|Year : 2023 | Volume
| Issue : 1 | Page : 13-19
Impact of oral diseases on oral health-related quality of life among older people
Department of Public Health, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Submission||05-Jun-2021|
|Date of Decision||22-Oct-2021|
|Date of Acceptance||25-Nov-2021|
|Date of Web Publication||17-Feb-2023|
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
Context: Oral diseases are an important public health problem because of their high prevalence, their impact on individuals and society, and the expensive nature of their treatment. The oral health of the older population is a global concern. Major problems include a high prevalence of missing teeth, dental caries, periodontal disease, and wasting diseases. Poor oral health has an influence on the quality of life (QoL) as well. We attempted to assess the impact of oral diseases on oral health-related QoL (OHRQoL) using the Geriatric Oral Health Assessment Index (GOHAI) questionnaire. Aim: To investigate the impact of oral diseases on OHRQoL using the GOHAI questionnaires. Settings and Design: The study was a population-based cross-sectional survey conducted among the older populations in South Kerala. Subjects and Methods: This was a population-based cross-sectional study, in which 399 people participated: 200 were female and 199 were male. People above 60 years of age, who were permanent residents of the district, were recruited for the study. The sampling method used was circular systemic random sampling. Clinical examination was done according to the World Health Organization Oral Health Assessment Form 2013, and OHRQoL was recorded using GOHAI questionnaire. Statistical Analysis Used: Descriptive analysis was performed using frequencies of variables, such as means and standard deviations. The bivariate analysis used Student's t-test to determine the association between variables. Results: The mean age of the subjects was 65 ± 5.5 years. Significant associations were found between the psychosocial domain and missing teeth (P < 0.05) and periodontitis (P < 0.05). In multivariate regression analysis, an association between the pain/discomfort domain was found in denture wear (P < 0.046) and tooth sensitivity (P < 0.003). Conclusions: The study found a reduction in the OHRQoL among the study population. The study finding underscores the impact of oral diseases on QoL.
Keywords: Dental caries, Geriatric Oral Health Assessment Index, older people, oral diseases, oral health-related quality of life
|How to cite this article:|
Salim R. Impact of oral diseases on oral health-related quality of life among older people. Indian J Dent Sci 2023;15:13-9
|How to cite this URL:|
Salim R. Impact of oral diseases on oral health-related quality of life among older people. Indian J Dent Sci [serial online] 2023 [cited 2023 Mar 27];15:13-9. Available from: http://www.ijds.in/text.asp?2023/15/1/13/369896
| Introduction|| |
Oral diseases are an important public health problem because of their prevalence, their impact on individuals and society, and the expensive nature of their treatment. Globally, poor oral health among older people has been seen in high rates of missing teeth, dental caries, periodontal disease, and oral cancer. In recent years, researches demonstrated the impact of oral health on the quality of life (QoL) and general health of the older population.,
The World Health Organization (WHO) defined QoL as an “individual perception of his or her living situation, understood in a cultural context, value system and about the objectives, expectations, and standards of a given society.” From this perspective, health-related QoL includes areas such as physical health, psychological state, level of independence, personal relationships, beliefs in a particular context or the natural environment, and social support.,
For people suffering from chronic diseases, QoL has become a critical measure. There are two main approaches to understanding the QoL of the older people. The first is improvement in health care and leads to a decrease in both mortality and morbidity, resulting in improved QoL. The second is that medical technologies are improving, resulting in improved QoL measurements.
The older we get, the more we suffer physical ailments and social problems. The major social problem older people face is adjusting to their surrounding social world in general and their immediate families in particular. Often, older people feel neglected and forgotten by their family, which leads to sorrow, frustration, and anger, which also cause tension in the family, which may result in inappropriate dietary intake.,,
The aging of the population is more of a victory for health care than a challenge for it. The biggest challenge the policymakers will face is dealing with the diseases of old age. Systemic diseases and oral diseases share many risk factors. Age-related oral health problems are a global concern, occurring in the form of missing teeth, dental caries, periodontal disease, and wasting diseases. According to the WHO, oral health is an integral part of general health and well-being and an important determinant of QoL.
Understanding how older people perceive and evaluate their oral conditions is vital because their perception determines whether or not they will use dental services. It is essential to understand how older people perceive and evaluate their oral conditions because this perception conditions the patient to utilize dental services. It is uncommon for people to recognize their health issues that affect eating, speaking, chewing, physical appearance, and social life, causing pain and leading to depression.
