|Year : 2020 | Volume
| Issue : 2 | Page : 151-155
Oral health-related quality of life of older patients attending a government dental hospital in India
Abhishek Mehta1, Murali Govind2, Jonathan Broadbent3
1 Department of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
2 Department of Prosthodontics, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
3 Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
|Date of Submission||21-Nov-2019|
|Date of Decision||14-Apr-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||24-Jun-2020|
Dr. Abhishek Mehta
Department of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Caries, periodontal disease, and tooth loss affect the quality of life of older people. There is a need for research on the oral health of older Indians. Aim: To assess oral health and its impact on the quality of life of older adults visiting a government dental hospital in New Delhi, India. Methods: A cross-sectional study was conducted on a convenience sample of 255 older adults (above 60 years). Dental caries experience was quantified by a count of teeth that were carious, restored, and missing due to caries (Decayed, Missing, and Filled Teeth), while periodontal health was quantified using the Community Periodontal Index. Oral health-related quality of life (OHRQoL) was assessed using a Hindi version of the General Oral Health Assessment Index (GOHAI). Results: The mean GOHAI score was 24.2 (SD 4.3). More than half of the study participants had untreated caries and periodontal problems. Regression analysis showed that OHRQoL scores were associated with age, female sex, poorer educational level, and number of missing teeth in the sample population. Conclusion: Unmet need for dental treatment was prevalent and affects the quality of life of older Indians. Self-care and the use of preventive dental services should be promoted, while access to treatment services should be improved for this population group.
Keywords: Dental caries, older adults, periodontal disease, quality of life, tooth loss
|How to cite this article:|
Mehta A, Govind M, Broadbent J. Oral health-related quality of life of older patients attending a government dental hospital in India. J Indian Assoc Public Health Dent 2020;18:151-5
|How to cite this URL:|
Mehta A, Govind M, Broadbent J. Oral health-related quality of life of older patients attending a government dental hospital in India. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 Dec 1];18:151-5. Available from: https://www.jiaphd.org/text.asp?2020/18/2/151/287627
| Introduction|| |
Oral conditions such as dental caries, periodontal disease, and tooth loss are chronic and cumulative, and oral health is thus likely to be at its worst as people become older. Certain general health conditions can lead to increased risk of oral diseases, xerostomia, and altered taste sensation, and some treatments for general health conditions can also cause dental complications. Tooth loss due to chronic oral conditions among older people can cause eating difficulties and esthetic issues. In severe cases, difficulty in eating can affect nutrition and can cause severe debilitation. Older people are an increasingly large proportion of the global population. By 2050, the number of older people is expected to rise to 2 billion, 80% of whom will be living in developing countries. According to the latest census (2011) of India, older people comprise 8.6% of the total population, or 103.2 million people, with a caries prevalence ranging 31.5%–100% across population groups.
Oral health promotion programs for populations are generally targeted based on clinical assessment of oral conditions, but it is important to consider the characteristics and special needs of the population being served. Simply recording the prevalence of oral conditions does not help understand whether this may affect the quality of life. Therefore, there is a need to incorporate oral health-related quality of life (OHRQoL) measures when investigating population oral health. For example, the World Health Organization considers improving OHRQoL to be an important part of its global oral health program.
Several indices exist for the measurement of OHRQoL. Those most commonly used among older people are the General Oral Health Assessment Index (GOHAI) and the Oral Health Impact Profile-14. Numerous studies have concluded that GOHAI is more useful in assessing OHRQoL among older people,,,, and a validated Hindi translation is available.
The rising prevalence of oral diseases, especially among the population of low-income and middle-income countries such as India, is a matter of public health concern. This study was planned with the hypothesis that oral health has a negative impact on the quality of life of older adults. The main objective of this study was to assess the oral health and its impact on OHRQoL on older adults of 60 years and above age visiting a government hospital in Delhi from dental treatment. The collected data from this study might contribute to knowledge of oral health, its impacts, and care-seeking behavior of older people residing in urban regions of India.
| Methods|| |
A cross-sectional observational study was conducted on patients aged 60+ years who attended for dental treatment at the Department of Prosthodontics, Faculty of Dentistry, Jamia Millia Islamia, between October 05, 2017, and January 15, 2018. The participation rate was 100%, but patients were not coerced to participate, and they were advised that their treatment would be unaffected if they declined to participate. There were no exclusion criteria except refusal by a patient to participate in the study. Ethical approval to conduct the research was obtained from the Ethical Research Committee of Jamia Millia Islamia University, New Delhi (Proposal No. 1 [16/9/118/JMI/IEC/2017]). All data were collected at the time of each participant's initial visit to the department.
