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Oral health of elderly occupants in residential homes
RESEARCH LETTERS
Research letters
Oral health of elderly occupants in residential homes D Simons, E A M Kidd, D Beighton
In March, 1994, there were 16 000 residential and nursing homes for the elderly in the UK. By March, 1998, this number had increased to 19 000 homes with a capacity for 453 000 people. The greatest increase was for the mentally infirm elderly whose bed provision increased 235% from 9133 places in 1994, to 21 500 places in 1998. It has been reported that these institutionalised elderly people have poorer oral health than those who live independently at home.1 We offered to assess the oral health of elderly occupants in a random sample of 55 of the 110 residential and nursing homes in West Hertfordshire. 48 homes accepted. We recorded participants’ age, sex, length of time in the home, medications, number of medicines administered as syrups, and type of dentures worn. Extraoral and intraoral soft tissues, denture hygiene status, clinical status of each coronal and root surface, plaque and gingival indices were examined and recorded. A questionnaire that covered oral health and past dental care was completed in the form of a structured interview and was conducted with all those residents who were able to respond. The sample consisted of 249 men and 792 women, with a mean age of 83·9 (SD 7·8) years, who had spent 24·9 (26·2) months in the residential homes. 598 residents were edentulous, 203 residents had only teeth, and 240 had teeth and dentures. The results (table) are consistent with findings in other institutionalised populations.2–5 All studies showed high levels of both coronal and root caries. The plaque and gingival indices were high in this study at 2·3 (0·7) and 1·7 (0·4), respectively, and this poor oral hygiene was significantly related (p<0·0001) to the presence of root caries. Plaque retention is a problem in elderly people who have difficulty in mechanically removing plaque owing to diminished manual dexterity, impaired vision, or illness. The highest denture debris levels were on the fitting surface of the upper denture, mean 1·56 (0· 85). This was significantly related to the levels of clinically diagnosed denture stomatisis (p<0·001) and wearing dentures at night (p<0·001). Poor denture hygiene has been found in other studies, which showed that dentures cleaned by staff were no cleaner than those cleaned by residents. 5 12% of the denture wearers had clinically diagnosed denture stomatitis, 13% angular cheilitis, and 9% both. The incidence of oral ulceration was 3%, glossitis or sore or fissured tongue 8·5%, and 19 red or white lesions were found: these were reviewed and one
Number of participants Number of dentate participants Age range (years) Mean age (years) % Edentulousness DMFT % retained roots %RCI % of population with coronal decay % of population with root decay Mean number of teeth per person
Hertfordshire, UK 1996/97
Norway 1980 (4)
1041 443 65·6–101 83·9 57 22·2 29·9 54·4 41 51·2 11·7
190 38 67– — 80 25·7 — — — — 12
resident was referred for further examination. The questionnaire showed that 250 of the residents had difficulty eating, 206 had problems with taste, and 261 found it hard to care for their mouth. Although 343 residents preferred assistance in cleaning their teeth and dentures, only 94 reported that the staff had helped them. 927 residents received medications known to produce xerostomia, 396 were given syrups containing sugar and 385 residents reported suffering with dry mouth. The managers and deputy managers indicated that there was no systematic approach to arranging dental care. Dental care was sought only when residents or their relatives complained of acute dental problems such as pain or a broken denture. Dental assessments were not carried out when residents were admitted, neither was a care plan developed that included intraoral care. Only 4% of the edentate and 20% of the dentate residents had seen a dentist in the past 2 years. The poor oral status of the institutionalised elderly, found in this and previous studies, may contribute to the eating problems and low nutrient and vitamin C levels found in this group. These results, combined with the reduced ability of elderly people to communicate, may cause weight loss, dehydration, and debility. It is surely a disgrace that the mouth, one of the most personal and intimate areas of the body, should be neglected in such a manner. 1
2
3
4
5
Steele JG, Sheiham A, Marcenes W, Walls AWG. National diet and nutrition survey: people aged 65 years and over. Vol 2: Report of the oral health survey. London: Stationery Office, 1998. Kiyak HA, Grayston MN, Crinean CL. Oral health problems and needs of nursing home residents. Community Dent Oral Epidemiol 1993; 21: 49–52. Budtz-Jorgensen E, Mojon P, Rentsch A, Roehrich N, von der Muehll D, Baehni P. Caries prevalence and associated predisposing conditions in recently hospitalised elderly persons. Acta Odont Scand 1996; 54: 251–56. Jokstrad A, Ambjornsen E, Eide KE. Oral health in institutionalised elderly people in 1993 compared with 1980. Acta Odont Scand 1996; 54: 303–08. Merelie DL, Heyman B. Dental needs of the elderly in residential care in Newcastle-upon-Tyne and the role of formal carers. Community Dent Oral Epidemiol 1992; 20: 106–11.
West Herts Community Dental Services, Dental Department, Principal Health Centre, St Albans, Herts AL1 3LA, UK (D Simons); and Departments of Conservative Dentistry and Oral Microbiology, Dental Institute, Guy’s, King’s and St Thomas’ Schools of Medicine and Dentistry and Biomedical Sciences, London Norway 1993 (4) 243 112 67–102 83·2 54 22·9 30 — 60 — 15·7
Washington, USA 1991 (2) 1063 450 72–98 — 52·7 — 23·6 — 26·3 36 —
UK 1994/95 (1) 274 57 65– — 79 — — 46 31 39 10·7
Geneva, Switzerland 1995 (3) 216 120 69–97 83 55 — 23 — 33 54 11·1
References in brackets.
