|Year : 2019 | Volume
| Issue : 4 | Page : 313-321
Assessment of oral health status and treatment needs among institutionalized elderly population of four major Cities of Madhya Pradesh
Upendra Singh Bhadauria1, Pralhad L Dasar2, N Sandesh2, Prashant Mishra2, Shaijal Godha2
1 CDER, AIIMS, New Delhi, India
2 Department of Public Health Dentistry, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
|Date of Submission||31-Oct-2018|
|Date of Decision||03-Nov-2019|
|Date of Acceptance||16-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Dr. Upendra Singh Bhadauria
CDER, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Background: The world is undergoing a demographic transition, and the proportion of elderly people is growing faster than any other age group. According to census 2011, older people comprise 8.14% of the total population. The literature on assessment of oral health status of the institutionalized elderly particularly for the state of Madhya Pradesh (MP) remains to be sparse and scant. Aim: The present study aimed to assess the oral health status and treatment needs of institutionalized elderly population of four major cities of MP. Materials and Methods: A descriptive cross-sectional study was conducted to assess the oral health status and treatment needs among the institutionalized elderly residing in old-age homes of four major cities of MP, India. The study was conducted among 487 inmates of 12 old-age homes of Indore, Bhopal, Jabalpur, and Gwalior cities. Statistical analysis was done using SPSS 20 software. The Chi-square test was used to compare the categorical variables. ANOVA test was performed for quantitative variables. P ≤0.05 was considered statistically significant. Results: About 5.6% of the inmates with 6 different types of oral-mucosal condition were reported. The prevalence of periodontal diseases in accordance with Community Periodontal Index scores was found to be 96.8%. Only 41.02% of the population had sound teeth, 4.48% were affected by caries, 6.34% were missing due to caries, and 43.12% required no treatment needs. The mean decayed, missing, and filled teeth score of 15.57 ± 10.08 was seen in the age group of 60–75 years, 18.95 ± 9.79 in the age group of 76–90 years, and 19.18 ± 9.97 in the elderly aged 91 years and above. Conclusion: Based on the results of the present study, it can be concluded that oral health status of institutionalized inmates was found to be poor with higher prevalence of dental caries and periodontal diseases, poor prosthetic status, and higher prosthetic needs.
Keywords: Aged, disease, oral health
|How to cite this article:|
Bhadauria US, Dasar PL, Sandesh N, Mishra P, Godha S. Assessment of oral health status and treatment needs among institutionalized elderly population of four major Cities of Madhya Pradesh. J Indian Assoc Public Health Dent 2019;17:313-21
|How to cite this URL:|
Bhadauria US, Dasar PL, Sandesh N, Mishra P, Godha S. Assessment of oral health status and treatment needs among institutionalized elderly population of four major Cities of Madhya Pradesh. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2020 Jan 20];17:313-21. Available from: http://www.jiaphd.org/text.asp?2019/17/4/313/272786
| Introduction|| |
Aging is universal and inevitable for all of us. “The United Nations defines a country as aging” where the proportion of people over 60 years reaches 7%. “By 2000, India had exceeded that proportion (7.7%) and is expected to reach 12.6% in 2025.” Thus, by the definition itself, “India qualifies as an aging” country. An aging population puts an increased burden on the resources of a country with more mouths to feed and less hands to earn. “Old-age homes are geriatric long care facilities which provide supervision and assistance in activities of daily living with medical and nursing services when required.”
Elderly or old age consists of ages nearing or surpassing the average life span of human beings. “The Government of India adopted the National Policy on Older Persons” in January 1999 which defines a “senior citizen” or “elderly” as a person who is of age 60 years or above.
The world is undergoing a demographic transition, and the proportion of elderly people is growing faster than any other age group. Approximately 600 million people are aged 60 years and over, and this number will double by 2025. By 2050, the number is expected to rise to 2 billion with 80% living in developing countries. Developing countries with a large population like India have a large number of people now aged 60 years or more. The population over the age of 60 years has tripled in the past 50 years in India and will relentlessly increase in the near future. According to census 2001, older people were 7.7% of the total population, which increased to 8.14% in census 2011. The projections for population over 60 years in the next four censuses are 133.32 million (2021), 178.59 million (2031), 236.01 million (2041), and 300.96 million (2051).
