ABSTRACT
Vyšniauskaite S. Oral health behaviour, conditions and care among dentate elderly patients in
Lithuania: preventive aspects. Department of Oral Public Health, Institute of Dentistry,
University of Helsinki, Helsinki, Finland, 2009. 72 pp. ISBN 978-952-92-6312-7
The present cross-sectional study aimed to assess or
al health behaviour, dental and periodontal
conditions, dental care, and their relationships among elderly dentate patients in Lithuania.
The target population in the study were dentate patients aged 60 and older attending public
dental services in Kedainiai, Lithuania. The data collection took place between the autumn of
1999 and the winter of 2001. Data were collected by means of a self-administered questionnaire
for all (n=174) and a clinical examination targeting about half of the subjects (n=100). The
questionnaire inquired about oral health behaviour, the life-first and also the most recent dental
treatments, sources on and self-assessed knowledge of oral self-care, a self-reported number of
teeth, and socio-demographic information. The clinical examination included basic dental and
periodontal conditions.
A total of 82 women and 92 men completed the questionnaire; their mean age was 69.2 and
their average number of teeth was 16.2 (CI 95% 15.4-17.1). In all, 25% had 21 or more teeth
and 32% indicated wearing removable dentures. The oral health behaviour, the participants
reported, was poor: 30% reported twice daily toothbrushing, 57% responded that they always
use fluoride toothpaste, 19% indicated daily interdental cleaning, nearly all said they take sugar
in their coffee and tea, and 30% indicated going for check-ups. As the main source of
information on oral self-care, the subjects indicated health professionals (82%), followed by
social contacts (72%), broadcasted media (58%), and printed media (42%). A total of 34%
assessed their knowledge of oral self-care as good, and their self-assessed knowledge correlated
(r=0.52) with professional guidance they had received about oral self-care. In their most recent
treatment, conservative (39%) and non-conservative (34%) treatments dominated, and
preventive ones were the least reported (7%). Regarding guidance in oral self-care, 54%
reported having received such about toothbrushing, 32% about interdental cleaning, and 33%
had been given visual information. Clinical examinations revealed the presence of plaque,
calculus, bleeding on probing and deepened pockets in all of the subjects; 70% of the subjects
were diagnosed with pockets of 6mm and deeper, 94% with caries, and 73% with overhangs of
restorations. Those subjects assessing their knowledge of oral self-care as good and reporting a
higher intensity of guidance in oral self-care as received, indicated practicing the recommended
oral self-care more frequently. Twice daily toothbrushing was associated with good self-
assessed knowledge of oral self-care (OR 4.1, p<0.001) and a university education (OR 5.6,
p<0.001). Those subjects with better oral health behaviour had a greater number of teeth.
Having 21 or more teeth was associated with good self-assessed knowledge of oral self-care
(OR 4.1, p=0.03). Better periodontal conditions were associated with a higher frequency of
toothbrushing. The presence of periodontal pockets of 6mm and deeper was associated with the
level of self-assessed knowledge of oral self-care being below good (OR=3.0, p=0.04) and the
level of dental cleanliness being poor (OR=2.7, p=0.02).
To conclude, oral health behaviour and conditions call for improvement in elderly subjects in
Lithuania. To improve the oral health of their elderly dentate patients, dentists should apply all
the available tools of chair-side prevention and active guidance. The latter would be an effective
means of updating the knowledge of oral self-care and supporting recommended oral health
behaviour. A preventive approach should be strongly emphasized in countries with limited
resources for oral health care, such as Lithuania.
