| Abstract|| |
Aim: To assess the oral health status and treatment needs among elderly people aged 60 years and above residing as inmates in the old age homes of Hyderabad and Secunderabad, Andhra Pradesh, India.
Settings and Design: A cross-sectional study was performed to determine the oral health status and treatment needs among elderly people.
Materials and Methods: In order to assess the oral health status and treatment needs, the clinical assessment of oral mucosa, community periodontal index, loss of attachment, dentition status and treatment need, prosthetic status and prosthetic need was recorded based on a modified World Health Organization 1997 proforma.
Statistical Analysis Used: Multi-group analysis was done using analysis of variance. P < 0.05 was considered statistically significant.
Results: Of the 812 inmates, 431 (64.0%) of the study participants had oral mucosal lesions. In terms of periodontal status, all sextants were excluded (Code "X") in 324 (39.9%) subjects. Out of dentate population, a majority of the inmates (219; 27.0%) presented with deep pockets (Code "4") followed by shallow pockets (Code "3" - 183; 22.5%). The majority of the subjects had no prosthesis in the upper arch (85.0%) and lower arch (86.6%).
Conclusion: The study demonstrated poor oral health among institutionalized elderly inmates. Oral mucosal lesions were found to be higher and periodontal status was also poor amongst the study population.
Keywords: Edentulousness, elderly inmates, old age homes, oral health, oral mucosal lesions, treatment needs
|How to cite this article:|
Shaheen S S, Kulkarni S, Doshi D, Reddy S, Reddy P. Oral health status and treatment need among institutionalized elderly in India. Indian J Dent Res 2015;26:493-9
Since the turn of century, the world is witnessing an explosion in the proportion of old people as modern medicine and health enable people to live longer.  Perhaps it becomes the mission of health professionals to not merely increase the lifespan but also, make the later years of life more productive and enjoyable.  The aging is, of course, a biologic reality that has its own dynamic, largely beyond human control that can be viewed as a bio-psychosocial process. 
|How to cite this URL:|
Shaheen S S, Kulkarni S, Doshi D, Reddy S, Reddy P. Oral health status and treatment need among institutionalized elderly in India. Indian J Dent Res [serial online] 2015 [cited 2019 Aug 18];26:493-9. Available from: http://www.ijdr.in/text.asp?2015/26/5/493/172045
Elderly or old age consists of ages nearing or surpassing the average life span of human beings. Globally, 600 million people are aged 60 years and over, and this manner will double by 2025.  The Government of India has adopted "National Policy on Older Persons" in January 1999, which defines "senior citizen" or "elderly" as a person who is of age 60 years or above. In India, the proportion of older people has crossed 100 million mark and the number is expected to increase to 323 million constituting 20% of the total population of 2050, posing the greatest challenge to provide affordable, accessible, and equitable health care to this population. Aging phenomenon emerges as the most significant issue of the twenty-first century throughout the world. 
The phenomenon of aging is both a medical and sociological problem indicating a greater demand for the health services of a community.  Nevertheless, because of the increasing risks of systemic disease and its treatment with age, there can be a substantial alteration in both the risk and the implications of oral disease. 
Although a majority of the aged live independently in the community, a growing number of the elderly receiving institutional care has increased.  Homes for the older age people has been set up for destitute elderly persons as they serve as an alternate to home care, to ensure social and financial stability and to provide rehabilitation.  The residential home environment has several unique features ever since it serves frailer population who are at greater risk for illness and functional loss. 
Oral diseases are progressive and cumulative across the life span contributing to the functional difficulties like chewing, swallowing and social interaction.  Several oral conditions such as tooth loss, denture wearing, dental caries experience, periodontal disease, xerostomia, and cancer are highly prevalent in older populations. 
Furthermore, the residents of the old age homes have poor oral health as they often rely on caregivers for their daily oral hygiene maintenance. Adequate access to dental care can reduce morbidity and mortality, preserve function, and enhance overall quality of life.
Moreover, studies have indicated that the dental status of the institutionalized older people is generally poor. , Therefore, an integrated care approach to promote oral health among elderly people residing in the old age homes should be developed.
Hence, the present study was intended to assess the oral health status and treatment needs of elderly people residing as inmates in the old age homes of Hyderabad and Secunderabad, Andhra Pradesh, India.
| Materials and methods|| |
A cross-sectional study was performed to determine the oral health status and treatment needs among elderly people residing as inmates in the old age homes of Hyderabad and Secunderabad, Andhra Pradesh, India. All the inmates aged 60 years and above formed the study population.
Approval for the study was obtained from the Institutional Review Board of Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre (PMVIDS/PHD/0010/2011).