Data were collected from a predesigned proforma. It consists of questionnaire and clinical examination part. To avoid problems with low literacy among participants, questionnaires were administered verbally by the investigators. Participant baseline characteristics (age, gender, and level of education) were recorded, as well as medical history and oral hygiene practices. A Hindi version of the GOHAI(GOHAI-Hi) was used to assess OHRQoL. The GOHAI-Hi has the same number of questions as original GOHAI (12) but differs in the number of responses recorded for each item. Whereas, in the original GOHAI, six options are given for each item of the questionnaire, the developers of GOHAI-Hi reduced these to three options (namely “always,” “sometimes,” and “never”). In GOHAI-Hi, a score of 1, 2, and 3 is awarded according to the response of the participant with the highest score given for “never” option; hence, a higher total GOHAI-Hi score implies better OHRQoL.
A clinical examination was conducted to investigate participants' oral health. The Decayed, Missing, and Filled (DMF) Index and the Community Periodontal Index (CPI) were utilized to assess individual participants' caries and periodontal status, respectively. The clinical examination was performed by one of the two investigators (AM and MG) after undergoing a calibration exercise on 30 older patients. The inter-examiner reliability was calculated using kappa statistics for CPI indices, and a kappa score of 0.72 was achieved, indicating satisfactory reliability.
Data were entered into an electronic database and analyzed using Stata I/C 15.1 (StataCorp LLC, Texas State, USA). Univariate statistics were calculated to report on the overall characteristics of the sample, while the statistical significance of observed differences was tested using Chi-square and Wilcoxon tests, where appropriate. Linear regression was used to model GOHAI score by oral health and potential confounders. P < 0.05 was considered statistically significant.
| Results|| |
During the recruitment period, 255 eligible patients were invited to participate and all consented, completed the questionnaire, and participated in the clinical examination. Participant ages ranged from 60 to 88 years (mean: 65.2), and nearly two-thirds were male (61.2%). A third of the participants were illiterate (34.1%), while just under half (43.1%) had completed secondary school or received tertiary education. Two-thirds of the participants (65.5%) claimed to be free from any medical health problems. Among those who did have a health condition, hypertension and diabetes were the most prevalent [Table 1].
Among the 217 dentate participants, a large majority (88.0%) brushed their teeth using a toothbrush and toothpaste. Among these, nearly a third brushed twice daily. Brushing was performed more frequently among females and those with greater education [Table 2].
|Table 2: Dental self-care by sex, age group, and education of dentate participants|
Click here to view
Among the 193 participants (75.6%) who had lost one or more teeth, 38 were edentulous (14.9%). Edentulism was twice as prevalent among those aged 70+ years (25.0%) than those aged 60–69 years (12.8%, χ2= 4.2, P = 0.039). Edentulism prevalence was lower among those with higher qualifications (5.2%) than those with middle or high school education (10.0%) and those with primary school or no education (24.3%, χ2= 13.5, P < 0.001). The prevalence of tooth loss was 75.6% among the dentate patients. Among these, the mean number of missing teeth was 9.9 ± 10.5. Complete dentures were worn by two-thirds (65.8%) of edentulous patients, while one-fifth (22.8%) of the partially dentate patients wore a partial denture.
A third of the participants (33.7%) had no teeth with untreated decay, but this included the 38 (14.9%) edentulous individuals. Among the dentate participants, the prevalence of untreated dental caries was 77.8%. The frequency analysis of CPI scores showed that the highest code was 2 (presence of calculus) which was affecting 48.2% (n = 123) individuals, followed by code 3 (shallow pocket of 4–5 mm) in 22.4% (n = 57).