Author’s address:
Sonata Vyšniauskaite, Department of Oral Public Health, Institute of Dentistry, University of Helsinki,
P.O.Box 41, FI-00014 Helsinki, Finland. E-mail: sonata.vysniauskaite@helsinki.fi
ABBREVIATIONS
ADA American Dental Association
ANOVA Analysis of variances
AAPD American Academy of Paediatric Dentistry
CI Confidence interval
CHX Chlorhexidine
CPITN Community Periodontal Index of Treatment Needs
DMFT Decayed, missing or filled teeth
FDI Federation Dentáire International (World Dental Federation)
FPD Fixed partial dentures (also known as fixed dental prosthesis)
OR Odds ratio
RCT Randomized controlled trial
RPD Removable partial dentures
SD Standard deviation
UK United Kingdom
USA United States of America
WHO World Health Organization
TABLE OF CONTENTS
1. INTRODUCTION 9
2. LITERATURE REVIEW
10
2.1. Oral health behaviour in the elderly 1
0
2.2. Dentition status in the elderly 12
Presence of teeth 12
Dental caries 13
Periodontal conditions 14
Factors predisposing periodontal conditions 15
2.3. Sources of information and knowledge of oral se
lf-care 16
Sources of information 16
Knowledge regarding oral self-care 17
2.4. Dental treatment experiences 18
In-office prevention 19
Conventional dental treatment 20
Provision of oral health care in Lithuania 21
2.5. Prevention of oral diseases in the elderly 21
Theoretical basis for dental prevention 22
Individual-dependent measures: oral self-ca
re 22
Dental office as a setting for prevention 24
3. AIMS OF THE STUDY
27
3.1. Working hypotheses 27
3.2. General aim 27
3.3. Specific aims 27
4. MATERIAL AND METHODS
28
4.1. General description of the study 2
8
4.2. Theoretical framework 29
4.3. Study population 29
4.4. Questionnaire 30
Oral health behaviour 30
Sources of information on oral self-care 31
Self-assessed knowledge of oral self-care 31
Dental treatment experiences 31
Professional guidance in oral self-care 3
2
Socio-demographic background and self-assessed dental conditions 32
4.5. Clinical examination 33
4.6. Statistical analysis 34
5. RESULTS
35
5.1. Oral health behaviour (I, II) 3
5
5.2. Dental and periodontal conditions (I, IV) 36
5.3. Information sources on and knowledge of oral self-care (III) 38
Information sources 38
Self-assessed level of knowledge of oral self-care 39
5.4. Dental treatment experiences (II, III) 39
Active professional prevention 40
5.5. Oral self-care in relation to knowledge and professional guidance (I, III) 42
5.6. Dental and periodontal conditions in relation t
o oral health behaviour and
knowledge (I, II, III, IV)
43
6. DISCUSSION
46
6.1. Methodological aspects 46
6.2. Results of the study 47
Oral health behavior 47
Dental and periodontal conditions 48
Information sources on oral self-care 49
Dental treatment experiences 4
9
Oral self-care, knowledge of and professional guidance in oral self-care 51
Dental and periodontal conditions, and oral health behaviour 52
7. CONCLUSIONS AND RECOMMENDATIONS
53
8. SUMMARY
54
9. ACKNOWLEDGMENTS
56
10. REFERENCES
57
11. APPENDIX
71
ORIGINAL PUBLICATIONS
9
1
. INTRODUCTION
The elderly population is growing fast, especially i
n most industrialized countries (Petersen &
Yamamoto 2005, SHARE 2005). Lithuania holds the worldwide pattern of industrialized
countries with seniors being a rapidly increasing segment of the population (Statistics
Lithuania). The vast majority of the elderly are independent up to a very old age, and a minority
are frail and functionally dependent.
Rates of edentulousness range from 6% to 78% worldwide (Petersen et al. 2005), but in
industrialized countries an ever growing number of elderly retain an increasing number of their
teeth. For functioning dentition, a minimum of 20 teeth has been suggested since the 1980s
(Käyser & Witter 1985, Käyser 1981). It has been adopted as a goal by the WHO (1982) that
more than 50% of those aged 65 and older possess at least 20 functioning teeth. Such a goal has
been achieved in Sweden (Österberg & Carlsson 2007), Norway (Holst 2008, Henriksen 2004),
and nearly in the UK (Kelly et al. 2000).
To guide the public in the maintenance of oral health, authorities in a number of countries issue
recommendations. A large proportion of elderly subjects in industrialized countries follow such
recommendations regarding twice daily toothbrushing, interdental cleaning, and going
habitually for check-ups.
