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Oral status in home-dwelling elderly dependent on moderate or substantial supportive care for daily living: prevalence of edentulous subjects, caries and periodontal disease
Objectives: The aim of this study was to compare the prevalence of edentulous subjects, caries and periodontal disease among the home-dwelling elderly with moderate and substantial needs of support for daily living.
Materials and method: A sample of 302 randomly selected elderly with moderate or substantial needs of supportive care were examined in Sweden. Several oral clinical variables were registered: number of teeth, dentures, caries, probing pocket depth, gingival bleeding and Eichner’s index.
Results: Both in general and in oral health, the differences were small when comparing elderly with moderate and substantial care needs for daily living. Those with substantial needs had more caries lesions (p < 0.01) and more gingival bleeding (p < 0.05), while the number of teeth and prevalence of edentulous subjects did not differ in relation to the need of daily support. The elderly had, on average, 9.8–11.7 teeth, one-third of whom had no natural teeth. According to Eichner’s index, half of the elderly in both groups had no opposing tooth contacts. Fifty-five per cent used dentures.
Conclusions: Elderly people with needs of supportive care have lost many teeth before they become dependent. Health promotion should be a priority in early ageing populations to prevent oral diseases and tooth loss.
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- Materials and methods
The number of elderly people is increasing rapidly in Sweden and in the rest of the world1. Oral health among the elderly has improved in recent decades. In a study of octogenarians by Hugoson2, the proportion of edentulous individuals decreased from 56% in 1983 to 5% in 2003. Oral health in the elderly has mainly been investigated in healthy populations, but a few studies describe conditions among the elderly with dysfunctions. Poorer oral health among the institutionalised elderly and a higher prevalence of dental problems in the medically compromised have been reported3,4. An increase in oral health problems can result in pain and infections and may compromise chewing capacity, leading to impaired nutritional status5,6. It is not known whether dental status differs among the elderly in relation to their need of daily support.
In 1999, legislation came into effect in Sweden giving elderly people in need of extensive supportive care from the community the right to a free, at-home, oral health assessment7. Eligibility is based on the level of supportive care for daily living required by the individual, and following the oral health assessment, dental treatments is offered at very low cost. In nursing homes, practically all residents are eligible, but for elderly people living at home, a case manager decides who has a sufficiently high level of supportive care – three times per day with night monitoring – to be eligible. In Sweden, 153 000 elderly people live at home with help from the social services. The number of people living in their homes and receiving home care has increased during the early twenty-first century8.
The Dental Act9, which is the guiding document for dental care in Sweden, declares that particular attention should be paid to prevention. Elderly people, irrespective of their level of care needs, have a significantly increased risk of developing oral diseases as compared with younger individuals10. Older people, like younger ones, want to keep their teeth and favour functional and aesthetically pleasing solutions11,12. Reports suggest that the strategy of investing in people with high care needs means that instead of a preventive approach, dental personnel have to focus on treating extensive damage that has already occurred through neglect of dental care13. The result is needless suffering for the individual, infections that threaten the individuals’ oral and general health, and extensive irreversible damage. In addition, elderly people with extensive needs of care have major difficulties taking in advice about oral care and managing long treatments, as compared with elderly people with less needs of care14.
From several perspectives, it would therefore be desirable to offer oral assessments and dental care to elderly people before the dental damage becomes extensive and while the opportunities to prevent dental diseases are greater. The aim of this study was to compare the prevalence of edentulous subjects, caries and periodontal disease among the elderly living at home with moderate and substantial needs of support for daily living.
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- Materials and methods
In three counties in Sweden, 302 people over 65 years of age and in need of supportive care for daily living from the municipality participated in the study. Half of the participants had substantial needs of supportive care, i.e. three times per day with night monitoring, and half had moderate needs defined as supportive care of 15–50 h per month. Approximately one hundred participants were included from each of the counties Gävleborg, Uppsala and Västmanland, and the sample consisted of both urban and rural populations. The municipal officials provided the lists of all residents with moderate and substantial levels of supportive care, and from these lists, individuals born on certain dates were chosen. Birth dates were chosen at random by drawing lots, and as new participants had to be included, more dates were added. In larger municipalities, eight dates sufficed to obtain enough participants, while in the smallest municipalities, 28 dates had to be chosen. A flow chart of the study is shown in Fig. 1.