It is particularly important to note that poor oral conditions have a negative impact on daily life for older people. Extensive tooth loss reduces chewing ability and impacts food choices. There are several factors that link poor oral health with poor general health; for example, severe periodontal disease is associated with diabetes mellitus, ischemic heart disease, and chronic respiratory disease. Tooth loss has also been linked with an increased risk of stroke. Access to oral health care is limited in underdeveloped nations, according to studies, and teeth are frequently extracted due to pain or discomfort, or a lack of supplies for dental treatment.
Over the past 20 years, a variety of oral health-related quality of life (OHRQoL) instruments have been developed, as a result of increased concern about the impact of oral diseases on a person's QoL. The most commonly used tool is the Geriatric Oral Health Assessment Index (GOHAI). GOHAI is an important indicator of health because it expresses the individual's cultural beliefs as regard his/her oral health.,
To investigate the impact of the presence of oral diseases on OHRQoL using the GOHAI questionnaires.
| Subjects and Methods|| |
The present study is a population-based cross-sectional study of older people residing in Kollam, district of southern Kerala, South India. The study was carried out over a period of 3 months in 2017. The study was approved by the Institutional Ethics Committee of Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. Participants were selected from both urban and rural areas of the district. Random numbers were generated for the rural and urban study areas separately (lottery method). Participants were chosen by circular systematic random sampling from the sampling frame. To determine the sampling interval in each category, we divided the total number of older people by the number of people required in each category (rural and urban). The first person in each category was identified by a random number between one and the last number corresponding to the last person on the list, and that number was selected at random. The person corresponding to the random number was selected from the list. Participants were selected in a circular manner by adding successive sample intervals to the first random number. The older person was contacted either personally or through ASHA workers in the area. Those who had consented were approached directly at their homes, workplaces, or any other convenient location.
The sample size for this population-based cross-sectional study was determined by taking the prevalence of unmet tooth extraction needs of older people from a previous study. The sample size was calculated using Open-source Epidemiologic Statistics for Public Health (OpenEpi) version 3.03a. The required sample size at 95% confidence level was 317 older people from the entire district. To accommodate the nonresponse rate, the sample was increased by 20% and rounded to whole numbers. Hence, the total sample size was 381, rounded off to 400.
The final sample had 399 participants (dropped out from study n = 1). The inclusion criteria of the study were people aged 60 years and above and who were permanent residents of the district (according to information provided by local self-government department [LSGD]) and who all had responded rationally. The exclusion criteria included people who were not willing to provide informed consent and people with dementia.
The survey was conducted by a single examiner; this helped introduce reliability. The data collection included a semistructured questionnaire collecting sociodemographic details, WHO Oral Health Assessment Form 2013. The investigator went through the process of training and calibration to assess clinical oral health status and GOHAI questionnaire.
The sociodemographic characteristics included age (age groups 60–70, 71–80, and 80 and above); gender (male and female); marital status (married, unmarried, and others); level of education (matriculation, matriculation, and above); occupation (office work, skilled, semiskilled, unskilled, and unemployed.); income (Antyodaya Anna Yojana, below poverty line, and above poverty line); past dental visit (visit within 1 year visit more than a year, and others).
The clinical assessment included dental caries, gingivitis, missing teeth, prosthesis, periodontitis, and sensitivity. According to the WHO standards, clinical examinations were conducted with a plane mouth mirror and metallic probes (community periodontal index [CPI] probes). The area for conducting examinations was planned and arranged for maximum ease of operation. The locations were either the participant's house or a nearby primary health subcenter. The participants' examination position is determined by the available furnishings. The participant was requested to sit in a chair with the examiner standing behind. The possibility of cross-infection when conducting examinations or handling contaminated instruments was minimized. Current national recommendations and standards were followed for both infection control and waste disposal.
QoL was assessed by the general/GOHAI. The GOHAI measure is a 12-item questionnaire developed by Atchison and Dolan for use with older populations with 3 months' time reference.
The questionnaire was developed to evaluate three dimensions of oral health-related QoL among older people, which includes physical functions such as eating, speech, and swallowing; psychosocial functions such as worry, worry about oral health, discontent with appearance, self-consciousness about oral health, and avoidance of social contacts because of oral problems; and pain or discomfort including the use of medication or discomfort from the mouth. GOHAI gives more weightage to pain and discomfort. It mainly focuses on the subjective assessment of oral health.
The 12-item GOHAI questionnaire contains both negatively and positively worded items. The low score indicated an oral health problem and a high score indicated a good oral health.
