Gender-wise comparison of oral health-related quality of life and its relationship with periodontal status among the Indian elderly.

AIM: The aim of this study is to assess if there are any gender differences in oral health-related quality of life (OHRQoL) and periodontal status among the elderly population of Haryana.
MATERIALS AND METHODS: A cross-sectional study was conducted among 1200 geriatric population of Faridabad district of Haryana. Subjects were selected by a combination of systematic, cluster, and multistage sampling techniques. Primary, secondary, and tertiary sampling units were chosen as wards, areas, and households, respectively. SELF-ADMINISTERED QUESTIONNAIRE: Geriatric oral health assessment index was used to assess the OHRQoL among males and females. Periodontal status was assessed using the World Health Organization oral health survey pro forma with some modifications.
RESULTS: Results were analyzed using the Statistical Package for the Social Sciences 21 software. Gender-wise association of periodontal status with OHRQoL revealed a significant association with mobile teeth (P < 0.05). No relation was seen between OHRQoL, gingival bleeding, periodontal pocket, and loss of attachment (P > 0.05).
CONCLUSION: No significant differences were observed in periodontal status among males and females, but OHRQoL was found to be better among males than females. Indian policymakers can use the conclusion derived from this study for planning and implementing public oral health strategies for the geriatric population. Copyright:

INTRODUCTION

Oral health can be defined as being free of oral maladies; it is “a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.”[1]

Concept of oral health-related quality of life (OHRQoL) can be used for the evaluation of people's needs, their problems, their satisfaction levels, and effects of intervention provided to them for specific subpopulations as applicable. In descriptive population-based research, instruments for measuring OHRQoL have been used for recording nonclinical horizon of oral health. A more comprehensive measurement of the impact of oral diseases on subjective well-being can become possible when OHRQoL measures are used alongside clinical methods.[2]

Acute and chronic health problems affect the overall quality of life (QoL), but such a consequence of bad oral health is avoidable by practicing the efforts to maintain good oral health. Efforts should not only be targeted toward cure of physical diseases, but it should also be made for patients' psychosocial well-being. Hence, health-related QoL, measuring for domains, viz., physical health, psychological well-being, social relationships, and environment, has become a research focus.[3]

Aging, once seen as a physiological phenomenon, has become a reality now in India; thus, health of this subgroup of the population is increasingly arising the interest of researchers. Data direct that by 2040, developing countries will have the geriatric population of around 1 billion. Given the high graph of this growth, care with this specific vulnerable age group is essential since poor oral health affects the overall health as well as affects your role or relationship in influencing the QoL of the population.[4]

QoL is often affected by the burden of oral diseases in the elderly. The elderly who have lost the majority of their teeth suffer from serious functional limitations, which lead to nutritional problems. Coordination and cost-effectiveness of the health policies become more critical for such age group. Trends in periodontal diseases are more complicated, but it seems that incline in gingivitis and periodontal diseases during the late stages of life is common in developed countries, reflecting a need of increased social awareness and better oral hygiene.[5]

Presenting oneself as a healthy person, one needs to maintain good oral health to improvise individual's longevity and happiness. In India being a country of traditions, customs, superstition, and social taboos, there are said measures that women are at risk of comparatively deteriorated oral health when compared with men; hence, they are suggested to take more initiative and efforts to maintain their oral health, including physical activity, no alcohol or tobacco consumption, healthy diet, and practicing good general health maintenance measures. Thus, the present study was conducted to assess if there is any gender difference in OHRQoL and periodontal status among the geriatric subpopulation of Faridabad.

MATERIALS AND METHODS

The present study was a cross-sectional study, and participants were elderly subjects of Faridabad city. The clinical and OHRQoL measures were chosen to operationalize the validated geriatric oral health assessment index (GOHAI). Forward and backward translation of geriatric oral health assessment index for adapting it to the Indian setting was done by another three dentists. This translated version was compared with the original version, and no major discrepancies were found between original and translated version. Ethical clearance was sought from the institutional ethical committee. An information sheet was provided to each subject.

Elderly people currently residing in Faridabad city for at least past 1 year and who were willing to give informed consent were included in the study. Subjects with some physical issues and mentally not fit elderly people and those with cognitive or terminal illness were excluded.

