Dental caries in an elderly population in Brazil.

This study evaluated dental caries according to the presence of natural teeth and sociodemographic conditions of an elderly population in the state of São Paulo, Brazil. Examinations were performed according to the World Health Organization's guidelines. The sample of 1,192 elderly individuals aged 65 to 74 years was stratified according to the presence of teeth and the following variables: gender, race, age, city size and Human Development Index (HDI). The Mann Whitney and Kruskal Wallis tests were applied at a confidence level of 95% for analysis of results. In the total sample, 68.9% (n=822) were edentulous; the mean of present teeth was 3.5 and the DMFT was 30.2, being 28.5 of missing teeth. Among dentate individuals (n=370), the mean of present teeth was 11.3, the DMFT was 26.2 and the missing component accounted for 20.7 teeth. The differences observed in the evaluated conditions should be highlighted: the mean number of present teeth was higher among younger individuals (from 65 to 69 years) [12.1] and among those living in cities with high HDI [12.9]; the DMFT was lower among men [24.9] and non-Caucasians [25.1]. Based on these findings, it may be concluded that specific dental programs should be established, with emphasis on oral health promotion and dental caries control, as well as public health policies that may enhance the access to the services provided.

INTRODUCTION

Dental caries is still an important oral health problem in most industrialized countries, affecting most adults and having tooth loss as its main outcome13. In Brazil, the proportion of edentulous individuals older than 65 years is still high and may reflect the difficult access to dental services for a large portion of the population, or even the lack of importance assigned by these individuals to oral health along their lives. Conversely, international studies have shown that, when adequate attention is provided to elderly individuals, a larger number of natural teeth and lower DMFT are achieved8,10,23,24 and hence the number of missing teeth is reduced, which enhances the quality of life. However, some regions worldwide still present a high percentage of edentulism13,20.

Until 1998, no epidemiological studies involving adults older than 65 to 74 years had been conducted in Brazil, considering the country as a whole or its states. The existing results were restricted to some regions in which the oral conditions were associated with a high percentage of edentulism, high DMFT index (mean of decayed, missing and filled teeth) and need of prostheses1,2,6,12,14.

Thus, this study aimed to evaluate dental caries according to the presence of natural teeth and sociodemographic conditions of an elderly population in the state of São Paulo, in Southeast Brazil.

MATERIAL AND METHODS

This cross-sectional study was conducted in the state of São Paulo, Southeast Brazil. Twenty-nine cities were selected for inclusion in this study [for further information, please, refer to www.saude.sp.gov.br/saude_bucal/html/saude_bucal_est_epide.html]16. The sample size according to age and city size was calculated according to recommendations of the World Health Organization (WHO)25 (1987).

This was the first investigation on elderly individuals addressing the entire state of São Paulo. This work was considered an exploratory study, in which the random sample included elderly individuals attending associations and participating in health programs to the elderly. The subjects were elderly individuals who attended a third age group, as well as users of public health services aged 65 to 74 years, who were examined at the environment where they were recruited. The elderly individuals were comfortably placed on a chair in front of the examiner, both sitting. Examinations were performed with the aid of dental mirrors and CPI "ball point" periodontal probes under natural light by 66 properly calibrated dentists. The dental caries experience was measured by the DMFT index according to criteria recommended by the WHO26 (1997), considering 32 teeth. In the calibration phase, the percentage of inter-examiner agreement was 84.5%. Data were collected between August and December 1998, with a total number of 1,192 valid examinations.

For analysis of results, the sample was stratified in relation to the presence of teeth, in addition to sociodemographic variables such as gender, race (Caucasian and non-Caucasian), age (65-69 and 70-74 years), city size (small, medium, large) and HDI - a composite measurement summarizing information on income, educational level and longevity - where 19 cities presented medium HDI (0.645 to 0.799) and 10 presented high HDI (0.800 to 0.908)15. The Mann-Whitney and Kruskal-Wallis tests were applied at a confidence level of 5% (p<0.05) for the analysis of results, considering that sample did not show a normal distribution.

Even though the data were secondary, the study was revised and approved by the Institutional Review Board of the Dental School of Piracicaba (protocol n. 017/2003).

