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Oral health status and treatment requirements of different residential homes in Istanbul: A comparative study
Archives of Gerontology and Geriatrics 53 (2011) e67–e74
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Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Oral health status and treatment requirements of different residential homes in Istanbul: A comparative study ¨ zkan b,* Altay Uludamar a, Buket Akalın Evren b, Ufuk Is¸eri c, Yasemin Kulak O a
Bu¨klu¨m Sok. No. 53 Kat. 4, 06660 Kavaklidere-Ankara, Turkey Marmara University, Faculty of Dentistry, Department of Prosthodontics, Bu¨yu¨kc¸iftlik Sok. No. 6, 34350 Nis¸antas¸ı-Istanbul, Turkey c Yeditepe University, Faculty of Dentistry, Department of Prosthodontics, Bag˘dat Cad. No. 238, 81006 Go¨ztepe-Istanbul, Turkey b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 July 2010 Received in revised form 27 October 2010 Accepted 28 October 2010 Available online 18 December 2010
The purpose of this study was to investigate dental/denture status of the elderly people living in different residential homes. In 346 elderly people from different residential homes two belonging to the state (Group 1 and Group 2) and one supported by private foundations (Group 3) were examined. Sixty percent of participants were edentulous and 22.8% of participants had no complete dentures which 9 (7.4%) of them were in Groups 1 and 2. Over 50% of the participants had no or low income and 45% of participants were illiterate. All of the participants who were illiterate and had low income were in Group 1 and Group 2. Oral hygiene was good for 15.4% and only 19.4% of participants removed their dentures overnight. Denture stomatitis was observed in 61.7% of subjects. Significant correlation was found between denture hygiene and age of participant, general health status, denture stomatitis, and overnight denture wear (p = 0.001). The decayed, missing and filled teeth (DMFT) scores were 25.52 3.37. There was statistically significant differences between groups for DMFT scores (p = 0.016). Dental health education is also needed focusing on the special needs of this neglected and socioeconomically deprived population to improve their quality of life. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Oral and dental health Edentulism Edentulousness Institutionalized elderly
1. Introduction At the global level, prevalence rates and patterns of oral diseases changed considerably over the past two decades (Wang et al., 2002). The general trend is for a reduction in edentulism and an increase in the retention of natural teeth until later life (Fiske et al., 2000). This statement is based on epidemiologic studies of stratified samples of the general population and of geographically localized populations (Jorkstad et al., 1996). The dental disease pattern and oral health status are changing in Turkey as well as in the world. The elderly population in Turkey has increased 33% since 1990 reaching 3,858,949 in the year 2000, which is approximately 5.7% of the entire population (SIS, 2003). Expected number of people who are 65 year-old and over is 7.5 million and this represents 12.5% of the whole population in Turkey by the year 2010 (SIS, 2003). Although the majority of elderly live independently in the Turkish society, a growing number of older people reside in different kinds of institutions. While a total of 11,885 elderly live in 94 public retirement homes, 5457 elderly are residing in 105 private nursing or retirement homes (TC Basbakanlık, 2005). It is uncertain however, if there has been a
* Corresponding author. Tel.: +90 212 231 9120; fax: +90 212 246 5247. ¨ zkan). E-mail address: [email protected] (Y.K. O 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.10.029
general improvement in dental health status among elderly people living in residential homes due to lack of follow-up studies amongst them (Jorkstad et al., 1996). Most surveys indicate that the elderly who live in residential care have the worst oral health condition. There are claims that elderly people living in residential and nursing homes have poorer dental health than those residing at home and experience high levels of clinically measured oral disease (Frenkel et al., 2000; Saub and Evans, 2001; Chalmers et al., 2002). Although interest in geriatric dentistry has increased in the dental profession worldwide (Hunt et al., 1985; Weintraub, 1985; Ainamo and Osterberg, 1992; Ettinger, 1992; Gift et al., 1997; Marchini et al., 2004; Petersen and Yamamoto, 2005), comprehensive data on the oral health status and dental treatment needs of elderly living in different residential homes in Turkey is deficient (Saydam et al., 1990; Nalc¸aci et al., 2007; Unlu¨er et al., 2007; Akar and Ergu¨l, 2008). As a result, there is a need for epidemiological studies evaluating the oral health status of elderly and compare it with other cross-cultural studies. In contrast, many developing countries are now facing the problems of poor oral health and this seems particularly to be the case for those countries where community-based oral health care systems have not been established. Residential homes in Turkey have been structured and run in a different manner compared to many other countries. These residential homes can be diversified in four different categories:
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(1) residential homes fully financed by the state and provides service to old age pensioners with no income, (2) residential homes supported by the state and provides service to old age pensioners with limited income, (3) residential homes subsidized by the state and provides service to old age pensioners with good income, and (4) private residential homes. Recently there is an increase in these types of private residential homes but studies carried out in such places do not always exhibit the reality amongst the population that struggle for financing their basic needs. Applying the results of studies conducted in certain category of residential homes where the economical, social and cultural levels are similar, it may be misleading in representing the oral hygiene habits of entire old age pensioners in one country. Studies taking into account this diversity amongst the subjects are rare. Therefore, there is a need for evaluating the subjects in their own category. Effectiveness and deficiencies of the state policies concerning oral health of old age pensioners and defining effective oral health programs can only be determined in the light of such studies. Detriments of economical, social and physical capacity result in unfavorable oral hygiene leading to dental decay, periodontal problems and eventually losses in dentition. Dental caries is the major oral health problem for the populations. Some studies have shown that Turkish children, adolescent and adults have a high caries rate but there are few studies about elderly people. According to the only nationwide study which was carried out by Saydam et al. (1990), the prevalence of edentulousness was 75% and decayed, missing and filled teeth (DMFT) score was 28.76 among Turkish people aged 65 and over. Moreover, Unlu¨er et al. (2007) stated that the mean DMFT was 29.3 5.8 for elderly people living in residential homes. The more elderly people retain their natural teeth, the more teeth are at risk of dental disease and therefore the demand for dental service will increase (Saub and Evans, 2001; Unlu¨er et al., 2007). As a result, there is need for epidemiological studies evaluating the oral health status of older adults and compare it with other cross-cultural studies. In contrast, many developing countries are now facing the problems of poor oral health and this seems particularly to be the case for those countries where communitybased oral health care systems have not been established. The purpose of this study is to describe the oral and dental status, the occurrence of dental caries and the periodontal health conditions of elderly people living in different residential homes. To date, only a few studies have been conducted to determine the oral health status of different residential homes which have different socioeconomical status. This study was undertaken with the following aims and objectives: (i) To assess the oral health status and treatment requirements of different residential homes in Istanbul. (ii) To study the relationship between dental caries and variable factors. (iii) To provide guidelines for different residential homes. 2. Subjects and methods 2.1. Study participants This epidemiological study was carried out in three residential homes in Istanbul, Turkey (Group1: residential homes fully financed by the state and provides service to old age pensioners with no income; Group 2: residential homes supported by the state and provides service to old age pensioners with limited income; and Group 3: residential homes subsidized by the state and provides service to old age pensioners with good income two belonging to the state and one supported by private foundations). A total of 346 subjects, 145 male (mean age 75.7 8.9 years) and 201 female (mean age 77.3 9.4 years) were involved in this study. Only subjects of 65 years of age or older and who have communicable condition were included in the study.
2.2. Comprehensive interview Before clinical examinations all subjects were interviewed to define their attitude towards dental health care. The subjects were interviewed using a structured questionnaire and were clinically examined according to World Health Organization (WHO, 1997) criteria. Questions are comprised of oral hygiene methods, oral habits and the history of dental visits. In addition, demographic data including age, sex, general health status, level of education and income were recorded. 2.3. Clinical examinations After the interviews, clinical examinations were conducted in the wards. Each patient was made to sit on a chair and examined under the natural light with the help of mouth mirror, explorer and WHO periodontal probe. Disposable instruments and WHO basic oral health survey assessment form was used (WHO, 1997). DMFT, visible plaque, calculus and gingivitis were recorded for each tooth, as suggested by WHO. The third molar was not included in the examination. The CPI probe (Martin, Solingen, WHO 973&80, Germany) was employed for caries diagnosis without radiographs. Decay was defined as a cavity with softened and rough colored floor or walls on probing (Jorkstad et al., 1996). The periodontal condition was assessed by recording periodontal pockets exceeding 4 mm as described by Jorkstad et al. (1996). Visible plaque was scored in accordance with Silness and Loe index (Silness and Loe, 1964). Patients with plaque on less than one-third of the teeth were categorized as patients with good oral hygiene. Plaque on more than two-thirds of the remaining teeth resulted in poor oral hygiene score (Jorkstad et al., 1996). Edentulous patients’ denture cleanliness, denture stomatitis, denture status and related treatment needs were assessed. Denture cleanliness was examined using a plaque disclosing medium (proflavine monosulphate in 0.3% aqueous solution) to detect the plaque on the fitting surfaces of the maxillary dentures ¨ zkan et al., 2002). Based on the quantity of plaque on the (Kulak-O denture base, a previously described index was used for classification of denture cleanliness (Budtz-Jorgensen and Bertram, 1970). Excellent: None or only few spots of plaque, Fair: More extended plaque, less than half of the denture base covered by plaque, Poor: More than half of denture base covered by plaque. Denture stomatitis was identified as previously described (BudtzJorgensen and Bertram, 1970; Budtz-Jorgensen et al., 1975). 2.4. Statistical analysis Data in the text and tables are expressed as means S.D. Statistical evaluation was performed by means of the chi-squared test for differences of frequencies, and the independent sample t-tests and ANOVA for comparisons of means in various subgroups. The level of statistical significance was chosen as p < 0.05. All data were statistically analyzed by SPSS (11.0 for Windows, IL, USA). 3. Results 3.1. Demographic data and results of comprehensive interview Three hundred and forty-six individuals were included in the study. The age of participants was varied from 65 to 90 years. Some socio-demographic and personal characteristics of the interviewed elderly people are shown in Table 1. Of the participants, 57.8% were male and 42.1% were female and 72.8% were less than 85 years of age. The mean ages of subjects were 75.2 8.3 years in males and 79.1 7.9 years in females. Over 50% of the participants had no or low income; only 5.1% of the subjects had high income and 45% of
A. Uludamar et al. / Archives of Gerontology and Geriatrics 53 (2011) e67–e74 Table 1 Demographic data in 346 elderly subjects, n (%).