The sample size was estimated using nMaster software (2.1 Version, CMC, Vellore, Tamil Nadu, India). A sample size of 1200 adults was determined following a pilot study on 66 subjects. The study subjects were selected by a combination of systematic, cluster, and multistage sampling techniques. The primary sampling unit (PSU) for this survey was ward. In total, there are 35 wards within Municipal Corporation of Faridabad. To determine the number of PSUs to be selected, a “sample take” value was considered. It was predecided that 100 elderly were included from each ward of Faridabad. By dividing the total sample size, i.e., 1200 by the “sample take,” i.e., 100 at ward level (PSUs), the number of required PSUs in the Faridabad arrived at 12. From a list of all PSUs, 12 wards were selected by random systematic sampling. For this, a number was selected from 1 and 2, and then, every third ward was selected for inclusion in the study. In this way, a total of 12 wards were selected from the list of 35 wards in Faridabad. Areas coming under the selected wards formed the secondary sampling units (SSUs). Two areas were randomly selected from each of the selected wards with equal probability by lottery method. It was also predecided that from each area of selected ward, 50 subjects were included. If, in a ward, a sample size of 100 could not be achieved in two areas, then a third area was further randomly chosen to achieve the required number. Within the SSUs, households formed the tertiary sampling units. The investigator found a fixed location within the boundaries of the selected area (such as a school or temple) and (following the left-hand rule) proceed to the starting household, i.e., the fifth house from the fixed starting point. A household in this survey was defined as a unit of people who share the same “kitchen” as opposed to people who share the same roof. All the elderly persons of that household were enrolled for the study. After completing the interview and clinical examination, four households would be skipped (using the left-hand rule), thereby calling on the fifth household. Selecting the household one by one was continued until the prescribed number was achieved, i.e., 50 elderly adults from that area. In situations such as absence of elderly subjects in the selected household and refusal for undergoing interview/clinical examination, the next fifth house was selected.

Data collection

The data collection was done by a combination of questionnaire administration and clinical examination for the assessment of severity of periodontal condition. The clinical examination was performed by a single trained, calibrated dentist using sterilized instruments.

Periodontal status, loss of attachment using the World Health Organization (WHO).[6] Tooth mobility was assessed using modified Miller's index [Table 1 and Annexure].[7] Prior training and calibration of the examiner and training of the recording assistant were done. The intraexaminer variability (kappa value) ranged from 0.82 to 0.86 for all the observations.

Table 1

Study variables, measures, and data collection points

Variable	Measure	References	Number of items	Response set
Clinical factors
Periodontal status	Bleeding on probingPeriodontal pocketsLoss of attachment	WHO-2013
	Mobility	Miller’s index
OHRQoL	GOHAI-12	Atchinson and Doland	12 items	Likert scale

WHO – World Health Organization; OHRQoL – Oral health-related quality of life; GOHAI – Geriatric oral health assessment index; LOA – Loss of attachment

Statistical analysis

The data were analyzed using Statistical Package for the Social Sciences (SPSS 21) Package (IBM Corp., 2015, Virginia, US) for relevant statistical comparisons. Student's t-test was used for comparing two groups and one-way ANOVA when comparing more than two groups on continuous, normally distributed variables. Multivariate logistic regression was carried out for predictive analysis of the impact of variables on OHRQoL. Chi-square test was used for categorical variables. A P < 0.05 was considered statistically significant.

RESULTS

A total of 1200 study subjects comprised the study sample. Majority were males and a comparatively lesser number of population were female subjects [Table 2]. Minimum score for ADD GOHAI (Total GOHAI item score) scores was found to be 16 and maximum was found to be 50. Minimum score for SC GOHAI (Simple count GOHAI score) scores was found to be 0 and maximum was found to be 11 [Table 3]. Gender-wise, no significant difference was observed in the prevalence of gingival bleeding, periodontal pocket, and tooth mobility status of the study population, when compared gender-wise as P > 0.05 [Table 4].

