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ORAL HEALTH STATUS AND 'ORAL HEALTH-
RELATED QUALITY OF LIFE IN l'WO
ELDERLY HOMES IN NAIROBI. '
INVESTIGATOR: Wambugu Silvana Mbuthia
V28/2023/2011.~ i
Bachelor of Dental Surgery; BDS 3 .'}
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Duration of study: Jan to September 2014
The Community dentistry research proposal submitted in partial fulfilment
of Bachelor of Dental Surgery University of Nairobi.
DECLARATION
I hl~.htj.M :..S~\~.9.J!l:k~:~ BDS ).U;~leclare that this is my
original work and has not been submitted by any other person of research purpose, degree or
whatsoever the purpose.
Signature
DateElQ,nd MQ. Q II........................0 0',....
ii
SUPERVISORS APPROVALThis research project has been submitted for partial fulfilment of bachelor of dental surgery
upon the approval of university supervisors.
INTERNAL SUPERVISOR
Prof L.W Gathece BDS., MPIl., PhD.(Nbi)
Department Of Periodontology/ Community And Preventive Dentistry,
School Of Dental Sciences,
University Of Nairobi.
Signature ~~~ Date ~.?..\.?. Po-t Lf-
EXTERNAL SUllERVISOR
Dr Veronica Wanjiru Wangari BDS (Nbi)
Department of Periodontology,
School of Dental Sciences,
University of Nairobi.
Signature ~ Date ?:}1..~1.f
iii
TABLE OF COTENT
ContentsDECLARATION ii
SUPERVISORS APPROVAL iii
ABBREVIATIONS vi
SUMMARy: vii
Objecti ve: To describe the oral health status and oral heath related qual ity 0 f life among elderlypatients at two elderly patients home around Nairobi vii
CHAPTER I 1
1.0 INTRODUCTION 1
1.1 LITERATURE REVIEW 2
1.1.1 Edentulism and denture wearing 2
1.1.2 Teeth caries 2
1.1.3 Periodontal conditions 4
1.1.4 xerostomia 5
1.2 Oral health-general health-quality of life 5
CHAPTER 2 7
2.0 STATEMENT OF RESEARCH PROBLEM AND JUSTIFICATION 7
2.1 Statement of the research problem 7
2.2 Justification 7
General objective . . 7
To describe the oral health status and oral heath related qual ity of life among elderly patients at twoelderly patients home around Nairobi 7
Speci fie objective 7
Hypothesis......................................................................................................................... . 8
Variables .. 8
CHAPTER 3 9
3.0 MATERIALS AND MET'HOD 9
3.1 Study area 9
3.2 Study design : 9
3.3 Study population 9
3.4 Sample size determination 9
iv
3.5 Sampling methods 10
3.5.1 Inclusion criteria _ _ 10
3.5.2 Exclusion criteria 11
3.6 Data collection instruments and technique 11
3.7 Reliability and validity 11
3.8 Data quality control and analysis 11
3.9 Ethical considerations 11
3.10 Perceived benefits: 12
3.11 Study limitations 12
BUDGET 13
SCHEDULE OF ACTiViTy 14
REFERENCES 15
CONSENT FORM _ 18
QUESTIONNAIRE: MODIFIED WHO ORAL HEALTH ASSESSMENT FORM FOR ADULTS, 2014 21
v
ABBR~VIATIONS
BDS
MDS
VON
WHO
OHIP
KNH
Bachelor Of Dental Surgery
Masters Of Dental Surgery
University Of Nairobi
World Health Organisation
Oral Health Impact Profile
Kcnyatta National Hospital
vi
SUMMAI~Y;
BaCkgrOUn~eral studies have been carried out to assess the oral health status and oral
health related quality of Ii fe in the ederly. Gobally, poor oral health among old people has
resulted in high caries experience, tooth loss, high prevalence of periodontal diseases,
xerostomia and precancer/cancerous conditions among the ederly. This is expected to impact
on their day to day lite negatively.
