|Year : 2021 | Volume
| Issue : 4 | Page : 453-465
Impact of oral health factors on quality of life of geriatric population - A systematic review
Shalu Rai1, Deepankar Misra1, Akansha Misra2, Ankit Jain3, Suman Bisla1
1 Department of Oral Medicine and Radiology, Institute of Dental Studies and Technologies, Modinagar, UP, India
2 Department of Oral Pathology, Institute of Dental Studies and Technologies, Modinagar, UP, India
3 Department of Oral Medicine and Radiology, DJ Dental College, Modinagar, UP, India
|Date of Submission||27-May-2020|
|Date of Decision||22-Nov-2021|
|Date of Acceptance||27-Nov-2021|
|Date of Web Publication||27-Dec-2021|
Dr. Shalu Rai
Institute of Dental Studies and Technologies, Kadrabad, Modinagar, UP - 201 201
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The innumerable special needs and challenges faced by geriatric patients in healthcare has attracted the attention of the modern world. Various basic oral functions contribute to good physical and psychological health and are likely to deteriorate with frailty. The aim of the study was to examine effects of aging on oral health related quality of life (OHRQoL) and assess importance of dental care amongst older persons. An electronic search in PubMed Central's database was performed. The search strategy was limited to human studies (single and double-blinded trials, cross-sectional and case-control studies), full-text English articles published from first of January 2010 until the end of April 2021. Irrelevant articles or articles with inadequate information were omitted. Data was searched and analyzed using following MeSH terms/keywords: Geriatric Assessment, Oral Health Related Quality of Life. 43 studies were included. In most of the studies it was identified geriatric assessment is essential to avoid comorbidities in such patients. Furthermore judicious use of polypharmacy is advocated in such patients. An association between OHRQoL and dental care of older people was found. This indicates prevention and early intervention with treatment modalities in the increasing elderly population with an apparent solicitousness of their health needs
Keywords: Geriatric dentistry, health status, oral health-related quality of life, patient acceptance of health care
|How to cite this article:|
Rai S, Misra D, Misra A, Jain A, Bisla S. Impact of oral health factors on quality of life of geriatric population - A systematic review. J Indian Acad Oral Med Radiol 2021;33:453-65
|How to cite this URL:|
Rai S, Misra D, Misra A, Jain A, Bisla S. Impact of oral health factors on quality of life of geriatric population - A systematic review. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 May 21];33:453-65. Available from: https://www.jiaomr.in/text.asp?2021/33/4/453/333883
| Introduction|| |
Gerodontology is concerned with delivery of dental care for the elderly with a particular consideration on patients suffering from different ailments along with the care of their physiological, physical, and/or psychological needs. “Geriatric population” has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as “early elderly” and those over 75 years old as “late elderly.” World Health Organization has reported an estimated 2.5% increase in annual rate of the geriatric population., Oral health is associated with quality of life of elderly individuals and strongly affects their general health and interests, persuading variety of aspects of public living, communications, and self-esteem. The importance of oral hygiene and dental health in elderly lies in the fact that these patients have overlapping comorbidities such as cardiovascular disease, osteoporosis, dementia, osteoarthritis, and diabetes. Therefore, good dental care is an integral part of good general health that should be reinforced in old patients.
The concept of geriatrics has to be applied by oral health care providers before the delivery of oral health care. Impairment of oral functions leads to poor dietary intake and weight loss of the geriatric patient, thereby affecting their social and psychological state along with the ability to withstand infections. Approaches to develop oral health grades of the old population ought to commence by analyzing the problems faced by them and risk of frailty in each patient. Objective approaches to consider in the elderly should include salivary flow rate measurements, oral mucosal pain testing, and tests for gustatory function. Subjective assessments include the Oral Health Impact Profile (OHIP) and the Geriatric Oral Health Assessment Index.,, The aim of the current study was to provide a systematic review to piece together and elucidate the effects of aging on oral health-related quality of life (OHRQoL) among older population. This study also sought to explore importance of oral health assessment and prompt diagnosis and management of common dental disorders that potentially promote improvements in OHRQoL of this population.