Table 2

Descriptive statistics of the study population

Age group	Males, n (%)	Females, n (%)	Total
60-69 years	658 (61.2)	417 (38.8)	1075
70-79 years	77 (75.5)	25 (24.5)	102
80 and above	11 (47.8)	12 (52.2)	23
Total	746 (100	454 (100	1200
Mean age	64.06±4.02

n – Number of subjects

Table 3

Descriptive statistics for geriatric oral health assessment index

	ADD GOHAI	SC GOHAI
Mean	34.5675	7.2625
Median	37.0000	9.0000
SD	8.38704	3.75215
Minimum	16.00	0.00
Maximum	50.00	11.00
25th percentiles	26.0000	3.0000
75th percentiles	41.0000	11.0000

ADD GOHAI – Sum total score of geriatric oral health assessment index; SC GOHAI – Simple count score of geriatric oral health assessment index; SD – Standard deviation

Table 4

Gender-wise comparison of periodontal status of the study population

Variable	Males, n (%)	Females, n (%)	χ2	P
Gingival bleeding >65 units	207 (34.4)	396 (65.6)	2.02	0.08 (NS)
Gingival bleeding ≤65 units (median cutoff)	115 (30)	267 (70)
Periodontal pocket	267 (44.2)	187 (48.9)	0.163	0.294 (NS)
LOS
0-3 mm	541 (72.5)	352 (77.5)	4.83	0.072 (NS)
4-5 mm	50 (6.7)	27 (5.9)
6-8 mm	11 (1.5)	6 (1.3)
9-11 mm	2 (0.3)	0 (0.0)
Not recorded	142 (19)	69 (15.2)
Tooth mobility	348 (57.4)	226 (60.5)	0.920	0.338 (NS)

Chi-square test. Level of significance at P≤0.05. *Significant difference. NS – Statistically not significant; n – Number of subjects; P – Probability value; χ2 – Chi Square value; LOA – Loss of attachment

When gender-wise comparison was made for different GOHAI items, significant difference was seen between males and females, except for GOHAI item 4 and 7, and i.e., no difference was found in the mean GOHAI scores of males and females when they were asked about how pleased are they with the look of the teeth [Table 5]. Only factor which was found to be significantly associated with OHRQoL was mobile teeth, i.e., QoL was better among subjects without mobile teeth [Table 6].

Table 5

Gender-wise distribution of geriatric oral health assessment index item scores

GOHAI-Hi items	Mean±SD		P
	Males	Females
1. Limit the kinds of food	2.11±1.07	2.37±1.13	<0.0001*
2. Trouble biting or chewing	2.47±1.12	2.40±1.18	0.200
3. Able to swallow comfortably	4.69±0.78	4.77±0.84	<0.0001*
4. Problems to speak clearly	2.33±1.25	2.31±1.30	0.969 (NS)
5. Discomfort when eating any kind of food	3.78±1.59	4.20±1.46	<0.0001*
6. Limit contact with people	2.10±1.05	2.50±1.37	<0.0001*
7. Pleased with look of teeth	3.74±1.16	3.73±1.18	0.722 (NS)
8. Used medication to relieve the pain	2.61±1.15	2.85±1.36	<0.0001*
9. Worried about teeth, gums, or dentures	2.57±1.22	2.80±1.12	<0.0001*
10. Self-conscious of teeth, gums, or dentures	2.45±1.22	2.59±1.33	0.014*
11. Uncomfortable eating in front of others	2.50±1.04	2.39±1.02	0.050*
12. Sensitive to hot, cold, or sweet foods	2.79±1.11	2.67±1.12	0.008*

Mann-Whitney U-test. Level of significance at P≤0.05. *Significant difference. SD – Standard deviation; NS – Statistically not significant; P – Probability value; GOHAI – Geriatric Oral Health Assessment Index

Table 6

Association of periodontal status with oral healthrelated quality of life

Variables	Mean ADD GOHAI±SD	P
Gingival bleeding
>65	41.23±8.43	0.265 (NS)
≤65 (median cutoff)	40.61±8.39
Periodontal pocket	40.86±8.29	0.402 (NS)
Absence of periodontal pocket	41.00±8.56
LOA
0-3 mm	40.80±8.38	0.957 (NS)
4-5 mm	41.76±8.68
6-8 mm	44.11±9.36
9-11 mm	37.00±1.41
Not recorded	40.62±8.58
Proportion of tooth showing mobility	38.02±8.08	0.0001*
Proportion of tooth not showing mobility	44.87±7.08

Level of significance at P≤0.05. *Significant difference. NS – Statistically not significant; OHRQoL – Oral health-related quality of life; SD – Standard deviation; P – Probability value; LOA – Loss of attachment; ADD GOHAI – Sum total score of geriatric oral health assessment index

Overall, the regression model significantly predicted the outcome variable (ADD GOHAI: dependent variable. Sex, bleeding, mobility, loss of attachment: predictor variable) i.e. for every unit rise in mobility, the ADD GOHAI score decreases by 0.415 times [Table 7].