Objective: To describe the oral health status and oral heath related quality of life among
elderly patients at two elderly patients home around Nairobi.
Study design: Descriptive cross-sectional study.
~Data collection tools and techniques: \he data will be collected using questionnaires and
clinical evaluation forms.
Sample and sampling: patients will be selected using simple random sampling method.
Perceived benefits: The results obtained from this study will help dentists and dental
practitioners in the proper management or elderly patients in a way that wil aim at improving
their oral related quality or lire.
,l
Setting: The study will be conducted at two elderly homes ~d Nairobi.
Study population: the study will be conducted in Kenyan African elderly persons aged 65
years and above at the two elderly homes.
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CHAPTER I
1.0 INTRODUCTION
The oral health of individuals at any particular age is of utmost importance when assessing
the general health of the individual. Advancing age is associated with a massive deterioration
of the oral health of an ind ividual. Periodontal diseases, loss of teeth, precancerous/cancerous
d· . /'~ tr ~\ d xerostomi di . I -1- Icon mons, ~carIes an xerostomia are among common con It Ions t rat al ect t re
elderly'. Consequently. research has shown a correlation between oral conditions and other
major aspects of the individual including economically, socially, psychologically and
emotionally'.
The quality of life of the individual is greatly affected. Aspects such edentulism compelsJ1
individual to seek dentures which presents a financial handle~. Periodontal diseases and tectile.tt \-l(
caries are associated with pain and discomfort which weigh greatly on the patients
emotionally' .
The aim of this study is to determine the perceived impact of oral health on the general~
quality of life of elderly patients. The findings of this study will help promot10ral health of
the elderly through provision of better health care including treatment that will aim at
producing the best impact on their general quality of life. The findings will also be useful in
providing a current update of literature on the pattern of occurrence of oral conditions among
the elderly in our Kenyan elderly population.
1
1.1 LITERATURE REVIEWGlobally, poor oral health among older people has particularly been seen in a high level of
tooth loss, dental caries experience, high prevalence rates of periodontal disease, xerostomia,
and oral precancer/cancer'. More of significance is the negative impact of poor oral
conditions on daily life among edentulous people.
1.1.1 Edentulism and denture wearing
Edentulisim is a debilitating and irreversible condition that is common in elderly persons' and
is described as the "final marker of disease burden for oral health,,2. Prevalence of complete
tooth loss has declined over the last decade, however edentulism remains a major disease
worldwide especially among older adults3. The tooth loss reduces chewing perfo~ance and
affects food choice e.g edentulous people tend to avoid dietary fibre and prefer foods rich in
saturated fat and cholesterol". Edentulousness is also known to be an independent risk factor
for weight loss" and social handicaps related to communication".
Edentulousness leads to acquisition of removable dentures has been associated with denture
stomatitis, a common oral mucosal lesion of clinical importance in old age populations". The
prevalence rate of stomatitis is reported within the range of 11-67% in complete denture
wearers".
1.1.2 Teeth caries
Tooth decay is when acids in the mouth dissolve the outer layers of the teeth. Over time,
symptoms of tooth decay can include toothache, when eating or drinking and visible
diS_CO_l_o_ur_e_d_s_p_o_ts_on_y~o_u_r_te_e_th_"'_< ----'- =:> tu~~uild up of plaque has been shown to lead to complications such as tooth decay and
periodontal disease. Data worldwide shows that dental caries is a major public health problem
in older people and closely linked to behaviouralfactors6,11.
2
I
II
High prevalence rates of coronal dental caries and root surface caries are found among old
age populations in several countries worldwide''. In developing countries, data on dental
caries among older people are scarce. However in developed countries the mean number of
decayed and filled root surfaces in older people lies between 2.2 and 5.38-1°. Due to
increasing life expectancy of the dentition, older adults are experiencing root caries and
gingival recession, putting them at even higher risk for periodontal disease. Root caries is the
major cause of tooth loss in older adults, and tooth loss is the most significant oral health-
related negative variable of quality of life for the elderly'". Nearly half of all individuals aged
75 and older have root caries'"
There appear to be a wide variety of risk indicators and risk factors implicated in root caries.
