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1Department of Oral Surgery, Oral Medicine and Hospital Dentistry, Department of Ambulatory Care and Community Medicine, School of Medicine, University of Lausanne, Switzerland
2North of Vaud & Broye Long Care Term Facilities Association, Switzerland
Received date: May 11, 2012; Accepted date: August 21, 2012; Published date: August 23, 2012
Citation: Carlos M, Tové K, Aline R, Marcelo A, Yves K (2012) Bio-Psycho-Social Oral Health Features in 2 Long-Term Care Facilities in Western Switzerland. J Palliative Care Med S1:004.doi: 10.4172/2165-7386.S1-004
Copyright: © 2012 Carlos M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: The objectives of this exploratory study are to screen oral conditions of residents living in two longterm facilities (LTCF’s) in the canton of Vaud, West Switzerland, and to assess the impact of oral health status of the patients on their quality of life and nutritional balance.
Results: Eighty-two patients accepted to participate in this study. After mental and dexterity examination, 39 patients fulfilled the inclusion criteria conditions. The mean Deciduous Missing Filled Teeth value (DMFT) at baseline was 30.7 (SD 2.6). Ninety five percent of the residents wore removable dentures. Denture hygiene was considered poor or very poor in nearly one third of the residents. Wearing dentures at night was a common feature among the residents. Mean Oral Health Impact Profile-14 score at baseline was 4 (SD 5) and 4 (SD 5.4) at 6 months evaluation. After paired sample t-test, there were no statistically significant differences between the two evaluations. Several basic foods were reported as, at least, difficult to eat.
Conclusions: Within its limits, this study shows that the oral status of patients living in the 2 reported LTCF’s is poor. High scores of missing and decayed teeth are reported. Most of the residents are partially or fully edentulous, wearing removable dentures. There is a lack of denture hygiene in an important proportion of the residents. Several patients report important problems in their selection of food. Paradoxically, oral health related quality of life is high, maybe related to a high resilience in this oldest population.
Oral health; Elderly; Long term facilities; Quality of life; Food
According to a report of the WHO of 2003, the proportion of older people will continue to grow everywhere in the world. By 2050, there will be 2 billion people over the age of 60, 80% of them living in developing countries. Cancer, cardiovascular diseases, diabetes, respiratory infections and, very often ignored, a very poor oral status, due mainly to loss of teeth, are frequent in this group of patients [1,2].
Impaired mental capacities, less visual acuity, lack of manual dexterity and lack of knowledge about cleaning techniques are the common issues directly related with the poor oral status [3-5].
The oral health status of elderly patients living in Long Term Care Facilities (LTCF’s) is mainly affected by infections (candidiasis affect 25% of patients), and by xerostomia. At least 25 to 30 % of the population older than 65 years complains also about non-infectious diseases of the oral mucosa, especially vesiculobullous disorders (e. g. pemphigus, mucous membrane pemphigoid, Linear IgA disease). Orofacial pain is another major problem for this population (e. g. trigeminal neuralgia) [6].
Partially or fully edentulous patients represent a particular group. The loss of teeth during life must be compensated by functionally effective dentures [7]. But, poor fitting of prolonged use of dentures are a common issue in partially or fully edentulous individuals and is directly related to Denture Related Stomatitis (DRS) [8]. In addition, Salerno et al. report that patients suffering from DRS often do not receive instructions concerning oral and denture hygiene [9].
The aspiration of oral bacteria by institutionalized elderly individuals is a risk factor for pneumonia [10]. A correlation between oral hygiene and pneumonia episodes, using measurable indexes as Dental Plaque Index (DPI) or Tongue Plaque Index (TPI), has been reported. The number of patients who developed pneumonia was significantly higher (p<0.01) for those ranked as poor DPI [11]. Another study of 613 elderly nursing home residents demonstrates that two of nine modifiable risk factors have a significant association with pneumonia risk. These two factors are inadequate oral care and difficulty in swallowing [12].
Oral health quality of life seems to be correlated to the number of teeth and quality of dentures [13]. A significant relationship between poor dental health conditions and lowered lifestyle activity has been reported [14]. Recently, research has suggested the impact of oral and general health on the quality of life in older populations [15].
Oral status of elderly affects their perceived ability to eat a range of common foods. A significant percentage of older people living in Long Term Care Facilities (LTCF’s) (ranging from 5% to 57%, depending of the food) reported that they had difficulties or could not eat at all various types of essential foods [16].