Validation of the tool: First, we did the translation and linguistic adaptation of the questionnaires into Malayalam, the local language. We followed the guidelines regarding the translation of the questionnaire into Malayalam. The version translated by a professional (language expert) was compared by the principal investigator. The translation was done to achieve the equivalence of a word or a phrase. The meaning of the sentence was adapted and gave the best of the translation in a simple, clear, and understandable manner. The translated version was given to a group of people and they were asked to rephrase the question in their own words or to say what they think the item means (cognitive debriefing). After this stage, the process of “back translation” was done. Each item was translated back to the source language English by a second person, and the English versions were checked for consistency. Conflicts were resolved by repeating this cycle. Each item in the translated and back-translated questionnaires had undergone strict verification and necessary corrections until both versions became agreeably consistent in the final questionnaire.
GOHAI is a self-administered questionnaire. The questions were about oral problems and difficulties in the past 3 months. The answers were on a Likert scale, with options of 1 = always/often, 2 = sometimes/seldom, and 3 = never. Participants were instructed to give a tick mark to the appropriate answer to each question. Using a self-administered questionnaire was possible in this population who had a high rate of literacy.
The data were entered and analyzed using the statistical package, SPSS, (Version 17, IBM, SPSS Statistics). Descriptive analysis was performed using frequencies of variables, such as means and standard deviations. The bivariate analysis used Student's t-test to determine the association between variables. A confidence level of 95% was adopted for all statistical tests. A multivariate analysis was undertaken to evaluate the relationship of the variables that demonstrated some significance with domains of GOHAI questionnaire.
| Results|| |
The sample population from the two LSGDs (one urban and one rural) consented to the study was 400 individuals. Of these, 399 participated in the present study, and of these, all participants exhibited the suitable cognitive capacity to respond to the GOHAI. Of these, 199 (50) were male. Age ranged between 60 and 89 years and with a mean age of 65.3 ± 5.5. The majority of the participants were married (372; 92.3%) and were living with family. Fifty-two percent of the study population belonged to the below the poverty line. The study showed that 33.4% of the study population had consulted a dentist within the past year [Table 1].
|Table 1: Sociodemographic characteristics of the study population (n=399)|
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The oral health status of older people revealed that 49.6% had dental caries and 31.5% had periodontitis. Periodontal conditions were analyzed using CPI index. The results showed that prosthetic rehabilitation was inadequate in the study population as 80.9% had reported missing teeth and no evidence of dentures [Table 2].
The GOHAI questionnaire consisted of 12 questions with three dimensions psychosocial, physical, and pain/discomfort. The scores are recorded as 1 = always/often, 2 = sometimes/seldom, and 3 = never. Reverse scoring was done for items 1, 2, 4, 6, 8, 9, 10, 11, and 12, so that the directions of all responses were the same [Table 3].
|Table 3: Oral health-related quality of life assessment using Geriatric Oral Health Assessment Index questionnaire|
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A score ≥50 was considered high, score from 49 to 30 indicated moderate, and ≤29 indicated low rating for oral health. A score of 60 indicated a good OHRQoL. There was no recommended cutoff value for the GOHAI to discriminate between good and poor oral health [Table 4].
The variables of sociodemographic details and domains of GOHAI questionnaire were statistically analyzed for the association. A significant association was found between education and psychosocial domain (P < 0.05) and past dental visit and pain domain (P < 0.05) [Table 5].
|Table 5: Mean and standard deviation of Geriatric Oral Health Assessment Index dimensions according to socio demographic details|
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In bivariate analysis, a significant association was found between the psychosocial domain and missing teeth (P < 0.05) and periodontitis (P < 0.05). The results from multivariate logistic regression indicated that there were no significant associations between the physical domain of GOHAI questionnaire and missing teeth, filled teeth, gingivitis, dental caries, and denture wear and teeth sensitivity. However, a significant association was found between periodontitis and physical domain (P < 0.000). The dependent variable taken was the physical dimension of GOHAI questionnaire [Table 6].
|Table 6: Mean and standard deviation of clinical variables with Geriatric Oral Health Assessment Index questionnaire|
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The association between pain and discomfort domain was found in denture wear (P < 0.046) and tooth sensitivity (P < 0.003). There was no significant association between pain domain and missing teeth, filled teeth, gingivitis, periodontitis, and dental caries. The dependent variable used is the psychosocial domain of GOHAI questionnaire [Table 7]. A significant association was found between sensitivity (P < 0.003) and pain domain in GOHAI [Table 8].