The dental profession faces a challenge to care for the increasing number of elderly. They are
one of the priority groups emphasized by WHO (Petersen & Yamamoto 2005, Petersen 2003),
that predominantly retain their own teeth, or their own teeth and dentures combined. The elderly
prefer dental treatment that allows them to preserve their own teeth and, furthermore, keeps
their teeth looking nice (Niessen 2000). Fillings and prosthetic therapy dominate in the
treatment of the cumulative consequences of dental and periodontal diseases in the elderly.
In industrialized countries, chair-side prevention has been well incorporated into overall dental
treatment, as both elderly subjects and their dentists report. Users of dental services should be
aware of oral self-care, risks, and self-efficacy (Widström 2004). However, active preventive
measures encouraging personal responsibility and active participation of elderly subjects in their
oral self-care seem to be rare.
Knowledge of oral health-related aspects is rather uncommon in the new EU countries that had
similar oral health systems in the past, but which are now undergoing development, such as in
the three Baltic countries. In these countries, the bulk of population based data cover subjects
only up to 64 years of age (Grabauskas et al. 2007, Pudule et al. 2007, Kasmel et al. 1999).
Among those subjects aged 55-64 oral self-care habits are at a low level compared to the elderly
in industrialized countries. As previously reported in Lithuania, oral self-care, the use of oral
health care services among the elderly are below international recommendations, and the use of
sugar is abundant (Abaravicius et al. 2008, Petersen et al. 2000, Aleksejunien÷ et al. 2000). The
scarce data on those aged 65 and older reveal the majority of them having decayed teeth and
periodontal pockets of 6mm and deeper (Skudutyte et al. 2001, Skudutyte et al. 2000,
Aleksejunien÷ et al. 2000).
The present study aimed to assess oral health behaviour, dental and periodontal conditions,
dental care, and their relationships, focusing on preventive aspects among elderly dentate
patients in Lithuania.
10
2
. LITERATURE REVIEW
2.1. Oral health behaviour in the elderly
O
ral health behaviour refers to the subjects’ oral self-care habits, such as toothbrushing, use of
fluoride toothpaste, interdental cleaning, restriction of sugar use, and habitual dental attendance.
The establishment of teeth cleaning behaviour in children is influenced by their parents’ attitude
towards toothbrushing for their children and their own oral hygiene habits (Okada et al. 2002).
Favourable oral hygiene habits are easier to establish in childhood, and, when learnt early, are
more change-resistant later in life (Kiyak 1996). Furthermore, dental care utilization patterns are
learnt as early socialization (Ahacic & Thorslund 2008) and tend to continue into old age
(Bomberg & Earnst 1986). Consequently, few of today’s elderly in Lithuania and apparently in
many other countries have established the recommended oral health behaviour as children.
Toothbrushing is a basic oral self-care method allowing effective control of plaque levels for
prevention of caries and maintaining healthy periodontal conditions (Attin & Hornecker 2005,
Sheiham 1970). Toothbrushing in the evening is emphasized to eliminate food remnants and to
allow fluoride to be present for a prolonged period of time in the mouth when levels of saliva
decrease (Attin & Hornecker 2005). Toothbrushing after a meal helps to prevent impaction of
food during the daytime, and has been an acceptable habit to practice for the adult population in
Japan (Kawamura & Iwamoto 1999). Consequently, toothbrushing in the evening and after a
meal may be advised for elderly subjects, even though current recommendations focus on the
frequency of toothbrushing.
The recommended frequency is brushing teeth on a twice daily basis (ADA 2007a, 2000, Löe
2000). In industrialized countries, from 40% to 97% of elderly subjects report following this
recommendation compared to 21% in Lithuania (Table 2.1).
Table 2.1. Percentages of independent dentate elderly, reporting at least twice daily toothbrushing
and daily interdental cleaning, according to population-based studies.
Country & year of study
Publication
Age n Toothbrushing
2+/day (%)
Daily interdental
cleaning (%)
Nordic countries
Finland 2000
Suominen-Taipale et al. 2008
65+ 964 40 (men)
69 (women)
n.a.
Denmark 2000
Christensen et al. 2003
65+ 428 54 50 (toothpicks)
16 (floss)
Other industrialized countries
UK 1998
Kelly et al. 2000
65+ 669 67
16 (floss, 65-74yr)
12 (floss, 75+yr)
USA
Davidson et al. 1997
65-74 1445 59-97 25-72 (floss)
D
eveloping-economy countries
China
Zhu et al.2005
65-74 3742 23 n.a.