All the old age homes listed by the Greater Hyderabad Municipal Corporation (GHMC) of Hyderabad and Secunderabad were obtained. A total of 84 old age homes were listed. Out of the 84 old age homes listed by GHMC of Hyderabad and Secunderabad, 30 were nonfunctional. Of 54 old age homes that were functional, permission to carry out the survey was obtained from only 22 of them. The study participants were selected based on the following criteria.
- All the inmates aged 60 years and above
- Subjects present in the old age home on the day of examination.
The proforma was designed to collect the information of the demographic details (age, sex, education, and marital status), name of the old age home, duration of stay in the old age home, medical history, history of medication used, dental visit, last visit, personal history (smoking, smokeless tobacco, pan chewing, and alcohol), oral hygiene practices, and diet. The oral health status with treatment needs was recorded using a modified World Health Organization (WHO) 1997  proforma, and all the details were filled by the examiner.
- Those who did not give the informed consent
- Inmates who refused for oral examination.
The survey was carried out from the month of November 2012 to February 2013. The examiner was trained and calibrated in the Department of Public Health Dentistry. In the clinical oral examination, oral mucosa, community periodontal index (CPI), loss of attachment (LOA), dentition status and treatment needs, prosthetic status and prosthetic needs was examined by the examiner based on the codes and criteria according to WHO proforma.
The data was analyzed using Statistical Package for Social Sciences (SPSS) version 18.0. Chi-square analysis was used to find the significance of two or more variables. t-test was used for comparison between two variables. Multi-group analysis was done using analysis of variance. P < 0.05 was considered statistically significant.
| Results|| |
The demographic distribution of the study subjects according to gender, age groups, marital status, and education are shown in [Table 1].
|Table 1: Distribution of study subjects based on duration of stay at old age homes according to gender and age groups |
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The analysis of the medical histories revealed that hypertension 405 (49.9%) was most commonly noticed. Cardiac problems were seen among 42 subjects, but asthma was least commonly observed for males (4; 57.1%) and females (4; 42.9%).
On an average, a higher percentage of females 335 (57.5%) were on medicationas compared to males 248 (42.5%). A statistically significant difference was noted for age groups based on medication used, of which majority of 80-89-year-old subjects (34.3%) were on medication (P = 0.03).
More than half of the study participants (52.5%) had never been to a dentist. Moreover, a greater percentage of subjects (34.5%) visiting the dentist was more frequently observed among 80-89 years aged as compared to other age groups, whereas only 46 (11.9%) of the subjects above 90 years had been to a dentist.
A total of 173 (21.3%) had a history of smoking habit constituting a greater proportion of males (170; 98.3%) and lesser number of females (3; 1.7%). Few subjects, 3.2% reported of tobacco chewing habit with a higher presentation of males (23; 88.5%). In contrast, a more number of subjects (786; 96.8%) did not present with a habit of tobacco chewing. Alcohol habit was observed among 70 (8.6%) of the subjects, comprising of only male subjects (100.0%). Overall, there was a noted significant difference for all the personal habits among gender (P = 0.00).
Based on frequency of personal habits, a higher mean score was observed for smoking (1.22 ± 4.24) and alcohol habit (0.09 ± 0.53) with a lower mean score for tobacco chewing (0.51 ± 0.15). Majority of the inmates (488; 62.8%) claimed using toothbrush as their main oral hygiene aid, while rest of them reported using finger (303; 34.6%) and twig (21; 2.6%).
Furthermore, most of the study population 361 (45.2%) practiced horizontal method for tooth cleaning, while 354 (42.9%) followed circular method and only 97 (11.9%) practiced vertical method. For most of the subjects, toothpaste (531; 65.4%) was the mode of tooth cleaning followed by tooth powder (166; 20.4%) and other materials (100; 12.3%) such as brick, salt, and neem stick.
Tongue cleaning was performed by 628 (77.3%) inmates whereas 184 (22.7%) did not have a habit of tongue cleaning. Other oral hygiene aids like mouth rinse and floss were not utilized by most of the subjects (640; 78.7%). However, 20.2% of them used mouth rinse, and only 5 (1.1%) of the subjects used floss for their oral hygiene as adjuncts.
431 (64.0%) of the study participants had oral mucosal lesions. The most common being oral ulceration (46.2%) followed by candidiasis (26.4%) and abscess (20.7%). On the other hand, only few subjects reported malignant tumor (0.5%), leukoplakia (4.2%) and other conditions (1.1%) in their oral cavity. The most common site of the oral mucosal lesions was buccal mucosa (28.3%), followed by tongue (24.3%), gingiva (22.2%) and commissures (19.2%).
