visited a dentist during the previous year, was low. Although time since last dental visit was not associated to OHRQoL, agreeing with several studies, elderly who visited a dentist the previous year showed a poorer and higher prevalence of poor OHRQoL of life.[11],[22]

The researchers suggested that the elderly tend to visit a dentist only due to oral problems linked to a painful or uncomfortable experience and also suggest that decision to visit a dentist would respond to prevailing oral health-related attitudes, dental care phobia linked to bad dental experience, that could influence behaviors such as visiting a dentist, leading to a vicious circle that worsens the problems of oral health.[11],[23] It is likely that the lack of association reported in our study would also be explained by the very low prevalence of a dental visit during the previous year, maybe also reflecting the lack of access to dental care in Spain.[14]

It is also claimed that the elderly population has lived in a context in which the loss of teeth and poor oral conditions seemed to be considered as normal in aging people. It is likely that lower prevalence of poor OHRQoL reported in other studies reflects a widespread cultural attitude[1],[11],[12],[17] which is little expressed in our study population. That is, there are different perceptions of what is “problematic” according to individual contexts, besides regional and historical tradition, where dental treatment is still poorly accessible, and where it will be more or less likely that a problem was interpreted or perceived as such. We must also consider that clinical indices tend to measure disease that might be asymptomatic, unknown, or not valued by people while subjective indexes aim to evaluate human and health-related experiences.[24] Many elderly tend to be considered unhealthy due to acute oral and dental manifestations but not in cases of chronic irreversible oral processes that lead to tooth loss and even edentulism, a situation in which people tend to believe that their mouths do not need oral health care.[1],[11] Even in countries with specific programs for this group, the main reason for not seeking dental treatment is the failure to perceive the need for dental care.[1],[23]


  Conclusion Top


In our study, institutionalized elderly with 65 years and older showed higher prevalence of poor oral health status and unmet needs for oral health care that were associated with poor OHRQoL. Therefore, it is necessary to improve health and social importance of oral health and oral health care for elderly, aspects that become relevant in relation to healthy aging and human rights issues in the discussion about economic efficiency and health-care spending. Thus, it is necessary to include oral health-care program at the government level, especially to contribute to the healthy oral health. The OHRQoL can provide the basis for oral health-care program and nutritional status in elderly, and a strong association was found between GOHAI and OHRQoL. The limitation of our study is that more work is needed to integrate the oral health assessment into comprehensive geriatric assessment so that the patient's total health is examined and considered. Similarly, larger sample size may be required for further in-depth studies on the relationship between quality of life, nutritional status, and more such studies need to be carried out in other large cities of the country to build comprehensive database for future policy decisions on OHRQOL, nutritional status, and other factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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