Self-perceived oral health and orofacial appearance in an adult population, 60 years of age

Objective: The study aimed to compare self-perceived oral health and orofacial appearance in three different cohorts of 60- year-old individuals. Method: A cross-sectional design, based on data obtained from a questionnaire used in the Swedish National Study of Aging and Care. The

varies in different parts of the world depending on the perception of age. 4 However, the chronological age of 60 or 65 years, and over, is commonly used as a definition for older adults. 8od oral health is one of the essential determinants for active ageing. 9However, there is an enlarged risk for general health problems, and for poor oral health with increasing age. 10In 2016, the World Dental Federation (FDI), alongside the theoretical framework of oral health, which encompasses different dimensions of oral health, approved a new definition of oral health. 11These dimensions include the orofacial functions such as chewing and swallowing and the ability to express emotions without pain or discomfort. 12Oral health is an integral part of general health and well-being and can affect the quality of life (QoL). 11,13Depending on whether oral health is described as self-perceived or judged by the profession, oral health is defined differently.In dental care, oral health has often been described as the presence or absence of oral disease. 14,15Self-perceived oral health accounts for the individual's experience and how oral health affects functioning and social well-being. 16tural teeth have been shown to contribute to a positive body image and self-esteem. 15Teeth are essential to maintain the shape of the face and are of importance for the perception of the appearance of the face and teeth (orofacial appearance). 17The orofacial appearance is an essential dimension of oral health and QoL, 18 and has been associated with oral health problems in older adults. 17Alkhatib et al. 19 have reported that changes, such as darker tooth colour, gingival retractions and root caries, are associated with ageing.These factors may alter dental and facial appearance among older adults 19 and may cause dissatisfaction with dental appearance. 18When assessing attractiveness, the mouth has been identified as one of the most important facial features. 20Orofacial appearance is often the first feature judged by others in social interaction. 21Accordingly, satisfaction with orofacial appearance, based on the judgement from other people, has been reported to be relevant. 22ere is a lack of knowledge on how older adults perceive their oral health and orofacial appearance where the focus is on the perception itself, and not in relation to any other aspects such as diseases and impairments.To consider 60-year-olds as older gives an opportunity to capture ageing and the transition from work to retirement. 23This study aimed to compare self-perceived oral health and orofacial appearance in three different cohorts of 60-year-old individuals.

| Study design
The study design is cross-sectional and based on data got from the Swedish National study of Aging and Care (SNAC) questionnaires.

The study was approved by the Research Ethics Committee at
Lund University, Sweden (No: LU 604/00), and all procedures were conducted consistent with the Declarations of Helsinki. 24l participants signed informed consent prior to enrolment in the study.The collected data were anonymously processed.

| Context
Swedish National study of Aging and Care is an ongoing populationbased longitudinal cohort study in age groups 60-96 years.The study started in 2001 and has four participating centres. 23Karlskrona, a municipality in Blekinge in southeastern Sweden, is one of these centres and the only centre where a dental examination is performed.
The subjects included in the SNAC-Blekinge study are selected from Karlskrona's civil registration database (60,596 inhabitants, 2001), including urban and rural areas.New 60-year-olds are invited to participate in the longitudinal study every sixth year.The subjects were invited by mail to participate in a medical, psychological and oral health examination at a medical research centre.A questionnaire, which covers different areas, was attached to the invitation letter and was filled out by the participants in advance.

| Sample and data collection
The inclusion criteria in this study were 60

| Questionnaire
Data included in the study are based on demographic questions (n = 5) from the main questionnaire and questions (n = 15) derived from the oral health questionnaire.The oral health questionnaire used in the SNAC-Blekinge is based on questions deriving from validated questionnaires. 25,26Minor modifications have been made to some of these questions.
The demographic variables from the main questionnaire contain questions about the participants' gender, place of birth, living arrangement, level of education and economy in terms of cash margin.The oral health questionnaire includes items dealing with satisfaction of appearance, oral health-related problems and social interacting.Dichotomization of the response alternatives was made to all the questions with more than two response alternatives (Table 1).

| Statistical analysis
The data were analysed using descriptive and analytical statistics.
Descriptive analysis, with frequencies (n) and percentages (%), was used to illustrate the participants' characteristics, self-perceived oral health and orofacial appearance in the three cohorts.Using Fisher's exact test, comparisons were made within and between the cohorts.Independent bivariate analysis was performed concerning oral health and orofacial appearance items using Fisher's exact test (Tables 2-7).Statistical significance was considered at p < 0.05 for all analyses.The IBM SPSS (Statistical Software Package) version 27.0 (PASW statistics, IBM Corporation) was used for the statistical analysis.

