Assessment of Periodontal Health and Necessity of Dental Treatment in the Institutionalized Elderly Population of East Godavari District, Andhra Pradesh.

AIM: To assess the periodontal health condition and treatment needs among elderly people aged 60-85 years residing as inmates in the eight old age homes in East Godavari district, Andhra Pradesh, India. SETTINGS AND
DESIGN: A cross-sectional descriptive study was conducted to verify the oral health condition and treatment needs among elderly people aged 60-85 years.
MATERIALS AND METHODS: Modified World Health Organization (WHO) 2013 oral health assessment pro forma for adults was used to assess the oral health status and treatment needs, the clinical assessment of oral mucosa, loss of attachment (LOA) , community periodontal index, dentition status, and treatment need. Prosthetic status and prosthetic needs and related oral health information were obtained from WHO Oral Health Assessment Questionnaire. STATISTICAL ANALYSIS USED: SPSS 23 was used for statistical analysis. Chi-square test was used for age- and gender-wise comparison. P < 0.05 was considered statistically significant.
RESULTS: Among the study subjects aged 60-74 years, there were 28.1% males and 25.9% females, and in 75-85 years, 30.6% were males 15.3% were females. In terms of periodontal status (pocket scores), 66.2% of elderly people have pocket scores 6 mm or more and presence of gingival bleeding in 75.9% of study subjects. Almost 24.4% had LOA scores of 12 mm or more. Comparison of LOA scores based on age and gender was statistically significant (P < 0.001). Of the study participants, 50.3% need prompt treatment (including scaling). Almost more than half of the study participants require one or multiunit prosthesis as only 10.93% of elderly population has ≥20 or more natural teeth present.
CONCLUSION: The study showed poor periodontal health among institutionalized elderly inmates. Oral mucosal lesions were found to be higher and oral health status was very deprived among the study population.

INTRODUCTION

Aging is both a medical and a psychological problem indicating the greater demand for the health services of a community.[1] In geriatric populations, several oral conditions such as tooth loss, denture wearing, dental caries experience, periodontal disease, xerostomia, and cancer are highly prevalent.[2] Older age people comprise a substantial portion of the population and the number is expected to increase exponentially due to changes in the life expectancy brought about by economic development in many parts of the world. The number of persons 60 years and older is expected to increase from about 670 million to almost a billion worldwide by the year 2050.[3] India is a country with an ancient culture and a hoary tradition where elderly people enjoyed a respectable place in the society. Old age and wisdom are considered synonymous in the traditional agrarian Indian culture and care for the elderly was never a problem. But the rapid spread of modernization, growing urbanization, and crumbling of joint family system have conspired to increase insecurity and loneliness among the geriatric population in the last few decades. Lack of family support, poor financial status, physical and mental disorders, and guilt of being dependent on others are some of the problems nagging the elderly population. As people age, their needs and vulnerabilities change, as do their medical requirements. Oral health is important for overall systemic well-being besides affecting mastication and swallowing, aesthetics, speech, psychological well-being, and the quality of life.[4] Relatively few epidemiologic studies of tooth loss at old age have been conducted in developing countries. In the developing countries, however, access to oral health services is limited and teeth are often extracted because of pain or discomfort, or because of the lack of materials needed for dental treatment.[5] Poor accessibility to oral health care facilities and uneven distribution of dental expertise are the major barriers for provision of oral health care to the elderly.

MATERIALS AND METHODS

A descriptive cross-sectional survey was conducted to assess the periodontal health status of the institutionalized elderly population of East Godavari District, Andhra Pradesh, India, from September 2018 to November 2018. The study protocol was reviewed by the ethical committee of GSL Dental College and Hospital and the ethical clearance was granted. An official permission was obtained from the chief of old age homes. After explaining the purpose and details of the study, a written informed consent was obtained from all the subjects who were willing to participate. Before the commencement of the study, the examiner was standardized and calibrated in the Department of Public Health Dentistry by the Head of Department to ensure uniform interpretations, understanding, and application of the codes and criteria for the diseases to be observed and recorded, and to ensure consistent examination.

