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Prevalence of soft tissue oral lesion in elderly and its relations with deleterious habits
Introduction: With ageing, the oral mucosa becomes more susceptible to external stimuli.
Objective: To investigate the prevalence of soft tissue oral lesion in elderly and its relations with deleterious habits.
Materials and methods: It was a quantitative research conducted at the dental clinic of UNIFOR, Fortaleza-CE, in the period from 1998 to 2006. The sample consisted of all 756 records of the elderly, and the data were processed by SPSS 15.0 (SPSS, Inc., Chicago, IL, USA).
Results: The majority (63.0) were women, age 60–92, mean age 67 ± 6. The most significant proportions were married (48.4%), retired (42.3%) and incomplete primary school (31.5%). It was found a prevalence of 18.3% of oral lesions, with the risk being 1.6 times higher (p = 0.030) among youngest (up to 65 years) and 1.7 times higher among smokers (p = 0.048). Although this risk is 1.6 times higher among those who drank alcohol, it was not statistically significant (p = 0.122).
Conclusion: The elderly showed a high prevalence of oral lesion, being the youngest, the smokers and the alcohol consumers those most vulnerable to the emergence of these diseases. Dental services need to implement programs of elderly care and health education, essential to clarify the risks and their associations with oral diseases, aiming to promote health.
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The population ageing and the change in the age structure require, from public policies and health professionals, attitudes adjusted in the interdisciplinary approach1. Within this context, medicine and dentistry should interact by exchanging information, once the oral factors may compound the evolution of systemic diseases, and these may jeopardise the dental work and/or the quality of life of the infected individuals2. In agreement with this reasoning, Hamalainen et al.3 concluded that a poor oral health is directly related to an increasing mortality rate among elderly people, because it affects their general health.
Authors report that the prevalence of lesions are mainly associated with changes in the mucosa because of mechanical and chemical irritation, poor fitted prostheses, tobacco use, and to a lesser degree related to systemic diseases and precancerous conditions4.
Thus, pathological processes can be developed in the oral cavity such as periapical lesions, cysts or neoplasia; though, an oral pathology is not necessarily restricted to its local of origin and may disseminate through distinct ways according to the nature of the lesion5.
The continuous populational growth, as well as its ageing, will affect the cancer impact worldwide, mainly in low and medium developing countries6. It is emphasised that in Brazil, cancer constitutes a big public health concern and the one related to the oral cavity shows high incidence with expected rate of 10.64/10.000 for men and 3.76/10.000 for women in 20107.
Studies have showed that the incidence of oral cancer accompanies the patterns of the consumption of tobacco and alcohol, which work as powering and risk factors,8 and the excessive consumption of alcohol causes effective alterations in cells of the oral mucosa even in the absence of the exposure to tobacco9.
The use of tobacco is nowadays the major isolated cause of avoidable diseases that are known among the non-immunisable. It is a morbid agent introduced and kept by man himself10. The smoker elderly is a real survival who often underestimate the risks, believes to be immune to the tobacco evil, denies the existing symptoms, is little motivated to quit smoking or thinks he is not able to do it11.
This requires the interference of the dentist surgeon, concerning the research of risk factors that may influence on oral and systemic health of patients and also to seek a correct diagnosis and treatment of the dental needs.
Thus, the elderly people’s oral health promotion is directly related with educative and preventive attitudes of the professionals, however, understanding and respecting their peculiarities. Concerning this problem, this work aimed to investigate the occurrence of oral lesions and deleterious habits, as well as to contextualise socio-demographic aspects of the elderly who looked for assistance in the dental clinic of the University of Fortaleza – UNIFOR, since the period of its foundation and the relation of these lesions with deleterious habits.
Such information, for having historical characteristics, will work as a subsidy for the planning elaboration in the curative and preventive aspects as well as for the education and promotion actions in health to the referred population.
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It was a quantitative research, cross-sectional study, conducted in the dental clinic of UNIFOR, Fortaleza, Ceará, in the period from 1998 to 2006.
The dental clinic of UNIFOR is a reference to the State of Ceará. Patients enter spontaneously, and, through a classification of the clinical profile, they enter in the System of Academic Information following, according to the complexity previously detected, to the different attendance sectors.
The population consisted of all the 1361 records of elderly patients, attended within that period in the dentistry course. The sample was reduced to 756 records, due to the fact that many did not have information about oral lesions and deleterious habits (tobacco, alcohol/drugs), the object of study.