| RE SULTS
Background characteristics are shown in Tables 2 and 3.The gender distribution and living arrangements were similar for all three cohorts.There were no significant differences between gender within the cohorts in living arrangements, except for 2007-2009, in which 24.3% women and 8.2% men were reported to live alone (p = 0.002) (Table 2).Participants with more than 9 years of education increased from 52.4% in 2001-2003 to 91.0% in 2014-2015 (p = <0.001).No statistically significant differences could be seen between genders within the cohorts for the level of education (Table 2).However, concerning level of education, statistical differences were found between the cohorts (p = 0.001 for all three comparisons) (Table 3).
The results show a low number of participants that reported self-perceived problems with oral health.Self-perceived oral health concerns from the oral cavity divided by gender in the three cohorts are shown in Table 4.In 2014-2015 (39.3%), a higher proportion of participants experienced discomfort with bleeding gums.The selfperception of bleeding gums has increased over the years (Table 4).(p = 0.017) (Table 5).Discomfort with bleeding gums was experienced by 46.4% of the men in 2014-2015 (Table 4), which was about  4).However, no statistical differences could be seen between the cohorts (Table 5).Dry mouth during the day was experienced in 27.8%-33.3% of the participants, and for dry mouth during the night, the figures were 40.0%-49.4%.Significant gender differences were found only for the cohort 2001-2003, both at day and night (p = 0.027 and p = 0.016) (Table 4).
Self-perceived orofacial concerns from the oral cavity in all three cohorts indicate that most of the participants (74.9%-83.9%)were satisfied with the appearance of their teeth (Table 6).Although not significant, this experience increased in the different cohorts over time.A significant difference could be seen within the cohort 2001-2003, where twice as many women compared to men were dissatisfied with their dental appearance (p = 0.011) (Table 6).A difference was also found for the women between 2001-2003 and 2007-2009   (p = 0.035) (not shown in table).As seen in Table 6, self-reported perception of dissatisfaction with dental appearance has decreased among the different cohorts.In contrast, increased self-perceived concerns with dental gaps could be seen over time.Approximately 30% of the participants in each cohort experienced discomfort with oral halitosis and discoloured teeth.A statistically significant difference for discoloured teeth was seen between gender within the cohort 2001-2003 (p = 0.020), where nearly twice as many women as men experienced discomfort with discoloured teeth (Table 6).An increase in discomfort with self-perceived discoloured teeth could be seen among men between cohorts, from 20.  ).