Lithuania 1997-1998
Petersen et al. 2000
65-74 259 21 26 (toothpicks)
6 (floss)
11
Toothbrushing twice daily has become considerably more common among adult and elderly
subjects in industrialized European countries during recent decades. In Finland, the change has
been particularly noticeable among elderly women aged 65 and older: twice daily brushing has
increased from 45% in 1980 to 69% in 2000 (Suominen-Taipale et al. 2008). Among adults in
the UK the increase has been from 78% to 98% among women and from 64% to 74% among
men between 1978 and 1998 (Kelly et al. 2000). In Lithuania, among those aged 55-64 twice
daily brushing has increased from 30% to 39% among women but no improvement among men
was seen (15% vs. 15%) in 1998-2006 (Grabauskas et al. 2007, 1999). No corresponding data
are available for elderly subjects.
Toothpaste is the most common vehicle of daily fluoride application. The majority of elderly
subjects use fluoride toothpaste: 76% in Finland and 63% in Lithuania (Suominen-Taipale et al.
2008, Petersen et al. 2000).
Interdental cleaning performed by means of dental floss, toothpicks, and interdental brushes, has
been recommended daily (ADA 2000). Table 2.1 shows daily use of interdental devices,
revealing the use of toothpicks among 50% of elderly Danes and dental floss among up to 72%
of elderly Americans.
The detrimental effect of sucrose on dental health relates both to the frequency and quantity of
consumption, with highly refined sugars being the most harmful in terms of developing caries
(Moynihan 2005, Gustafsson et al. 1954). A general recommendation is restriction of sugary
products to no more than four times per day, or less than 40g per day of “simple sugars”
(Mobley 2003, WHO 2003). Use of sugar in coffee or tea is the most common way of its
consumption between meals. In Finland, 53% of elderly women and 61% of elderly men report
daily use of sugar in their coffee or tea (Suominen-Taipale et al. 2008). In the Baltic countries,
71% to 89% of those aged 55-64 take sugar in coffee or tea (Grabauskas et al. 2007, Pudule et
al. 2007, Kasmel et al. 1999).
The interval of time since one’s most recent dental visit is a common indicator to describe
dental attendance (Nuttall 1997), and annual visits have been suggested as an acceptable
indicator of appropriate use of dental care (Vargas et al. 2001). In recent decades use of dental
services on a yearly basis has obviously increased among elderly subjects in industrialized
countries. In Australia such an increase has been from 54% to 68% between 1987-88 and 2004-
2006 (Spencer & Harford 2007), among the USA elderly from 15% in 1950 to 55% in 2003
(Brown 2008), and in Finland from 30% in 1980 to almost 60% in 2000 (Suominen-Taipale et
al. 2008). In Lithuania, the corresponding changes from 1998 to 2006 among those aged 55 to
64 show an increase from 58% to 67% for women, but for men, a decrease from 54% to 42%
(Grabauskas et al. 2007, 1999).
Presently, the differences in the use of dental services remain remarkable between industrialized
countries and those with developing economies. Of the dentate 65-74-year-olds in the
population study in the UK, 74% report having seen a dentist within one year (Kelly et al. 2000)
and 85% in the regional study in Southern Sweden report having gone to a dentist within the
previous year (Bagewitz et al. 2002). In comparison, only 23% of those aged 65-74 in China
(Zhu et al. 2005), and 42-44% in Lithuania see a dentist annually (Petersen et al. 2000,
Aleksejuniene et al. 2000).
12
Going for dental check-ups is an indicator of the individual’s habitual dental attendance, being a
recommended habit with the only variation between countries being its frequency. According to
population studies, 68% of the elderly subjects in the UK and 50% in Finland employ such a
habit (Suominen-Taipale et al. 2008, Kelly et al. 2000). In Denmark, 66% of those aged 65-74
report that going to see a dentist within five years is considered regular attendance for them
(Petersen et al. 2004). In the Osaka region of Japan, 33% of elderly subjects report going for
check-ups (Ikebe et al. 2002), but only 1% do so in China (Zhu et al. 2005).