3.2. Results of clinical examinations
Group 1
Group 2
Group 3
Total
135a
117a
94a
346a
p<
Sex Female Male
71 (52.6) 64 (47.4)
74 (63.2) 43 (36.8)
55 (58.5) 39 (41.5)
200 (57.8) 146 (42.2)
Age 60–70 70–80 80 over
27 (20) 56 (41.5) 52 (38.5)
54 (46.2) 37 (31.6) 26 (22.2)
44 (46.8) 34 (36.2) 16 (17)
125 (36.1) 127 (36.7) 94 (27.1)
Education Non-educated Primary school High school University
90 (66.7) 41 (30.3) 4 (3) –
66 33 7 11
(56.4) (28.2) (6) (9.4)
– 5 (5.3) 67 (71.2) 22 (23.4)
156 79 78 33
107 (91.5) 10 (8.5) –
– 42 (44.6) 53 (56.4)
241 (69.6) 52 (15) 53 (15.3)
0.01
89 (76.0) 20 (17) 17 (14.5)
70 (74.3) 17 (18) 7 (7.4)
231 (66.8) 71 (20.1) 44 (12.7)
0.001
Income ($) 1000 1000–5000 5000–10,000
134 (100) 0 0
Self-reported general health Good 72 (53.3) Moderate 34 (25.1) 29 (21.4) Bad a
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(45) (22.8) (22.5) (9.5)
0.22
0.01
0.01
Number.
participants were illiterate, 22.8% of participants had received primary school education. Of the total, 66.8% reported that they had good general health. When comparing dentate versus edentulousness, there was statistically significant differences between sex, income, education and general health (p = 0.001, p = 0.001, p = 0.001 and p = 0.001, respectively) (Table 1). Comparing the socio-economic and some personnel status of participants among groups, 80 years of age and over participants were in Group 1. All of the illiterate participants were in Group 1 and Group 2 and all of the participants who had no or low income were in Group 1 and Group 2. Most of the subjects (65.9%) who stated that they had poor general health were in Group 1. There was statistically significant differences between groups, age, education, income and self reported general health (p = 0.001, p = 0.001, p = 0.001 and p = 0.001, respectively) (Table 1). Sixty percent of participants were edentulous and 38.7% were partially dentate; 25.4% had complete denture which 56.8% of them were in Group 1 and 22.8% of participants had no complete dentures which 97.4% of them were in Groups 1 and 2. 11.6% had no lower denture that nearly of all them were in Groups 1 and 2 and 12% of participants had been wearing only upper dentures. Of the 134 partially dentate subjects, 61 participants had no dentures, 51 of them being in Groups 1 and 2. Only 1.4% of participants were dentate. All of the subjects stated that they only visited the dentist when they had a complaint. Only 34.3% of participants stated that they visited a dentist once in a year. Among these participants, 52.5% were in Group 3. There was statistically significant differences between groups for visiting a dentist (p = 0.001). Forty three percent of the participants stated that they are using toothbrush for cleaning dentures/teeth while 35.9% of participants stated that they use nothing to clean dentures/teeth; those of 78% were in Groups 1 and 2. Thirty-six of participants stated that they never brushed their denture/teeth. Only 5% of the participants stated that they brushed their denture/teeth twice a day. There was statistically significant differences between groups for denture status, brushing habits and brushing frequency (p = 0.001). Only 19.4% of participants removed their dentures overnight.
Denture/dental hygiene were recorded among 267 participants (79 edentulous patients had no dentures). Denture/dental hygiene was rated as ‘‘good’’ for 41 subjects (15.4%), ‘‘fair’’ for 77 (28.8%) and ‘‘poor’’ for 149 (55.8%). There was no statistical significant difference between groups about dental hygiene and overnight denture wearing (p = 0.385 and p = 0.34, respectively). Among 128 participants wearing complete dentures, denture stomatitis was observed in 61.7% of subjects. Localized denture stomatitis was seen in 23 subjects (18 subjects were in Groups 1 and 2) while generalized denture stomatitis was seen in 56 subjects (46 subjects were in Groups 1 and 2). There were statistically significant differences between groups for denture stomatitis (p = 0.001) (Table 2). Significant correlation was found between denture hygiene and age of participant, general health status, denture stomatitis and overnight denture wear (p = 0.001). Table 3 shows distribution of denture stomatitis by age, income, general health status, denture hygiene and overnight denture wearing. When subjects with denture stomatitis were compared with those without stomatitis, significant differences were found in the following variables: (1) Age: denture stomatitis was more prevalent in elderly subjects (p = 0.003). (2) Income: the prevalence of denture stomatitis increased significantly in line with a decrease in income (p = 0.001). (3) General health: the prevalence of denture stomatitis increased significantly in line with a worsening in self-reported health status (p = 0.004). (4) Denture hygiene: the prevalence of denture stomatitis increased significantly in line with a decrease in denture hygiene (p = 0.001). (5) Overnight denture wearing: denture stomatitis was more prevalent in subjects using denture overnight (p = 0.001). There was no statistically significant correlation between denture stomatitis, brushing methods and frequency; however, there was a statistically significant correlation between denture stomatitis and denture hygiene (p = 0.001). Among 139 dentate subjects, 4 subjects could not be examined because of their aggressive behavior and definite refusal to open their mouth, leaving 135 subjects’ dental status was recorded (Table 4). The mean number of missing teeth (MT) in dentate subjects was 20.77 4.45 teeth, varying with groups. The dentate participants usually had 15 to 20 MT (42.2%), whereas 30.4% had 21 to 25 MT, and 21.5% had more than 26 MT (Table 5). The MT scores were slightly lower in Group 3 whereas similar for Groups 1 and 2. There were statistically significant differences between groups for MT scores (p = 0.047) (Table 4). There was no statistically significant difference for MT scores between sex and age (p = 0.07 and p = 0.35, respectively) (Table 5). The mean number of decayed teeth (DT) was 3.44 2.31 teeth, varying with groups (Table 4). Forty six percent of participants had 1 to 3 caries, 28% had 4 to 6 caries. The DT scores were higher in Group 3 (Table 5). There was statistically significant difference between groups for DT scores (p = 0.001) (Table 4). There was no statistically significant difference for DT scores between sex and age (p = 0.91 and p = 0.77, respectively) (Table 5). The mean number of filled teeth (FT) per person was 1.24 1.67 (Table 4). Forty two percent of the participants had 1 to 3 FT and 9.6% of the participants had more than 4 FT (Table 5). The FT scores were higher in Group 3 whereas similar for Groups 1 and 2. There was a statistically significant difference between groups for FT scores (p = 0.001) (Table 4). There was no statistically significant difference for FT scores between sex and age (p = 0.83 and p = 0.38, respectively) (Table 5). The DMFT scores were 25.52 3.37 per teeth and 94.8% of the participants had 20 to 29 DMFT scores. The DMFT scores were higher in Group 3. There was a statistically significant difference between groups for DMFT scores (p = 0.016). There was no
A. Uludamar et al. / Archives of Gerontology and Geriatrics 53 (2011) e67–e74
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Table 2 Distributions of clinical evaluations of subjects among groups, number, n (%). Group 1
Group 2
Group 3
Total
135a
117a
94a
346a
Denture/dental status Complete denture Edentulous (no denture at all) Edentulous (only upper dentures) Partial dentures Partial edentulous (no dentures) Partial denture (only upper or lower denture) Dentate
16 37 27 12 32 10 1
23 40 12 17 19 3 3
49 2 1 23 10 8 1
88 79 40 52 61 21 5
Visiting dentist 1 year 1–5 years 5–10 years
36 (26.7) 57 (42.2) 42 (31.1)
(11.8) (27.4) (20.0) (8.9) (23.7) (7.4) (0.7)
(19.6) (34.1) (1.2) (14.5) (16.2) (2.5) (2.5)
21 (17.9) 16 (13.6) 80 (68.2)
(52.1) (2.5) (1.1) (24.5) (10.6) (8.5) (1)
62 (65.9) 23 (24.4) 9 (9.5)
(25.4) (22.8) (11.6) (15.0) (17.6) (6.1) (1.4)
119 (34.3) 96 (27.7) 131 (37.8)
p<
0.001
0.001
Group 1
Group 2
Group 3
Total
98a
77a
92a
267a
Brushing habits Toothbrush Solution Toothbrush and paste Nothing
53 (54.1) 0 4 (4.8) 41 (41.83)
28 (36.4) 8 (10.4) 0 41 (53.2)
34 20 16 22
(36.9) (21.8) (17.4) (23.9).