On the basis of the structure of the records, a formulary was elaborated as an instrument of data collection, containing the same data of identification (age, gender, marital status); socio-economic level (income, schooling); lesions of the soft tissues, detected at the moment of the anamnesis; and deleterious habits (tobacco, alcohol/drugs). It was considered elderly all the individuals who were 60 years old or older, according to the National Health Policy of The Elderly12.
The data were organised in tables. The following measures were calculated: average, standard deviation and odds ratio with its respective CI95%. It was employed the chi-square test for comparisons, considering statistically significant the analyses with p < 0.05. It was used the Software‘Statistical Package for Social Science’– SPSS version 15.
A consent form was signed by the legal depository, responsible for the records of the patients, where this research was conducted, and the project was approved by the Ethics Committee of the University of Fortaleza, under Opinion No. 069/2007, according to Standard No. 196/96.
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From the 756 records, 479 belonged to women (63%) and 277 to men (37%), whose age ranged from 60 to 92 years (mean, 66.99 years of age; SD, ±6.05). The most expressive proportions were married elderly [366 (48.4%)], retired [320 (42.3%)] and incomplete elementary school [238 (31.5%)]. Income of up to two minimum wages [547 (72.4%0] prevailed. It was found a prevalence of 138 (18.3%) cases of oral lesions, which are shown in Table 1, according to the types detected and categorised according to Neville13.
Table 1. Frequency of the 138 individuals who showed oral lesions, according to type, in the period from 1998 to 2006. UNIFOR, Fortaleza, Ceará, 2009.
| Characterisation || N 0 ||%|
|Lesions by use of prostheses (stomatitis, fibrous hyperplasia, traumatic ulcer, tissue proliferation of suction chamber)||55||40.0|
|Fungal lesions (Candidíase, queilite angular)||28||20.3|
|Indeterminate lesions (Identified without type specification)||21||15.2|
|Soft tissue tumours||10||7.2|
|Pré-malign lesions (Leukoplakia, actinic cheilitis)||04||2.9|
|Salivary gland lesions||04||2.9|
|Autoimmune lesions (Líquen plano, pênfigo bolhoso)||04||2.9|
|Non-pathological alterations (Lingual varicosity, fissured tongue)||04||2.9|
Table 2 shows the distribution of frequency of oral lesions in the age groups of the studied population.
Table 2. Distribution of the number of elderly and oral lesions, according to age group. Fortaleza, Ceará, 2009.
| || Number of elderly (a) || Number of lesions (b) ||%(b/a)|
|80 ou +||35||03||8.6|
From the 138 cases of oral lesions, 68 (49.27%) were identified in patients with deleterious habits of tobacco and alcohol. It was detected the risk 1.5 times bigger (p = 0.030) among younger patients (up to 65 years old) and 1.7 times bigger among smokers (p = 0.048). Despite this risk being 1.6 times bigger among those who consumed alcohol, this was not statistically significant (p = 0.121).
In Table 3, it is visualised the odds ratio to risk factors for oral lesions in elderly assisted in the dental clinic of the university.
Table 3. Odds ratio to risk factors for oral lesions in elderly from dental clinic of UNIFOR, Fortaleza, Ceará, 1998–2006.
| Factor || Category || OR || CI95% || p a |
|Use of alcohol||Yes||1,6||0.9–3.0||0.121|
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The findings of this study confirm the high prevalence of oral lesions in researched elderly (18.3%), as shown in Table 1, overall among those related to the use of dental prosthesis [55 (40%)], followed by fungal lesions [28 (20.3%)]. Espinoza et al.14 researching the prevalence of lesions of oral mucosa in 889 elderly from Santiago, Chile, concluded that the most common lesion was the denture stomatitis (22.3%), followed by irritative hyperplasia (9.4%). Another study15 proves that the hygiene and integrity of the prosthesis were related to the presence of oral lesions such as angular cheilitis, denture stomatitis and inflammatory fibrous hyperplasia, which were also statistically associated with prosthesis use. Moreover, many pathological processes can be developed in the oral cavity such as periapical lesions, cists or neoplasia5.
Table 2 shows the distribution of the frequency of oral lesions, according to the age group of the 756 elderly patients from this research. It was observed an elevated presence of oral lesions in all the age groups, although it was verified the reduction in the percentage of cases as the age of the population studied increases. The prevalence of oral lesion was 18.3%, with age groups from 60 to 64 years rating the major percentage (21.3%). These findings differ from the ones of Ferreira et al16 in which the prevalence increases with age, although we must consider that its population was made of institutionalised elderly. Another study reports that most of the oral lesions were observed in patients with age ranging from 60 to 74 years4.