| DISCUSS ION
The main findings in this study were that, regardless of the cohort, no self-perceived problems or discomfort with oral health or orofacial appearance were found for the majority of the 60-year-old individuals in all cohorts.Only a small proportion of 60-year-olds in the different cohorts reported discomfort or problems with their oral health and orofacial appearance.In addition, some self-perceived concerns increased over time and were more common in cohort 2007-2009 and/or 2014-2015 than in the 2001-2003 cohort, such as oral halitosis, tongue coating, bleeding gums and discoloured teeth.There is possibly a societal perspective on specific aspects of oral health, as self-perceived concerns simultaneously seem to be affected by the trends that prevail in society.The findings regarding the increase in problems with oral halitosis and tongue coating may, for example, be a result of the oral health-related information conveyed by the mass media.In 2007, the SB12 mouthwash, a new product for the treatment of oral halitosis, was launched in Swedish daily retail and promoted in mass media. 27Mass media can be a tool to promote oral health and aiming to prevent disease.A message placed in media can reach many individuals for a shorter or longer care than previous cohorts, thus making them more aware of gingival bleeding, which could explain the higher frequency of selfperceived bleeding gum in this cohort.Gingival bleeding may be related to either gingivitis or periodontitis.However, participants' perception of bleeding only reflects a symptom that is easy to recognize.Untreated gum disease can, however, apart from causing pain, also affect appearance and self-esteem. 39re women than men reported discomfort with discoloured teeth, although women have been shown to have less yellow incisor teeth. 40The cause of their self-perceived discoloration remains unknown.Previous studies have reported that the colour and shade of the teeth become yellower and darker with age. 40,41The natural signs of ageing teeth are related to several behavioural and biological factors.Behavioural aspects of diet and oral hygiene may, apart from disease, also impact the tooth appearance and tend to retain more extrinsic staining. 41This is interesting since women have been reported to have better oral hygiene than men. 42The social perception may be that women care more about appearance and have higher aesthetic demands, including dental appearance, than men do.The focus on external appearance is a societal trend that especially may affect women who may be more susceptible to messages about appearance ideals, because they face a more complex and detailed appearance ideal than men do. 43,44Gender differences in physical appearance are well documented, [43][44][45][46] which also seems to apply to various orofacial features.White teeth may have a positive effect on physical appearance and psychological/mental health and may therefore increase the person's self-confidence.In addition, white teeth may lead to judgements, favouring more positive personality traits, where individuals are often perceived as socially more competent and intelligent. 40,47Perhaps, because of these attributes assigned to women, physically visible ageing is more difficult for women to deal with.
Twice as many women as men experienced problems with sensitive teeth in all three cohorts.Blaizot et al., 48 has also reported that sensitive teeth were significantly more frequent in women than men.0][51] Furthermore, women are usually more attentive to their overall health, including their oral health.Women more often and willingly also seek medical help for health problems, 52 and it may not be entirely unreasonable to assume that women are also more prone to articulate concerns with sensitive teeth.
Approximately 30% of the participants experienced mouth dryness during the day.At night, the figure was about 10%-15% higher for all three cohorts, which is consistent with the report by the prevalence of mouth dryness, both day-and nighttime, was higher among women.The primary causes of mouth dryness are systemic diseases and medication. 54The present study is, however, based solely on self-perceived experience with mouth dryness dayand nighttime with no other information, and hence, the study cannot relate to such causes.
The 60-year-olds perceived their oral health and orofacial appearance to be satisfying in all three cohorts.Given that the 2001-2003 cohort was born during World War II, it is not unreasonable to assume that the differences in self-perceived oral health and orofacial appearance would be more significant than they were.In 1938, public dental care was introduced in Sweden, 56 and all three cohorts have received school dental care.They have also been subjected to the public health information campaign starting in 1957 and the shift from reparative oral care to preventive oral care, based on results from the Vipeholm study. 57lf-perceived oral health and orofacial appearance are the only variables that were examined in the study, and analysis on associations to socioeconomic status was never performed as it was not the intention of the study.However, near 50% of the study participants in cohort 2001-2003 had an educational level of a maximum of 9 years.Poor oral health has been associated with socioeconomic factors, such as lower level of education and the possibility of obtaining a large sum of money (15,000 SEK) in a week. 58For those born around 1941 in Sweden, it was not uncommon for 8 years in elementary school to be the highest level of education. 59In Karlskrona, an educational level of maximum 9 years for this age group was 29%.
The corresponding figure for Sweden was 26%. 60Although an analysis of the dropouts has been made, the educational level is unknown among this group.Conclusion must be drawn with caution, but since there is a lower level of education in the study in cohort 2001-2003, the result may have been underestimated.
Other methodological aspects worth considering are the fact that the questions in the oral health questionnaire are composed of singled-out questions, deriving from different validated instruments.The questionnaire in its current form is, however, not validated, which may reduce the validity of the results.Also, the dichotomization made due to low response rate to some of the response alternatives may pose a risk of missing nuances in the result.Although the size of the cohorts varied, the cohorts were homogenous in terms of gender, which could make the results transferable to similar populations in medium-sized cities.
The gender differences were consistent with the gender distribution of all 60-year-olds in Karlskrona at the time for the survey Another explanation could be that in 2014-2015, the 60-year-olds often still worked and may not consider themselves as being old.
According to Benyamini and Burns, 61 older adults feel 14 years younger than their actual age.

| CON CLUS ION
In conclusion, the 60-year-olds irrespective of birth cohort, perceived their oral health and orofacial appearance as satisfactory.

| Scientific rationale
With a focus on healthy ageing, make self-perceived oral health and orofacial appearance visible in older adults.

| Principal findings
Overall, 60-year-old individuals perceive their oral health and orofacial appearance to be satisfactory, which appear constant over time.