115 28 20 104
(43.1) (10.4) (7.5) (38.9)
0.001
Brushing frequency Seldom Once a day Twice a day Never
58 (59.2) 15 (15.3) – 25 (25.5)
18 (23.4) 14 (18.2) 0 45 (58.4)
26 25 14 27
(28.2) (27.1) (15.2) (29.3)
102 54 14 97
(38.2) (20.2) (5.2) (36.3)
0.001
Denture/dental hygiene Good Fair Poor
16 (16.3) 34 (35.0) 48 (49.0)
13 (16.9) 20 (25.9) 44 (57.1)
12 (13) 23 (25.0) 57 (62.0)
41 (15.4) 77 (28.8) 149 (55.8)
0.385
Group 1
Group 2
Group 3
Total
65a
55a
81a
201a
Overnight denture wearing No 12 (18.5) Yes 53 (81.5)
10 (18.2) 45 (81.8)
17 (20.9) 64 (79.1)
39 (19.4) 162 (80.6)
Denture stomatitis LDS GDS NS a
Group 1
Group 2
Group 3
Total
43a
35a
50a
128a
12 (27.9) 23 (53.5) 8 (18.6)
6 (17.1) 23 (65.7) 6 (17.1)
5 (10.0) 10 (20.0) 35 (70.0)
23 (18.0) 56 (43.8) 49 (38.2)
p<
p<
0.34
p<
0.001
Number.
statistically significant difference for DMFT scores between sex and age (p = 0.46 and p = 0.30, respectively) (Tables 4 and 5). Bleeding on probing was recorded on approximately one-third of all teeth examined (n = 736). The number of teeth with bleeding per person varied from 1 to 18 teeth, with a mean of 3.4 4.9. Teeth with gingival pockets exceeding 4 mm was recorded in 8% of all examined teeth (n = 736). The number of teeth with gingival pockets deeper than 4 mm per person varied from 0 to 15 teeth, with a mean of 1.2 0.7 teeth. The number of teeth bleeding on probing and with gingival pockets exceeding 4 mm was similar for the groups. 4. Discussion No comprehensive data were available for denture status, oral hygiene and dental caries prevalence in different residential home retirements in Turkey. Despite the limitation of the survey sample, this study demonstrates that screening is effective in identifying the dental needs and oral health status of elderly. In fact, large nationwide surveys can give the most reliable picture of oral health and oral self-care in a country. The number and percentage of elderly population is rapidly increasing in many developed and developing countries, and this
rapid increase results in potential serious health problems. With the increased life expectancy, the demand for dental services for the elderly has also increased. Unfortunately, the use of dental services by elderly people is much less in Turkey, than in the industrialized countries (Mumcu et al., 2004). Generally, the percentage of the edentulous rate in older populations has often been used as an indicator of dental status (Marcus et al., 1996). In a previous survey performed almost two decades ago, 80% of Turkish population above 65 years of age was found to be edentulous (Saydam et al., 1990). Unlu¨er et al. (2007) found that among elderly people living in residential homes, the proportion of edentulousness was 67.4% whereas Akar and Ergu¨l (2008) reported that 86.6% of people were edentulous. In this study, it was found that the proportion of edentulousness was 58.2%. Our study confirms the study of Unlu¨er et al. (2007). Gift et al. (1997) stated that, almost half of the 8056 residents of the nursing home (47%) were totally edentulous. A study conducted in a residential home in Athens reported that the percentage of edentulousness was similar (64.4%) (Karkazis and Kossini, 1993). Among institutionalized elderly people in Italy, edentulousness was 59.8% (Angelillo et al., 1990), and 66% in South Australian nursing home residents (Chalmers et al., 2002). Our results confirm
A. Uludamar et al. / Archives of Gerontology and Geriatrics 53 (2011) e67–e74 Table 3 Distribution of denture stomatitis related age, income, general health status, denture hygiene and overnight denture wearing, n (%). LSD
GSD
Total
23a
56a
79a
Age 60–70 years 70–80 years >80 years
4 (17.4) 11 (47.8) 8 (34.8)
10 (17.9) 28 (50.0) 18 (32.1)
14 (17.7) 39 (49.4) 26 (32.9)
Income ($) 1000 5000 5000–10,000
3 (13) 14 (60.9) 6 (26.1)
6 (10.7) 37 (66.1) 13 (23.2)
9 (11.4) 51 (64.6) 19 (24.1)
General health Good Moderate Bad
4 (17.4) 6 (26.1) 13 (56.5)
5 (9.0) 11 (19.6) 40 (71.4)
9 (11.4) 17 (21.5) 53 (67.1)
0.004
Denture hygiene Good Moderate Bad
2 (8.7) 4 (17.4) 17 (73.9)
3 (5.4) 11 (19.6) 42 (75)
5 (6.3) 15 (19) 59 (74.7)
0.001
Overnight denture wearing No 15 (65.2) 8 (34.8) Yes
44 (78.6) 12 (21.4)
59 (74.7) 20 (25.3)
0.001
a
Table 5 Distribution of the results by gender and age, n (%).
0.001
p<
Gender
p<
0.003
e71
Females
Males
Total
72a
63a
135a
Number of missing teeth 10 7 (9.7) 15–20 23 (31.9) 21–25 25 (34.7) 26+ 17 (23.6)
1 34 16 12
(1.6) (54) (25.4) (19)
8 57 41 29
(5.9) (42.2) (30.4) (21.5)
0.07
Number of decayed teeth 0 10 (13.9) 1–3 34 (47.2) 4–6 18 (25.0) 7–9 10 (13.9)
8 28 20 7
(12.7) (44.4) (31.7) (11.1)
18 62 38 17
(13.3) (45.9) (28.1) (12.6)
0.91
Number of filled teeth 0 34 (47.2) 1–3 31 (43.1) 4–6 6 (8.3) 6–9 1 (1.4)
32 25 5 1
(50.8) (39.7) (7.9) (1.6)
66 56 11 2
(48.9) (41.5) (8.1) (1.5)
0.83
Total number of DMFT <19 3 (4.1) 20–29 67 (93.1) 30+ 2 (2.8)
1 (1.6) 61 (96.8) 1 (1.6)
4 (3) 128 (94.8) 3 (2.2)
0.46
Age (years)
Number.
the results of these studies. Although it cannot be generalized, there seems to be a clear trend for less edentate subjects with the increasing age in this population. This may reflect general improvements of dental care delivery services in Turkey over the last decade. Although not performed in residential homes but at university settings (or from national surveys), similar trends were observed in this population. In this study it was found that among edentulous patients 38% of them had no dentures (these subjects belong to Groups 1 and 2). Private health insurance does not cover the cost of dental treatment in Turkey. Thus, dental insurance is only given to the employees, workers, or retired people by the government. In the three residential homes in our study, people were of various sociocultural and economic levels, and only 45% had social insurance. Only subjects living in Group 3 residential homes have social security and this group is different from other two groups when income, education and denture status is considered. The median income of the Turkish population is approximately $6.000 according to the latest report by UNICEF. In regard to the income of the residents surveyed, it can be stated that Group 1 and Group 2 fell under the average income level and in regard to the education of the residents surveyed, majority of Groups 1 and 2 were noneducated. In this study, a statistically significant increase in the number of dentures among the socially insured subjects was observed and there were statistically significant differences between education, income and edentulousness. Contrarily, Akar and Ergu¨l (2008) stated that no significant relationship was observed between the level of education and the use of dentures. The survey showed statistically significant differences in the edentulousness rates between males and females. This finding is different from the findings of Marcus et al. (1996) stating that
p<
65–74
75–84
85+
Total
58a
46a
31a
135a
Number of missing teeth 0 1 (1.7) 6 (13) 15–20 32 (55.2) 14 (30.4) 21–25 15 (25.9) 15 (32.6) 26+ 10 (10.7) 11 (23.9)
1 11 11 8
(3.2) (35.4) (35.4) (25.9)
8 57 41 29
(5.9) (42.2) (30.4) (21.5)
0.35
Number of decayed teeth 0 10 (17.2) 1–3 22 (37.9) 4–6 20 (34.5) 7–9 6 (10.3)
4 24 10 8
(8.7) (52.2) (21.7) (17.4)
4 16 8 3
(12.9) (51.6) (25.8) (9.7)
18 62 38 17
(13.3) (45.9) (28.1) (12.6)
0.77
Number of filled teeth 0 25 (43.1) 1–3 26 (44.8) 4–6 7 (12.1) 6–9 0
26 (56.5) 18 (39.1) 2 (4.3) 0
15 12 2 2
(48.4) (38.7) (6.5) (6.5)
66 56 11 2
(48.9) (41.5) (8.1) (1.5)
0.38
Total number of DMFT <19 1 (1.7) 20–29 57 (98.3) 30+ –
3 (6.5) 43 (93.5) –
28 (90.3) 3 (9.7)
4 (3) 128 (94.8) 3 (2.2)
0.30
a
n.
edentulousness rates did not show significant difference between genders. These findings however are similar to the findings of earlier surveys where higher prevalence of edentulism among women in all age groups were reported (Hunt et al., 1985; Weintraub, 1985; Nalc¸aci et al., 2007). Dental visits found were not very common. Sixty four percent of the surveyed subjects had visited a dentist within the last 5 years and 36.1% of the subjects had not seen a dentist during the previous 5 or more years. Frenkel et al. (2000) stated that more than 70% of the 412 residents included in their study had not seen a dentist for
Table 4 DMFT index of groups, mean S.D.
