Abstract
Objective: This cross-sectional study aimed to evaluate the association of oral
health-related quality of life with prosthetic rehabilitation status and
dental prosthesis condition in residents of Brazilian long-term care
facilities.
Methods: The oral health-related quality of life of older adults (n = 194; mean
[standard deviation] age = 78.93 [9.10]) was assessed by the Geriatric Oral
Health Assessment Index and the Oral Health Impact Profile questionnaires.
Prosthetic rehabilitation status was recorded according to the absence of
teeth and use of dental prostheses. Dental prosthesis condition was
considered good or poor based on stability, retention, occlusion, vertical
dimension, and defects. Poisson regression models were plotted to analyze
the data (α = 0.05).
Results: Lower Geriatric Oral Health Assessment Index scores were associated with
edentulism with denture use only on one jaw (B = -0.05) and poor dental
prosthesis stability (B = -0.04). Similarly, edentulous participants with
denture only on one jaw (B = 0.59) and those wearing dental prostheses with
poor stability (B = 0.36) are more likely to achieve higher Oral Health
Impact Profile scores. Also, lower Oral Health Impact Profile scores were
associated with denture defects (B = -0.34).
Conclusion: In summary, the oral health-related quality of life of older adults living in
longterm care facilities is negatively impacted by edentulism with denture
only on one jaw and use of dental prostheses with poor stability. Therefore,
long-term care facilities should provide oral health training to caregivers,
include dental professionals in the staff, and articulate demands with oral
health teams in the primary care system.
Keywords: Aged, homes for the aged, dental prosthesis, dental prosthesis, dentures, quality of life.
Resumo
Objetivo: Este estudo transversal objetivou avaliar a associação da qualidade de vida
relacionada à saúde bucal com o status de reabilitação protética e a
condição da prótese em residentes de instituições de longa permanência no
Brasil.
Metodologia: A qualidade de vida relacionada à saúde bucal dos idosos (n = 194; média
[desvio padrão] idade = 78,93 [9,10]) foi avaliada pelos questionários
Geriatric Oral Health Assessment Index e Oral Health Impact Profile. O
status de reabilitação protética foi registrado de acordo com a ausência de
dentes e uso de próteses dentárias. A condição da prótese foi considerada
boa ou ruim com base na estabilidade, retenção, oclusão, dimensão vertical e
defeitos. Modelos de regressão de Poisson foram plotados para analisar os
dados (α = 0,05).
Resultados: Como resultado, menores escores no Geriatric Oral Health Assessment Index
foram associados ao edentulismo com o uso de dentadura em apenas uma arcada
(B = -0,05) e ao uso de próteses com estabilidade ruim (B = -0,04). De forma
similar, participantes edêntulos que usavam dentadura em apenas uma arcada
(B = 0,59) e aqueles que portavam prótese com estabilidade ruim (B = 0,36)
são mais propensos a ter maiores escores no Oral Health Impact Profile. Além
disso, menores escores no Oral Health Impact Profile foram associados a
defeitos na prótese (B = -0,34).
Conclusão: Sumarizando, a qualidade de vida relacionada à saúde bucal de idosos
residentes em instituições de longa permanência é negativamente impactada
pelo edentulismo com o uso de dentadura em apenas uma arcada e uso de
prótese com estabilidade ruim. Assim, instituições de longa permanência
devem promover capacitação em saúde bucal aos cuidadores, incluir dentistas
no quadro de funcionários e articular com as equipes de saúde bucal da
Atenção Primária à Saúde.
Palavras-chave: Idoso, instituição de longa permanência para idosos, prótese dentária, dentaduras, qualidade de vida.