Based on literature, there are serious concerns of health authorities, and the regional administration of the LTCF’s of the canton of Vaud concerning the oral status of LTCF’s residents, and this study intend to provide exploratory data on oral health status of elderly patients living in two of these LTCF’s.
The objectives of this study were to screen oral conditions of patients of two LTCF’s in the canton of Vaud, West Switzerland, and to assess the impact of oral health status of the patients on their quality of life and nutritional balance.
This study was approved by the Ethical Committee of the Faculty of Biology and Medicine, University of Lausanne. The residents of two different LTCF’s located in West Switzerland agreed to participate in this study after receiving informed consent.
The two LTCFs were located in Western Switzerland. One was an urban facility (EMS les 4 Marroniers: LTCF1) located in the heart of a city of 25,000 inhabitants, and the second was a rural facility (EMS la Veillée: LTCF2) located in a community of 400 inhabitants. Other than their location, there were no major differences (mean age, male/ female proportion, co-morbidities, and level of income) between the residents of both LTCF’s.
Inclusion criteria were as follows: 65-years-old or more, adequate capacity to understand the procedure (cognitive state evaluation), and adequate dexterity. Exclusion criteria were non-compliance (cognitive status) or lack of interest in the subject, and need for antibiotic prophylaxis before oral examination.
Prior evaluation
All the residents of the LTCF’s were individually invited to participate in this study. Residents accepting to participate were evaluated for dexterity and cognitive status. Dexterity ability was evaluated by means of the nine-hole peg test of finger dexterity (9HPT). Mini Mental State Examination, computer based - French version (MMS), was used for grading the cognitive state of patients. Patients scoring 24 points or less are considered being impaired from a cognitive point of view [17].
Clinical examination
82 residents of the two LTCF’s (LTCF1 n= 50 and LTCF2 n= 32) were assessed. The assessment was performed by two experienced dentists previously calibrated. Two examinations of the oral cavity (baseline and 6-month control) were performed and the next conditions were collected:
- Dental status: Decayed, Missing or Filled Teeth (DMFT) for 32 teeth [18].
- Denture condition: type, condition, stability, habits/prosthesis. A modified questionnaire was completed by the calibrated dentist [19].
Oral health-related quality of life and food choice
The OHIP-14 and Shaiham food choice questionnaire were used. OHIP-14 consists of 14 simple questions gives a multidimensional approach of dental, prosthetic and oral dysfunction’s on, for example, phonation, taste, mastication, and aesthetics. The OHIP-14 score gives a value ranging from 0 for very high quality of life to 56 for very poor quality of life. Shaiham food choice questionnaire asses 16 individual key foods, listed from those that are considered to be easy to those that are considered to be difficult to chew. Three options are given: eatable 1= easily; 2=with some difficulty; 3=not at all [16,20,21].
No radiographic examination was performed. With the help of a pocket lamp, one of the calibrated dentists performed the clinical examination of the oral cavity and established a dental chart. Before examination, the teeth (if present) were cleaned with sterile gauze.
All other relevant pathology (e. g. DRS) was noted and communicated to the patient.
Results were stored in Excel file table. Data were afterwards analyzed with Statistical Packages of the Social Sciences (SPSS) version 20 (IBM SPSS Statistics 20).
Eighty-two residents accepted to participate. After 9HPT and MMS examination, 39 residents (47.5%) fulfilled the inclusion criteria, meaning that more than half of the residents were excluded because of lack of dexterity and/or cognitive deficiencies.
Two clinical examinations and questionnaire assessments (baseline and 6 months after) were performed.
The mean age of the selected residents at baseline was 87.3 (SD 7.8) years, 30 were females. Six months later 7 patients had deceased, and so the mean age became 87 (SD 8.1) years, with 23 female residents. There were no statistically significant differences in age between males and females.
Twenty-nine patients lived in the LTCF1. After six months this number had decreased to 23.
Dental status
The mean DMFT value at baseline was 30.7 (SD 2.6), with a mean of 28.3 (SD 5.9) of missing teeth; a mean of 1.3 (SD 2.7) of decayed teeth and a mean of 1 (SD 2.6) of filled teeth. These results reflect a very poor oral status.
Denture condition
Ninety-five percent of the residents carried a removable denture (n=37 in the maxilla and n=32 in the mandible). Thirty-three of the screened patients had worn removable dentures for more than 5 years. Complete and detailed distribution of the dentures is presented in Table 1.
| Baseline | Baseline | 6 months | 6 months | |
|---|---|---|---|---|
| Type of denture | Maxilla | Mandible | Maxilla | Mandible |
| Complete | 35 | 21 | 28 | 18 |
| Partial (resin) | 1 | 4 | 2 | 2 |
| Partial (metal frame) | 2 | 7 | 1 | 5 |
| None | 1 | 7 | 1 | 7 |
Table 1: Type and distribution of dentures at baseline and 6 months.