DMFT Missing teeth (MT) Decayed teeth (DT) Filled teeth (FT)
Group 1
Group 2
Group 3
Total
p<
25.78 3.32 21.54 4.68 3.60 2.01 0.73 1.10
23.98 4.52 21.02 4.10 2.29 2.28 0.67 0.84
26.44 7.40 19.57 4.36 4.38 2.26 2.46 2.20
25.52 3.37 20.77 4.45 3.44 2.31 1.24 1.67
0.016 0.047 0.001 0.001
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more than 5 years. C´atovic et al. (2003) reported that only 19.8% of the 175 subjects had seen a dentist within the past 5 years, and 39% had not seen a dentist in at least 10 years. Interestingly, more than half of the studied subjects in our population did not have the need or urge to visit a dentist although their dental conditions were not ideal. Costs and dental fear played major roles in neglecting the visits to the dentist. Reasons why dental care is not sought more frequently are generally complex and involve many factors. Among these include: differences between perceived and real need, lack of mobility and accessibility to care, fear of dentistry and high cost (Ettinger, 1992; Pietrokovski et al., 1995; Samaranayake et al., 1995). Usually the education and socio-economic level of the subjects are related to the status of oral health. Through education, financial stability, and the availability of dental insurance, individuals may become more increasingly concerned with their oral health (Suominen-Taipale et al., 1999) Those who have attained higher levels of education are more likely to have greater financial opportunity to place a higher priority on dental health. Individuals with greater financial resources usually have better access to dental care. It should also be noted that in the Turkish society, residential houses are usually solutions for subjects who have no relatives and also who cannot afford living alone. This reflects the fact that studies and conclusions derived from the residential houses, by design, is only valid for people living in such conditions. General statements therefore cannot be made for the whole elderly population. It can also be attributed to the lack of compulsory visits to the dentist in Turkey, since it was noted that more than one-third of the subjects have not visited a dentist within the last 5–10 years. The negative impact of poor denture hygiene among older adults is an important public health issue (Petersen and Yamamoto, 2005). Characteristic of elderly institutionalized people is very poor oral hygiene. The data collected in this study showed poor oral health conditions among the groups. Oral selfcare of the elderly group was excessively poor with a high percentage not having a toothbrush (43%) and most of these subjects were in Group 1 and Group 2. Brushing either with or without toothpaste was the most frequent method used to clean ¨ zkan et al. dentures. This finding was similar to that of Kulak-O (2002), Marchini et al. (2004), Dikbas et al. (2006) and Nalc¸aci et al. (2007) whereas Hoad-Reddick et al. (1990) found that a combination method was most often used. Only 8.9% of subjects were using chemical agents and majority of these subjects were in Group 1. Sixty four percent of subjects reported that they cleaned their denture never or very seldom. Majority of these subjects (72.7%) were in Group 1 and Group 2. Wirz and Tschappat (1989) found that, of the 100 nursing home residents, only 38% brushed their teeth three times daily. According to the results of Zhu et al. (2005), 23% of the 65–74 year olds brushed their teeth at least twice a day. In the present study only 5.3% of subjects brushed teeth/dentures twice a day and these subjects were in Group 3. These findings are lower than the findings of studies above. Denture hygiene was found poor in 55.8% of the participants. These results are similar to the results of Hoad-Reddick et al. ¨ zkan et al. (2002), (1990), Jagger and Harrison (1995), Kulak-O Peltola et al. (2004) and Unlu¨er et al. (2007). Also, during examination of dentate patients’ remaining teeth it was seen that there was a heavy plaque accumulation and bleeding on probing. There was a distinct discrepancy between the information provided by the subjects and denture/oral hygiene level detected by the professionals. It was clearly evident that hygiene practices were not performed adequately. This discrepancy could be also attributed to the large variety of oral hygiene habits and attitudes due to physical capability, manual dexterity, motivation, awareness, and educational background of the residents, together with the medical and dental supervision and care available (Ainamo
and Osterberg, 1992). The use of dental services by elderly people is much less in Turkey than in industrialized countries and residents in these institutions tended to have very poor socioeconomic conditions, and the findings of the present study indicate that dental health care for the poorest and oldest in society needs more attention. In previous studies, rates of denture stomatitis have been reported to range from 11 to 67% (Budtz-Jorgensen and Bertram, ¨ zkan 1970; Budtz-Jorgensen et al., 1975; Shou et al., 1987; Kulak-O et al., 2002) and the prevalence of denture stomatitis has been strongly correlated with denture hygiene and/or the amount of denture plaque (Budtz-Jorgensen et al., 1975; Shou et al., 1987; ¨ zkan et al., 2002). In this study, the rate of denture Kulak-O stomatitis was found to be 60% in compliance with other studies. It was interesting that our study results showed that there was no difference between males’ and females’ incidence of denture stomatitis. This finding was in line with a previous report (Vigild, 1993), while others (Budtz-Jorgensen and Bertram, 1970; BudtzJorgensen et al., 1975; Nevalainen et al., 1997) have reported higher rates of denture stomatitis among females than males. The variation in sex-based differences reported may be due to differences in the overall health status of study subjects. In this study it was found that there was a statistically significant difference between groups and denture stomatitis prevalence. Since it was found that denture stomatitis was more prevalent in elderly subjects, the prevalence of denture stomatitis increased significantly in line with a decrease in income and the prevalence of denture stomatitis increased significantly in line with a worsening in self-reported health status. This could be explained by differences between groups. Vigild (1993) reported that risk factors for denture stomatitis include overnight denture wear. Our study also found a significant relationship between continuous wearing of dentures and denture stomatitis. Other studies have shown denture stomatitis to be associated with a lack of preventive hygiene programs (Budtz-Jorgensen et al., 2000), poor denture ¨ zkan et al., 2002; Marchini et al., 2004) hygiene habits (Kulak-O and failure to remove dentures overnight (Fenlon et al., 1998). Our study confirm the study above. The mean number of caries experiences expressed as the DMFT was found to be 25.5 of which the missing component was 20.1. Unlu¨er et al. reported that DMFT was 29.3 for elderly people living in residential homes. Gaiao et al. (2009) reported that in northeast Brazil, the DMFT in institutionalized people was 29.7. Our results are lower than the results of these studies whereas one study stated that, among institutionalized adults aged 65 years and older, the mean DMFT was 25 for Spanish people (Spanish Geriatric Oral Health Research Group, 2001). Saub and Evans (2001) and Stubbs and Riordan (2002) reported that in Australia this score was around 24.9 and 24.7, respectively. Our scores are similar to these scores but higher than the reported scores for institutionalized elderly in China (DMFT (1/4) = 12.4) and India (DMFT (1/4) = 13.5) (Thomas et al., 1994; Wang et al., 2002). The DMFT varies considerably not only between different socioeconomic groups, but also between different countries and cultures, and it is consistently higher in institutionalized people than among community-dwelling populations. In this study and in the other studies, it has been shown that the number of decayed (coronal and root) and filled teeth is decreasing with age because of the decreasing number of remaining teeth in elderly adults (Mack et al., 2004; Peltola et al., 2004; Unlu¨er et al., 2007). It has been predicted that as older adults retain their teeth longer, more teeth will be at risk of coronal and root caries (Reinhardt and Douglass, 1989). This study showed that there was no statistically significant difference between age groups and sex for DMFT, which is different from other studies which reported that the number of decayed and
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filled teeth is decreasing with age because of the decreasing number of remaining teeth in elderly adults (Mack et al., 2004; Peltola et al., 2004; Unlu¨er et al., 2007). The data suggested that all the older people are indeed a caries-susceptible group. Treatment of dental caries is not only expensive but has simply been inaccessible to the majority of the elderly population in Turkey. Of clinical importance is the finding that although there was no gender difference in dentate status or number of teeth, males consistently had more dental caries. Shallow pockets and bleeding on probing were not comparable because of the lack of number of the sextants with index tooth. Tooth loss was found to be widely prevalent in the study group although no significant differences were found between male and female residents. Functional dentitions, as measured by the retention of at least 20 natural teeth were found to be a rare condition (5.3%) among the residents in this study. In a study carried out by Simons et al. (2001) among people of 80 years and over, a minority of subjects (27%) had a functional dentition of 21 or more teeth. In Germany, 29% of the elderly had 20 or more teeth (Mack et al., 2003). In a 2000 survey of adult Danes aged 65–74 years, 40% had 20 or more teeth (Christensen et al., 2003). Among residents, the treatment needs at all levels (restorative, periodontal and prosthetic) was large especially in Group 1. Dental health service system factors: prices and subsidies of dental services, availability and accessibility and behavior of the dentist were strongly related with the improvement of oral health. Elderly people living in residential and nursing homes often rely on careers for their daily care. Since no assistance was offered from the nursing staff for oral hygiene, the subjects were responsible from the hygiene of their dentures themselves. Authorities and nursing staff showed a lack of understanding of the oral hygiene needs of elderly, especially for the denture wearers’. Staff did not effectively perform oral health care service appropriate to residents’ needs. Regular oral care and recall sessions with periodical demonstrations could be provided for the residents and for the care-taking staff. Simple measures such as improved hygiene protocols with respect to denture care and increased awareness of the staff in the oral problems of the elderly may help to improve quality of dentures in such cohorts. Furthermore, oral health programs should be implemented with emphasis on routine preventative and maintenance in addition to curative care. Additional research is needed to accurately characterize the oral health status and needs of the growing number of homebound and institutionalized older people. Affordable and prevention oriented oral health care should be organized to provide an improved quality for life of the elderly. This must be of relevance to the dental profession because geriatric patients require different approaches to the management of oral disease. 5. Conclusions On the public health level, health education programs focusing on the special needs of these populations are mandatory. An integrated approach is needed, and oral health education should include all stakeholders. Additionally, it is necessary to implement curative and rehabilitation measures in these populations to reduce the need for future dental treatment. This study shows that the dental status of institutionalized older people in the city of Istanbul is very poor. There is a lack of perceived need for dental services and of adequate oral self-care. Dental health education is also needed focusing on the special needs of this neglected and socioeconomically deprived population to improve their quality of life. Conflict of interest statement None.