Inclusion and exclusion criteria

The exclusion criteria were as follows: those who were not willing to participate and those who had systemic diseases with cognitive impairment and psychological disorders. The inclusion criteria were as follows: those who were willing to participate and aged 60 years and older.

Pro forma details: The pro forma consisted of three sections:

General information.

Information about oral hygiene practices and adverse habits.

Clinical parameters (WHO 2013 “Oral Health Assessment Form”)[6]

RESULTS

Descriptive [Table 1–9] were tabulated according to modified WHO 2013 “Oral Health Assessment Form and questionnaire.”[6] Of the total 320 elderly people examined, 58.8% were males and 41.2% were females [Table 1, Graph 1]. Of the total elderly people examined, 35.2% males and 46.8% females used toothbrush and toothpaste to clean their teeth [Graph 2]. Of the females, 36.6% reported that they use home/self-remedies for toothache and 31.7% of male said that they go directly to medical shop for medication for toothache problem [Graph 3]. While comparing gender and community periodontal index (CPI; gingival bleeding) score, they were statistically significant [Table 3]. However, age and CPI (gingival bleeding) score were statistically insignificant [Table 4]. Majority of males were smokers and were having oral mucosal lesions more than females [Graph 4]. The comparison of age with CPI (pocket scores) and loss of attachment (LOA) was statistically insignificant [Tables 6 and 8]. Of the total 320 study participants, more than half of elderly people required some sort of oral treatment and intervention urgency irrespective of age and gender [Table 9].

Table 1

Distribution of study subjects according to age and gender

Gender	Age		Total
	60–74 years	75–85 years
Males, n (%)	90 (28.1)	98 (30.6)	188 (58.8)
Females, n (%)	83 (25.9)	49 (15.3)	132 (41.2)
Total, n (%)	173 (54.1)	147 (45.9)	320 (100)

Table 9

Distribution of study subjects based on urgent need of intervention according to age and gender

	Intervention urgency (age and gender wise)
	Males	Females	60–74 years	75–85 years
No treatment needed, n (%)	4 (1.2)	0 (0)	4 (1.2)	0 (0)
Preventive or routine treatment needed, n (%)	8 (2.5%)	32 (10)	31 (9.7)	9 (2.8)
Prompt treatment (including scaling needed), n (%)	114 (35.6)	47 (14.7)	69 (21.6)	92 (28.8)
Immediate (urgent) treatment needed due to pain or infection of dental/or oral origin, n (%)	44 (13.8)	43 (13.4)	59 (18.4)	28 (8.8)
Referred for comprehensive evaluation or medical treatment (systemic condition), n (%)	18 (5.6)	10 (3.1)	10 (3.1)	18 (5.6)

Pearson chi-square = 40.04, P = 0.01 (statistically significant); Pearson chi-square = 30.48, P = 0.01 (statistically significant)

Graph 1

Distribution of study subjects according to age and gender

Graph 2

Oral hygiene practices among the elderly aged 60–85 years according to gender

Graph 3

Study subjects' response for consultation/remedial solution for toothache

Table 3

Periodontal condition (gingival bleeding) of study participants based on community periodontal index (modified) according to gender

Gender	Gingival bleeding				Total
	Code 0 = absence of condition	Code 1 = presence of condition	Code 9 = tooth excluded	X = tooth not present
Males, n (%)	18 (5.6)	124 (38.8)	27 (8.4)	19 (5.9)	188 (58.8)
Females, n (%)	0 (0)	119 (37.2)	8 (2.5)	5 (1.6)	132 (41.2)
Total, n (%)	18 (5.6)	243 (75.9)	35 (10.9)	24 (7.5)	320 (100)

Pearson chi-square = 27.63, P = 0.001 (statistically significant)

Table 4

Periodontal condition (gingival bleeding) of study participants based on community periodontal index (modified) according to age

Age (years)	Gingival bleeding				Total
	Code 0 = absence of condition	Code 1 = presence of condition	Code 9 = tooth excluded	X = tooth not present
60–74, n (%)	11 (3.4)	139 (43.4)	12 (3.8)	11 (3.4)	173 (54.1)
75–80, n (%)	7 (2.2)	104 (32.5)	23 (7.2)	13 (4.1)	147 (45.9)
Total, n (%)	18 (5.6)	243 (75.9)	35 (10.9)	24 (7.5)	320 (100)

Pearson chi square = 7.491, P = 0.58 (statistically not significant).

