Periodontal health of the geriatric population in old-age homes of Delhi, India.

BACKGROUND: Periodontal disease is one of the leading causes of tooth loss in the geriatric population. Assessment of periodontal disease in a population is an important step in planning effective prevention and control programs for periodontal disease. Therefore, a study was carried out in old-age homes of Delhi to assess the periodontal status of 65-74-year-old elderly and recommend interventions to improve their periodontal health.
MATERIALS AND METHODS: A cross-sectional study was conducted among 464 elderly from old-age homes of Delhi. Periodontal health status of the participants was determined using the WHO oral health assessment form. Community Periodontal Index (CPI) and loss of attachment (LOA) were recorded. Collected data were analyzed using SPSS version 23. Chi-square test was used to determine statistically significant difference among CPI scores and LOA according to age and gender. P ≤ 0.05 was considered statistically significant.
RESULTS: The result of the study showed that 25.4% of the elderly had healthy periodontium, 71.1% had a periodontal pocket of 6 mm or more, and 2.40% had a pocket depth of 4-5 mm. Around 36% had 6-8 mm LOA and 34.70% had 9-11 mm LOA. The difference between CPI scores among gender and age group was not significant (P = 0.20, P = 0.096). However, the difference among gender for LOA was found significant (P = 0.014).
CONCLUSION: The results from this study show that periodontal health of elderly residing in old-age homes is very poor. The periodontal status of this population can be enhanced by special collaborative efforts from the government and various nongovernmental organizations toward preventive and curative periodontal health services. Copyright:

INTRODUCTION

According to the present trends of increase in the geriatric population, it has been projected that the population of elderly individuals may reach 1.5 billion by 2050.[1] Oral diseases, owing to their high prevalence in the elderly, pose a major health-care concern in this population. The elders have very limited access as well as functional physical limitations which makes them more prone to oral diseases. Moreover, lack of financial support, institutionalization, and the presence of physical impairment limits maintenance of oral hygiene which is often associated with poor oral health among the elderly.[23]

Periodontal diseases are the most commonly found oral health problem among the elderly. Tissue destruction associated with aging leads to a greater incidence and severity of periodontal problems in the geriatric population.[4] Untreated gingivitis may also result in worsening into periodontitis in old age. The other hypothesis which explains the relationship between periodontal tissue destruction and advancing age is age-related susceptibility. The risk of periodontitis increases with age as the regulation of the immune system gets impaired.[5] Various studies have shown that there has been an impairment in the healing process of periodontal tissue of the elderly. Restoration of this damaged periodontal tissue is required to overcome the continuous exposure to inflammatory reactions.[67]

A national survey conducted in Australia reported that 44% of population had moderate or severe periodontitis from 55- to 74-year-age group, which increased to 61% for 75-year age group geriatric population.[8] Similar data were reported by the World Health Organization where it was seen that 45% of those aged 65 and over had Community Periodontal Index (CPI) scores of 3 or more, while only 7% had no symptoms.[9] Sometimes, preventable periodontitis in older adults is so severe, and it becomes difficult to treat completely because of the tissue damage due to the underlying systemic conditions.[101112]

Periodontal disease is one of the leading causes of tooth loss in the geriatric population. It affects the quality of life of the elderly as it causes functional limitations, reduced self-confidence, and impaired social relationship, and hence, it is a major public health problem.[1314] A significant negative correlation has also been seen when the quality of life was compared with a pocket depth of 5 mm or more.[151617]

Further, there has also been a positive correlation between the number of teeth and his/her self-perceived satisfaction of their oral condition.[15] Hence, oral hygiene maintenance is important in the elderly because not only it causes periodontal problems but also it is important for their psychological health as well.

Institutionalized elderly stands at a greater risk of development of periodontal disease owing to poor oral hygiene and oral health status. Studies in India as well as other countries have consistently pointed toward a greater occurrence of periodontal disease among dwellers at old-age homes. The treatment needs of this population are different and more enhanced. Therefore, the interventions required in these populations should be planned differently according to the needs of this population. However, there is a dearth of recent data on the periodontal status of institutionalized elderly in Delhi. Therefore, a study was carried out in old-age homes of Delhi to assess the periodontal status of 65–74-year-old elderly and recommend interventions to improve their periodontal health.

MATERIALS AND METHODS

The present observational study was conducted in Delhi. Delhi, officially the National Capital Territory of Delhi, has the largest area and it is also considered the second most populated city of India. The participants of the study were 65–74 years' residents of old-age homes of Delhi.