| Methods|| |
The methodological approach was based on the PRISMA guidelines. In this systematic review, an electronic search in PubMed/PubMed Central's database was performed using the following MeSH terms/keywords: Oral Health Related Quality of Life, Geriatric Oral Health Assessment Index, Polypharmacy, Burning Mouth Syndrome (BMS)/etiology*, Deglutition Disorders/etiology, Taste Disorders/etiology*, Xerostomia/etiology*, Dental Caries, Periodontal Disease, Tooth loss, Candidiasis/Oral, Temporomandibular Joint (TMJ) Disorders/complications, and Practice Patterns. In this systematic review, the search strategy was limited to human studies;, full-text English articles published from January 2010 until the end of April 2021. Irrelevant articles or articles with inadequate information were omitted. Single- and double-blinded trials and cross-sectional and case-control studies published as full text in English Language were included in this review. Exclusion criteria were reviews not focusing on effect of aging on general and dental health, gray literature, case reports, and case series.
[Figure 1] shows that the initial computerized search strategy where 2529 abstracts were retrieved. In the first selection, two reviewers with 10 years' experience in the field screened the articles and 1911 articles were obtained after omission of duplicate articles. Out of these, 1610 articles were further excluded as they did not fulfill the inclusion criteria. Out of those 301 eligible articles, 258 were excluded due to lack of demographic data and discrepancy in outcome. Remaining 43 full text articles fulfilled our inclusion criteria and were included in the study.
|Figure 1: PRISMA flowchart showing number of publications identified excluded and included in the study|
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The PICO model was used to extract data and studies characteristics (title of the paper, author's information, year of study): population: elderly (described as greater than or equal to 65 years, with or without systemic comorbidities), interventions: (prediction, prevention, treatment), comparison: control (comparator), and outcomes: (accuracy, validity, effect of intervention). Two reviewers independently extracted data using the standard data extraction form. Differences between the reviewers were sorted out by mutual discussion.
| Results|| |
[Table 1] summarizes 43 eligible studies from preexisting literature. Most studies used the OHIP, or a variety of the OHIP, to measure OHQoL. The other assessment tools used by the studies were Geriatric Oral Health Assessment Index and Oral Impact on Daily Performance questionnaire to measure OHQoL. EuroQOL 5 was also used in one study to measure general quality of life.
|Table 1: Summary of studies from preexisting literature pertaining to OHRQoL in elderly population|
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Natural dentition was assessed in domains such as edentulism, number of teeth, number of missing teeth, and number of occluding pairs which have been found to affect OHRQoL, respectively, with positive and negative outcomes. The associations between OHQoL and decayed teeth, decayed missing and filled teeth, filled teeth, root caries, and retained roots have been described, and no consensus on the negative association between caries and OHQoL was found in most studies. Associations between pocket depth, mobility, bleeding, gingivitis, periodontitis, and abnormalities of the oral mucosa and OHQoL were investigated, and no consensus on the negative association between periodontal conditions and OHQoL was found. In most studies, no consensus of association between the prosthetic status and OHQoL was found. Being satisfied with dentures, proper function of the dentures and no need for denture treatment were positively associated with OHQoL. Several studies show that a positive effect of implant retained overdentures on OHQoL, and one study showed a positive correlation of the SDA concept compared to RPD. Most studies found statistically significant negative associations between xerostomia and OHQoL scores. A study reported no significant associations between OHQoL and orofacial pain, in contrast to majority of studies that found negative associations. Furthermore, negative associations between OHQoL and various oral health factors were reported in several studies such as burning mouth, presence of symptoms in the temporomandibular joint, sensitive teeth, halitosis, and clinically assessed treatment need.
[Table 1] The mean number of geriatric population using medications for various ailments in form of polypharmacy was 12.2 ± 4.5. Patients in the highest use of medications reported 4.1 more oral symptoms such as dryness of mouth (xerostomia) than in the group with the lowest use (95% CI: 1.5–6.6; P = 0.002).