RESULTS

General sample and dentate individuals

During data collection, the intra-examiner agreement was 98%. A total of 1,192 elderly individuals were examined, being 36.7% (n=437) males and 63.3% (n=755) females. In this work, edentulous individuals corresponded to 68.9% (n=822) and 370 individuals were dentate. The sample distribution for all examined individuals as well as for dentate individuals according to sociodemographic variables is presented in Table 1.

TABLE 1

Sample distribution according to gender, race, age, city size and HDI. Southern Region of the state of São Paulo

	General Sample n (%)	Dentate Individuals n (%)
Gender
Male	437 (36.7)	163 (44.1)
Female	755 (63.3)	207 (55.9)
Race
Caucasian	871 (73.2)	260 (71.3)
Non-Caucasian	321 (26.8)	110 (29.7)
Age
65 - 69 years	697 (58.5)	251 (67.8)
70 - 74 years	495 (41.5)	119 (32.2)
City size
Small	388 (32.6)	128 (34.6)
Medium	360 (30.2)	97 (26.2)
Large	444 (37.2)	145 (39.2)
HDI*
Medium	546 (45.8)	176 (476)
High	646 (54.2)	194 (52.4)

HDI (Human Development Index): a composite measurement summarizing information on income, educational level and longevity.

Table 2 presents data corresponding to the mean number of present teeth and the DMFT index and its components, both for the total examined population and for dentate individuals. Individuals presenting 20 or more teeth in this study accounted for 18.1% (n=67) of the entire sample.

TABLE 2

Mean of present teeth and caries experience in all individuals and among dentate individuals. Southern Region of the state of São Paulo

Southeast region	All individuals (n=1,192)	Dentate individuals (n=370)
Variables
Mean of present teeth	3.5	11.3
DMFT (CI95%)	30.2 (30.0-30.4)	26.2 (25.6-26.7)
Decayed (CI95%)	0.5 (0.4-0.7)	1.8 (1.4-2.1)
Missing (CI95%)	28.5 (26.3-27.6)	20.7 (19.9-21.4)
Filled (CI95%)	1.2 (1.0-1.4)	3.7 (3.2-4.3)

Sociodemographic variables

The sociodemographic variables analyzed in this study included gender, race, age, number of inhabitants in the city, HDI and city size.

Table 3 shows the mean number of present teeth, as well as the caries experience according to gender, race, age and HDI. The males presented lower DMFT, higher mean of decayed teeth and fewer filled teeth. With regard to race, DMFT was the only variable presenting difference between groups, with higher DMFT for the Caucasians. Younger individuals (65-69 years) presented more teeth, more decayed teeth and fewer missing teeth. Individuals living in cities with high HDI presented higher mean of present teeth, more filled teeth and fewer decayed and missing teeth.

TABLE 3

Clinical variables in dentate individuals according to gender, race, and age. Southern Region of the state of São Paulo

	GENDER			RACE			AGE			HDI
	Male (n=163)	Female (n=207)	P	Caucasian (n=260)	Non-Caucasian (n=110)	P	65-69 years (n=251)	70-74 years (n=119)	P	Medium (n=176)	High (n=194)	P
Mean of present teeth (SD)	12.4	10.5	0.05	11.2	11.6	0.32	12.1	9.7	0.003	9.6	12.9	<0.001
	(8.3)	(6,8)		(7.8)	(7.1)		(7.8)	(6.8)		(6.9)	(7.9)
DMFT (SD)	24.9	27.1	0.001	26.6	25.1	0.02	26.0	26.5	0.95	25.8	26.5	0.40
	(6.1)	(4.4)		(5.1)	(5.8)		(5.7)	(5.0)		(5.8)	(4.8)
Decayed (SD)	2.3	1.3	<0.001	1.6	2.0	0.22	2.0	1.2	0.006	2.0	1.5	<0.001
	(3.4)	(2.6)		(2.8)	(3.4)		(3.2)	(4.5)		(2.8)	(3.2)
Filled (SD)	3.0	4.3	0.001	4.2	2.8	0.10	4.1	3.0	0.37	1.4	5.8	<0.001
	(5.4)	(5.5)		(5.9)	(4.2)		(5.9)	(4.5)		(2.6)	(6.5)
Missing (SD)	19.6	21.5	0.05	20.8	20.1	0.32	19.9	22.3	0.003	22.4	19.2	<0.001
	(8.4)	(6.8)		(7.8)	(7.1)		(7.8)	(6.8)		(6.9)	(7.9)

Table 4 shows the caries experience according to the city size. This table reveals differences between city size and the decayed and filled components. Elderly living in small cities presented more decayed teeth and fewer filled teeth. Table 5 presents data on the mean number of present teeth, DMFT index and its components, according to city size, in the sample stratified by gender and age. Females living in small cities exhibited more decayed teeth and fewer filled teeth. Younger individuals living in small cities presented more filled teeth, and older individuals living in small cities exhibited lower mean of filled teeth compared to medium and large cities.