All participants reported impacts at least sometimes across one or more of the GOHAI items (mean GOHAI scores -24.2, SD 4.4). Among the GOHAI items, using medications to control dental pain, experience of sensitive teeth, and worry/concern due to condition of teeth was marked as “always” option by significantly more women than men [Table 3].
|Table 3: Dental caries, loss of attachment, and General Oral Health Assessment Index by participant characteristics (sometimes category omitted for clarity)|
Click here to view
Simple linear regression analysis was conducted to measure the extent of relationship between dependent variable i.e GOHAI scores and the independent variables such as age, sex, education, Decayed Teeth/Filled Teeth/Missing Teeth components of DMF Teeth and highest CPI, loss of attachment (LOA) scores. Higher age (β: −0.05; confidence interval [CI]: −0.16, 0.06), more number of missing teeth (β: −0.14; CI: −0.19, −0.09), and female gender (β: −1.15; CI: −2.22, −0.08) had a negative impact on OHRQoL of the participants. When only dentate participants (n = 217) were considered for analysis, it was found that the highest LOA score (β: −0.81; CI: −1.34, −0.28), count of missing (β: −0.14; CI: −0.23, 0.04), restored teeth (β: −0.27; CI: −0.52, −0.02), and female gender (β: −1.56; CI: −2.74, −0.39) were associated with poor OHRQoL [Table 4].
|Table 4: Linear regression model for General Oral Health Assessment Index score (lower score indicates greater impacts)|
Click here to view
| Discussion|| |
The prevalence of oral diseases and other noncommunicable diseases is rising among the elderly, especially in developing countries such as India. In the current study, multiple factors were assessed which could affect OHRQoL among older people. First, it was observed that age was inversely associated with GOHAI scores, implying poorer OHRQoL. Previous studies conducted on the elderly in Delhi also reported a poor OHRQoL with increasing age., Many reasons have been suggested regarding the association between age and OHRQoL of the elderly, such as change in their perception toward health, restrictions in availing health-care services due to impaired physical health, effect of medications on oral health, and finally, poor condition of teeth or dentures. In the present study, females reported significantly poorer OHRQoL than males. The reasons for this are unclear; while this is consistent with some previous findings, other studies have reported null or contrary findings.
Our study suggests an association between edentulism and poor OHRQoL, consistent with previous findings. Age and lack of education of the study participants were associated with tooth loss and poor OHRQoL, this finding is also consistent with previous reports.,, This is a reflection of the lack of availability or utilization of oral health services in our country for this population group.
A high prevalence of untreated caries was observed among the study participants. Various national and international studies had reported high caries experience in the elderly population.,, Studies conducted on the elderly population of France and Germany reported a significant association between untreated caries and OHRQoL scores although one Indian study found no such association. Results of regression analysis of our study showed that the GOHAI scores are affected by number of untreated carious teeth.
Analysis of individual items of the GOHAI-Hi questionnaire showed that oral health problems were associated with impaired physical functioning, pain, and psychological and behavioral well-being of the study participants. This finding is contrary to that of the first study that reported on the GOHAI-Hi, in which participants were not much concerned about their oral health, especially its psychosocial impact. The possible reason could be differences in sample populations; the sample for the original GOHAI-Hi study was drawn from a medical hospital where people attended with various health ailments, not necessarily dental problems, while in our study, participants were dental patients visiting a dental hospital with a complaint to oral cavity, so they were possibly more concerned about their oral health at that point of time.
Strength and limitations of the study
Before considering the implications of these findings, it is important to consider the weaknesses and strengths of this research. Foremost among the weaknesses are the small sample size and the lack of generalizability of the findings, due to the convenience sampling strategy of investigating individuals attending for treatment. Owing to the context in which the data were collected, these limitations were unavoidable, and the findings are nonetheless informative as they provide useful information on the oral health of individuals seeking care. Attendance at hospital clinics is likely to be uncommon for those who have no dental health problems, so the estimates provided may be overestimates of the true levels of oral disease in the population. However, it may alternatively be true that those with the means to attend for care may be those with greater education and financial means (among whom disease levels tend to be lower). The fact that proportionally more participants were male may support this idea, as women in India are tend to be less educated and more likely to face financial hardship. The study also has a number of positive features. First, the oral health of older people is a current dental health issue of concern, and this research contributes to the body of knowledge, since such data have not been previously reported elsewhere. The study has some advantageous features, such as the use of the GOHAI and high participation rate.
| Conclusions|| |
Unmet need for dental treatment is high among older Indians attending for dental treatment at the Faculty of Dentistry, Jamia Millia Islamia, in New Delhi. Much of the oral disease burden is among the poorly educated, and their dental health problems frequently affect their quality of life. Poor self-care habits are common and were observed across the socioeconomic spectrum. Self-care and the use of preventive dental services should be promoted, while access to treatment services should be improved for this population group.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Peres MA, Macpherson LM, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al.