Graph 4

Oral mucosal lesions among the study subjects

Table 6

Periodontal condition (pocket scores) of study participants based on community periodontal index (modified) pocket scores according to age

Age	Pocket scores					Total
	Code 0 = absence of condition	Code 1 = pocket 4–5 mm	Code 2= pocket 6 mm or more	Code 9 = tooth excluded	X = tooth not present
60–74, n (%)	1 (0.3)	16 (5)	118 (36.9)	19 (5.9)	19 (5.9)	173 (54.1)
75–80, n (%)	0 (0)	2 (0.6)	94 (29.4)	26 (8.1)	25 (7.8)	147 (45.9)
Total, n (%)	1 (0.3)	18 (5.6)	212 (66.2)	45 (14.1)	44 (13.8)	320 (100)

Pearson chi-square = 14.49, P = 0.006 (statistically significant)

Table 8

Loss of attachments scores among the study subjects according to age

Community periodontal index (modified)	60–74 years n (%)	75-85 years n (%)	Total n (%)
Loss of attachment
0–3 mm	4 (1.2)	0 (0)	4 (0.6)
4–5 mm	18 (5.6)	1 (0.3)	19 (5.9)
6–8 mm	38 (11.9)	8 (2.5)	46 (14.4)
9–11 mm	67 (20.9)	56 (17.5)	123 (38.4)
12 mm or more	29 (9.1)	49 (15.3)	78 (24.4)
9 = not recorded	9 (2.8)	10 (3.1)	19 (5.8)
X = excluded sextant	8 (2.5)	23 (7.2)	31 (9.7)

Pearson chi-square = 50.41, P = 0.01 (statistically significant)

DISCUSSION

There is an increasing need for geriatric oral health care in all developing countries including India, as two-thirds of the world’s elderly people live in developing countries. Geriatric population must receive attention from policymakers according to the changing demands for social and health services including oral health services. Limited resources, rather than being aspiration to provide all treatment needed, should have a road map to answer the present and future geriatric oral health concerns in a most efficient manner in a developing country. Treatment needs were generally higher in men than in women, but the difference was not significant except in regard to the need for extraction. Men had more badly decayed teeth and hopeless retained roots than women had. Generally, the need for tooth extraction was very high, which was similar to the study by Panchbhai.[7], almost half of the subjects, consistent with previous studies performed.[8] Of the study subjects, 68.2% had never been to a dentist, which is more than the study by Shaheen et al.[9] Pocket score 6 mm or more were detected in 66.2% of them. These findings were almost similar to other studies.[91011] LOA 4–5 mm was seen in the majority of examined people. These findings are similar to the study conducted by Agrawal et al.[12] but contradictory to the study conducted by Shaheen et al.[9] LOA 12 mm or more was seen in 24.4% of the total elderly people examined, and 97% required some sort of oral treatment. Among them, 83% required some sort of prosthesis. Of which, 10% required complete denture and 78% required partial denture whereas 10% did not require any prosthesis and 8.9% already had prosthesis. These findings were similar to the studies by Syed et al.,[10] Sujatha et al.,[11] and Al-Shehri.[13] The LOA score between male and female elderly participants was found to be statistically significant, which is in contrast to the study conducted by Shaheen et al.[9] LOA and age were found to be statistically significant, which was in contrast to the study conducted by Mary et al.[14] but similar to the study conducted by Khanal et al.[15] More than half of the study participants had oral mucosal lesions. The most commonly observed oral mucosal lesions are followed by candidiasis (30.1% in males and 20.8% in females), abscess (10.7% in males and 14.2% in females), and oral ulceration (11.6% in males and 9.2% in females).Only few subjects reported malignant tumor, which is similar to the study by Khanal et al.[15]