This demographic change is not only expected to have a deleterious effect on general health and well-being but also a major impact on dental professionals and oral health-care delivery. Poor oral health including dental caries, periodontal disease, mucosal lesions, and loss of teeth can adversely affect the dietary intake and nutritional status and thereby compromise health. Similarly, systemic diseases and the adverse side effects of their treatments can lead to an increased risk of oral diseases. Barriers to oral health care among the elderly are also considerable. Impaired mobility delays access to oral health care. Given some elderly may experience financial hardship following retirement, the cost or perceived cost of dental treatment, together with poor attitudes to oral health, may deter them from visiting a dentist.
Previous literature on oral health status illustrates the darker side and suggests that elderly people living in old-age homes have poorer oral health and greater treatment need than the noninstitutionalized elderly. The population rarely receives an emergency treatment for dental pain and discomfort and no dental professional works regularly for them.
Globally, there are several studies on the oral health status and treatment needs of institutionalized elderly population indicating poor oral health status and greater treatment needs.,, Immense interest in this population in the past decade has enhanced the literature regarding the oral health status of this population, but even now, the data on a national level and particularly for the state of Madhya Pradesh (MP) remain to be sparse and scant.
In MP, India, there are 59 old-age homes as per the list provided by the Department of Social Justice, Government of MP, with one-third of the institutionalized elderly living in the four major cities (Indore, Bhopal, Gwalior, and Jabalpur) of the state. However, a considerable number of them are nonfunctional while all the old-age homes of major cities are in functional state. The data regarding oral health stature of the institutionalized elderly residing in the old-age homes of major cities of MP have not been previously documented, and these data are needed to understand the burden of oral diseases on this population as well as to know the utilization of existing oral health-care facilities by this population.
Thus, keeping in mind the need for a comprehensive oral health assessment, the present study was carried out to assess the oral health status and treatment needs among the institutionalized elderly of four major cities of MP. The baseline data collection would be helpful for dental professionals to plan and implement prevention-based programs to improve the oral health of institutionalized elderly population.
| Materials and Methods|| |
A descriptive cross-sectional study was conducted to assess the oral health status and treatment needs among the institutionalized elderly residing in old-age homes of four major cities of MP, India. The study was conducted among 12 old-age homes of Indore, Bhopal, Jabalpur, and Gwalior cities. The study is a total enumeration of the entire of these old-age homes fulfilling the inclusion criteria.
The ethical clearance was obtained before starting the study SAIMS/IEC/28/2015. Permissions for conducting study and clinical examinations on institutionalized elderly population were obtained from the respective authorities of old-age homes. Written informed consent for participation was obtained from institutionalized elderly inmates before the conduction of the study.
MP (meaning Central Province) is a state in Central India. MP is the second-largest state in the country by area. MP consists of large number of institutionalized old-age homes. There are 59 old-age homes as per the list by the Department of Social Justice, Government of MP. These homes are established under the MP Nirashriton Avam Nirdhan Vyaktiyon Ki Sahayata Adhiniyam, 1970. According to this Adhiniyam, poor and destitute elderly people shall be housed in old-age homes. The major cities in MP are four in number and include Bhopal, Indore, Gwalior, and Jabalpur. The four cities consist of 12 collectorate registered old-age homes with approximately 519 inmates.
The target population for the present study consisted of the elderly aged 60 years and above living in institutionalized old-age homes of MP, India. Intellectually and physically capable institutionalized elderly people aged 60 years and above living in old-age homes of four major cities of MP and willing to participate were included in the present study, whereas severely debilitated and hearing- or speech-impaired inmates and participants who lacked the ability to cooperate with the study protocol were excluded.
A pro forma was designed to collect the desired information from the study participants. The pro forma consisted of two sections. The demographic details of the study participants such as name, age, gender, city, name of the institution, and time in the institution. The WHO Oral Health Assessment Form 1997 was used to record the oral health status and treatment needs of the study participants. The present study was an enumeration of assessment of Community Periodontal Index (CPI), loss of attachment (LOA), dentition, decayed, missing, and filled teeth (DMFT), and root caries status of elderly individuals.