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Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Oral health status and treatment requirements of different residential homes in Istanbul: A comparative study ¨ zkan b,* Altay Uludamar a, Buket Akalın Evren b, Ufuk Is¸eri c, Yasemin Kulak O a
Bu¨klu¨m Sok. No. 53 Kat. 4, 06660 Kavaklidere-Ankara, Turkey Marmara University, Faculty of Dentistry, Department of Prosthodontics, Bu¨yu¨kc¸iftlik Sok. No. 6, 34350 Nis¸antas¸ı-Istanbul, Turkey c Yeditepe University, Faculty of Dentistry, Department of Prosthodontics, Bag˘dat Cad. No. 238, 81006 Go¨ztepe-Istanbul, Turkey b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 July 2010 Received in revised form 27 October 2010 Accepted 28 October 2010 Available online 18 December 2010
The purpose of this study was to investigate dental/denture status of the elderly people living in different residential homes. In 346 elderly people from different residential homes two belonging to the state (Group 1 and Group 2) and one supported by private foundations (Group 3) were examined. Sixty percent of participants were edentulous and 22.8% of participants had no complete dentures which 9 (7.4%) of them were in Groups 1 and 2. Over 50% of the participants had no or low income and 45% of participants were illiterate. All of the participants who were illiterate and had low income were in Group 1 and Group 2. Oral hygiene was good for 15.4% and only 19.4% of participants removed their dentures overnight. Denture stomatitis was observed in 61.7% of subjects. Significant correlation was found between denture hygiene and age of participant, general health status, denture stomatitis, and overnight denture wear (p = 0.001). The decayed, missing and filled teeth (DMFT) scores were 25.52 3.37. There was statistically significant differences between groups for DMFT scores (p = 0.016). Dental health education is also needed focusing on the special needs of this neglected and socioeconomically deprived population to improve their quality of life. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Oral and dental health Edentulism Edentulousness Institutionalized elderly
1. Introduction At the global level, prevalence rates and patterns of oral diseases changed considerably over the past two decades (Wang et al., 2002). The general trend is for a reduction in edentulism and an increase in the retention of natural teeth until later life (Fiske et al., 2000). This statement is based on epidemiologic studies of stratified samples of the general population and of geographically localized populations (Jorkstad et al., 1996). The dental disease pattern and oral health status are changing in Turkey as well as in the world. The elderly population in Turkey has increased 33% since 1990 reaching 3,858,949 in the year 2000, which is approximately 5.7% of the entire population (SIS, 2003). Expected number of people who are 65 year-old and over is 7.5 million and this represents 12.5% of the whole population in Turkey by the year 2010 (SIS, 2003). Although the majority of elderly live independently in the Turkish society, a growing number of older people reside in different kinds of institutions. While a total of 11,885 elderly live in 94 public retirement homes, 5457 elderly are residing in 105 private nursing or retirement homes (TC Basbakanlık, 2005). It is uncertain however, if there has been a
* Corresponding author. Tel.: +90 212 231 9120; fax: +90 212 246 5247. ¨ zkan). E-mail address: [email protected] (Y.K. O 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.10.029
general improvement in dental health status among elderly people living in residential homes due to lack of follow-up studies amongst them (Jorkstad et al., 1996). Most surveys indicate that the elderly who live in residential care have the worst oral health condition. There are claims that elderly people living in residential and nursing homes have poorer dental health than those residing at home and experience high levels of clinically measured oral disease (Frenkel et al., 2000; Saub and Evans, 2001; Chalmers et al., 2002). Although interest in geriatric dentistry has increased in the dental profession worldwide (Hunt et al., 1985; Weintraub, 1985; Ainamo and Osterberg, 1992; Ettinger, 1992; Gift et al., 1997; Marchini et al., 2004; Petersen and Yamamoto, 2005), comprehensive data on the oral health status and dental treatment needs of elderly living in different residential homes in Turkey is deficient (Saydam et al., 1990; Nalc¸aci et al., 2007; Unlu¨er et al., 2007; Akar and Ergu¨l, 2008). As a result, there is a need for epidemiological studies evaluating the oral health status of elderly and compare it with other cross-cultural studies. In contrast, many developing countries are now facing the problems of poor oral health and this seems particularly to be the case for those countries where community-based oral health care systems have not been established. Residential homes in Turkey have been structured and run in a different manner compared to many other countries. These residential homes can be diversified in four different categories:
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(1) residential homes fully financed by the state and provides service to old age pensioners with no income, (2) residential homes supported by the state and provides service to old age pensioners with limited income, (3) residential homes subsidized by the state and provides service to old age pensioners with good income, and (4) private residential homes. Recently there is an increase in these types of private residential homes but studies carried out in such places do not always exhibit the reality amongst the population that struggle for financing their basic needs. Applying the results of studies conducted in certain category of residential homes where the economical, social and cultural levels are similar, it may be misleading in representing the oral hygiene habits of entire old age pensioners in one country. Studies taking into account this diversity amongst the subjects are rare. Therefore, there is a need for evaluating the subjects in their own category. Effectiveness and deficiencies of the state policies concerning oral health of old age pensioners and defining effective oral health programs can only be determined in the light of such studies. Detriments of economical, social and physical capacity result in unfavorable oral hygiene leading to dental decay, periodontal problems and eventually losses in dentition. Dental caries is the major oral health problem for the populations. Some studies have shown that Turkish children, adolescent and adults have a high caries rate but there are few studies about elderly people. According to the only nationwide study which was carried out by Saydam et al. (1990), the prevalence of edentulousness was 75% and decayed, missing and filled teeth (DMFT) score was 28.76 among Turkish people aged 65 and over. Moreover, Unlu¨er et al. (2007) stated that the mean DMFT was 29.3 5.8 for elderly people living in residential homes. The more elderly people retain their natural teeth, the more teeth are at risk of dental disease and therefore the demand for dental service will increase (Saub and Evans, 2001; Unlu¨er et al., 2007). As a result, there is need for epidemiological studies evaluating the oral health status of older adults and compare it with other cross-cultural studies. In contrast, many developing countries are now facing the problems of poor oral health and this seems particularly to be the case for those countries where communitybased oral health care systems have not been established. The purpose of this study is to describe the oral and dental status, the occurrence of dental caries and the periodontal health conditions of elderly people living in different residential homes. To date, only a few studies have been conducted to determine the oral health status of different residential homes which have different socioeconomical status. This study was undertaken with the following aims and objectives: (i) To assess the oral health status and treatment requirements of different residential homes in Istanbul. (ii) To study the relationship between dental caries and variable factors. (iii) To provide guidelines for different residential homes. 2. Subjects and methods 2.1. Study participants This epidemiological study was carried out in three residential homes in Istanbul, Turkey (Group1: residential homes fully financed by the state and provides service to old age pensioners with no income; Group 2: residential homes supported by the state and provides service to old age pensioners with limited income; and Group 3: residential homes subsidized by the state and provides service to old age pensioners with good income two belonging to the state and one supported by private foundations). A total of 346 subjects, 145 male (mean age 75.7 8.9 years) and 201 female (mean age 77.3 9.4 years) were involved in this study. Only subjects of 65 years of age or older and who have communicable condition were included in the study.
2.2. Comprehensive interview Before clinical examinations all subjects were interviewed to define their attitude towards dental health care. The subjects were interviewed using a structured questionnaire and were clinically examined according to World Health Organization (WHO, 1997) criteria. Questions are comprised of oral hygiene methods, oral habits and the history of dental visits. In addition, demographic data including age, sex, general health status, level of education and income were recorded. 2.3. Clinical examinations After the interviews, clinical examinations were conducted in the wards. Each patient was made to sit on a chair and examined under the natural light with the help of mouth mirror, explorer and WHO periodontal probe. Disposable instruments and WHO basic oral health survey assessment form was used (WHO, 1997). DMFT, visible plaque, calculus and gingivitis were recorded for each tooth, as suggested by WHO. The third molar was not included in the examination. The CPI probe (Martin, Solingen, WHO 973&80, Germany) was employed for caries diagnosis without radiographs. Decay was defined as a cavity with softened and rough colored floor or walls on probing (Jorkstad et al., 1996). The periodontal condition was assessed by recording periodontal pockets exceeding 4 mm as described by Jorkstad et al. (1996). Visible plaque was scored in accordance with Silness and Loe index (Silness and Loe, 1964). Patients with plaque on less than one-third of the teeth were categorized as patients with good oral hygiene. Plaque on more than two-thirds of the remaining teeth resulted in poor oral hygiene score (Jorkstad et al., 1996). Edentulous patients’ denture cleanliness, denture stomatitis, denture status and related treatment needs were assessed. Denture cleanliness was examined using a plaque disclosing medium (proflavine monosulphate in 0.3% aqueous solution) to detect the plaque on the fitting surfaces of the maxillary dentures ¨ zkan et al., 2002). Based on the quantity of plaque on the (Kulak-O denture base, a previously described index was used for classification of denture cleanliness (Budtz-Jorgensen and Bertram, 1970). Excellent: None or only few spots of plaque, Fair: More extended plaque, less than half of the denture base covered by plaque, Poor: More than half of denture base covered by plaque. Denture stomatitis was identified as previously described (BudtzJorgensen and Bertram, 1970; Budtz-Jorgensen et al., 1975). 2.4. Statistical analysis Data in the text and tables are expressed as means S.D. Statistical evaluation was performed by means of the chi-squared test for differences of frequencies, and the independent sample t-tests and ANOVA for comparisons of means in various subgroups. The level of statistical significance was chosen as p < 0.05. All data were statistically analyzed by SPSS (11.0 for Windows, IL, USA). 3. Results 3.1. Demographic data and results of comprehensive interview Three hundred and forty-six individuals were included in the study. The age of participants was varied from 65 to 90 years. Some socio-demographic and personal characteristics of the interviewed elderly people are shown in Table 1. Of the participants, 57.8% were male and 42.1% were female and 72.8% were less than 85 years of age. The mean ages of subjects were 75.2 8.3 years in males and 79.1 7.9 years in females. Over 50% of the participants had no or low income; only 5.1% of the subjects had high income and 45% of
A. Uludamar et al. / Archives of Gerontology and Geriatrics 53 (2011) e67–e74 Table 1 Demographic data in 346 elderly subjects, n (%).