TABLE 4

Mean of present teeth and dental caries experience in dentate individuals according to city size. Southern Region of the state of São Paulo

City size	Large (n=128)	Medium (n=97)	Small (n=145)	p
Variables
Mean of present teeth (SD)	11.6 (7.5)	11.7 (7.1)	10.7 (8.0)	0.24
DMFT (SD)	26.4 (5.1)	26.6 (5.3)	25.5 (6.1)	0.66
Decayed (SD)	1.2 a (2.2)	1.8 a (3.6)	2.4 b (3.2)	<0.001
Filled (SD)	4.8 a (6.2)	4.5 a (45.5)	1.8 b (3.9)	<0.001
Missing (SD)	20.4 (7.5)	20.3 (7.2)	21.3 (8.0)	0.25

Means followed by different letters in rows indicate statistically significant difference according to city size.

TABLE 5

Mean of present teeth, DMFT index and its components, according to city size, in the sample stratified by gender and age in dentate elderly individuals. Southern region of the State of São Paulo

	Gender								Age
	Males (n=163)				Females (n=207)				Younger (n=251)				Older (n=119)
	Small	Medium	Large	P	Small	Medium	Large	P	Small	Medium	Large	P	Small	Medium	Large	P
Mean of present teeth (SD)	12.2	12.3	12.6	0.93	8.9	11.3	11.0	0.05	11.2	12.8	12.4	0.21	9.5	10.0	9.4	0.74
	(8.8)	(7.8)	(8.3)		(6.7)	(6.5)	(6.9)		(8.2)	(7.3)	(7.7)		(7.5)	(6.5)	(6.3)
DMFT (SD)	24.4	25.6	25.2	0.68	26.8	27.4	27.1	0.94	25.4	26.3	26.3	0.66	25.7	26.9	26.8	0.95
	(6.5)	(5.0)	(6.4)		(5.5)	(3.4)	(4.1)		(6.2)	(4.8)	(5.6)		(6.1)	(3.3)	(3.5)
Decayed (SD)	2.4	2.6	1.8	0.60	2.4	1.1	0.8	<0.001	2.7	2.1	1.4	0.002	1.8	1.1	0.5	0.04
	(3.3)	(4.0)	(2.7)		(3.1)	(3.0)	(1.7)		(3.4)	(3.8)	(2.4)		(2.7)	(3.1)	(1.0)
Filled (SD)	2.2	3.3	3.9	0.27	1.4	5.6	5.4	<0.001	1.9	5.1	5.3	<0.001	1.4	3.8	3.7	<0.001
	(4.3)	(5.1)	(6.7)		(3.3)	(5.6)	(5.9)		(4.0)	(5.9)	(6.6)		(3.4)	(4.6)	(4.9)
Missing (SD)	19.8	19.6	19.4	0.92	22.9	20.7	20.9	0.05	20.7	19.1	19.6	0.22	22.5	21.9	22.6	0.75
	(8.8)	(7.8)	(8.3)		(6.7)	(6.5)	(6.9)		(8.3)	(7.3)	(7.7)		(7.5)	(6.5)	(6.3)

DISCUSSION

Dental caries and periodontal disease have been considered as main determinants for the high occurrence of tooth loss and consequently for the high percentage of edentulism4,14, In developing countries like Brazil, tooth loss is associated with the lack of oral health policies aimed at older adults and the elderly population11.

Since this study was an exploratory investigation, the obtained results should not be extrapolated to the general population, but only for this study group.

Considering that edentulism is an important indicator of the population's oral health condition4, the high prevalence of edentulism found in this study reflects a dissatisfactory condition, which has also been reported in other studies1,12,13.This indicates the result of ineffective dental treatments performed along their lives. Therefore, when this population reaches the third age, rehabilitative treatment becomes their only option. Conversely, in places with adequate attention to this population group, satisfactory oral health conditions may be observed, with lower prevalence of edentulism17,19.