Carátula del artículo
SPECIAL CALL “GERIATRIC DENTISTRY AND ORAL HEALTH”
Oral health-related quality of life of older adults living in
long-term care facilities and its association with dental prosthesis use and
condition
Qualidade de vida relacionada à saúde bucal de idosos residentes em
instituições de longa permanência: associação com o uso e condição da
prótese
Mariana Marinho Davino de Medeiros
Universidade Estadual de Campinas, Brazil
Mayara Abreu Pinheiro
Universidade Estadual de Campinas, Brazil
Olivia Maria Costa de Figueredo
Universidade Estadual de Campinas, Brazil
Luiz Fabrício Santos de Oliveira
Universidade Federal da Paraíba, Brazil
Rayssa Lucena Wanderley
Universidade Federal da Paraíba, Brazil
Yuri Wanderley Cavalcanti
Universidade Federal da Paraíba, Brazil
Renata Cunha Matheus Rodrigues Garcia regarcia@unicamp.br
Universidade Estadual de Campinas, Brazil
Geriatrics, Gerontology and Aging, vol. 17, e0230007, 2023
Sociedade Brasileira de Geriatria e Gerontologia,
SBGG
Received: 11 November 2022
Accepted: 17 January 2023
Funding
Funding source: FAPESP
Contract number: 2018/06185-6
Funding
Funding source: FAPESP
Contract number: 2021/02463-4
Funding
Funding source: CAPES
Contract number: Code 001
Funding statement: This study was supported by the São Paulo Research Foundation
(FAPESP, Process numbers 2018/06185-6 and 2021/02463-4) and Coordenação e
Aperfeiçoamento de Pessoal de Nível Superior (CAPES, Code
001).
INTRODUCTION
The Brazilian population is undergoing a remarkable demographic transition.1 Older adults (aged 60 years or over) accounted
for 9.70% of the Brazilian people in 2004;1
currently, they are 14.70%2 and are expected
to reach 18.60% in 2030.1 The increase in this
age group comes with the need to establish who is responsible for caring for older
people. According to Brazilian legislation (Law number 10.741/2003),3 family members should care for their older
persons; however, institutionalization is accepted for those with no family members
or needing specialized care to survive. Thereby, long-term care facilities (LTCFs)
have become suitable places for older adults to live in.4
Besides housing and nursing, LTCFs also provide daily living assistance for older
people, including oral care.5 However, most
Brazilian LTCFs do not have a dental professional on staff.6 Consequently, caregivers and nursing aides are primarily
responsible for the oral care of LTCF residents, although they frequently have no
proper knowledge, education, or training in providing such care.5,7 Thus,
they might face difficulties in identifying oral disorders, either dental or denture
ones, which would require a dentist appointment.8 Considering these barriers, older adults living in LTCFs are more
likely to have poorer oral health than community-dwelling ones.9
One of the main oral health problems in LTCF residents are missing teeth without
dental prosthesis replacement (66.37%) and use of unsatisfactory dental prostheses
(86.60% among denture wearers).10,11 These oral health problems are reported as
negative predictors of masticatory function in nursing-home residents.10,11,12,13 Also, it is well-established that limited masticatory
function is associated with worse oral health-related quality of life (OHRQoL).10,14,15 Therefore, the absence of
teeth and dentures and the use of ill-fitting dental prostheses might negatively
impact the OHRQoL of older adults living in LTCFs.
In this context, previous cross-sectional studies16,17,18,19 identified an
association between worse OHRQoL and ill-fitting dental prostheses in nursing-home
residents. However, these investigations only evaluated dental prostheses according
to the need for repair/replacement or retention. Thus, a study performing a detailed
denture evaluation in terms of stability, retention, occlusion, vertical dimension,
and defects may provide additional information regarding this association, which
could be used for clinical decision-making for dental prosthesis replacement aiming
a better OHRQoL. Therefore, this cross-sectional study evaluated the association of
OHRQoL with prosthetic rehabilitation status and dental prosthesis condition in
older adults living in LTCFs.
METHODS
This study was supported by the São Paulo Research Foundation (FAPESP, Process
numbers 2018/06185-6 and 2021/02463- 4) and Coordenação e Aperfeiçoamento de Pessoal
de Nível Superior (CAPES, Finance Code 001). The study protocol was submitted to a
Research Ethics Committee. Following ethical approval (Protocol numbers 66122
917.6.0000.5188 and 66122917.6.3001.5418), the eligible volunteers were invited to
participate in the study, and those who agreed to it signed a consent form.
This cross-sectional study consisted of a co-participation of 17 Brazilian LTCFs in
southeastern (n = 10) and northeastern (n = 7) Brazil and was conducted between
January and August 2019. The LTCFs were either non-profit (n = 10) or private (n =
7) facilities that offer residence, nursing services, and daily living assistance
for 848 individuals in total.