Figure 1. Flow chart of the study showing dropouts during different parts of the study and participants who completed the study.
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The inclusion criteria for participation were as follows:
Age ≥65 years;
living at home with supportive daily care of either (i) moderate needs defined as supportive care of 15–50 h per month or (ii) substantial needs, i.e. three times per day with night monitoring;
date of birth on one of the randomised chosen days;
possible to contact the person, a relative or proxy.
Exclusion criteria for participation were as follows:
All participants were offered an examination at a dental clinic but could instead choose an examination in their homes. The examinations were performed by three dentists and dental hygienists, one pair in each county. Before the study began, the dentists were calibrated with respect to the investigation procedure and to ensure the assessment of clinical variables by examining the same patients on 1 day. During the study examinations, the dentists did not know whether the patient had moderate or substantial needs of care. The examination was performed with a mirror, two kinds of probes (one for examining caries and one with millimetre mark for measuring gingival pockets) and a light from a flashlight or surgical lighting. The dentists were always assisted by a dental hygienist during the examination. All data were collected in a protocol designed for the study. If the examination was performed at a dental clinic, appropriate X-rays were taken with the purpose of diagnosing dental caries. When X-rays had been taken by other dentists during the months preceding the survey, such X-rays could be used to verify the clinical examination. Three photographs of the oral cavity, one front and two lateral, were taken.
The participants were interviewed before the examination. Structured questions were used and asked verbally by a dental hygienist. The interviewee answered questions about his or her general health and medications. Most of the participants answered the questions themselves, but when necessary, relatives or care personnel supplemented the answers. Medications were validated by registrations in the medical records.
Number of teeth The number of teeth with a natural root was registered. Roots without a crown but still functioning were also included in the number of teeth registered. To be counted as functioning, the root was not to have an active caries lesion, a noticeable infection or be covered by mucosa15.
Dentures The presence of full and partial dentures in the upper and lower jaw was registered. It was also noted if dentures were supported by implants.
Dental caries Caries affecting the dentine was registered with the tooth as the unit, decayed teeth (DT), and previously restored teeth, decayed and filled teeth (DFT), were noted in accordance with criteria described by Koch16 and Baume17. Caries in junction with a filling or artificial crown was registered, DsecT. When a root without a crown was affected by caries, it was counted as a carious tooth.
Periodontal status The number of teeth with pockets deeper than 5 mm at probing, measured on the mesial, buccal and distal surfaces, was registered. The number of mobile teeth was noted, assessed as levels18: (i) movability of the crown of the tooth 0.2–1 mm in horizontal direction, (ii) movability of the crown of the tooth >1 mm in horizontal direction and (iii) movability of the crown of the tooth 0.2–1 mm in vertical direction. Bleeding at probing was measured mesial, buccal and distal on all teeth. All measures were taken from the buccal side of the tooth. The index Modified Sulcus Bleeding Index19 with four levels was used: (i) no bleeding when probing with slight pressure along the marginal gingival, (ii) isolated points with bleeding at probing, (iii) continuous bleeding at probing and (iv) profuse bleeding at probing. The number of teeth consistent with each level of the index was noted.
Chewing capacity The number of teeth in contact with teeth in the opposite jaw was registered in accordance with Eichner’s index20 (Table 4).
Dry mouth The amount of saliva was measured using a simplified method. A dry dental mirror was moved over the buccal mucosa. When the mirror stuck to the mucosa, the mouth was considered to be dry21.
With the purpose of determining the sample size in the two groups of the elderly, a power assessment was made. Having a total of 150 individuals with moderate or substantial needs of supportive care, respectively, would make it possible to detect the mean differences of ≥7% between the two groups. The results of the questionnaires and clinical examinations were transferred to a database, and logical checks were made on individual and group levels. Quality controls of the transfer process showed a margin of error of 0.003. Descriptive analyses of the answers to the questionnaires were shown in frequency tables, split into needs of supportive levels. Differences between the groups were analysed with Mann–Whitney test or t-test when quantitative variables were analysed and Fisher’s exact test for qualitative variables. Several variables showed an uneven distribution, and t-test was therefore verified with the non-parametric Mann–Whitney test. When t-test and the non-parametric test differed, the disagreement was shown. Performing a large number of statistical tests increases the risk of mass significances. This risk was limited by a conservative interpretation of the analyses. A p-value <0.05 was considered statistically significant.