In terms of periodontal status, all sextants were excluded (Code "X") in 324 (39.9%) subjects (males: 139; 42.9% and females: 185; 57.1%). Of the dentate population (i.e., 488), the majority of the inmates (219; 27.0%) presented with deep pockets (Code "4") followed by shallow pockets (Code "3" - 183; 22.5%), whereas only 9.4% of the individuals had calculus (Code "2") and 1.2% had bleeding gums (Code "1") on probing. A Code of "0" (healthy) was not observed among any of the study subjects (0.0%) [Table 2].
|Table 2: Periodontal status of study subjects based on CPI and LOA according to gender and age groups |
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Except for Code "3" which is an attachment loss of 9-11 mm, for all other codes (Code 0: 51.2%, Code 1: 54.9% and Code 2: 55.3%) females comprised a higher proportion of LOA as compared to males. Furthermore, none of the individuals (P=0.00) had 12 mm or more of attachment loss (Code "4"). However, on the whole, the extent of attachment loss was greater in women than men [Table 2].
On periodontal examination, a higher score was observed among males with a mean score of 1.98 ± 1.69 for CPI and 0.82 ± 1.01 for LOA respectively. The differences were statistically insignificant (P = 0.76) based on periodontal status [Table 3].
|Table 3: The mean periodontal status of the study subjects based on CPI and LOA according to gender and age groups |
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The distribution of crown status per tooth showed that 262 (32.3%) teeth were decayed. The number of teeth filled with decay were 19 (2.3%), wherein filled with no decay was noticed for 37 (4.6%) teeth. A majority of teeth missing as a result of caries was observed for 236 (29.1%). 110 (13.5%) teeth were unerupted, and trauma (fracture) tooth was noted 23 (2.8%).
The mean decayed missing filled teeth DMFT recorded for the study subjects was 2.80 ± 4.70 (P = 0.90). Based on the age groups, the mean DMFT was greater among 60-69 years (2.87 ± 4.41) aged subjects [Table 4].
|Table 4: Mean distribution of study subjects based on dental caries experience (DMFT) according to gender and age groups |
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The prevalence of dental caries in this population was 49.0%, 398 whereas 44.2% (414) were caries free. The distribution of root status per tooth revealed that 131 (16.1%) teeth had carious root (males: 66 [18.3%] and females: 65 [14.4%]). Root caries was most commonly seen amongst the age groups of 60-69 years (25.9%).
Totally, 488 (60.1%) subjects were dentate while 324 (39.9%) subjects were edentulous comprising mostly of females (dentate: 54.5%andedentulous: 42.9%).
The majority of the subjects had no prosthesis in the upper arch (85.0%) whereas only a small proportion of the inmates had full removable dentures (12.8%). The number of subjects having more than one bridge and partial denture was reported by same number of subjects (8; 1.0%). A majority 248 (35.9%) of the subjects of 70-79 years elderly had no prosthesis in the upper arch. Full removable dentures (51; 49.0%) were noticed mostly among 80-89 years aged with a lesser number of persons having bridge of the same age group. A highly significant difference was noted only for age groups (P > 0.0001).
No prosthesis was observed among a larger group of subjects (86.6%), while only a smaller number of subjects reported of having more than one bridge (0.4%) in the lower arch. 96 (11.8%) subjects had full removable dentures in their lower arch comprising of comparable number of men and women. Concurrently half of the study subjects had full removable denture (50.0%) between the age group of 80-89 years. However, a statistically significant association was noted for age groups (P > 0.0001).
Based on the prosthetic needs, 332 (40.9%) of the subjects did not require any prosthesis, while the need for one-unit prosthesis was observed among 8.9% (72) study population and 28.1% of the subjects reported of need for full prosthesis. A higher proportion (53.1%) of the inmates belonging to 80-89 years reported for the requirement of full prosthesis [Table 5].
|Table 5: Distribution of study subjects based on prosthetic needs (upper and lower) according to gender and age groups |
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Likewise, no prosthesis was needed by 293 (36.1%) of the subjects, whereas full prosthesis was required by 230 (28.3%). Furthermore, 13.5% of the subjects needed multi-unit prosthesis and a combination of one- and/or multi-unit prosthesis was needed by 107 (13.2%) of the subjects. One-unit prosthesis was mostly needed by 60-69 years (34.8%) whereas multi-unit prosthesis (41.8%) was needed by 70-79 years. Finally, the need for full prosthesis was most commonly seen among the age group of 8-89 years aged (52.2%) subjects [Table 5].
| Discussion|| |
Demographic revolution is underway as the proportion of older people is growing faster than any other age group.  In addition to the other general health issues, there are tremendous implications for oral health. Oral health contributes significantly toward the quality of life and, therefore, the impact of poor oral conditions on daily life is particularly significant. 