2
.2. Dentition status in the elderly
Oral health status in the elderly reflects cumulativ
e outcomes of oral health behaviour, diseases
and their treatments during one’s life span. Nowadays it is increasingly common that the elderly
retain most of their teeth presenting a challenge for oral self- and professional care to maintain
their dentitions for a whole lifetime.
Presence of teeth
The presence of teeth is a basic measurement of oral health among adults and the elderly
(Whelton & O’Mullane 2007, Consensus workshop 2004). The average number of teeth and
having 20 or more teeth are common indicators of an individual’s dentition. WHO and FDI have
set the goal for the oral health of those aged 65 and older to achieve so that there are at least
50% with 20 and more teeth by the year 2000 (WHO 1982). Among elderly subjects
edentulousness varies considerably worldwide reaching as high as 78% in Bosnia and
Herzegovina. In Lithuanian elderly edentulousness appears to be low (14%) among those aged
65-74 (Petersen & Yamamoto 2005).
The number of teeth in adult and elderly subjects of industrialized countries is on a steady
increase, being an average of two teeth per 10 years (Suominen-Taipale et al. 2008, Österberg &
Carlsson 2007, Kelly et al. 2000). The average number of teeth among the elderly in
industrialized countries varies between 12.6 and 21.0 (Table 2.2). Corresponding information
for developing countries is rather scarce. In China, 65-74-year-olds possess on average 18.4
teeth (Wang et al. 2002). Lithuanian data on elderly present a median of 15 teeth (Aleksejuniene
et al. 2000).
Having 20 or more functioning teeth describes functional dentition, without the need for
prosthetic rehabilitation (Meeuwissen et al. 1995, Leake et al. 1994, Witter et al. 1994, Käyser
1990, Käyser & Witter 1985, Käyser 1981), if such dentition also satisfies the patients’
esthetics. Among elderly subjects, having 21 and more teeth and no RPD indicate overall
satisfaction with their dentition and problem-free eating (Steele et al. 1997a).
Despite the goal of at least 20 functional teeth, set by WHO, its database offers no
corresponding information. According to research articles, in industrial countries 29% to 65% of
the elderly have such a dentition (Table 2.2). Information for lower-economy countries and
those with developing oral health systems is not available.
13
Table 2.2. Mean number of teeth (NoT) and percentages of those having 20 and more teeth (20+T)
among independent dentate elderly in population-based studies.
Country & year of study
Publication
Age n
Mean
NoT
20+T
%
Study description
Nordic countries
Finland 2000
Suominen-Taipale et al. 2008
65+ 812 15.3 39 clinical data
Norway 2002
Holst 2008
60+ 783
n.a. 52 interviews and
questionnaires
(16% edentate)
Sweden 2001
Österberg & Carlsson 2007¶
70 484
21.0 65 clinical data
(7% edentate)
Denmark 2000-2001
Kristrup & Petersen 2006
65-74 290
20.0 n.a. clinical data
Norway 1996-1997
Henriksen 2004
67+
394 17.2
49
clinical data
Denmark 2000
Petersen et al. 2004
65+ 2976
n.a. 31
interview
(36% edentate)
Other industrialized countries
USA 1999-2004
Dye et al. 2007
65-74 3539
18.9 n.a. clinical data
UK 1998
Kelly et al. 2000
65-74 456 18.2 46¶¶ clinical data
Switzerland
Schürch jr.& Lang 2004
60-64
365
17.6 n.a. clinical data
Germany 1997-2001
Mack et al. 2003¶
60-64 1397 12.6 29 clinical data
J
apan 1992
Fukuda et al. 1997¶
50+ 1248 20.3 n.a. clinical data
¶ regional study
¶¶ reported 21+ teeth
Dental caries
Despite the general trend of decline in the occurrence of caries among adults in industrialized
countries, such a decline is least pronounced in elderly subjects (Brown 2008, Suominen-
Taipale et al. 2008, Kelly et al. 2000). The presence of caries is still a public health concern,
particularly in less developed countries and in underprivileged groups, such as the elderly
(Petersen & Yamamoto 2005). Dental caries is a major threat for tooth loss in the elderly,
accounting for up to 60% of extractions (Saunders & Meyerowitz 2005, Fure 2003). For the
elderly, the incidence of caries seems to be high: a Swedish follow-up study reports that 95% of
them develop caries over a 10-year period, being more prevalent with increasing age (Fure
2004, 2003). An incidence study from Australia reports 67% of the elderly having developed
coronal caries and 59% root caries within five years (Thomson et al. 2002). In Japan, 36% of the
elderly have developed root caries within the space of two years (Takano et al. 2003). Root
caries occurs in 12%-40% of elderly subjects, according to population and regional studies (Dye
et al. 2007, Imazato et al. 2006, Shah & Sundaram 2004, Mack et al. 2004, Kelly et al. 2000).