A total of 464 participants were recruited for this study. Initial sample size calculation was done using statistical methods. The power of the study was 80% (confidence interval at 95%). Using the prevalence of periodontitis as 44% in the previous study,[8] sample size determination was done from the formula

Where, Z = 1.96, P = 44%, and E = 0.05

The sample size achieved using this formula was 378. As per the information collected from the Delhi municipal office, there were 38 old-age homes in Delhi. Delhi was divided into five regions, i.e., South, North, East, West, and Central Delhi. Four old-age homes from each of these regions were randomly selected for this study. A total of 20 old-age homes of 38 were taken for the study by cluster randomized sampling. All the inmates who were in the age group of 65–74 years and who were residents or a day visitor to these 20 elders' homes were part of the study. This had led to the final sample size of 464. Elderly subjects who were not present on the day of the examination or who had not given the consent or were bedridden were excluded from the study.

Ethical clearance approval was obtained from the Institutional Ethical Committee. Further, permissions to conduct the study were obtained from all the old-age home authorities and informed consent was obtained from geriatric participants before explaining to them the purpose of the study. The study was carried out based on the WHO recommendations under natural lighting using disposable dental mirrors, dental explorer/probe, and dental tweezers. Training and calibration of the examiner was done so that there will be a uniform interpretation of the codes and criteria for periodontal disease. The kappa value for all items was found to be >0.84. The study schedule was prepared and 25–30 subjects were examined per day.

The WHO oral health assessment form was used to collect the information regarding the periodontal status of the geriatric population.[18] CPI Index and loss of attachment (LOA) were recorded. Demographic data were also obtained which included age and gender. The age group was dichotomized into 65–69 years and 70–74 years. The highest CPI Index score and LOA were compared among gender and age groups.

The data were compiled and analyzed by IBM SPSSTM Statistics for Windows, version 20.0 (IBM Inc., Armonk, NY, USA). Data were represented in the form of numbers and percentages. Chi-square test was used to find association and significance between CPI with age and gender and also between LOA with age and gender. P ≤ 0.05 was considered statistically significant (95% confidence interval).

RESULTS

The mean age of the study population in the present study was 69.4 ± 2. There were 291 male participants and 173 female participants in the study population [Table 1]. About 25.4% of the elderly had healthy periodontium (Score 0 as highest CPI score), 71.1% had a periodontal pocket of 6 mm or more (Score 4 as highest CPI score), and 2.40% had a pocket depth of 4–5 mm (Score 0 as highest CPI score). Nearly 36.20% had 6–8 mm LOA and 34.70% had 9–11 mm LOA.

Table 1

Distribution of sample by age group and gender

	Sex		Total
	Male	Female
Age group (years), n (%)
65-69	142 (58.40)	101 (41.60)	243 (100)
70-74	149 (67.40)	72 (32.60)	221 (100)
Total, n (%)	291 (62.70)	173 (37.30)	464 (100)
χ2, P	3.996, 0.046*

n – Number of participants, χ2- Chi Square, P - significance, *Significant (P≤0.05 was considered significant)

A higher proportion of males had poorer CPI scores as compared to females. However, when this difference was tested statistically, it was found that the difference is nonsignificant (P = 0.20) [Table 2]. However, according to the age groups, it was found that the older age group had a proportionally greater number of individuals with a higher CPI score. When CPI scores were compared among the age group of 65–69 and 70–74, then also it was found that the difference was not statistically significant (P = 0.096) [Table 3].

Table 2

Number and percentage of participants with community periodontal index by highest score according to gender

	Maximum CPI score
	Score 0 (healthy)	Score 1 (bleeding)	Score 2 (calculus)	Score 3 (pocket 4-5 mm)	Score 4 (pocket 6 mm or more)	Score X (excluded sextant)	Score 9 (not recorded)
Sex, n (%)
Male	71 (24.40)	0	0	9 (3.10)	208 (71.50)	2 (0.70)	1 (0.30)
Female	47 (27.20)	0	2 (1.20)	2 (1.205)	122 (70.50)	0	0
Total, n (%)	118 (25.40)	0	2 (0.40)	11 (2.40)	330 (71.10)	2 (0.40)	1 (0.20)

χ2 (chi square) = 7.205, P (significance) = 0.206 (P≤0.05 was considered significant). CPI – Community periodontal index

Table 3

Number and percentage of participants with community periodontal index by highest score according to the age group