Denture hygiene was considered poor or very poor in 28.2% of the residents at baseline, and in 25% of the residents at 6-month examination.
Dentures cleaning practice (at least once a day) was reported by 97.4% and 94% according to the examination period. Toothbrush was the most common instrument reported used to clean the dentures (92.3%). A 68.4% of the patients reported cleaning their dentures with toothpaste, followed by water (13.1%). Other additional methods like cleaning solutions or soap (13.1%) were represented in only 13.1% of the cases.
Night denture wearing was very common: 72% and 69% of the residents reported this practice at the baseline and the 6-month interview. Surprisingly enough, only 3 patients showed clinical signs (localized simple inflammation (type I)) of DRS.
Oral health-related quality of life and food choice
Regarding oral health related quality of life of residents, mean OHIP-14 score at baseline was 4 (SD 5) and 4 (SD 5.4) at 6-month evaluation. It was important to evaluate the validity of the questionnaire and its stability over time, and a paired sample t-test, used to compare repeated measures, showed there were no statistically significant differences between the two evaluations, which confirmed the 0-hypothesis. After weighting cases by facility, the Chi-Square test (alpha=0,05), used to compare two independent samples, revealed significant differences for quality of life between both facilities on both baseline and 6-month interview. Residents in the LTCF2 (rural facility) indicated a better total quality of life than their counterparts in the LTCF1 (urban facility).
Most residents were partially or fully edentulous, wearing removable dentures for more than five years. In this context, several of the sixteen basic foods enquired were reported to be, at least, difficult to eat (Table 2). Some foods were reported not to be eaten: crusty bread in 10.3% at baseline; toast in 10.3 % at baseline and at 6 months; well-done steaks in 10.3% at baseline and in 12.8% at 6 months; apples in 28.2% at baseline and in 15.4% at 6 months; tomatoes in 61.5% at 6 months; nuts in 25.6% at baseline and in 12.8% at 6 months.
| Baseline | 6 months | |||||
|---|---|---|---|---|---|---|
| You could eat it... | 1 | 2 | 3 | 1 | 2 | 3 |
| Sliced bread | 74.4% | 17.9% | 7.7% | 64.1% | 17.9% | 0% |
| Crusty bread | 61.5% | 28.2% | 10.3% | 69.2% | 28.2% | 2.6% |
| Toast | 61.5% | 28.2% | 10.3% | 35.9% | 35.9% | 10.3% |
| Cheese | 84.6% | 10.3% | 5.1% | 84.6% | 12.8% | 2.6% |
| Tomatoes | 71.8% | 20.5% | 7.7% | 33.3% | 61.5% | 5.1% |
| Raw carrots | 94.9% | 5.1% | 0% | 89.7% | 10.3% | 0% |
| Roast potatoes | 89.7% | 7.7% | 2.6% | 87.1% | 10.3% | 2.6% |
| Cooked greens | 89.7% | 10.3% | 0% | 87.1% | 10.3% | 0% |
| Lettuce | 71.8% | 25.6% | 2.6% | 69.2% | 25.6% | 5.1% |
| Sliced cooked meats | 97.4% | 2.6% | 0% | 82.1% | 17.9% | 0% |
| Well done steaks | 33.3% | 56.4% | 10.3% | 56.4% | 30.8% | 12.8% |
| Apples | 28.2% | 43.6% | 28.2% | 28.2% | 56.4% | 15.4% |
| Oranges | 82.1% | 7.7% | 10.3% | 87.1% | 10.3% | 2.6% |
| Nuts | 53.8% | 20.5% | 25.6% | 69.2% | 17.9% | 12.8% |
| Crisps | 84.6% | 15.4% | 0% | 94.8% | 2.6% | 2.6% |
| Chocolates | 76.9% | 17.9% | 5.1% | 82% | 17.9% | 0 |
Table 2: Reported eat ability of sixteen types of essential food.
Even if extensive reviews of the literature show a rapid decrease in the rate of edentulism, poor oral health is still frequently reported among institutionalized elderly people. This feature was confirmed in the present study [22].
It must be stressed that the data presented should be analyzed with caution. This is an exploratory study, where only two LTCF’s were screened, giving a small sample. It must also be noted that from the 80 residents initially screened roughly half of them fulfilled dexterity and cognitive requirements. There is no reason to believe that the oral condition of the excluded population would be better than the one of the participants.