CONCLUSION AND RECOMMENDATIONS

The results of this study showed that institutionalized elderly population has extensively high periodontal-related diseases being the most common. And many of them require complex treatment for the same. Although the elderly are retaining their dentition longer than in the past, dental morbidity prevalence of dental diseases continues to be high. Despite these conditions or diseases affecting the elderly being treatable or preventable, many of the elderly do not avail the needed treatment. This may be because, most of the current people older than 60 years were not introduced to the concept of preventive dentistry at a young age and thus are not inclined to it. Many still hold the opinion that tooth loss is a normal part of the aging process and is not preventable. Others have adapted to a compromised oral health status and sought treatment only when an emergency arises. Treatment of oral diseases is accorded least priority by the elderly themselves as well as by their caregivers. In the country like India, oral health care is offered by private dental practitioners and there is a substantial lack of insurance coverage for oral health care of older people. The introduction of financially fair third-party payment schemes will help to finance oral health care and effective disease control, particularly among the poor and disadvantaged elderly people. Integrated approaches in health care, i.e., collaboration between oral health personnel and other medical professionals trained in geriatric health care, will help to improve the quality of oral health care. The elderly people residing in old age homes of East Godavari district had poor oral health and the unfilled treatment need was high. Almost all the elderly (97%) required some sort of oral treatment. The prosthetic need was higher among all the other treatment needs. Government, nongovernment agencies, and private institutions can play a major role to improve the overall quality of life and well-being of the old people by conducting various health care programs for them. This study can provide the baseline data regarding the oral health status of institutionalized elderly people of East Godavari district. To generalize the findings in Andhra Pradesh, further study should be performed on a large scale.

Limitations

Study was carried out on very small number of population and convenience sampling technique was used, so generalizability cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 2

Distribution of study subjects based on number of natural teeth present in the oral cavity according to age and gender

Age vs. natural teeth	Number of teeth present
	60–74 years				75–85 years
As per WHO Oral Health Questionnaire 2013	0	≤9	10–19	≥20	0	≤9	10–19	≥20
	0 (0%)	5 (1.6%)	148 (46.2%)	20 (6.2%)	17 (5.3%)	41 (12.8%)	74 (23.1%)	15 (4.7%)

Pearson chi-square= 68.8, P = 0.001 (statistically significant)

Table 5

Periodontal condition (pocket scores) of study participants based on community periodontal index (modified) pocket scores according to gender

Gender	Pocket scores					Total
	Code 0 = Absence of condition	Code 1 = pocket 4–5 mm	Code 2 = pocket 6 mm or more	Code 9 = tooth excluded	X = tooth not present
Male, n (%)	1 (0.3.)	13 (4.1)	121 (37.8)	23 (7.2)	30 (9.4)	188 (58.8)
Female, n (%)	0 (0)	5 (1.6)	91 (28.4)	22 (6.9)	14 (4.4)	132 (41.2)
Total, n (%)	1 (0.3)	18 (5.6)	212 (66.2)	45 (14.1)	44 (13.8)	320 (100)

Pearson chi-square = 4.99, P = 0.28 (statistically not significant)

Table 7

Loss of attachments scores among the study subjects according to gender

Loss of attachment scores	Males n (%)	Females n (%)	Total n (%)
0–3 mm	2 (0.6)	2 (0.6)	4 (0.6)
4–5 mm	6 (1.9)	13 (4.1)	19 (5.9)
6–8 mm	27 (8.4	19 (5.9)	46 (14.4)
9–11 mm	81 (25.3)	42 (13.1)	123 (38.4)
12 mm or more	32 (10)	46 (14.4)	78 (24.4)
9 = not recorded	15 (4.7)	4 (1.2)	19 (5.8)
X = Excluded sextant	25 (7.8)	6 (1.9)	31 (9.7)

Pearson chi-square = 27.9, P = 0.01 (statistically significant)