To be included in the study, the volunteers must be 60 years of age or over and be
edentulous or partially dentate with dental prostheses on at least one jaw. However,
those with a communication disability (impaired hearing, speech, or voice),
according to LTCF records, or with a cognitive impairment, according to the
Mini-Mental State Examination (final score < 13 points),20,21 were excluded from
the study. Thereby, 194 individuals met the eligibility criteria and participated in
the study.
Age and sex were recorded, and the participants were evaluated for OHRQoL, prosthetic
rehabilitation status, and dental prosthesis condition. OHRQoL was considered the
outcome measurement, and prosthetic rehabilitation status and dental prosthesis
condition were the predictor variables tested.
Oral health-related quality of life
The Brazilian versions of the Oral Health Impact Profile (OHIP-14)22,23 and the Geriatric Oral Health Assessment Index (GOHAI)24,25 were used to assess OHRQoL. OHIP- 14 measures the impact of
teeth, mouth, or denture problems on well-being in the past 6 months across 7
dimensions (functional limitation, physical pain, psychological discomfort,
physical disability, psychological disability, social disability, and handicap).
A 5-point scale (0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often,
4 = very often) is used for each item. Finally, the 14-item scores are summed to
obtain a total OHIP-14 score ranging from 0 to 56 points. Higher OHIP-14 scores
mean worse OHRQoL. OHIP-14 scores mean worse OHRQoL.
GOHAI is a self-report 12-item index that assesses the presence of impairment
in:
- 1.
Physical function in terms of eating, speech, and swallowing;
- 2.
Psychosocial function referring to concerns, self-image,
self-consciousness, and social interaction; and
- 3.
Pain or discomfort due to oral health problems in the past 3 months.
The items have 3 response options (always/often, sometimes/ seldom, and never),
corresponding to 1, 2, and 3 points, respectively. The points are summed to
obtain the GOHAI score (12-36 points), and higher scores correspond to better
oral conditions.
Prosthetic rehabilitation status
Prosthetic rehabilitation status was recorded according to the absence of teeth
(edentulous or partially dentate) and use of dental prostheses (complete denture
[CD] or removable partial denture [RPD]).11 Thus, the participants were classified as
- 1.
Edentulous or partially dentate with CD and/or RPD in both jaws;
- 2.
Partially dentate with CD or RPD only on one jaw; or
- 3.
Edentulous with CD only on one jaw.
Dental prosthesis condition
The assessment of dental prosthesis condition was performed by two trained
examiners according to the Vigild method with some modifications.11,26 The proposed method evaluated the dental prostheses based on
stability, retention, occlusion, vertical dimension, and defects. Stability
problems were recorded when the CD or RPD had a horizontal displacement under
slight bilateral pressure on the posterior region. Similarly, retention problems
were considered in case of vertical displacements during a slight pull on the CD
anterior region (incisor region) and RPD clasps. The evaluation of dental
prosthesis occlusion was slightly adapted from the Vigild method; it was based
on the occlusal contact between artificial teeth or between artificial and
natural teeth. Accordingly, dental prostheses with a lack of occlusal contact
were recorded as poor occlusion conditions. Moreover, the vertical dimension was
considered poor when, even in case of dental prosthesis use, the lower third of
the face in the older adults seemed to be reduced. Dental prosthesis defects
were considered when there were broken parts, missing teeth, or excessively worn
teeth; however, in our study, those defects were individually recorded. Finally,
dental prostheses showing problems in at least one of these criteria were
considered in poor condition.
SPSS, version 20.0 (for Windows; SPSS Inc, Chicago, IL, USA), was used to perform
the statistical analyses. Mean and standard deviation (SD) were obtained to
describe the age and OHRQoL of the participants. Also, Poisson regression models
were plotted to analyze the association of OHRQoL (outcome variable) with
prosthetic rehabilitation status and dental prosthesis condition (predictors).
Moreover, the Backward-Wald procedure was used to obtain an adjusted model.
Variables with the highest p-value were removed stepwise until the remaining
variables reached a p-value < 0.20.