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- Materials and methods
A total of 302 subjects participated in the study. The dropout rate was 30.6% for people with moderate needs of supportive care and 20.4% for those with substantial needs. Reasons for not participating in the study were insufficient strength, that they already had a dentist or did not experience a need of dental care. Individuals who declined participation were older than the participants and more women than men refused to take part (Table 1).
Table 1. Age (years) and sex of dropouts with moderate and substantial needs of supportive care.
| N = 65|| N = 40|
|Age, mean|| 87.2|| 85.3|
|Men, %|| 30.3|| 25.0|
|Women, %|| 69.7|| 75.0|
Twelve per cent of the elderly participants with moderate support needs and 13% of those with substantial needs chose to be examined at the dental clinic. In 41% of the examinations of participants with natural teeth and moderate need of support, X-rays were available for diagnosing caries. Among the elderly with substantial needs of support, the corresponding proportion was 33%. Participants with moderate needs of supportive care were older than those with substantial needs, but no differences concerning general health and use of medicines between the groups were observed. A large proportion of the elderly suffered from cardiovascular diseases, and they used an average of almost seven medications. Women dominated irrespective of needs for support (Table 2). Sixty per cent of the participants, irrespective of supportive need, stated that they had a regular dental contact.
Table 2. Age (years), sex and general health of participants with moderate and substantial needs of supportive care. Quantitative variables are analysed with Mann–Whitney test and qualitative variables with chi-square test.
| ||Moderate||Substantial|| p-value |
|Age, range||66–98||66–100|| |
|Heart disease, %||74.8||74.2||NS|
|Frequent pneumonia, %||9.9||12.6||NS|
|Number of medicines, median||6||7||NS|
|Number of medicines, range||0–22||0–27|| |
No difference concerning the number of teeth, prevalence of edentulous subjects and use of removable dentures could be seen when comparing individuals with moderate and substantial needs of supportive care. The prevalence of edentulous subjects was high; approximately one-third of the elderly irrespective of extent of supportive care had no natural teeth. The mean number of teeth was 11.7 and 9.8 among the elderly with moderate and substantial needs of support, respectively (Table 3). The proportion of individuals with 20 teeth or more was 25.8 and 18.0%, respectively (data not shown). More than half of the participants in both groups wore dentures. According to Eichner’s index, 19.1% of the individuals with moderate needs and 17.9% of those with substantial needs had occlusal contacts in all four occluding zones. Of these, seven individuals achieved some or all occlusal contacts with support from dental implants. As the number of occlusal supporting zones decreased, the prevalence of dentures increased (Table 4). Totally, implants were found in fewer than 10% of the elderly, and no difference between the groups was registered (Table 3).
Table 3. Number of teeth, prevalence of edentulous subjects, implants, caries and periodontal status among participants with moderate and substantial needs of supportive care (mean and 95% confidence interval, CI). (Edentulous individuals excluded for the variables describing caries, gingival pockets, bleeding and mobility). Quantitative variables are analysed with t-test, and qualitative variables, with chi-square test.