Oral surveys of institutionalised elderly
THE LANCET • Vol 353 • May 22, 1999
1761
Research letters
Oral health of elderly occupants in residential homes D Simons, E A M Kidd, D Beighton
In March, 1994, there were 16 000 residential and nursing homes for the elderly in the UK. By March, 1998, this number had increased to 19 000 homes with a capacity for 453 000 people. The greatest increase was for the mentally infirm elderly whose bed provision increased 235% from 9133 places in 1994, to 21 500 places in 1998. It has been reported that these institutionalised elderly people have poorer oral health than those who live independently at home.1 We offered to assess the oral health of elderly occupants in a random sample of 55 of the 110 residential and nursing homes in West Hertfordshire. 48 homes accepted. We recorded participants’ age, sex, length of time in the home, medications, number of medicines administered as syrups, and type of dentures worn. Extraoral and intraoral soft tissues, denture hygiene status, clinical status of each coronal and root surface, plaque and gingival indices were examined and recorded. A questionnaire that covered oral health and past dental care was completed in the form of a structured interview and was conducted with all those residents who were able to respond. The sample consisted of 249 men and 792 women, with a mean age of 83·9 (SD 7·8) years, who had spent 24·9 (26·2) months in the residential homes. 598 residents were edentulous, 203 residents had only teeth, and 240 had teeth and dentures. The results (table) are consistent with findings in other institutionalised populations.2–5 All studies showed high levels of both coronal and root caries. The plaque and gingival indices were high in this study at 2·3 (0·7) and 1·7 (0·4), respectively, and this poor oral hygiene was significantly related (p<0·0001) to the presence of root caries. Plaque retention is a problem in elderly people who have difficulty in mechanically removing plaque owing to diminished manual dexterity, impaired vision, or illness. The highest denture debris levels were on the fitting surface of the upper denture, mean 1·56 (0· 85). This was significantly related to the levels of clinically diagnosed denture stomatisis (p<0·001) and wearing dentures at night (p<0·001). Poor denture hygiene has been found in other studies, which showed that dentures cleaned by staff were no cleaner than those cleaned by residents. 5 12% of the denture wearers had clinically diagnosed denture stomatitis, 13% angular cheilitis, and 9% both. The incidence of oral ulceration was 3%, glossitis or sore or fissured tongue 8·5%, and 19 red or white lesions were found: these were reviewed and one
Number of participants Number of dentate participants Age range (years) Mean age (years) % Edentulousness DMFT % retained roots %RCI % of population with coronal decay % of population with root decay Mean number of teeth per person
Hertfordshire, UK 1996/97
Norway 1980 (4)
1041 443 65·6–101 83·9 57 22·2 29·9 54·4 41 51·2 11·7
190 38 67– — 80 25·7 — — — — 12
resident was referred for further examination. The questionnaire showed that 250 of the residents had difficulty eating, 206 had problems with taste, and 261 found it hard to care for their mouth. Although 343 residents preferred assistance in cleaning their teeth and dentures, only 94 reported that the staff had helped them. 927 residents received medications known to produce xerostomia, 396 were given syrups containing sugar and 385 residents reported suffering with dry mouth. The managers and deputy managers indicated that there was no systematic approach to arranging dental care. Dental care was sought only when residents or their relatives complained of acute dental problems such as pain or a broken denture. Dental assessments were not carried out when residents were admitted, neither was a care plan developed that included intraoral care. Only 4% of the edentate and 20% of the dentate residents had seen a dentist in the past 2 years. The poor oral status of the institutionalised elderly, found in this and previous studies, may contribute to the eating problems and low nutrient and vitamin C levels found in this group. These results, combined with the reduced ability of elderly people to communicate, may cause weight loss, dehydration, and debility. It is surely a disgrace that the mouth, one of the most personal and intimate areas of the body, should be neglected in such a manner. 1
2
3
4
5
Steele JG, Sheiham A, Marcenes W, Walls AWG. National diet and nutrition survey: people aged 65 years and over. Vol 2: Report of the oral health survey. London: Stationery Office, 1998. Kiyak HA, Grayston MN, Crinean CL. Oral health problems and needs of nursing home residents. Community Dent Oral Epidemiol 1993; 21: 49–52. Budtz-Jorgensen E, Mojon P, Rentsch A, Roehrich N, von der Muehll D, Baehni P. Caries prevalence and associated predisposing conditions in recently hospitalised elderly persons. Acta Odont Scand 1996; 54: 251–56. Jokstrad A, Ambjornsen E, Eide KE. Oral health in institutionalised elderly people in 1993 compared with 1980. Acta Odont Scand 1996; 54: 303–08. Merelie DL, Heyman B. Dental needs of the elderly in residential care in Newcastle-upon-Tyne and the role of formal carers. Community Dent Oral Epidemiol 1992; 20: 106–11.
West Herts Community Dental Services, Dental Department, Principal Health Centre, St Albans, Herts AL1 3LA, UK (D Simons); and Departments of Conservative Dentistry and Oral Microbiology, Dental Institute, Guy’s, King’s and St Thomas’ Schools of Medicine and Dentistry and Biomedical Sciences, London Norway 1993 (4) 243 112 67–102 83·2 54 22·9 30 — 60 — 15·7
Washington, USA 1991 (2) 1063 450 72–98 — 52·7 — 23·6 — 26·3 36 —
UK 1994/95 (1) 274 57 65– — 79 — — 46 31 39 10·7
Geneva, Switzerland 1995 (3) 216 120 69–97 83 55 — 23 — 33 54 11·1
References in brackets.
Oral surveys of institutionalised elderly
THE LANCET • Vol 353 • May 22, 1999
1761