A total of 812 study subjects comprising of 361 males (44.5%) and 451 (55.5%) females with a mean age of 76.5 ± 8.68 years were part of the study. In the current study, females constituted a higher proportion as compared to males that was consistent with the other studies done by Kiyak et al.  Most of the subjects were educated, with 211 (26.0%) having primary education, 239 (29.4%) possessing secondary education, 187 (23.0%) had graduation.
In this study, based on duration of stay a majority (350; 43.1%) of the subjects were residing since 1-2 years constituting of higher proportion of females (54.9%) whereas the duration of stay among Turkish elderly was 5.49 years as reported by Akar and Ergul. 
According to medical history, hypertension 405 (49.9%) was most commonly noticed, of which males constituted 170 (42.0%) and females 235 (58.0%). A study by Jokstad et al.  in Skedsmo, Norway, stated that 89% of the subjects were receiving continuous medication, while in our study on an average 71.8% (583) of the study population were on medication.
In the current study, more than half of the study participants (52.5%) had never been to a dentist and most of the subjects (59.3%) had their last dental visit between 6 months and 1 year.
Majority of the inmates (488; 62.8%) claimed using toothbrush as their main oral hygiene aid, while rest of them reported using finger (303; 34.6%) and twig (21; 2.6%) in our study. In this study, brushing once a day was practiced by the majority of the subjects (84.7%) aged 80-89 years this was in agreement with the study done by Arpin et al.  among canadian population.
Of the 812 inmates, the prevalence of oral mucosal lesions reported in the present study was 64.0%. These findings are in accordance with the study conducted by Vigild  in Denmark. The most common site of the oral mucosal lesions was buccal mucosa (28.3%), followed by tongue (24.3%), gingiva (22.2%) and commissures (19.2%). According to Pisanty et al.,  16.80% of the European-American elderly people in Jerusalem had lesions on their buccal mucosa respectively.
In the present study, all the sextants were excluded (Code "X") in 39.9% of the study subjects whereas in a study by Cornejo et al.  reported that 44.2% of the older subjects in Barcelona had excluded sextants. None of the subjects had attachment loss of 12 mm or more in the current study.
In the current study, the caries experience among the dentate subjects was 49.0% with a mean DMFT of 2.80 ± 4.70. 488 (60.1%) subjects were dentate while 324 (39.9%) subjects were edentulous.
The present study results revealed that majority of the subjects had no prosthesis in the upper arch (85.0%), this was in agreement with the study by Grabowski and Bertram  among elderly Danish population. The number of the inmates having full removable dentures (12.8%) was higher in this study. The number of subjects having more than one bridge and partial denture was reported by lesser number of subjects (8; 1.0%) as compared to the findings in a study conducted by Locker  in Toronto. No prosthesis in the lower arch was observed among a larger group of subjects (86.6%) in the present study.
Based on the prosthetic needs, 332 (40.9%) of the subjects did not require any prosthesis, while the need for one-unit prosthesis was observed among 8.9% (72) of the study population. A higher number of individuals were in need of full prosthesis (28.1%) in this study as compared to a study by Simunkovic et al.  among Zagreb, Southern Croatia population. Likewise in our study, no prosthesis was needed by 293 (36.1%) of the subjects, whereas full prosthesis was required by 230 (28.3%) of the subjects. Need for a combination of one- and/or multi-unit prosthesis was needed by 107 (13.2%) of the subjects while only 72 (8.9%) of the subjects were in need of one-unit prosthesis.
Though the study determines the oral health status and treatment needs among elderly inmates, it presents with certain limitations. Although the study was carried out at various old age homes, it was limited to the geographic region of Hyderabad and Secunderabad, Andhra Pradesh. Out of 54 old age homes, the study was conducted only among 22 old age homes.
| Conclusion|| |
The present study demonstrates poor oral health among institutionalized elderly inmates. Oral mucosal lesions were found to be higher, and the periodontal status was poor amongst the study population. The prevalence of denture wearing was low despite the higher prevalence of edentulousness in this study group. The evidence suggests that poor oral hygiene among the old age people is a much greater problem than commonly realized.
Further research is recommended to investigate oral health status and treatment needs among elderly inmates residing in the old age homes so that the government should promote the programs to train the geriatric caregivers and organizers regarding the oral health care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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S Sabiha Shaheen
Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Hospital, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]