These factors include not only oral' factors, but also medical, behavioral, and social factors.
There are several indicators that provide insight into the incidence and prevalence of caries in
elderly people and the medical or disability conditions that place individuals at increased
caries risk. One indicator is the presence of Mutans streptococci, an established etiologic
agent for caries activity". One of the main oral behaviors to reduce the amount of bacteria in
the oral cavity is regular tooth brushing with a fluoride-containing dentifrice. Inadequate
exposure to fluoride accelerates the disease, because fluoride can remineralize decalcified
structure. Conditions that compromise good oral hygiene behaviors and oral health are also
positively associated with caries risk. These include certain illnesses, physical and mental
disabilities, and the presence of existing restorations or oral appliances. Fermentable
carbohydrate consumption fuels acid formation and demineralization and is associated with
caries, particularly in the absence of fluoride24. The amount, consistency, and frequency of
consumption determine the degree of exposure. Long-term regular doses of medications,
which the elderly are prone to, containing glucose, fructose, or sucrose may also contribute to
caries risk25.
Studies among the elderly population, have investigated age-related differences in whole
and parotid saliva secretion related to the production of saliva, as well as the immune factors
in saliva. The levels of serum immunoglobulin G (IgG) and IgM were significantly reduced
in older individuals, whereas no significant reduction in the level of IgA with age was
observedr'. No significant changes in any immunoglobulin levels with age were found in
parotid saliva, but significant reductions in the secretion rates of IgA and IgM, but not IgG, in
whole saliva were detected in the oldest age individuals. The results demonstrate a decline in
3
immunoglobulin concentrations with increased age, which may contribute to the increasedsusceptibility of elderly individuals to oral diseases.
Cardiovascular diseases have also been associated with higher caries experience, particularly
in individuals 80 years or 01der23• Individuals with three or more active root caries lesions
have more than twice the odds of cardiac arrhythmias than ones without active root caries.
These results did not notably change after adjusting for age, medications that reduce saliva,
and number of teeth. The findings indicate that there may be a link between active root caries
and cardiac arrhythmias in those aged 80 and older. One explanation for these findings is that
both cardiac arrhythmias and' caries are simply markers of declining general health.
Medications that affect the amount of saliva in the mouth as noted under xerostomia also play
a major part in caries risk in the elderly.
1.1.3 Periodontal conditions
Periodontal disease is a chronic infection of the hard and soft tissue supporting the teeth27
and is a leading cause of tooth loss in older adults'". Tooth loss impairs dental function and
quality oflife in older adults". The chronic infections associated with periodontitis can
increase the risk for aspiration pneumonia in older adults and has been implicated in the
pathogenesis of chronic inflammation that impairs general health29,3o. The severity of
periodontal disease can be categorized as mild, moderate, or severe on the basis of multiple
measurements of periodontal pocket depth, attachment loss, and gingival inflammation
around teeth'" .
Globally the percentage of subjects with deep sockets (4mm and above), ranges from
approximately 5-70% among older people'<. Studies show poor oral hygiene and high levels
of dental plaque are associated with high prevalence rates and severity of periodontal disease
in older adults6,12.
1.1.4 xerostomia
Dry mouth is a common complaint in older people and the condition is reported in
approximately 30% of the population aged 65 and older13• It is commonly associated with
4
oral disease, has also been associated with type 2 diabetes mellitus'". These persons
experience difficulty in chewing, eating communication and high levels of dental caries",
Medications that are prescribed to the elderly in fact can cause impaired salivary flow with no
change in the immune system". Many medications, chemotherapy, radiation treatments, and
some diseases can decrease salivary gland function and therefore make caries and other oral
diseases more likely to occur. Some common drugs that may cause dry mouth are high blood
pressure drugs, cholesterol lowering drugs, pain medications, muscle relaxants, allergy, and
asthma medications. No matter what the cause, it is undisputed that saliva is essential in
neutralizing the acidic environment, thus inhibiting the growth of bacteria. Any decreased
levels of saliva can put one at increased risk for developing caries.