Training and calibration of the investigator was carried out in the Department of Public Health Dentistry, Sri Aurobindo College of Dentistry, under the guidance of an expert examiner. Clinical training and calibration was done first by practicing on group of 10 participants and then on 20 participants twice with a time interval of ½ h and with a wide range of level of disease conditions. This was done to ensure uniform interpretation, understanding, and application of the codes and criteria for various conditions to be observed and recorded. The kappa value (0.8) for calibration exercise showed substantial agreement for observations and measurement. A recording assistant was trained to assist in recording the clinical data. The examiner gave clear instructions about recording data during training and calibration exercise. The recorder was told the meaning of the terms that will be used and instructed in the coding system so as to recognize obvious mistakes or omissions made by the examiner.
A single investigator carried out the oral examination of all the institutionalized elderly inmates. The clinical examination and recording took about 5–10 min per elderly. On an average, 20–25 elderly people were examined per day. The examiner accompanied by a recording assistant traveled to all the four cities, and the selection of cities was based on the time scheduling and permission by old-age home authorities. The elderly who fulfilled the eligibility criteria and provided consent were further considered for oral examination.
Participants were examined in the premises of the old-age homes in institutionalized settings. Available infrastructure and furniture was utilized. Instrument and supplies were placed on the table within easy reach of the examiner. The clinical examination involved an inspection of the oral cavity with plane mouth mirror and CPI probe under good illumination. American Dental Association Type III examination was followed. Participants were seated comfortably in upright position on a chair under maximum illumination. Where sufficient natural light was not available, battery-operated torchlight was used. The investigator was assisted by cooperative and trained recording clerk who recorded the findings on the pro forma. An adequate number of assessment forms were taken along. A trained recording assistant was seated close to the investigator so that the scores could be clearly heard and the investigator could view the entries. Survey findings were reported to respective old-age home authorities after the completion of examination. Authorities were also reported about the prevailing adverse habits and other oral hygiene practices. The inmates and the caregivers were demonstrated with correct brushing technique and oral hygiene practices.
All the old-age homes of four major cities of MP were included in the present study. Lists were rechecked during the subsequent visit to the cities to avoid data discrepancy and exclusion of any old-age home. The study is a total enumeration of the entire participants of 12 old-age homes included in the study fulfilling the inclusion criteria. The four major cities contain 12 registered old-age homes with approximately 519 inmates (subject to daily variation). The present study was intended to include all the institutionalized elderly inmates of all the registered old-age homes of four cities. A total of 32 inmates were excluded from the study due to inability to cooperate with the study protocol. Thus, the final sample size of the present study was 487 inmates of 12 old-age homes present on the day of examination fulfilling the inclusion criteria.
A pilot study was carried out on a convenience sample of 25 institutionalized elderly people aged 60 years and above from an old-age home different from the one included in the study to check the feasibility and practicability of the procedure in collecting clinical data. Consideration was given to time requirement in examination of inmates, recording of data, and finalizing the pro forma to be used in the main study. The old-age home authorities were contacted well in advance and convenient date, and time for data collection was decided. Care was taken not to disturb the routine activities of inmates. The study was carried out from September 2015 to January 2016.
Sufficient numbers of autoclaved instruments were taken to avoid interruption during examination. Disposable masks and gloves were worn while examination. The used instruments were collected separately, washed, disinfected with chemical method, and autoclaved at local dental clinics or dental colleges and hospitals.
The data collected were entered in Microsoft Excel and subjected to statistical analysis using the Statistical Package for the Social Sciences (SPSS, IBM version 20.0, Chicage, Ilinois, U.S.A). The level of significance was fixed at 5%, and P ≤ 0.05 was considered statistically significant. Descriptive statistics were used to find the frequencies, mean, and standard deviation of variables considered in the study. The Chi-square test was used to compare the categorical variables. ANOVA test was performed for quantitative variables. For the convenience of comparison, the age was categorized into three groups of 60–75 years old, 76–90 years old, and 91 years and above. The Kolmogorov–Smirnov test and Shapiro–Wilk test were employed to test the normality of data.
| Results|| |
The present study was carried out among the institutionalized elderly aged 60 years and above. The results of the assessment of oral health status and treatment needs from 487 institutionalized elderly people living in four major cities of MP are presented here.