Oral diseases: A global public health challenge. Lancet 2019;394:249-60.
Bianco VC, Rubo JH. Aging, Oral Health and Quality of Life. In: Manakel J. Periodontal Diseases- A Clinician's Guide. 1st ed. London (UK): Intech Open; 2012. p. 357-68.
Gerritsen AE, Allen PF, Witter DJ, Bronkhorst EM, Creugers NH. Tooth loss and oral health-related quality of life: A systematic review and meta-analysis. Health Qual Life Outcomes 2010;8:126.
Emami E, de Souza RF, Kabawat M, Feine JS. The impact of edentulism on oral and general health. Int J Dent 2013;2013:498305.
Srivastava R, Nongkynrih B, Mathur VP, Goswami A, Gupta SK. High burden of dental caries in geriatric population of India: A systematic review. Indian J Public Health 2012;56:129-32.
] [Full text]
Mehta A, Kaur G. Oral health-related quality of life the concept, its assessment and relevance in dental research and education. Indian J Dent 2011;2:26-9.
Sischo L, Broder HL. Oral health-related quality of life: What, why, how, and future implications. J Dent Res 2011;90:1264-70.
Atchison KA, Dolan TA. Development of the geriatric oral health assessment index. J Dent Educ 1990;54:680-7.
Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9332805
. [Last accessed on 2017 Oct 24].
Locker D, Matear D, Stephens M, Lawrence H, Payne B. Comparison of the GOHAI and OHIP-14 as measures of the oral health-related quality of life of the elderly. Community Dent Oral Epidemiol 2001;29:373-81.
Hassel AJ, Steuker B, Rolko C, Keller L, Rammelsberg P, Nitschke I. Oral health-related quality of life of elderly Germans--comparison of GOHAI and OHIP-14. Community Dent Health 2010;27:242-7.
Ikebe K, Hazeyama T, Enoki K, Murai S, Okada T, Kagawa R, et al
. Comparison of GOHAI and OHIP-14 measures in relation to objective values of oral function in elderly Japanese. Community Dent Oral Epidemiol 2012;40:406-14.
El Osta N, Tubert-Jeannin S, Hennequin M, Bou Abboud Naaman N, El Osta L, Geahchan N. Comparison of the OHIP-14 and GOHAI as measures of oral health among elderly in Lebanon. Health Qual Life Outcomes 2012;10:131.
Mathur VP, Jain V, Pillai RS, Kalra S. Translation and validation of Hindi version of geriatric oral health assessment index. Gerodontology 2016;33:89-96.
World Health Organization. Oral Health Surveys – Basic Methods. 5th
ed. World Health Organization; 2013.
Rekhi A, Marya CM, Nagpal R, Oberoi SS. Assessment of oral health related quality of life among the institutionalised elderly in Delhi, India. Oral Health Prev Dent 2018;16:59-66.
Murariu A. Oral Health and Quality of Life in the Adult Population. Laisi, Romania: Junimea Publishing House; 2008.
Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2002;62:140-7.
Tubert-Jeannin S, Riordan PJ, Morel-Papernot A, Porcheray S, Saby-Collet S. Validation of an oral health quality of life index (GOHAI) in France. Community Dent Oral Epidemiol 2003;31:275-84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12846850
. [Last accessed on 2018 Sep 25].
Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21st
century–the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.
Bali DR, Mathur DV, Talwar PP, Channa HB. National Oral Health Survey and Fluoride Mapping. New Delhi: Dental Council of India; 2002.
Hassel AJ, Rolko C, Koke U, Leisen J, Rammelsberg P. A German version of the GOHAI. Community Dent Oral Epidemiol 2008;36:34-42.
[Table 1], [Table 2], [Table 3], [Table 4]