3.2. Results of clinical examinations
Group 1
Group 2
Group 3
Total
135a
117a
94a
346a
p<
Sex Female Male
71 (52.6) 64 (47.4)
74 (63.2) 43 (36.8)
55 (58.5) 39 (41.5)
200 (57.8) 146 (42.2)
Age 60–70 70–80 80 over
27 (20) 56 (41.5) 52 (38.5)
54 (46.2) 37 (31.6) 26 (22.2)
44 (46.8) 34 (36.2) 16 (17)
125 (36.1) 127 (36.7) 94 (27.1)
Education Non-educated Primary school High school University
90 (66.7) 41 (30.3) 4 (3) –
66 33 7 11
(56.4) (28.2) (6) (9.4)
– 5 (5.3) 67 (71.2) 22 (23.4)
156 79 78 33
107 (91.5) 10 (8.5) –
– 42 (44.6) 53 (56.4)
241 (69.6) 52 (15) 53 (15.3)
0.01
89 (76.0) 20 (17) 17 (14.5)
70 (74.3) 17 (18) 7 (7.4)
231 (66.8) 71 (20.1) 44 (12.7)
0.001
Income ($) 1000 1000–5000 5000–10,000
134 (100) 0 0
Self-reported general health Good 72 (53.3) Moderate 34 (25.1) 29 (21.4) Bad a
e69
(45) (22.8) (22.5) (9.5)
0.22
0.01
0.01
Number.
participants were illiterate, 22.8% of participants had received primary school education. Of the total, 66.8% reported that they had good general health. When comparing dentate versus edentulousness, there was statistically significant differences between sex, income, education and general health (p = 0.001, p = 0.001, p = 0.001 and p = 0.001, respectively) (Table 1). Comparing the socio-economic and some personnel status of participants among groups, 80 years of age and over participants were in Group 1. All of the illiterate participants were in Group 1 and Group 2 and all of the participants who had no or low income were in Group 1 and Group 2. Most of the subjects (65.9%) who stated that they had poor general health were in Group 1. There was statistically significant differences between groups, age, education, income and self reported general health (p = 0.001, p = 0.001, p = 0.001 and p = 0.001, respectively) (Table 1). Sixty percent of participants were edentulous and 38.7% were partially dentate; 25.4% had complete denture which 56.8% of them were in Group 1 and 22.8% of participants had no complete dentures which 97.4% of them were in Groups 1 and 2. 11.6% had no lower denture that nearly of all them were in Groups 1 and 2 and 12% of participants had been wearing only upper dentures. Of the 134 partially dentate subjects, 61 participants had no dentures, 51 of them being in Groups 1 and 2. Only 1.4% of participants were dentate. All of the subjects stated that they only visited the dentist when they had a complaint. Only 34.3% of participants stated that they visited a dentist once in a year. Among these participants, 52.5% were in Group 3. There was statistically significant differences between groups for visiting a dentist (p = 0.001). Forty three percent of the participants stated that they are using toothbrush for cleaning dentures/teeth while 35.9% of participants stated that they use nothing to clean dentures/teeth; those of 78% were in Groups 1 and 2. Thirty-six of participants stated that they never brushed their denture/teeth. Only 5% of the participants stated that they brushed their denture/teeth twice a day. There was statistically significant differences between groups for denture status, brushing habits and brushing frequency (p = 0.001). Only 19.4% of participants removed their dentures overnight.
Denture/dental hygiene were recorded among 267 participants (79 edentulous patients had no dentures). Denture/dental hygiene was rated as ‘‘good’’ for 41 subjects (15.4%), ‘‘fair’’ for 77 (28.8%) and ‘‘poor’’ for 149 (55.8%). There was no statistical significant difference between groups about dental hygiene and overnight denture wearing (p = 0.385 and p = 0.34, respectively). Among 128 participants wearing complete dentures, denture stomatitis was observed in 61.7% of subjects. Localized denture stomatitis was seen in 23 subjects (18 subjects were in Groups 1 and 2) while generalized denture stomatitis was seen in 56 subjects (46 subjects were in Groups 1 and 2). There were statistically significant differences between groups for denture stomatitis (p = 0.001) (Table 2). Significant correlation was found between denture hygiene and age of participant, general health status, denture stomatitis and overnight denture wear (p = 0.001). Table 3 shows distribution of denture stomatitis by age, income, general health status, denture hygiene and overnight denture wearing. When subjects with denture stomatitis were compared with those without stomatitis, significant differences were found in the following variables: (1) Age: denture stomatitis was more prevalent in elderly subjects (p = 0.003). (2) Income: the prevalence of denture stomatitis increased significantly in line with a decrease in income (p = 0.001). (3) General health: the prevalence of denture stomatitis increased significantly in line with a worsening in self-reported health status (p = 0.004). (4) Denture hygiene: the prevalence of denture stomatitis increased significantly in line with a decrease in denture hygiene (p = 0.001). (5) Overnight denture wearing: denture stomatitis was more prevalent in subjects using denture overnight (p = 0.001). There was no statistically significant correlation between denture stomatitis, brushing methods and frequency; however, there was a statistically significant correlation between denture stomatitis and denture hygiene (p = 0.001). Among 139 dentate subjects, 4 subjects could not be examined because of their aggressive behavior and definite refusal to open their mouth, leaving 135 subjects’ dental status was recorded (Table 4). The mean number of missing teeth (MT) in dentate subjects was 20.77 4.45 teeth, varying with groups. The dentate participants usually had 15 to 20 MT (42.2%), whereas 30.4% had 21 to 25 MT, and 21.5% had more than 26 MT (Table 5). The MT scores were slightly lower in Group 3 whereas similar for Groups 1 and 2. There were statistically significant differences between groups for MT scores (p = 0.047) (Table 4). There was no statistically significant difference for MT scores between sex and age (p = 0.07 and p = 0.35, respectively) (Table 5). The mean number of decayed teeth (DT) was 3.44 2.31 teeth, varying with groups (Table 4). Forty six percent of participants had 1 to 3 caries, 28% had 4 to 6 caries. The DT scores were higher in Group 3 (Table 5). There was statistically significant difference between groups for DT scores (p = 0.001) (Table 4). There was no statistically significant difference for DT scores between sex and age (p = 0.91 and p = 0.77, respectively) (Table 5). The mean number of filled teeth (FT) per person was 1.24 1.67 (Table 4). Forty two percent of the participants had 1 to 3 FT and 9.6% of the participants had more than 4 FT (Table 5). The FT scores were higher in Group 3 whereas similar for Groups 1 and 2. There was a statistically significant difference between groups for FT scores (p = 0.001) (Table 4). There was no statistically significant difference for FT scores between sex and age (p = 0.83 and p = 0.38, respectively) (Table 5). The DMFT scores were 25.52 3.37 per teeth and 94.8% of the participants had 20 to 29 DMFT scores. The DMFT scores were higher in Group 3. There was a statistically significant difference between groups for DMFT scores (p = 0.016). There was no
A. Uludamar et al. / Archives of Gerontology and Geriatrics 53 (2011) e67–e74
e70
Table 2 Distributions of clinical evaluations of subjects among groups, number, n (%). Group 1
Group 2
Group 3
Total
135a
117a
94a
346a
Denture/dental status Complete denture Edentulous (no denture at all) Edentulous (only upper dentures) Partial dentures Partial edentulous (no dentures) Partial denture (only upper or lower denture) Dentate
16 37 27 12 32 10 1
23 40 12 17 19 3 3
49 2 1 23 10 8 1
88 79 40 52 61 21 5
Visiting dentist 1 year 1–5 years 5–10 years
36 (26.7) 57 (42.2) 42 (31.1)
(11.8) (27.4) (20.0) (8.9) (23.7) (7.4) (0.7)
(19.6) (34.1) (1.2) (14.5) (16.2) (2.5) (2.5)
21 (17.9) 16 (13.6) 80 (68.2)
(52.1) (2.5) (1.1) (24.5) (10.6) (8.5) (1)
62 (65.9) 23 (24.4) 9 (9.5)
(25.4) (22.8) (11.6) (15.0) (17.6) (6.1) (1.4)
119 (34.3) 96 (27.7) 131 (37.8)
p<
0.001
0.001
Group 1
Group 2
Group 3
Total
98a
77a
92a
267a
Brushing habits Toothbrush Solution Toothbrush and paste Nothing
53 (54.1) 0 4 (4.8) 41 (41.83)
28 (36.4) 8 (10.4) 0 41 (53.2)
34 20 16 22
(36.9) (21.8) (17.4) (23.9).