| ||Moderate||Substantial|| p-value |
|Mean (95% CI)||Mean (95% CI)|
|Number of teeth upper jaw||5.2 (4.4–6.1)||4.5 (3.7–5.3)||NS|
|Number of teeth lower jaw||6.5 (5.6–7.3)||5.4 (4.6–6.2)||NS|
|Total number of teeth||11.7 (10.1–13.3)||9.8 (8.3–11.4)||NS|
|Totally edentulous, %||31.8||32.5||NS|
|At least one edentulous jaw %||44.4||54.3||NS|
|Wearing removable dentures %||54.3||55.6||NS|
|≥1 implants %||8.6||6.0||NS|
|DFT||12.9 (11.6–14.3)||11.3 (10.1–12.5)||NS|
|DFT/T||0.76 (0.71–0.81)||0.84 (0.77–0.92)||NS|
|DT/T||0.10 (0.06–0.14)||0.23 (0.14–0.32)||0.008|
|DsekT/T||0.04 (0.02–0.06)||0.10 (0.06–0.14)||0.006a|
|Number of roots||0.32 (0.16–0.48)||0.51 (0.28–0.74)||NS|
|Number of teeth with pockets ≥6 mm||0.58 (0.35–0.82)||0.76 (0.43–1.10)||NS|
|Number of teeth with bleeding level 1||12.8 (11.2–14.4)||8.67 (7.09–10.3)||<0.001|
|Number of teeth with bleeding level 2||3.36 (2.57–4.15)||3.55 (2.85–4.24)||NS|
|Number of teeth with bleeding level 3–4||0.65 (0.37–0.93)||1.66 (0.92–2.39)||0.011|
|Number of teeth with mobility degree 1||0.52 (0.33–0.72)||0.70 (0.43–0.97)||NS|
|Number of teeth with mobility degree 2–3||0.33 (0.17–0.50)||0.26 (0.14–0.39)||NS|Table 4. Number of teeth, prevalence of dentures and implants related to Eichner’s index and need of supportive care.
The prevalence of caries, DFT, was equal in the groups. Individuals with substantial needs of supportive care had more teeth with active caries lesions than those with moderate needs, shown as both mean of DT/T and the number of individuals with no caries lesions at all (Table 3). Still, almost half of the individuals with substantial needs had no teeth at all with caries (Fig. 2). Participants with no X-rays available had fewer caries lesions compared with those with X-rays (the mean number of decayed teeth was 1.24 and 1.90, respectively). No differences between the groups could be seen as regards teeth with gingival pockets of 5 mm or deeper. More individuals with moderate needs showed no bleeding from the gingiva at all when probing, and more individuals with substantial needs had teeth with the worst levels of bleeding at probing (Fig. 2). No differences could be seen concerning tooth mobility and salivation (Table 3). Concerning oral health status, no differences between men and women could be seen (data not shown).
Figure 2. Proportion of dentate individuals who did not suffer from caries, probing pockets depth >5 mm, teeth with bleeding level 3–4 and teeth with mobility degree 2–3. *Statistically significant differences p < 0.05 (Mann–Whitney test). Moderate, Substantial.
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- Materials and methods
In this randomised study, 302 elderly individuals identified by the municipality as dependent on supportive care for daily living were examined and interviewed about their general health and some of their living conditions. Individuals with substantial needs of supportive care had more caries and bleeding gums, while other aspects of oral health status were equivalent between the two groups. The prevalence of edentulous individuals was high, but at the same time, a majority of individuals showed no signs of active oral diseases.
No differences regarding general health could be found. The participants in both groups had a large number of medications, a mean of seven drugs with a wide range (0–27). Use of systematic medication is the most important explanation for low salivary flow among the elderly22. About 20% of the participants in this study had signs of dry mucosa, but the method for registering dry mouth had unknown validity and reliability as there are no valid methods to measure salivary flow in people with a reduced ability to cooperate. Hyposalivation leads to nutritional problems in the elderly and has a significant impact on quality of life23. Three quarters of the participants in both groups had cardiovascular disease. Slightly, more subjects with moderate needs reported diabetes than those with substantial needs, and approximately 10% of the elderly reported frequent pneumonia (more than one incident the last year). Bacterial pneumonia is related to oral hygiene in the elderly in hospitals and nursing homes24. One explanation for the relatively low prevalence of pneumonia in this study could be that the participants were healthier than those studied in the review by Sjögren et al.24. The reported prevalence of diseases in this study could have been underestimated because the participants in most cases answered the questions themselves and they could have forgotten or misunderstood them. The number of drugs, however, was validated with data from medical records.