Risk of bias assessment across individual studies: All studies demonstrated low-risk bias using COCHRANE BIAS TOOL for randomization, whereas high-risk bias was found for allocation concealment and blinding of participants. No inadequacy toward outcome data was observed for all studies. [Table 1]a
| Discussion|| |
With the advent of new medical facilities, an exponential increase in the life expectancy and a paradigm shift in the geriatric population of our country has been observed. Despite this upsurge in the health sector, the impediment of dental disorders still pretense a gigantic confront in our country making these diseases widespread in an elderly population. The overall well being of the elder inhabitants of the nation state is still at stake. Thus, making it difficult for the health care professionals to maintain their healthy oral conditions, regardless of the progress in the medical field.
Geriatric patient assessment
It is considered as the primary step for management of these patients. The assessment tool is multidimensional and often described as OSCAR – Oral, Systemic, Capability, Autonomy, Realty. The Clinical Frailty Scale and Care Dependency Scale can enhance determination of the impact of frailty, care dependency, and disability on oral health maintenance so that appropriate treatment plans can be crafted and used as a baseline for successful outcomes.,,
A recent keynote lecture at the Canadian Geriatrics Society Annual Meeting provided an algorithmic chart for the elderly by means of the values of the foundation capability represented by the geriatric 5Ms (mind, mobility, medications, multicomplexity, and matters most to me).
Tools for medication/polypharmacy assessment
Geriatric population has an increased risk for drug-related complications. Most common problems among the elderly population include adverse drug reactions and polypharmacy. Absorption, distribution, metabolism, and elimination of drugs are influenced by physiologic aging of an individual. The Beers Criteria assist healthcare providers in improving medication safety in older adults. Various tools such as ARMOR tool (Assess, Review, Minimize, Optimize, Reassess) can be utilized in polypharmacy. The goal of this tool is to improve functional status and mobility of a patient and reduce polypharmacy, cost of care, and decrease hospitalization. Another European-based 2014 tool is Screening Tool of Older Person's Prescriptions and Screening Tools to Alert Doctors to Right Treatment criteria of potentially inappropriate and underused medications for the elderly population.
Association between various oral health factors and OHQoL in elderly
The range of oral health factors and associated ailments affecting OHQoL is here conferred.
Xerostomia is commonly faced by elderly patients and is subjective in nature. The prevalence rate for xerostomia ranges between 25 and 30% in the geriatric population. The role of aging on salivary function is debatable, yet it is generally agreed upon that aging of major salivary glands decreases their ability to maintain normal salivary flow as the anatomy of these glands changes from secretory to fibrotic independent of the multimorbidity of disease and poly pharmacy. Age-related systemic conditions and medical interventions along with a variety of medications used for their treatments have been directly related to xerostomia.
Risk of caries
Dental Caries accounts for alterations of salivary function secondary to polypharmacy and periodontal compromise resulting in gingival recession and poses a significant oral concern of the elderly. Salivary hypofunction results in increase in cariogenic microorganism colonization producing acids that demineralize the tooth surface. This compromised microenvironment alters the homeostatic demineralization/remineralization cycle, resulting in an increase in caries. The consequence is additionally reflective for root decay since cementum and dentin break up at a higher pH than enamel.
Aging decreases collagen of gingiva and periodontal ligaments thereby weakening them. The periodontal ligament disintegrates resulting in gingival recession and subsequent root caries., Pena and colleagues (2017) suggested that interaction of microbiota and aging of the immune system and motor systems contribute to exacerbation of chronic disease in elderly. Association of periodontal disease and disorders like dementia and Alzheimer's disease may be attributed to alterations in the ratio of several inflammatory mediators directly related to pathogenesis of both neurodegenerative disease and periodontal disease.,
Disorders in taste
Dysgeusia in elderly patients affect their quality of life and may result from physiologic changes in the taste cells altering taste perception. Additional features influencing it are deprived nourishment, systemic diseases, medications, and inadequate dentition.