115 28 20 104
(43.1) (10.4) (7.5) (38.9)
0.001
Brushing frequency Seldom Once a day Twice a day Never
58 (59.2) 15 (15.3) – 25 (25.5)
18 (23.4) 14 (18.2) 0 45 (58.4)
26 25 14 27
(28.2) (27.1) (15.2) (29.3)
102 54 14 97
(38.2) (20.2) (5.2) (36.3)
0.001
Denture/dental hygiene Good Fair Poor
16 (16.3) 34 (35.0) 48 (49.0)
13 (16.9) 20 (25.9) 44 (57.1)
12 (13) 23 (25.0) 57 (62.0)
41 (15.4) 77 (28.8) 149 (55.8)
0.385
Group 1
Group 2
Group 3
Total
65a
55a
81a
201a
Overnight denture wearing No 12 (18.5) Yes 53 (81.5)
10 (18.2) 45 (81.8)
17 (20.9) 64 (79.1)
39 (19.4) 162 (80.6)
Denture stomatitis LDS GDS NS a
Group 1
Group 2
Group 3
Total
43a
35a
50a
128a
12 (27.9) 23 (53.5) 8 (18.6)
6 (17.1) 23 (65.7) 6 (17.1)
5 (10.0) 10 (20.0) 35 (70.0)
23 (18.0) 56 (43.8) 49 (38.2)
p<
p<
0.34
p<
0.001
Number.
statistically significant difference for DMFT scores between sex and age (p = 0.46 and p = 0.30, respectively) (Tables 4 and 5). Bleeding on probing was recorded on approximately one-third of all teeth examined (n = 736). The number of teeth with bleeding per person varied from 1 to 18 teeth, with a mean of 3.4 4.9. Teeth with gingival pockets exceeding 4 mm was recorded in 8% of all examined teeth (n = 736). The number of teeth with gingival pockets deeper than 4 mm per person varied from 0 to 15 teeth, with a mean of 1.2 0.7 teeth. The number of teeth bleeding on probing and with gingival pockets exceeding 4 mm was similar for the groups. 4. Discussion No comprehensive data were available for denture status, oral hygiene and dental caries prevalence in different residential home retirements in Turkey. Despite the limitation of the survey sample, this study demonstrates that screening is effective in identifying the dental needs and oral health status of elderly. In fact, large nationwide surveys can give the most reliable picture of oral health and oral self-care in a country. The number and percentage of elderly population is rapidly increasing in many developed and developing countries, and this
rapid increase results in potential serious health problems. With the increased life expectancy, the demand for dental services for the elderly has also increased. Unfortunately, the use of dental services by elderly people is much less in Turkey, than in the industrialized countries (Mumcu et al., 2004). Generally, the percentage of the edentulous rate in older populations has often been used as an indicator of dental status (Marcus et al., 1996). In a previous survey performed almost two decades ago, 80% of Turkish population above 65 years of age was found to be edentulous (Saydam et al., 1990). Unlu¨er et al. (2007) found that among elderly people living in residential homes, the proportion of edentulousness was 67.4% whereas Akar and Ergu¨l (2008) reported that 86.6% of people were edentulous. In this study, it was found that the proportion of edentulousness was 58.2%. Our study confirms the study of Unlu¨er et al. (2007). Gift et al. (1997) stated that, almost half of the 8056 residents of the nursing home (47%) were totally edentulous. A study conducted in a residential home in Athens reported that the percentage of edentulousness was similar (64.4%) (Karkazis and Kossini, 1993). Among institutionalized elderly people in Italy, edentulousness was 59.8% (Angelillo et al., 1990), and 66% in South Australian nursing home residents (Chalmers et al., 2002). Our results confirm
A. Uludamar et al. / Archives of Gerontology and Geriatrics 53 (2011) e67–e74 Table 3 Distribution of denture stomatitis related age, income, general health status, denture hygiene and overnight denture wearing, n (%). LSD
GSD
Total
23a
56a
79a
Age 60–70 years 70–80 years >80 years
4 (17.4) 11 (47.8) 8 (34.8)
10 (17.9) 28 (50.0) 18 (32.1)
14 (17.7) 39 (49.4) 26 (32.9)
Income ($) 1000 5000 5000–10,000
3 (13) 14 (60.9) 6 (26.1)
6 (10.7) 37 (66.1) 13 (23.2)
9 (11.4) 51 (64.6) 19 (24.1)
General health Good Moderate Bad
4 (17.4) 6 (26.1) 13 (56.5)
5 (9.0) 11 (19.6) 40 (71.4)
9 (11.4) 17 (21.5) 53 (67.1)
0.004
Denture hygiene Good Moderate Bad
2 (8.7) 4 (17.4) 17 (73.9)
3 (5.4) 11 (19.6) 42 (75)
5 (6.3) 15 (19) 59 (74.7)
0.001
Overnight denture wearing No 15 (65.2) 8 (34.8) Yes
44 (78.6) 12 (21.4)
59 (74.7) 20 (25.3)
0.001
a
Table 5 Distribution of the results by gender and age, n (%).
0.001
p<
Gender
p<
0.003
e71
Females
Males
Total
72a
63a
135a
Number of missing teeth 10 7 (9.7) 15–20 23 (31.9) 21–25 25 (34.7) 26+ 17 (23.6)
1 34 16 12
(1.6) (54) (25.4) (19)
8 57 41 29
(5.9) (42.2) (30.4) (21.5)
0.07
Number of decayed teeth 0 10 (13.9) 1–3 34 (47.2) 4–6 18 (25.0) 7–9 10 (13.9)
8 28 20 7
(12.7) (44.4) (31.7) (11.1)
18 62 38 17
(13.3) (45.9) (28.1) (12.6)
0.91
Number of filled teeth 0 34 (47.2) 1–3 31 (43.1) 4–6 6 (8.3) 6–9 1 (1.4)
32 25 5 1
(50.8) (39.7) (7.9) (1.6)
66 56 11 2
(48.9) (41.5) (8.1) (1.5)
0.83
Total number of DMFT <19 3 (4.1) 20–29 67 (93.1) 30+ 2 (2.8)
1 (1.6) 61 (96.8) 1 (1.6)
4 (3) 128 (94.8) 3 (2.2)
0.46
Age (years)
Number.
the results of these studies. Although it cannot be generalized, there seems to be a clear trend for less edentate subjects with the increasing age in this population. This may reflect general improvements of dental care delivery services in Turkey over the last decade. Although not performed in residential homes but at university settings (or from national surveys), similar trends were observed in this population. In this study it was found that among edentulous patients 38% of them had no dentures (these subjects belong to Groups 1 and 2). Private health insurance does not cover the cost of dental treatment in Turkey. Thus, dental insurance is only given to the employees, workers, or retired people by the government. In the three residential homes in our study, people were of various sociocultural and economic levels, and only 45% had social insurance. Only subjects living in Group 3 residential homes have social security and this group is different from other two groups when income, education and denture status is considered. The median income of the Turkish population is approximately $6.000 according to the latest report by UNICEF. In regard to the income of the residents surveyed, it can be stated that Group 1 and Group 2 fell under the average income level and in regard to the education of the residents surveyed, majority of Groups 1 and 2 were noneducated. In this study, a statistically significant increase in the number of dentures among the socially insured subjects was observed and there were statistically significant differences between education, income and edentulousness. Contrarily, Akar and Ergu¨l (2008) stated that no significant relationship was observed between the level of education and the use of dentures. The survey showed statistically significant differences in the edentulousness rates between males and females. This finding is different from the findings of Marcus et al. (1996) stating that
p<
65–74
75–84
85+
Total
58a
46a
31a
135a
Number of missing teeth 0 1 (1.7) 6 (13) 15–20 32 (55.2) 14 (30.4) 21–25 15 (25.9) 15 (32.6) 26+ 10 (10.7) 11 (23.9)
1 11 11 8
(3.2) (35.4) (35.4) (25.9)
8 57 41 29
(5.9) (42.2) (30.4) (21.5)
0.35
Number of decayed teeth 0 10 (17.2) 1–3 22 (37.9) 4–6 20 (34.5) 7–9 6 (10.3)
4 24 10 8
(8.7) (52.2) (21.7) (17.4)
4 16 8 3
(12.9) (51.6) (25.8) (9.7)
18 62 38 17
(13.3) (45.9) (28.1) (12.6)
0.77
Number of filled teeth 0 25 (43.1) 1–3 26 (44.8) 4–6 7 (12.1) 6–9 0
26 (56.5) 18 (39.1) 2 (4.3) 0
15 12 2 2
(48.4) (38.7) (6.5) (6.5)
66 56 11 2
(48.9) (41.5) (8.1) (1.5)
0.38
Total number of DMFT <19 1 (1.7) 20–29 57 (98.3) 30+ –
3 (6.5) 43 (93.5) –
28 (90.3) 3 (9.7)
4 (3) 128 (94.8) 3 (2.2)
0.30
a
n.
edentulousness rates did not show significant difference between genders. These findings however are similar to the findings of earlier surveys where higher prevalence of edentulism among women in all age groups were reported (Hunt et al., 1985; Weintraub, 1985; Nalc¸aci et al., 2007). Dental visits found were not very common. Sixty four percent of the surveyed subjects had visited a dentist within the last 5 years and 36.1% of the subjects had not seen a dentist during the previous 5 or more years. Frenkel et al. (2000) stated that more than 70% of the 412 residents included in their study had not seen a dentist for
Table 4 DMFT index of groups, mean S.D.