Moreover, two clinical examinations and questionnaire assessments (baseline and 6 months after) were performed, allowing obtaining stable figures. This is important because oral status may change fast in older populations in short time span. Secondly, we were not able to find the validated French version of OHIP questionnaire. Two assessment periods were necessary because it has been reported that in studies where the questionnaire had been translated into other languages, such as French, some questions and categories could not be properly translated, affecting the instrument’s reliability [21]. Finally, this report presents data from a multidimensional approach, and several aspects (oral status, nutritional habits and quality of life) were evaluated in the same population.
The very high DMFT of 30.7 of the reported population is consistent with findings of other populations reported in UK (DMFT=22.2), Croatia (DMFT=27), or Norway (DMFT=25.7) [23,24]. Even if missing teeth were the main problem, the presence of caries was also reported; this may result not only in pain, but also in the development of abscesses, cellulitis and bacteremia with a potential vital risk in older individuals [25]. Denture hygiene was considered poor or very poor in nearly one third of the reported residents during the two examinations. Denture plaque and poor oral hygiene are not only associated with DRS but they may also serve as a reservoir of other potentially infectious pathogens potentially at risk of severe pathologies like aspiration pneumonia [26,27].
Dentures night wearing, a common habit within elderly, is a factor directly related with DRS [9]. In a group of 150 complete denture wearers, 64% (96 subjects) declare to usually sleep with their dentures [5]. In the present study between 69%-72% of the residents reported to wear their dentures during sleeping on a regular basis. Even if this data was not collected in a systematic way, it is interesting to mention the fact that sleeping with the dentures in the mouth was not considered a health risk factor among residents and care providers.
Most residents in the present study reported relatively frequent denture cleansing; however, this apparently positive statement must be carefully evaluated. Actually, the frequency of denture brushing is not to be considered equivalent to effective cleansing. Even if impaired mental capacities or lack of dexterity were excluded from the reported population age related limitations strongly influence the effectiveness of brushing [3,4]. We assume that the lack of hygiene was related to unsatisfied needs for instructions concerning oral and denture hygiene. This unsatisfied needs influence the presented data more than cognitive or dexterity aspects [8].
The frequent reported use of toothpaste to clean dentures (68.4%) must be mentioned because might it have an influence on dentures surface roughness due to the presence of abrasives. Only 13.1% of the patients used non-containing abrasive products like soap to clean their dentures. Surface roughness being positively correlated with the rate of fungal colonization of biomaterials, and a rougher surface may be a risk factor for microorganism adhesion and biofilm formation [28,29].
It has been suggested that quality of life is particularly affected by oral status, and oral pathologies can cause a deterioration of life [15]. Locker et al. [30] suggested that oral disorders have a significant effect on the well-being and life satisfaction of older individuals. Surprisingly enough, the residents of the present study showed a low mean OHIP- 14 score, compared to other reported populations. The high mean age (87.3 years) of this reported population must be noted. Slade and Sanders reported a mean OHIP-14 score of 6.5 among 640 individuals older than 65 years. An explanation proposed for this score was the resilience (e.g. due to hardship experiences in the past) of older adults to poor clinical status [31]. The results of OHIP-14 of the reported research seem to confirm this statement.
Ability to bite and chew is important in older people and has an influence on their nutritional status [16]. Missing teeth can influence oral and systemic health, because it alters food selection resulting in carbohydrate rich diet (softer and more easily chewed), lacking fibers and proteins [32].
Sheiham et al. reported a higher percentage of edentates among institutionalized residents compared to free living individuals at same age range. Between 50 and 56 percent of participants in their study had difficulty in eating and could not eat several basic foods like apples, carrots, well-done steaks or toast [16]. As stated in the results section, roughly 15% of LTCF’s residents reported to have not been eating at all rich fiber and/or protein food.
Within its limits, this exploratory study shows that the oral status of patients living in the two reported LTCF’s of the canton of Vaud was poor. High scores of missing and decayed teeth are reported. Most of the residents were partially or fully edentulous, wearing removable dentures. There is a lack of denture hygiene in an important proportion of the residents. Selection of food was an issue as reported by approximately 15% of the residents. Paradoxically, oral health related quality of life was high, maybe related to a high resilience in this oldest population. A larger evaluation involving a larger number of facilities, and all the residents living there, is necessary in order to validate, or refute, the presented collected data from an epidemiological point of view.
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