Mastication and swallowing
Disorders of mastication and swallowing in elderly serve as significant risk predictors for poor oral health and malnutrition. In addition, loss of teeth potentiates impairment in elderly' life as a result of direct influence on mastication and swallowing. Improper prosthetic rehabilitation may worsen their masticatory function if conditions such as palatal stomatitis or traumatic ulcers develop. These complexities are further prevailing in aged individuals with occurrence of persistent sickness and neurodegenerative diseases that impede CNS control of gustatory function.,,
Burning Mouth Syndrome
BMS signifies burning sensations within the oral cavity that are continuous or intermittent and increase in intensity. The maximum occurrence of BMS occurs on the anterior one-third of the tongue, followed by the gingiva and palate. Dysfunction of the sensory input to the tongue may contribute to BMS.,
BMS is described in two forms (1) primary/essential BMS, with a cause of central neuropathologic pathways; and (2) secondary BMS, arising as a result of local, systemic, or psychological factors. BMS has been associated with fungal infections, geographic tongue, lichen planus, oral carcinomas, and microtrauma.
BMS in elderly manifests in a variety of systemic diseases (i.e., GERD, diabetes, hypertension, and autoimmune diseases) and in certain vitamins deficiencies (i.e., iron, vitamin B12, and folic acid). The management of BMS varies and the plan given gy Elsawy and Higgins is one of the effective model.
Candida infections prevalent in older age group
Disturbance of oral microflora due to long-term polypharmacy, along with the use of corticosteroids, xerostomia, immune defects, immunosuppression, blood dyscrasias, and diabetes, leads to Candidal infections in the elderly. It can be diagnosed due to its unique clinical presentation and management with treatment of the predisposing factors along with antifungal- oral suspension, lozenges, gels, or tablets.
TMJ/and orofacial pain disorders prevalent in older age group
Radiological evidence of TMJ disorders are seen in 45–70% elderly population and with minimal clinical signs. This may be due to the fact that the functional demands of the TMJ may exceed the repair and remodeling capacity of the joint resulting in degeneration. Conservative treatment is recommended in these patients as the disease is self-limiting.
Prosthetic status and OHRQoL
Edentulism reduces the ability to eat, analyze taste, bite, or gulp food in elderly. The shift in nutrition intake and decrease in mastication efficiency weave a pathway for a number of disorders including acute and chronic disease, alterations in the gastrointestinal tract, functional disabilities, chewing problems, and psychological and social factors.,
| Government Policies and our Recommendations|| |
A broad variation in the policies of the Nations Worldwide has been observed in gerodontology. The Government of India has recommended concerned authorities to set up a committee and involve dental professionals to execute a plan by reduction in overall burden of oral diseases of the country in a more widespread and realistic approach. Political, social, organizational, professional dedication, and support are essential to bring oral health and general health on a common platform.,,
An action plan should be developed for elderly population, particularly those who are frail and have functional limitations. Gerodontology should be taught at the undergraduate level and more training opportunities in oral well being for such patients ought to be accessible, so that an optimistic approach can be developed. Moreover, interdisciplinary and interprofessional training and collaborative practice with involvement of more postgraduates and continuing education programs on gerodontology should be developed and encouraged. Oral health assessment and promotion competencies should also be integrated into requirements for continuing education in nondental professionals along with theoretical and hands on training.
| Preventive Dental Care for Geriatrics|| |
Oral disease prevention is still the central focus for the elderly population as for other patient populations. Many older adults have difficulty achieving effective daily plaque control; manufacturers have developed and marketed several toothbrushes designed to facilitate tooth cleaning. An occupational therapist can assist a dentist and can make oral care easier for patients. Those with reduced ability to perform oral self-care should be seen more frequently for prophylaxis. Since denture-related and other oral mucosa lesions are common in the elderly, edentulous patients should be periodically evaluated by dental professionals.,,,
| Conclusion|| |
There is an association between OHRQoL and dental care of older people. This indicates prevention and early intervention with treatment modalities in the increasing elderly population with an apparent solicitousness of their health needs.
Gaining a better understanding of oral, systemic, and social determinants of health and applying these successful ways of anticipation and intrusion will throw in to humanizing both the existence and health-related quality of life in the geriatric patient population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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