Caries is a multifactorial disease with important risk factors in the elderly being fermentable
carbohydrates, plaque, especially in the presence of restorations and prosthesis, decreased
dexterity and saliva secretion, and the use of medications (Curzon & Preston 2004).
Modification of these factors alleviates the burden of the disease. Good oral hygiene by means
of toothbrushing and fluoride allows converting root caries from being active to inactive (Nyvad
& Fejerskov 1986). Consequently, those brushing their teeth more frequently (Imazato et al.
14
2006, Steele et al. 2001, DePaola et al. 1989, Vehkalahti & Paunio 1988) or avoiding frequent
intake of sugar (Steele et al. 2001, Vehkalahti & Paunio 1988) have less root caries.
A description of caries indicating decayed (D), missing (M), or filled (F) teeth (DMFT) reflects
the cumulative nature of the disease. According to the WHO data bank, the mean DMFT for
those aged 65 and older varies between 15.8 in Thailand to 25.5 in the Czech Republic, and 22.3
in Lithuania (WHO Area Profile Programme). However, this index may be less informative due
to the general decline of caries in populations, and less accurate to describe dental conditions in
adult and elderly populations (Brown 2008, Chattopadhyay et al. 2008, Whelton & O’Mullane
2007). An accepted way of defining the occurrence of caries in adults and the elderly is as the
presence of clearly cavitated teeth with softened dentine (WHO 1997). Population-based data on
the occurrence of untreated caries (decayed teeth DT>0) among independent elderly are shown
in Table 2.3.
Table 2.3. Percentages of independent dentate elderly with untreated dental caries (DT>0),
according to population-based studies.
Country & year of study
Publication
Age n % DT>0
Nordic countries
Finland 2000
Suominen-Taipale et al. 2008
65+ 964 51 (men)
30 (women)
Norway 1996-1997
Henriksen 2004
67+
394 30
Other industrialized countries
UK 1998
Kelly et al. 2000
65+ 484 48
USA 1999-2004
Dye et al. 2007
65-74 3539 17
Germany, Pomerania
Mack et al. 2004¶
60-69 611
15 (men)
10 (women)
Developing countries
India, Delhi
Shah & Sundaram 2004¶
60+ 1052
64
¶ regional study
Periodontal conditions
Periodontitis is regarded as a chronic inflammatory disease with the destruction of tissues
surrounding the teeth. Although a number of systemic, local, behavioural, and social risk factors
modify the disease, the presence of dental plaque on the one hand is crucial in initiating
inflammatory mechanisms of periodontitis and the host’s response on the other (Kornman et al.
1997, Offenbacher 1996). The response in the elderly is often immune-compromised (Fransson
et al. 1999, 1996, Holm-Pedersen et al. 1980, 1975), but, on the contrary, McArthur (1998) has
stated no defects in the immune system of the elderly for periodontal pathogens.
Periodontal diseases with their chronic inflammatory nature develop gradually, predisposed by
the presence of plaque and calculus, as gingivitis (Corbet 2007). Gingivitis is a mild expression
of periodontal disease which has been experimentally proven in humans in the 1970’s (Löe et al.
1965). Compared to young adults, gingivitis in the elderly may be more severe, develop faster
with plaque accumulating at higher rates and the differences in the microbial composition
tending toward more severe inflammation (Holm-Pedersen et al. 1975).
Không có nhận xét nào:
Đăng nhận xét