1.2 Oral health-general health-quality of life
The solemnity of this was such that the numerous health foundations including WHO created
various questionnaires which examine the impact of oral health conditions and its
psychosocial and functional effects on a person's wellbeing. About 17 dental questionnaires
or structured interviews(sometimes referred to as "socialdental indicators") have been
developed. These instruments have been developed to directly or indirectly measure the
impact of oral health on quality of life experiences. They include GOHAI. General oral health
assessment index- atchinson and dolan, 1990, Dental impact profile- strauss and hunt 1993,
OHIP, oral health impact profile- slade and spencer 1994 who proposed seven dimensions of
impact of oral condition. Each of the seven dimensions original scale was assessed from the
questions on the type of problem experienced (a total of 49 questions), OHIP-14, was later
developed based on a subset of 2 questions for each of the seven dimensions- Slade, 1977.
The aim of the oral health impact profile is to provide a comprehensive measure of self-
reported dysfunction, discomfort and disability arising from oral conditions. The oral health
impact profile is based on Locker's adaptation of the World health organisation's
classification of impairments, disabilities and handicaps(Locker, 1988). Locker suggested
that health problems may affect quality of life but such a consequence is not inevitable. The
implication of this is that people with chronic disabling disorders often perceive their quality
of life as better than healthy individuals.i.e poor health or presence of disease does not
inevitably mean poor quality of life. Allison et al attempted to further explain this
phenomenon by suggesting that quality of life was a " dynamic construct", and thus likely to
5
be subject to chanue over time. Individual attitudes are not constant, vary with time andexperience, and are modified by phenomena such as coping, expectancy and adaptation. They
give us an example of an individual who had eating problems due to pain and discomfort,
who would have rated this problem as extremely important at one point in time. However,
when this problem is diagnosed as oral cancer, and treated with radiotherapy and! or surgery,
the same individual may report the original problem as relatively unimportant. 18
The experience of pain, problems with eating and chewing, embarrassment about the shape of
the teeth or about missing, discoloured or damaged teeth can adversely affect people's daily
lives, self esteem and well being. Most recent research has demonstrated the obvious impact
of oral health on quality of life and general health 14-17. More importantly the interrelationship- 1417between oral health and general health being more pronounced among older people ' . Poor
oral health can compromise the general health of an individual due to nutritional deficiencies
that comes about due to compromised chewing and eating .abilities.
6
CHAPTER 2
2.0 STATEMENT OF RESEARCH PROBLEM ANDJUSTIFICATION
2.1 Statement of the research problem
Oral conditions prevalent among the elderly include edentulism, xerostomia, cancerous and
precancerous conditions, periodontal conditions and tooth caries. The oral cavity provides a
gateway to the rest of the body and aesthetically it is a crucial organ. Disorders associated
with the oral cavity in elderly patients therefore cause emotional distraught, functional
limitations. such as speech and feeding, discomfort and economic deprivation due to cost
incurred in the treatment.
Studies have shown that the elderly suffer from a number of oral conditions which are
thought to make their life difficult and sometimes contributing to other chronic conditions
and even death.
2.2 JustificationPresently there are no studies that have been carried out in Kenya or East Africa to seek the
relationship between oral health status and oral health related quality oflife. There is also a
significant knowledge gap on the oral disorders prevalent among the elderly in Kenya.
General objective
To describe the oral health status and oral heath related quality oflife among elderly patients
at two elderly patients home around Nairobi.
Specific objective
1. To determine the periodontal status of elderly in two homes in Nairobi.
H. To determine the caries experience of elderly in two homes.
HI. To determine the oral related quality of life among the elderly in two homes.
HypothesisNull hypothesis; Oral health status among the elderly have no effect on the psychosocial and
the functional well-being of the patient.
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