Majority of the participants in the present study were in the age group of 60–75 years (58.7%), were female (52.4%), and belonged to Hindu ethnicity (88.7%); majority (44.5%) of the participants were living in institution for <5 years [Table 1].
|Table 1: Distribution of study participants according to demographic variables|
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A significantly higher bleeding score (6.9%), pockets measuring 4–5 mm (6.3%), and pockets measuring 6 mm or above (0.7%) were reported in the elderly aged 60–75 years (P = 0.003) when compared to the elderly aged 76 years and above. The excluded sextant indicative of missing tooth component was higher in the elderly aged 76–90 years (50.5%) when compared to other age groups. Comparative evaluation of cities revealed that the elderly in Indore exhibited greater CPI scores, with greater pocket scores 6 mm or more (1.9%) when compared to the elderly living in Gwalior (1.8%), Bhopal, and Jabalpur [Table 2]. The mean number of sextants with a different CPI score distribution is represented in [Table 3].
|Table 2: Distribution of study participants according to the Community Periodontal Index codes|
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|Table 3: Mean number of sextants according to the Community Periodontal Index codes|
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In the present study, 13,729 permanent teeth were examined. In the present study, 13,729 permanent teeth were examined. Of which, 41.02% teeth were sound, 4.48% were affected by caries, 6.34% were missing due to caries whereas majority of teeth 6588 (47.98%) were missing due to other reasons [Table 4].
Of 13,729 permanent teeth examined, 5921 (43.12%) of teeth required no treatment. Among the 66.9% of teeth with treatment needs, 5761 (41.96%) required need for replacement by partial or complete prosthesis, 1640 (11.94%) required extraction of teeth, whereas 282 (2.06%) required crown for any reason [Table 5].
About 28.8% of the elderly were affected by root caries, whereas 71.2% remained unaffected. The elderly living in Jabalpur city showed a significantly higher (36.1%) root caries status when compared to those living in Gwalior (32.7%), Indore (25.9%), and Bhopal (23.5%) cities (P = 0.038) [Table 6].
|Table 6: Root caries status among the institutionalized elderly and comparison in accordance with age and gender|
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The mean DMFT score of 15.57 ± 10.08 was seen in the age group of 60–75 years, 18.95 ± 9.79 in the age group of 76–90 years, and 19.18 ± 9.97 in the elderly aged 91 years and above. The elderly living in institution for 11 years and above (18.95 ± 9.95) had significantly higher DMFT scores when compared to the elderly living in institution for 5–10 years (17.68 ± 10.45) and <5 years (15.43 ± 9.69) [Table 7]. Tukey's post hoc analysis indicated no significant difference between DMFT scores and duration in institution and DMFT scores and age groups.
|Table 7: Comparison of mean decayed, missing, and filled teeth score among study population with respect to age, gender, and duration in institution (post hoc analysis)|
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Only 14.2% of the elderly had prosthesis present, whereas 85.8% of the elderly had no prosthesis. The prosthetic status in the elderly aged 76–90 years (21.3%) was significantly higher than the elderly aged 60–75 years (9.1%) and 91 years and above (9.1%) [Table 8], and 83.6% had prosthetic need [Table 9].
|Table 8: Prosthetic status in elderly inmates and comparison with respect to age and gender|
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|Table 9: Prosthetic need in elderly inmates and comparison with respect to age and gender|
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A bivariate regression analysis was performed to assess the effect of various independent variables on periodontal disease, and a significant difference was only seen with LOA [Table 10].
|Table 10: Logistic regressing analysis assessing the effect of various independent variables on periodontal disease|
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| Discussion|| |
The present study was carried out to assess the oral health status and treatment need among institutionalized elderly population of four major cities of MP. The institutionalized elderly have been neglected, avoided, and rendered deficient oral health care.
The assessment of oral health status and treatment needs among 487 institutionalized elderly people aged 60 years and above living in four major cities of MP is reported and discussed here. The four major cities included in the present study were Indore, Bhopal, Jabalpur, and Gwalior.