Although this study aimed, mainly, to relate the presence of lesions and deleterious habits (tobacco and alcohol), it is important to mention that from the 138 elderly with oral lesion, 40% showed pathology related to the use of prosthesis, the most prevalent being stomatitis and hyperplasia. This result was corroborated by a research where the prevalence of lesions of oral mucosa (34.9%) appeared directly related to the elderly who use some kind of dental prosthesis17. These findings are similar to those of Kossioni18 who studied the prevalence of soft tissue lesions caused by prosthesis in 106 elderly patients in the Department of Prosthodontics of the Athens Dental School and found that 39.6% of the sample had denture stomatitis. The same evaluation was obtained in a research performed through 380 records of patients who used total prosthesis, detecting that 45% of them had oral lesions, being traumatic ulcer (19.5%) and denture stomatitis (18.1%) the most prevalent19.
The need to inform the elderly about the importance of the periodic check-ups for the evaluation of the prostheses regarding retention and stability aspects stands out, once there is the real possibility that poor fitted prostheses may cause damages to the soft and hard tissues of the oral cavity20.
The risk of lesions is 1.6 times bigger among the youngest elderly, 1.7 among smokers and 1.6 among alcohol consumers, regarding age. Scientific studies differ from these results when they point out that the incidence of lesions in the elderly group was higher than non-elderly group, as well as autoimmune diseases and salivary gland tumours21. However, patients who used tobacco were almost two times more likely to have lesions22.
Pipe and cigarette smoking vice, the consumption of alcohol, a poor oral hygiene and the use of poor fitted prostheses are risk factors associated with the development of oral carcinoma7, mainly in the tongue and on the floor of the mouth23.
In relation to alcohol use in this experiment, although this risk is 1.6 higher, it was not statistically significant (p = 0.121) (Table 3). The study was not deepened by a logistic regression because the number of significant factors was only two.
Although it was not detected statistical significance between the habit of drinking alcohol and oral lesions in this research, it is important to mention studies that relate the fact that alcohol has a synergic effect over tobacco, besides that the metabolism of ethanol to the carcinogenic acetaldehyde and the induction of pro-inflammatory cytokines may be important aetiological factors in oral cancer development24.
Barros et al.25 while evaluating the use of alcohol in a municipality of São Paulo found that the biggest frequency prevailed between adults and elderly, although youngsters showed a consumption of higher risk. The alcohol abuse turned into a health problem among elderly because of the increasing of the consumption and the effects in their health and quality of life26. People with alcoholism problems have a bigger incidence of the periodontal disease, caries and potentially precancerous oral lesions27.
The presence of malign lesions (carcinoma), although there are only two in this study, represents a very lethal pathology, highlighting that in Brazil the cancer related to the oral cavity shows high incidence7. Epidemological studies have found a strong association between the tobacco addiction and the development of cancer in many places such as lung, larynx, oesophagus among others28, and that tobacco use, along with alcoholism and a poor oral health, are associated with the prevalence of oral and upper gastrointestinal tract cancer29.
The presence of pre-malign (leukoplakia, actinic cheilitis) and malign lesions leads us to the lesson that many factors can influence on the state of dysplasia: the lesion period, patient’s age, intraoral place, risk habits and fungal infection, mainly candid and human papillomavirus30, even though leukoplakia shows an aetiology related to chronic irritations caused by tobacco and/or alcohol consumption21.
The use of tobacco constitutes the most common factor for the development of intraoral white lesions, being more frequent in tobacco chewers and pipe smokers than in those who smoke cigarettes31, and the excessive consumption of alcohol and tobacco in all its forms has been associated with periods of exacerbation of lichen planus, although its aetiological process is not fully understood yet32.
Previously seen as a lifestyle, smoking habit, nowadays, is recognised as an addiction that exposes people to many toxic substances7.
The understanding of the most prevalent lesions in the oral cavity of the elderly population can contribute to the guidance of the professional work, in the differential diagnosis of the uncountable oral diseases.
The dentist surgeon shall conduct a good anamnesis and identify the lifestyle of these patients, once the risk factors such as tobacco and alcohol are associated with upper gastrointestinal tract cancer23.
In this study, it was considered some limitations, such as registration of some lesions without a specified diagnosis, records suppression because of probable diagnosis errors and the fact that patients who, spontaneously, look for a dentist may have different characteristics from the general community.