The prevalence of edentulous individuals in this study was significantly higher than among healthy people of the same ages. In a repeated cross-sectional study of the population in a Swedish county, the proportion of edentulous 80-year-olds had decreased from 56% in 1983 to 5% in 20032. In a study of octogenarians in Gothenburg, Sweden, 22% were edentulous25, and in a Danish investigation, 41% of the studied 85-years-old had no natural teeth26. In this study, approximately one-third of the participants were edentulous. One explanation for the large variation in the proportion of edentulous elderly may be difficulties finding a representative sample to study. Elderly individuals with reduced functioning abilities may not respond to offers to take part in surveys, and healthy elderly people will be overrepresented. Other investigations only study available elderly individuals, for example at nursing homes, in which case people with major disabilities will be overrepresented. Very few investigations examine, as this study does, a randomised sample of elderly people who are dependent on daily support, and therefore, the results are of special interest. More women in the group with substantial needs of support refused to participate in the study, and one possible explanation is that women may be more afraid than men of letting unknown people into their homes. While this study shows few remaining teeth among the elderly, the majority had no caries lesions or signs of periodontal disease, and therefore, it is possible that the tooth loss took place a number of years ago. Previous studies have shown that poorer status in a wide range of health variables such as physical health, nutrition, disability and self-esteem is associated with edentulism and is also a marker of socioeconomic status earlier in life27,28. The chewing ability of the dependent elderly is related to poorer functioning ability and low Eichner’s score6. In this study, 18.5% of the elderly had opposing contacts in all supporting zones and 49.5% had no opposing contacts at all, while 55% used removable dentures. The presence of teeth in the elderly has other functions besides chewing capacity, for example good facial appearance and clear pronunciation.
The prevalence of caries was higher than among healthy octogenarians in Sweden2. Individuals with substantial needs of daily support show more active caries lesions, and this finding was in line with previous studies. Elderly people with reduced functioning abilities and cognitive impairments have more caries than more independent elderly people, and damage caused by caries seems to be the main threat to the oral health of the elderly26,29. Reports of prevalence of periodontal disease in the dependent elderly are rare. In this study, 70% of the elderly irrespective of support needs showed no probing pocket depth >5 mm. Compared with healthy elderly people, 90% of whom had pocket depth >4 mm and the elderly in this study seem to be healthier. However, the elderly in this study had an average of 10 remaining teeth as compared with 18 teeth among the healthy elderly2. We only measured buccal surfaces to obtain reliable data from all individuals, even those with cooperation difficulties. The most plausible explanation for the low prevalence of periodontal disease may be that the dependent elderly had already lost the teeth affected by periodontal disease.
With the purpose of obtaining good quality of clinical data, the intention was to examine all participants at a dental clinic30. When the elderly subjects were invited to participate, a large number declined, mostly because they found it too tiring to travel to the clinic. At the prospect of having massive dropouts in this randomised study, the method was changed and the elderly subjects, instead, had the option to choose examination in their homes. With this change, the number of dropouts was low, especially among those with substantial needs, although other disadvantages arose. Because radiographs could not be taken at the majority of examinations, there was a risk that the caries prevalence would be underestimated. However, the risk of underestimation was reduced, owing to the fact that root caries dominates among the elderly, and proximal surfaces on molars and premolars often have fillings2. In addition, the small number of teeth among the subjects, especially molars and premolars, limits the risk of underestimation, and if there was such an effect, it was probably the same in both groups of elderly subjects. All examinations were performed by dentists and dental hygienists in cooperation, all of whom were experienced in dental care for the elderly, which improved the reliability of the registered data. The fact that participants with radiographs available had fewer caries lesions compared with those without radiographs suggests that the former group more often had regular dental care. Municipal staff identified individuals who belonged to the moderate and substantial support groups. In some cases, their needs increased during the period between the identification and the performed examination. If the person had moved to a nursing home during that period, he or she was excluded from the study; otherwise, he or she was transferred to the group with substantial needs. One weakness with the sampling procedure of the study is that municipal staff may have different criteria to grant a certain amount of supportive care. Nevertheless, the studied classification of the elderly actually formed the basis of subsidised dental care. Another weakness is that it was not possible to obtain valid information about the length of time the subjects had been in need of support for daily life. Further, it cannot be excluded that some people needed more support than they were actually given, but had declined this help for financial reasons.