In the present study, 3.5% of the institutionalized elderly reported extraoral findings in the form of ulcerations, erosions, and sores in 3.3% of the inmates and enlarged lymph nodes in.2% of the inmates. This finding in the present study is believed to be the result of exclusion of the inmates with inability to cooperate with study protocol as well as regular medical examinations of the inmates.
An assessment of temporomandibular joint (TMJ) symptoms in the present study revealed that 4.7% of the inmates had TMJ symptoms. Of the elderly reporting TMJ symptoms, the elderly in the age group of 76–90 years (17.4%) and living in Indore city reported (6.7%) higher TMJ symptoms when compared to the elderly of other age groups and cities. Males reported significantly higher TMJ symptoms (9.9%) when compared to females. Camac et al., Bagis et al., and Santos et al. reported a greater prevalence of TMJ disorders in females as compared to males. The exact causes of TMJ syndrome in adults and elderly patients have not yet been identified, but the disorder may be connected to certain factors such as muscle spasms, changes in tooth structures or dental procedures, trauma to TMJ, and onset of arthritis which become more prevalent as age progresses.
In the present study, 5.6% of the inmates with 6 different types of oral-mucosal condition were reported. The oral-mucosal condition along with location in the present study showed that leukoplakia on the buccal mucosa was present most frequently (2.1%) and was seen in the elderly consuming tobacco and smoking bidi and cigarettes. Bánóczy et al. also concluded a higher prevalence rate of leukoplakia among smokers, with a dose–response relationship between tobacco use and oral leukoplakia. Neville and Day  also reported the most frequent location of leukoplakia as buccal mucosa.
Denture stomatitis in 1.4% of the elderly was seen on palatal surfaces in the elderly. Studies conducted by Jorge Júnior et al. reported 58.9% of the elderly in Brazil with oral-mucosal lesions with denture-induced stomatitis being the most common one, although corresponding to our study, only 3% reported leukoplakia. Glazar et al. reported 13 different oral mucosal conditions in the institutionalized elderly in Croatia. Shaheen et al. reported 64% of participants with oral mucosal lesions. Leukoplakia was associated with 4.2% of population with buccal mucosa as the most common location.
The prevalence of periodontal diseases in accordance with CPI scores was found to be 96.8%. CPI score 0 (healthy) was observed in only 3.2% of the elderly. In the present study, a significant association between age groups and CPI scores was observed with elderly people in the age group of 60–75 years reporting higher calculus scores (46.9%), bleeding score (6.9%), pockets measuring 4–5 mm (6.3%), and pockets measuring 6 mm or more scores (.7%). Excluded sextant component (Code X) indicative of tooth missing due to any reason (caries or any other reason) was higher in the age group of 76–90 years (50.5%). Agrawal et al. reported no participants with healthy periodontium; the most frequently observed periodontal condition in their study was shallow pockets (4–5 mm) in 52.1% of dentate participants.
The reason for higher calculus scores (45.2%) and lesser number of healthy periodontal scores (3.3%) in the present study is related to poor oral hygiene of inmates with heavy calculus band, systemic diseases, illfitting prosthesis, etc. In the present study, 18.9% of the elderly had no LOA (Code 0). Among the 81.1% of the elderly who reported LOA scores, LOA scores (12 mm or more) were seen in higher number in the male elderly (15.1%) in the age group of 60–75 years (10.1%) living in Jabalpur city (13.2%). In the present study, the longer the duration in institution, the higher the LOA scores were reported, i.e., higher LOA scores (10.7%) were significantly reported in the elderly living in institutes for >10 years.
An assessment of dentition status according to 1997 WHO Oral Health Survey Procedure in the present study showed only 41.02% of population with sound teeth, 4.19% with decayed teeth, 0.01% of filled teeth without any decay, 0.07% of filled teeth with decay, 0.09% of teeth with bridge abutments or crown, and only 0.01% with signs of trauma. Missing teeth comprised the maximum percentage of dentition status (54.32%) of which teeth missing due to caries were 6.34%, whereas teeth missing due to other reasons were 47.98%. Missing due to other reasons component primarily included teeth removed or lost due to poor periodontal conditions of inmates. To the best of our knowledge, none of the previous studies have taken into consideration individual teeth for assessment of dentition status. Ferreira et al. reported that among the dentate participants, 17.9% possessed 20 or more teeth in elderly population of Brazil. Adiatman et al. (2013) in their study reported 18% of participants as edentulous whereas the other participants had between 1 and 19 natural teeth (43%), 20 or more naturally occurring teeth present were present in 39% of the elderly. In contrast to the present study, Shaheen et al. reported that teeth (32.3%) were decayed, teeth missing due to caries were 29.1%, and 39.9% of participants were edentulous. The greater frequency of missing teeth in the present study was a result of aging changes and lack of knowledge regarding conservative treatment procedures.