Table 7

Multivariate gender-wise assessment of the oral health-related quality of life and periodontal status

Model	Unstandardized coefficients		Standardized coefficientsβ	Significance level	95.0% CI for B
	B	SE			Lower bound	Upper bound
	Model 1
Constant	35.714	0.828		0.000	34.089	37.338
Sex	0.833	0.500	0.049	0.096	−0.149	1.814
Mobility	−7.047	0.496	−0.415	0.000*	−8.020	−6.074
Bleeding	1.015	0.524	0.057	0.053	−0.014	2.043
LOS	−0.360	0.510	−0.021	0.480	−1.360	0.640
ANOVA
Model	Sum of squares		Degree of freedom	Mean square	F ratio	Significance
Model 1
Regression	12,097.812		4	3024.453	52.276	<0.0001*
Residual	56,293.844	973	57.856
Total	68,391.656	977

Level of significance at P≤0.05. *Significant difference. F ratio – Ratio of two mean square; SE – Standard error; CI – Confidence interval; B – Unstandardized Coefficients; LOA – Loss of attachment

DISCUSSION

The WHO recognizes OHRQoL as an important segment of the global oral health program.[8] The geriatric oral health assessment instrument (GOHAI), to measure OHRQoL was used in the present study. GOHAI was developed by Atchison and Dolan, which targets to complement clinical measures by paying special attention to problems related to physiological, physical, and psychological needs.[9] For planning and assuring the QoL among the elderly population (older than 60 years), such measures must be taken into account. The present study evaluated the effect of periodontal status on OHRQoL.

In addition to the other general health issues, there are tremendous implications for oral health as a result of demographic revolution among this age group; therefore, the impact of poor oral conditions on daily life is particularly significant.

In the present study, majority study population was comprised of male subjects (746 subjects). In terms of gender distribution, this study contains a homogeneous elderly population. The male:female ratio in the sample (47.8%) was slightly greater than that found in Haryana (46%), which suggests that men were slightly under-represented in this study. Women population is generally the greater proportion of participation to several household surveys as limiting the generalizability of the reported findings.[10]

The mean ADD GOHAI and SC GOHAI were found to be 34.56 ± 8.38 and 7.26 ± 3.75, respectively [Table 2]. Gender-wise, no significant association was found with different parameters of periodontitis [Table 3]. In the present study, a significant association was found between QoL and gender, i.e., OHRQoL was found to be better among males. This is in accordance with some studies found the same results, i.e., under similar clinical conditions; women tend to perceive more impact on their OHRQoL than men. Thus, it shows that the differences in gender vary between distinct populations.

Only GOHAI item 7 and 4 showed no significant difference when compared gender-wise [Table 5]. Gender-wise association of periodontal status with OHQQoL revealed a significant association with only mobile teeth [Tables 6 and 7].

Although majority of subjects rated their oral and general health as poor, it could be probably because most of the Indian elderly population consider poor oral conditions as an effect of aging and do not consider it having an impact of OHRQoL.

In the present study, a statistically significant association was found between proportion of mobile teeth and mean ADD GOHAI. After thorough literature search, only very few studies were found which have focused on tooth mobility and its impact on QoL. Similar finding pertaining to the present study was reported by Othman et al., 2006.[11] This could be explained by the fact that mobile teeth not only cause pain and discomfort but also interfere with the oral functions, thus affecting the OHRQoL negatively.

No significant association was found between loss of attachment and bleeding with ADD GOHAI and periodontal pockets. This component of the study could not be compared with other study due to paucity of documented literature.

CONCLUSION

Within the limitations of the study, it was found that OHRQoL was significantly associated with the main factor causing periodontal problems, i.e., mobile teeth. Grossly, no comparable difference was observed in the OHRQoL among males and females. Indian policymakers can use the conclusion derived from this study, viz., no association could be established between OHRQoL and gender for planning oral health services. Thus, for planning and implementing public oral health strategies, one needs to target the geriatric population as a whole.

Limitations

One of the major limitations of the present study is the cross-sectional nature of the study; thus, temporality cannot be established. Moreover, most of the information available is based on cross-sectional studies; thus, there is a need of longitudinal studies to broaden our current understanding of transitions in oral health during the late stages of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.