	Maximum CPI Score
	Score 0 (healthy)	Score 1 (bleeding)	Score 2 (calculus)	Score 3 (pocket 4-5 mm)	Score 4 (pocket 6 mm or more)	Score X (excluded sextant)	Score 9 (not recorded)
Age group (years), n (%)
65-69	51 (21.00)	0	2 (0.80)	4 (1.60)	184 (75.70)	1 (0.40)	1 (0.40)
70-74	67 (30.30)	0	0	7 (3.20)	146 (66.10)	1 (0.50)	0
Total, n (%)	118 (25.40)	0	2 (0.40)	11 (2.40)	330 (71.10)	2 (0.40)	1 (0.20)

χ2= (chi square)=9.341, P (significance)=0.096 (P≤0.05 was considered significant). CPI – Community periodontal index

When gender was compared for LOA, then it was found that males had higher LOA scores and this difference was found statistically significant (P = 0.014) [Table 4], whereas no statistical difference was found when subjects from the age group of 65–69 and 70–74 years were compared for LOA (P = 0.129) [Table 5].

Table 4

Number and percentage of participants with loss of attachment by the highest score according to the gender

	Maximum LOA						Total
	Score 0 (0-3 mm LOA), n (%)	Score 1 (4-5 mm), n (%)	Score 2 (6-8 mm), n (%)	Score 3 (9-11 mm), n (%)	Score 4 (12 mm or more), n (%)	Score X (excluded sextant), n (%)
Sex, n (%)
Male	72 (24.70)	9 (3.105)	93 (32.00)	114 (39.20)	3 (1.00)	1 (0.40)	291
Female	49 (28.30)	2 (1.205)	75 (43.40)	47 (27.20)	0	1 (0.40)	173
Total, n (%)	121 (26.10)	11 (2.40)	168 (36.20)	161 (34.70)	3 (0.60)	2 (0.40)	464

χ2 (chi square)=12.432, *P(significance)=0.014 (P<0.05 was considered significant). LOA – Loss of attachment

Table 5

Number and percentage of participants with loss of attachment by the highest score

	Maximum LOA						Total
	Score 0 (0-3 mm LOA), n (%)	Score 1 (4-5 mm), n (%)	Score 2 (6-8 mm), n (%)	Score 3 (9-11 mm), n (%)	Score 4 (12 mm or more), n (%)	Score X (excluded sextant), n (%)
Age group (years), n (%)
65-69	54 (22.20)	4 (1.60)	88 (36.20)	95 (39.10)	2 (0.80)	1 (0.40)	243
70-74	67 (30.30)	7 (3.20)	80 (36.20)	66 (29.90)	1 (0.50)	1 (0.40)	221
Total, n (%)	121 (26.10)	11 (2.40)	168 (36.20)	161 (34.70)	3 (0.60)	2 (0.40)

χ2 (chi square)=7.126, P (significance)=0.129 (P≤0.05 was considered significant). LOA – Loss of attachment

DISCUSSION

Age is a determinant as well as a risk factor for periodontal disease. The present study was done among 65–74-year-old elderly residing in oldage homes of Delhi to evaluate their periodontal health. Only 25.4% of the elderly had healthy periodontium (Score 0 as the highest CPI score). About 71.1% had a periodontal pocket of 6 mm or more and 34.70% had 9–11 mm LOA.

Qiao et al. conducted a study to find the periodontal status of the geriatric population in Haikou, China, and found that the prevalence rate of periodontal disorders was high and men had a higher risk of periodontal pockets as compared to females.[14] In a study by Nguyen et al., it was observed that 60% of females a had pocket depth of 4–5 mm and 17.6% had 6 mm or more.[19] About 64.6% of males had a pocket depth of 4–5 mm and 24.4% had 6 mm or more, respectively.[19] However, in the present study, 71.50% of males had 6 mm or more pocket and 3.10% had a pocket depth of 4–5 mm. When females were observed, 70.50% had 6 mm or more pocket and 1.20% had a pocket depth of 4–5 mm.

A study done by Mei Na et al. on the Singaporean geriatric population living in a community home revealed that only 13.9% had healthy periodontal tissue and in a study done by Al-Sinaidi, only 8.4% of the subjects had healthy periodontium.[2021] Similarly, in the study done by Puturidze. et al., only 6.3% of participants were observed to have healthy periodontal status.[22] However, in the present study, 25.4% of the elderly residing in old-age homes had healthy periodontium.