For the OHIP-14 model, the sequence of excluded variables was broken parts,
occlusion, missing artificial tooth, and retention of the dental prostheses.
Thus, the adjusted OHIP-14 model included the following variables: prosthetic
rehabilitation status, stability, vertical dimension, and excessively worn teeth
in dental prostheses. The variables gradually excluded from the GOHAI model were
broken parts, retention, vertical dimension, occlusion, missing tooth, and
excessively worn teeth in dental prostheses. Thereby, the adjusted GOHAI model
comprised prosthetic rehabilitation status and stability variables. After the
adjusted models were obtained, regression coefficients (B) and confidence
intervals (95%CI) were used to measure the associations, considering a
significance level of 5%.
RESULTS
The participants’ mean (SD) age was 78.93 (9.10) years. Most were middle-old (aged
between 74 and 85 years, n = 71, 36.80%) and female (n = 133, 68.60%). In addition,
they reported a good OHRQoL according to the mean (SD) GOHAI and OHIP-14 scores of
32.53 (3.80) and 7.16 (8.17), respectively. Finally, OHRQoL values were similar
across the age and sex groups (Table 1).
TABLE 1
Oral health-related quality of life of older adults living in long-term
care facilities according to age and sex.
SD: standard deviation; GOHAI: Geriatric Oral Health Assessment Index;
OHIP-14: Oral Health Impact Profile.
Regarding prosthetic rehabilitation status, 109 participants (56.20%) were edentulous
or partially dentate with CD and/or RPD in both jaws. Also, 165 participants
(85.10%) had dental prostheses in poor conditions due to stability (n = 103,
53.10%), retention (n = 108, 55.70%), occlusion (n = 117, 60.30%), and vertical
dimension (n = 108, 55.70%) problems.
A multivariate analysis revealed that edentulous participants with CD only on one jaw
(B = -0.05, 95%CI 0.90 – 1.00) and those wearing dental prostheses with poor
stability (B = -0.04, 95%CI 0.92 – 0.99) are more likely to present lower GOHAI
scores (worse OHRQoL) (Table 2). The same
associations were observed in the OHIP-14 regression model (Table 3). Higher OHIP-14 scores (worse OHRQoL) were associated
with edentulism with CD use only on one jaw (B = 0.59, 95%CI 1.15 – 2.82) and use of
CD or RPD presenting poor stability (B = 0.36, 95%CI 1.02 – 2.03). Also, lower
OHIP-14 scores were associated with excessively worn artificial teeth (B = -0.34,
95%CI 0.52 – 0.96).
TABLE 2
Poisson regression models of the factors associated with the oral
health-related quality of life (measured by Geriatric Oral Health Assessment
Index) of older adults living in long-term care facilities.
B: regression coefficient; CI: confidence interval; Ref.: reference
category; *Performed with variables with p < 0.20
according to the Backward-Wald procedure; †p-value <
0.05.
TABLE 3
Poisson regression models of the factors associated with the oral
health-related quality of life (measured by Oral Health Impact Profile-14)
of older adults living in long-term care facilities.
B: regression coefficient; CI: confidence interval; Ref.: reference
category; *Performed with variables with p < 0.20
according to the Backward-Wald procedure; †p-value <
0.05.
DISCUSSION
Missing teeth without denture replacement and use of ill-fitting dental prostheses
may negatively impact OHRQoL. However, previous studies did not evaluate specific
dental prosthesis conditions (stability, occlusion, and vertical dimension) and
their association with OHRQoL in older adults living in LTCFs. This study
investigated such aspect and revealed that the lack of dentures in edentulous
individuals and the use of dental prostheses with stability problems are major
factors associated with poor OHRQoL. Based on these findings, to improve the OHRQoL
of LTCF residents, edentulous older adults with no dentures should be prosthetically
rehabilitated, and those wearing dental prostheses with poor stability should
receive new and well-fitting ones.