A
significant increase was found both between 2001-2003 and 2014-2015 (p = 0.040) and between 2007-2009 and 2014-2015 twice as many compared to the proportion of men in the cohorts 2001-2003 (p = 0.013) and 2007-2009 (p = 0.032) (not shown in table).Sensitive teeth were experienced in 6.8%-31.6% of the participants.Twice as many women as men experienced discomfort with sensitive teeth in all cohorts, but statistical significance was only found in 2001-2003 (p = 0.005) and 2007-2009 (p = 0.001) (Table 0% in 2001-2003 to 34.7% in 2007-2009 (p = 0.033) (not shown in table).Self-perceived discomfort with tongue coating increased over time, and a significant difference was found between the cohorts 2001-2003 and 2007-2009 (p = 0.015) (Table 7), and between genders in 2014-2015 (p = 0.001) (Table 6).A difference in an increase over time was also found between women in the cohorts 2001-2003 and 2014-2015 (p = 0.002).However, a decrease in self-perceived discomfort with tongue coating was seen between men 2007-2009 and 2014-2015 (p = 0.022) (not shown in table

3 ,Note:Note:Note:
16015037, 2024, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/idh.12711by Malmo University Library & It Service, Wiley Online Library on [31/07/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 1 Presenting the questions from the Swedish National study of Aging and Care questionnaire that were included in this study and how they were dichotomized according to response options and coded.Norden countries 2-5 "Other country = 2" 3 = EU except the Norden countries 4 = Europe except EU/Norden countries 5 = Outside Europe Who lives with the participant?/brother-in-law 8 = Other What is your level of education?Level of education 1 = Incomplete/unfinished elementary school 1-3 "≤ 9 year of schooling = 0" 2 = Up to elementary school 3 = Elementary school 4 = Upper secondary school 4-8 "> 9 year of schooling = 1" 5 = Vocational education 6 = Education at least 1 year in college or university without a degree 7 = University/College with degree 8 = Postgraduate education Are you satisfied with the appearance of your teeth?Satisfaction with appearance?Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/idh.12711by Malmo University Library & It Service, Wiley Online Library on [31/07/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 2 Background characteristics in the three cohorts of 60-year-old individuals from baseline 2001-2003, 2007-2009 and 2014-2015 (total n, % and gender differences).Bold value was used to highlight the few values that were significant.a From baseline 2007-2009, the amount is SEK 15,000.*Statistical significance was considered at p < 0.05.16015037, 2024, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/idh.12711by Malmo University Library & It Service, Wiley Online Library on [31/07/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 3 Comparison of background characteristics between cohorts of 60-year-old individuals from baseline 2001-2003, 2007-2009 and 2014-2015 (%).Bold values was used to highlight the few values that were significant.a From baseline 2007-2009, the amount is SEK 15,000.*Statistical significance was considered at p < 0.05.16015037, 2024, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/idh.12711by Malmo University Library & It Service, Wiley Online Library on [31/07/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License TA B L E 4 Self-perceived oral health concerns from the oral cavity in the three cohorts of 60-year-old individuals from baseline 2001-2003, 2007-2009 and 2014-2015 (total n, % and gender differences).Bold values was used to highlight the few values that were significant.*Statistical significance was considered at p < 0.05.TA B L E 6 Self-perceived orofacial concerns from the oral cavity in the three cohorts of 60-year-old individuals from baseline 2001-2003, 2007-2009 and 2014-2015 (total n, % and gender differences).Bold values was used to highlight the few values that were significant.*Statistical significance was considered at p < 0.05.

( 49 .
2% women in 2001-2003, 49.7% in 2007-2009 and 50.4% in 2014-2015).The participating municipalities in SNAC represent different geographical regions and include both large cities, medium-sized cities and rural areas.Karlskrona in Blekinge represents a medium-sized city and can only be seen as generalizable to other medium-sized cities. 23 There were fewer participants in the 2014-2015 cohort.This may have impacted the results.One reason for the lower participation in 2014-2015 was that the data collection had to be concentrated due to the rebuilding of the research clinic and a high dropout rate in this cohort (40.5%).
Although few individuals reported concerns with oral health or orofacial appearance, it is important to meet oral self-perceived needs and demands of older adults.This highlights the necessity to investigate what expectations older adults have of their oral health and orofacial appearance and not just focus on what is clinically observed in the oral cavity.AUTH O R CO NTR I B UTI O N SSH contributed to conception, design, data collection, analysis and interpretation of data, preparation of manuscript and tables.PA and VWB contributed to conception and design, analysis, and interpretation of data, critically reading and revising the manuscript.SR and NL contributed to conception and design, critically reading and revising the manuscript.JSB provided the data, contributed to critically reading and revising the manuscript.All authors revised and approved the manuscript prior to submission.