While 2.40% had the highest score of 3 (pocket 4–5 mm) and 71.10% had the highest score of 4 (pocket 6 mm or more) in the present study population, in the study done by Mei Na et al., 30.6% had the highest score of 3 and 19.4% had the highest score of 4.[20] Similarly, in the study done by Sajankumar and Hegde, it was observed that 49.47% had the highest score 3 and 14.06% had the highest score 4.[23]

Furthermore, there was no statistically proved association between the highest CPI score, age, and gender in the study done by Mei Na et al. and study done by Al-Sinaidi.[2021] However, in the present study, when CPI score was compared among genders, then it was found that males had high CPI score as compared to females which means they have more periodontal disease as compared to female, but this difference was found to be nonsignificant (P = 0.20). Similarly, in the study done by Puturidze et al., males were more likely to have unhealthy periodontal tissue compared to females.[22] It was found in the study done by Sajankumar and Hegde that no such difference in CPI score was there, as P = 0.81.[23]

In the present study, it was found that 36.20% of the elderly had 6–8 mm LOA and 34.70% had 9–11 mm LOA, whereas in the study done by Khapung A, it was seen that 14.7% of participants had a score of 2 (attachment loss: 6–8 mm) and 1.6% of participants had a score of 3 (attachment loss: 9–11 mm).[24] Similarly, in the study done by Sajankumar and Hegde, it was seen that 14.06% of population had a score 2.[23] The reason for this may be that the elderly population in the study done by Khapung A et al. was the patients who were visiting the dental hospital, and in the present study, the population was elderly who were residing in old-age homes.[24] Hence, the periodontal condition of the present study population was poor as a result of the lack of utilization of oral health services due to the institutionalization of these elderly.

When gender was compared for LOA, then it was observed that males had a high score for LOA as compared to females and this difference was found statistically significant as well (P = 0.041). However, in the study done by Sajankumar and Hegde, it was seen that no statistical difference was there among genders for LOA (P = 0.79).[23]

Age is known to be one of the important factors in the development of periodontal disease. A recent study by Nazir et al. showed that periodontal disease was more common in old age with a dramatic increase in disease levels in later decades of life. The study showed that 63% of the population between 65 and 74 years in India had periodontal disease.[24] As compared to this study, the present study shows a greater prevalence of periodontal disease (74.6%) in institutionalized elderly people in Delhi. This difference may be due to the difference in population of the present study, which consisted of only institutionalized elderly, where care depends to a large extent on the institutional provision and support.[25]

Another recent study in periodontal condition among institutionalized elderly was conducted at old age homes of Ho Chi Minh City in Vietnam.[26] In that study, 26.2% of participants had deep pockets, while 9.5% had pockets 7 mm or more in depth. As compared to that study, the present study results show the occurrence of periodontal pockets with a depth greater than 6 mm in about 71% of the individuals. Thus, there was a major difference in prevalence among the two populations. The study in Vietnam states that the conditions in governmental residential facilities are better than other residential facilities in Ho Chi Minh City, which attributes to a better periodontal condition in these individuals. It is worth noticing here that by improving the facilities for dental care, old-age homes can make a statistically significant difference in periodontal health and quality of life of inmates. Therefore, proper access and availability of self as well as professional dental care in such institution is necessary.

Certain disabilities like cardiovascular problems, cerebral problems, dementia, and diabetes lead to deterioration in their ability to perform oral hygiene which make them exposed to periodontal complications. In addition, potential use of a variety of medications and altered immunity at old age results in periodontal problems in them. These challenges are faced by the majority of elders residing in old-age homes.

The present study has shown the periodontal conditions of elders residing in old-age homes of Delhi. However, the limitation of the study was that a history of oral hygiene habits and personal habits like smoking and alcohol was not asked from the participants as these factors might have affected the periodontal health of these elderly. Hence, further studies can be conducted at other old-age homes, and these habits should be taken into consideration to generalize the result on other population.

CONCLUSION

The present study has proved that periodontal health of the geriatric population living in the old-age homes of Delhi is very poor. Improving oral health-care provision through regular dental visits and providing the necessary treatment to this population is an important step that old-age homes should take. Further, provision of oral health education regarding maintaining oral hygiene as well as enhancing self-care in these individuals is an important step in improving periodontal health of these individuals. Oral health care of institutionalized elderly in Delhi, especially periodontal care, needs to be stepped up for improvement in oral health-related quality of life and periodontal health of this important and vulnerable population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.