DMFT Missing teeth (MT) Decayed teeth (DT) Filled teeth (FT)
Group 1
Group 2
Group 3
Total
p<
25.78 3.32 21.54 4.68 3.60 2.01 0.73 1.10
23.98 4.52 21.02 4.10 2.29 2.28 0.67 0.84
26.44 7.40 19.57 4.36 4.38 2.26 2.46 2.20
25.52 3.37 20.77 4.45 3.44 2.31 1.24 1.67
0.016 0.047 0.001 0.001
e72
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more than 5 years. C´atovic et al. (2003) reported that only 19.8% of the 175 subjects had seen a dentist within the past 5 years, and 39% had not seen a dentist in at least 10 years. Interestingly, more than half of the studied subjects in our population did not have the need or urge to visit a dentist although their dental conditions were not ideal. Costs and dental fear played major roles in neglecting the visits to the dentist. Reasons why dental care is not sought more frequently are generally complex and involve many factors. Among these include: differences between perceived and real need, lack of mobility and accessibility to care, fear of dentistry and high cost (Ettinger, 1992; Pietrokovski et al., 1995; Samaranayake et al., 1995). Usually the education and socio-economic level of the subjects are related to the status of oral health. Through education, financial stability, and the availability of dental insurance, individuals may become more increasingly concerned with their oral health (Suominen-Taipale et al., 1999) Those who have attained higher levels of education are more likely to have greater financial opportunity to place a higher priority on dental health. Individuals with greater financial resources usually have better access to dental care. It should also be noted that in the Turkish society, residential houses are usually solutions for subjects who have no relatives and also who cannot afford living alone. This reflects the fact that studies and conclusions derived from the residential houses, by design, is only valid for people living in such conditions. General statements therefore cannot be made for the whole elderly population. It can also be attributed to the lack of compulsory visits to the dentist in Turkey, since it was noted that more than one-third of the subjects have not visited a dentist within the last 5–10 years. The negative impact of poor denture hygiene among older adults is an important public health issue (Petersen and Yamamoto, 2005). Characteristic of elderly institutionalized people is very poor oral hygiene. The data collected in this study showed poor oral health conditions among the groups. Oral selfcare of the elderly group was excessively poor with a high percentage not having a toothbrush (43%) and most of these subjects were in Group 1 and Group 2. Brushing either with or without toothpaste was the most frequent method used to clean ¨ zkan et al. dentures. This finding was similar to that of Kulak-O (2002), Marchini et al. (2004), Dikbas et al. (2006) and Nalc¸aci et al. (2007) whereas Hoad-Reddick et al. (1990) found that a combination method was most often used. Only 8.9% of subjects were using chemical agents and majority of these subjects were in Group 1. Sixty four percent of subjects reported that they cleaned their denture never or very seldom. Majority of these subjects (72.7%) were in Group 1 and Group 2. Wirz and Tschappat (1989) found that, of the 100 nursing home residents, only 38% brushed their teeth three times daily. According to the results of Zhu et al. (2005), 23% of the 65–74 year olds brushed their teeth at least twice a day. In the present study only 5.3% of subjects brushed teeth/dentures twice a day and these subjects were in Group 3. These findings are lower than the findings of studies above. Denture hygiene was found poor in 55.8% of the participants. These results are similar to the results of Hoad-Reddick et al. ¨ zkan et al. (2002), (1990), Jagger and Harrison (1995), Kulak-O Peltola et al. (2004) and Unlu¨er et al. (2007). Also, during examination of dentate patients’ remaining teeth it was seen that there was a heavy plaque accumulation and bleeding on probing. There was a distinct discrepancy between the information provided by the subjects and denture/oral hygiene level detected by the professionals. It was clearly evident that hygiene practices were not performed adequately. This discrepancy could be also attributed to the large variety of oral hygiene habits and attitudes due to physical capability, manual dexterity, motivation, awareness, and educational background of the residents, together with the medical and dental supervision and care available (Ainamo
and Osterberg, 1992). The use of dental services by elderly people is much less in Turkey than in industrialized countries and residents in these institutions tended to have very poor socioeconomic conditions, and the findings of the present study indicate that dental health care for the poorest and oldest in society needs more attention. In previous studies, rates of denture stomatitis have been reported to range from 11 to 67% (Budtz-Jorgensen and Bertram, ¨ zkan 1970; Budtz-Jorgensen et al., 1975; Shou et al., 1987; Kulak-O et al., 2002) and the prevalence of denture stomatitis has been strongly correlated with denture hygiene and/or the amount of denture plaque (Budtz-Jorgensen et al., 1975; Shou et al., 1987; ¨ zkan et al., 2002). In this study, the rate of denture Kulak-O stomatitis was found to be 60% in compliance with other studies. It was interesting that our study results showed that there was no difference between males’ and females’ incidence of denture stomatitis. This finding was in line with a previous report (Vigild, 1993), while others (Budtz-Jorgensen and Bertram, 1970; BudtzJorgensen et al., 1975; Nevalainen et al., 1997) have reported higher rates of denture stomatitis among females than males. The variation in sex-based differences reported may be due to differences in the overall health status of study subjects. In this study it was found that there was a statistically significant difference between groups and denture stomatitis prevalence. Since it was found that denture stomatitis was more prevalent in elderly subjects, the prevalence of denture stomatitis increased significantly in line with a decrease in income and the prevalence of denture stomatitis increased significantly in line with a worsening in self-reported health status. This could be explained by differences between groups. Vigild (1993) reported that risk factors for denture stomatitis include overnight denture wear. Our study also found a significant relationship between continuous wearing of dentures and denture stomatitis. Other studies have shown denture stomatitis to be associated with a lack of preventive hygiene programs (Budtz-Jorgensen et al., 2000), poor denture ¨ zkan et al., 2002; Marchini et al., 2004) hygiene habits (Kulak-O and failure to remove dentures overnight (Fenlon et al., 1998). Our study confirm the study above. The mean number of caries experiences expressed as the DMFT was found to be 25.5 of which the missing component was 20.1. Unlu¨er et al. reported that DMFT was 29.3 for elderly people living in residential homes. Gaiao et al. (2009) reported that in northeast Brazil, the DMFT in institutionalized people was 29.7. Our results are lower than the results of these studies whereas one study stated that, among institutionalized adults aged 65 years and older, the mean DMFT was 25 for Spanish people (Spanish Geriatric Oral Health Research Group, 2001). Saub and Evans (2001) and Stubbs and Riordan (2002) reported that in Australia this score was around 24.9 and 24.7, respectively. Our scores are similar to these scores but higher than the reported scores for institutionalized elderly in China (DMFT (1/4) = 12.4) and India (DMFT (1/4) = 13.5) (Thomas et al., 1994; Wang et al., 2002). The DMFT varies considerably not only between different socioeconomic groups, but also between different countries and cultures, and it is consistently higher in institutionalized people than among community-dwelling populations. In this study and in the other studies, it has been shown that the number of decayed (coronal and root) and filled teeth is decreasing with age because of the decreasing number of remaining teeth in elderly adults (Mack et al., 2004; Peltola et al., 2004; Unlu¨er et al., 2007). It has been predicted that as older adults retain their teeth longer, more teeth will be at risk of coronal and root caries (Reinhardt and Douglass, 1989). This study showed that there was no statistically significant difference between age groups and sex for DMFT, which is different from other studies which reported that the number of decayed and
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filled teeth is decreasing with age because of the decreasing number of remaining teeth in elderly adults (Mack et al., 2004; Peltola et al., 2004; Unlu¨er et al., 2007). The data suggested that all the older people are indeed a caries-susceptible group. Treatment of dental caries is not only expensive but has simply been inaccessible to the majority of the elderly population in Turkey. Of clinical importance is the finding that although there was no gender difference in dentate status or number of teeth, males consistently had more dental caries. Shallow pockets and bleeding on probing were not comparable because of the lack of number of the sextants with index tooth. Tooth loss was found to be widely prevalent in the study group although no significant differences were found between male and female residents. Functional dentitions, as measured by the retention of at least 20 natural teeth were found to be a rare condition (5.3%) among the residents in this study. In a study carried out by Simons et al. (2001) among people of 80 years and over, a minority of subjects (27%) had a functional dentition of 21 or more teeth. In Germany, 29% of the elderly had 20 or more teeth (Mack et al., 2003). In a 2000 survey of adult Danes aged 65–74 years, 40% had 20 or more teeth (Christensen et al., 2003). Among residents, the treatment needs at all levels (restorative, periodontal and prosthetic) was large especially in Group 1. Dental health service system factors: prices and subsidies of dental services, availability and accessibility and behavior of the dentist were strongly related with the improvement of oral health. Elderly people living in residential and nursing homes often rely on careers for their daily care. Since no assistance was offered from the nursing staff for oral hygiene, the subjects were responsible from the hygiene of their dentures themselves. Authorities and nursing staff showed a lack of understanding of the oral hygiene needs of elderly, especially for the denture wearers’. Staff did not effectively perform oral health care service appropriate to residents’ needs. Regular oral care and recall sessions with periodical demonstrations could be provided for the residents and for the care-taking staff. Simple measures such as improved hygiene protocols with respect to denture care and increased awareness of the staff in the oral problems of the elderly may help to improve quality of dentures in such cohorts. Furthermore, oral health programs should be implemented with emphasis on routine preventative and maintenance in addition to curative care. Additional research is needed to accurately characterize the oral health status and needs of the growing number of homebound and institutionalized older people. Affordable and prevention oriented oral health care should be organized to provide an improved quality for life of the elderly. This must be of relevance to the dental profession because geriatric patients require different approaches to the management of oral disease. 5. Conclusions On the public health level, health education programs focusing on the special needs of these populations are mandatory. An integrated approach is needed, and oral health education should include all stakeholders. Additionally, it is necessary to implement curative and rehabilitation measures in these populations to reduce the need for future dental treatment. This study shows that the dental status of institutionalized older people in the city of Istanbul is very poor. There is a lack of perceived need for dental services and of adequate oral self-care. Dental health education is also needed focusing on the special needs of this neglected and socioeconomically deprived population to improve their quality of life. Conflict of interest statement None.
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