An assessment of treatment needs in the present study indicated 43.12% of population with no treatment needs. Of the 56.88% elderly requiring treatment needs in the present study, 7% of population required one or two surface fillings, pulp care and restorations were required by 19%, only 2.06% of inmates required crown for any reason. Two most frequent treatments needed in the present study were need for replacement and extractions. The need for extraction was required in 11.94% of the dentate elderly, whereas the need for replacement (removable or complete prosthesis) was needed in 41.96% of population. A study conducted by Adiatman et al. (2013) in the institutionalized elderly in Italy reported that 29.8% of the elderly required no need of dental treatment, 68.1% needed one or more dental extractions, whereas 37.2% needed restorative treatment for one or more teeth.
In the present study, an overall dental caries prevalence of 32.4% was reported with higher prevalence in the male elderly (32.7%) in the age group of 60–75 years (38.4%) and living in Jabalpur city (41.1%). Shaheen et al. reported 49.0% caries experience among the participants. The higher prevalence of root caries in present study was indicative of greater root exposure associated with aging changes.
The mean DMFT score among the institutionalized elderly was found to be 16.97 ± 10.08, whereas in contrast to the present study, a study conducted by Shaheen et al. reported the mean DMFT of 2.80 ± 4.70.
Post hoc analysis revealed no significant difference in the age group between DMFT scores and age groups and DMFT scores and duration in institution.
In the present study, 14.2% of the institutionalized elderly reported the presence of prosthesis, whereas prosthetic need was required in 83.6% of elderly inmates. Prosthesis status was significantly higher in the elderly belonging to the age group of 76–90 years, whereas the elderly in the age group of 90 years and above reported significantly higher prosthetic needs. In line with the present study, Eachempati et al. reported prosthesis in only 12.4% of participants, whereas 86% of participants were in need of prosthesis in the elderly of Mangalore city. Shenoy et al. reported that only 12% of participants had prosthesis, whereas 85% of participants needed prosthesis.
It seems appropriate to highlight some of the limitations of the study. As the present study was cross-sectional, differentiating cause and effect from simple association could not be done. The selection of purposive sampling limits the projection of data beyond the sample. The present study included assessment of elderly population in which the dentofacial anomalies were a result of compromised periodontal conditions; hence, to avoid misleading Dental Aesthetic Index scores, dentofacial anomalies were not reported. Exclusion of patients with inability to cooperate with the study protocol limited participants with need for immediate care and referral, and similarly, none of the participants reported dental fluorosis and enamel hypoplasia; hence, the results of the above two components were not tabulated either. Finally, a quantitative assessment of utilization of dental services could also have been more apt.
It must also be stressed that, despite the limitations mentioned, this is one of the first studies to have taken into consideration all the old-age homes and inmates of the four major cities; hence, planning strategies to improve the oral health stature can be projected effectively and appropriately in the study population. However, further studies involving more elderly and old-age homes should be carried out to understand the risk factors of oral health problems.
| Conclusion|| |
Based on the results of the present study, it can be concluded that oral health status of institutionalized inmates was found to be poor with a higher prevalence of dental caries and periodontal diseases, poor prosthetic status, and higher prosthetic needs. Need for replacement and extraction were two major treatment needs observed in institutionalized elderly population.
The results of the present reveal an unmet need of projecting effective planning and implementation strategies as well as a change in lifestyle and attitude of inmates and caregivers towards the improvement of oral health of this institutionally bound population.
The governmental agencies should come forward to improve and promote the oral health of this isolated and neglected institutionalized elderly population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]