The association between a poor OHRQoL and edentulism with CD use only on one jaw
agrees with the well-known idea that absence of dentures in edentulous nursing-home
residents compromises their masticatory function.10,11,12 In addition, the lack of dentures, mainly on the upper jaw,
affects aesthetics. Therefore, missing teeth without denture replacement impair
mastication and/or aesthetics, leading to functional, psychological, and social
problems, ultimately affecting OHRQoL.27,28,29
Our study also revealed that older adults wearing dental prostheses with stability
problems are more likely to present a worse OHRQoL. OHRQoL comprises oral complaints
or impacts on functional limitations, pain and discomfort, psychological function,
social disability, and handicap.22,24 In LTCF residents, poor dental prosthesis
stability is a predictor of functional disabilities (ie, chewing and swallowing
difficulties).11 Also, masticatory
function disabilities are related to worse OHRQoL outcomes.10,12 Thus, masticatory
function impairments might mediate the association between denture stability and
OHRQoL.
Although denture stability is associated with poor OHRQoL, this study could not
demonstrate an association with retention. Controversially, a previous
investigation16 found an association
between a poor OHRQoL assessed by OHIP-G49 and insufficient dental prosthesis
retention (ie, denture loosened spontaneously or during functional movements).
However, that study did not evaluate dental prosthesis stability. Conversely, we
assessed retention and stability and included both in a multiple regression model to
investigate their impact on LTCF residents’ OHRQoL. Then, only stability remained a
factor associated with OHRQoL. This finding suggests that dental prosthesis
stability is more critical to OHRQoL than retention. Still, future studies should
investigate the role of dental prosthesis retention in the OHRQoL of older adults
living in LTCFs.
Concerning dental prosthesis defects, although the frequency of excessively worn
teeth was low, this denture condition was associated with higher OHIP-14 scores.
Nonetheless, this result should not be considered an indication that artificial
teeth must be worn for a better OHRQoL to be obtained. Instead, it should be
interpreted as a possible adaptation over time in older adults to excessively worn
teeth on the dental prostheses. Because of this adaptation, perhaps this denture
problem does not negatively affect OHRQoL anymore.
Overall, our findings about the association between OHRQoL and dental prosthesis
condition are supported by previous studies of nursing-home residents.17,18,19 Klotz et al.17 assessed denture-related problems
dichotomously (yes and no) and found an increased risk of compromised OHRQoL in
participants with dentures needing treatment. In addition, Porter et al.18 reported that dentate participants with
loose or ill-fitting dentures were more likely to report at least one oral impact on
OHRQoL than those with well-fitting ones. Moreover, Zenthöfer et al.19 revealed that wearing dentures needing
repair (ie, at least one broken area/tooth or dentures loose) contributes to a worse
OHRQoL. In summary, wearing poorly fitting dentures is a major factor for a
compromised OHRQoL in LTCF residents.
Although this study provides crucial additional information for the association
between OHRQoL and dental prosthesis condition, some limitations must be
considered.
Importantly, we did not record the length of denture use. Commonly, older dental
prostheses are more defective and less functional than newer ones, which affects
denture satisfaction and, consequently, OHRQoL outcomes.30 At the same time, if recorded, that data might have produced
memory bias to the study because older adults do not accurately report the length of
dental prosthesis use. In addition, we only evaluated individual factors related to
OHRQoL and did not investigate possible factors mediating (eg, masticatory function)
the association between OHRQoL and denture condition. Therefore, future
investigations are encouraged to assess the influence of contextual variables and
mediating factors on the OHRQoL of older adults living in LTCFs.
Despite the aforementioned limitations, different from previous investigations, our
study performed a detailed denture evaluation in terms of stability, retention,
occlusion, vertical dimension, and defects. Thus, we could identify specific dental
prosthesis conditions negatively impacting the OHRQoL of LTCF residents. This
finding is particularly important for clinical decision-making of denture
replacement aiming to achieve a better OHRQoL, especially considering the barriers
faced by LTCF residents to accessing prosthetic treatment.
CONCLUSION
The OHRQoL of older adults living in LTCFs is negatively impacted by edentulism with
denture use only on one jaw and use of dental prostheses with poor stability.
Therefore, clinical decision-making for improving the OHRQoL of LTCF residents
should be based on the need for dentures and dental prosthesis stability. To address
this issue, we encourage LTCFs to provide oral health training to caregivers,
include dental professionals in the staff, and work together with oral health teams
in the Brazilian primary care system.