|Table 7: Multivariate logistic regression results of key variables and physical domain of Geriatric Oral Health Assessment Index questionnaire|
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|Table 8: Multivariate logistic regression analysis showing the association between key variables and pain domain in Geriatric Oral Health Assessment Index questionnaire|
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A significant association was found between missing teeth (P < 0.008), periodontitis (P < 0.002), and psychosocial domains of GOHAI. However, no association was found between filled teeth, gingivitis, dental caries, and denture wear and tooth sensitivity. The dependent variable used is the pain/discomfort domain of GOHAI questionnaire [Table 9].
|Table 9: Multivariate logistic regression results demonstrating the key variables with psychosocial domain of Geriatric Oral Health Assessment Index questionnaire|
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| Discussion|| |
According to the authors, the GOHAI questionnaire is a self-reported geriatric oral health assessment tool, not a replacement for clinical assessment. Psychological, emotional, socioeconomic, cultural, and spiritual issues all played a role in the OHRQoL. Thus, the psychosocial domain shows how the person behaves in society, their concern or care of their oral health, dissatisfaction with appearance, self-awareness on oral health, and avoidance of social contacts due to dental problems. The physical domain consists of physical function, physical performance, and physical pain and general health also involving issues of eating, speaking, and swallowing. Pain is related to discomfort when chewing food and sensitivity when having cold or hot foodstuffs. Pain is considered the most important reason to seek dental care.,
The OHRQoL of an older person is associated with various sociodemographic factors such as education and history of the dental visit. A significant association was found between the psychosocial domain and education of the person (P < 0.04). This shows that people who are more educated are more concerned about their oral health problems. Studies also showed that individuals of higher socioeconomic status will have better GOHAI scores. This issue generates social, psychological, and functional limitations, predominantly in relation to esthetics. These people experience eating difficulties, and they feel restricted in the other's presence.
Furthermore, literature studies have shown that missing teeth may have a negative influence on oral health-related QoL of older people, and in this study, missing teeth and psychosocial domains are significantly associated (P < 0.008). This finding was in consensus with the study carried out by Dantas Torres. However, there was a significant association between pain domain and history of dental visit (P < 0.04). This shows that pain is the most important outcome for utilization of dental services.
A significant association was found between the periodontal and psychosocial domain (P < 0.007). With regard to an opinion about dental caries, gingivitis, and prostheses, psychosocial dimension results were not found to be significant. The results from this study also identify the subjective oral health-care needs and clinically assessed needs of these diseases; the possible reason for not reporting poor oral health in GOHAI questionnaire may be due to the negative self-evaluation when expressing a bad opinion about their oral health conditions.
Pain is one of the most common reasons for older people to seek dental care. A significant association has been found between dental caries (P < 0.01), gingivitis (P < 0.001), and teeth sensitivity (P < 0.001). Pain is subjective, and sensation and perception of pain will vary from person to person., Pain is also related to the discomfort when chewing, sensitivity in the tooth and gum, and, finally, the need for treatment to relieve pain.
The physical domain involves issues with eating, speaking, esthetics, and swallowing. There are many reasons for poor scores in the physical domain among older people, as age increases changes in orofacial functions such as loss of muscle tone, psychomotor retardation, and changes in taste perception due to multi medication therapy or oral diseases which influence the eating habit of the person. The other issues faced by older people are loss of teeth due to dental caries or periodontal diseases and ill-fitting dentures. The missing teeth in an older person have different meanings as it promotes a feeling of shame and creates a need for the replacement of teeth, which is expensive for most of them and they remain edentulous for the rest of life.,, A significant association was found between gingivitis (P < 0.006), periodontitis (P < 0.001), missing teeth (P < 0.001), and prosthesis (P < 0.02). On multivariate analysis, a significant association was found between periodontal disease and the physical domain of GOHAI questionnaire. Older people with periodontal disease face problems with chewing. It was found that people with periodontitis have substantially lower OHRQoL compared to others. This research shows that there is an interrelationship between oral diseases and OHRQoL. This relationship is proved from previous research as well. The limitation of this study is that it had a small sample size and the study was localized to a particular area. Majority of the study participants were from the lower socioeconomic class and it has reflected on the study results.
| Conclusions|| |
The study focused on assessing the impact of oral diseases on OHRQoL. The study found a reduction in the OHRQoL among the study population. The study finding underscores the impact of oral diseases on QoL.
The use of GOHAI questionnaire had helped reveal information about the psychosocial and social factors of QoL, which would not have been obtained by clinical assessment alone.
Finally, a better understanding of relationships established between oral health problems and QoL among the older population will encourage the policymakers for public health planning that promotes health and include preventive and rehabilitation services for older people.
The study was approved by the Institutional Ethics Committee of Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, approval number SCT/IEC/1142/DECEMBER-2017.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]