Some studies have reported that the number of missing teeth was regarded as a negative predictor for the use of dental services. Among adults, edentulism has been considered one of the most important indicators of dental care and conditions21,22.

When the prevalence of edentulism observed for individuals aged 65 to 74 years is compared to data from the literature review, a variation of 14% to 44% was observed13, lower than the results found in the present study. When these results were compared to studies conducted in Brazil and for individuals older than 60 years, the results were quite similar, with institutionalized elderly individuals presenting a percentage of edentulism between 58.1% and 72%6,14. For noninstitutionalized elderly individuals, the prevalence ranged from 45.5% to 74%3,18. In this study, which also evaluated noninstitutionalized elderly individuals, the percentage of edentulism was high. However, the values found were similar to those observed in other Brazilian cities.

With regard to edentulism in the present study, it should be mentioned that many reasons other than dental caries may lead to tooth extraction in this age group, including periodontal disease, trauma, patient preference, and others. However, due to the difficulty to retrieve these data during examination, all missing teeth were considered as missing due to caries. This is an inherent limitation of the DMFT index applied to this age range.

As a result of early extractions, probably due to the lack of access to dental services and care, the elderly population presented a very low mean number of present teeth (3.5). However, when edentulous individuals were excluded from the general sample, the mean number of present teeth was approximately three times larger [11.3] [Table 2], as observed in previous studies9,10. In other words, when all individuals were considered for analysis of this variable, the edentulous individuals diluted the results, thus suggesting the inclusion of dentate individuals only when analyzing the mean number of present teeth. Another important point regarding the mean of present teeth is that this mean has been directly associated with the risk of caries onset12 as well as quality of life4,20.

In addition, the DMFT index in this population was quite high (Table 2). Nevertheless, these values are in agreement with results from other studies conducted in Brazil3,18. International studies commonly exclude edentulous individuals from the DMFT analysis. When this was performed in the present study, there was a decrease in the DMFT value, which is a similar result to that observed in international studies17,19,23.

The oral health conditions were analyzed in relation to the sociodemographic variables among dentate elderly individuals (Table 3). With regard to gender (Table 3), males presented lower DMFT, more decayed and fewer filled teeth, suggesting either a lack of access to dental services or a lower search for dental care, as reported by Carneiro, et al.2 (2005), who observed a higher percentage of women searching for dental assistance than men. The opposite was reported in a cohort study involving elderly individuals older than 80 years after a 10-year follow-up period, in which the women presented worse oral health conditions than men, with higher percentage of edentulism, fewer intact teeth, higher DMFT index, more restored and fewer decayed teeth compared to the men7.

When the oral health conditions were analyzed in relation to the age group (Table 3), differences were verified regarding the mean of present teeth and decayed teeth, with higher rate among younger individuals (65-69 years). Conversely, these elderly individuals presented more missing teeth. This result may be associated to the fact that, the chance of losing natural teeth increases with aging and hence these individuals are expected to present fewer decayed and filled teeth. This condition was also verified by Mack, et al. (2004) 10. Still according to Table 3, the HDI seemed to be a satisfactory instrument, revealing that, except for the DMFT, all other oral conditions analyzed in this study presented significant differences. Cities with medium HDI presented worse oral conditions, which indicates that people living in cities with higher socioeconomic level presented better oral conditions. Fernandes and Peres5 (2005) reported that cities with worse socioeconomic indicators exhibited higher rates of tooth extraction, which may be associated with advanced stages of the disease, in which no other therapeutic possibilities were offered.

The number of inhabitants in the city also showed differences in relation to the oral conditions. Individuals living in small-sized cities apparently presented worse oral conditions, since they had more decayed teeth and fewer filled teeth (Table 4). In addition to the first analysis, the city size was compared to the variables gender and age (Table 5). The results presented in Table 5 show that with regard to gender, only for the females, the percentage of decayed teeth was higher for people living in small cities and the percentage of filled teeth was smaller for individuals living in small-sized cities.

CONCLUSION

Poor oral health conditions were verified in the studied population, as demonstrated by the high percentage of missing teeth and high prevalence of edentulism. It may also be concluded that there is a lack of attention directed to this age group and that the use of specific and thorough dental programs aimed at health promotion and prevention of dental caries, as well as the establishment of public health policies with easy access to this population are necessary to improve oral health conditions in the elderly population.