Oral Health Related Quality of Life among Elderly People in a General Practice Setting in Lagos

Background: Oral health-related quality of life is a multidimensional construct. Oral health has an impact on an individual's daily functioning, well-being and the overall quality of life. The elderly are prone to several dental problems such as dental caries and periodontal disease which constitute the major oral health burden all over the world. These two diseases have a high prevalence rate, wide geographical spread, graded severity and are important public health challenges. It is therefore important to examine the role of oral diseases with age and its impact on the quality of life of the elderly. Aim: To assess the pattern of oral health and quality of life amongst elderly patients. Materials and Methods: It is a descriptive cross sectional study, conducted among 294 elderly patients attending Orile Agege General Hospital, Lagos. Data was collected using a semi-structured, interviewer administered questionnaire for individual's oral health using the WHO Oral Health Questionnaires for the adult and oral health related quality of life using Oral Health Impact Profile. Data obtained was subjected to descriptive, bivariate and multivariate analysis using IBM SPSS 20. Results: The mean age of the elderly was 68.65 ± 6.58 years. Nine point five percent of the respondents had less than 20 natural teeth, 46.6% were experiencing discomfort in mouth, 30.6% were using partial removable dentures and 4.8% were utilizing full lower or full upper removable dentures. Only 6.1% reported poor tooth condition and 8.2% stated poor gum condition. However, 42.9% of the respondents cleaned their teeth two times or more daily, 15.0% and 85.7% of subjects used tooth-brush/dental floss and fluoridated toothpaste respectively. On the oral health quality of life (OHQoL), 35.4% had some impact of oral health on QoL with the dominant domains being physical pain (50.3%), psychological discomfort (44.6%) and functional limitation (43.2%). OHQoL was influenced by the number of natural teeth (OR = 5.417, p<0.001), discomfort in mouth (OR = 2.128, p = 0.002), removable dentures (OR = 2.732, p = 0.001) and frequent tooth-brushing (OR = 1.770, p = 0.021). Conclusion: The number of natural teeth, discomfort in the mouth, presence of removable dentures and frequent mouth-washing influenced the quality of life of the elderly.


Introduction
examination, the number of missing teeth was counted. In Nigeria, the present population of elderly is over 5 million which is perhaps the largest concentration of Data Analysis the elderly in West Africa. The population of the elderly is projected to be 16 million by 2030 and 47 The data was entered and analysed using SPSS-1,2 million by year 2060 . There is a high prevalence of Version 20. Three levels of analyses were employed. periodontal diseases among the elderly which is The univariate analysis was used to calculate the about 90.8% for gingivitis and 75.4% for mean and standard deviation for continuous data 3 periodontitis . The mouth, like every other part of the while proportions were determined for all the body reflects the elderly's health and well-being as categorical data. The bivariate analysis was utilized to oral diseases have an impact on many aspects of determine associations between variables. Chi 3 general health . square Statistics was used to determine the relationship between oral health, oral hygiene As high as 50.0% of mortality from the ten leading practices and quality of life of the elderly. Multivariate causes of death among the elderly in Nigeria and analysis was employed for regression and the level of other Sub-Sahara African countries can be linked to significance was defined at 95% confidence interval attributes of life-style such as physical inactivity and (p<0.05). 4 poor oral hygiene . It is therefore important to examine the interplay of oral diseases with age, and The questionnaire used to obtain information about the impact of the diseases on the quality of life for the an individual's oral health and the oral hygiene 5 practices was adapted from WHO Oral Health elderly . 10 Questionnaires for the Adult . The individual scores Oral health-related quality of life is a multidimenwere summed up to evaluate the oral health selfsional construct. Oral health has an impact on assessment and the oral hygiene practices. The individual's daily functioning, well-being and the reliability and validity scores for this study were 6 overall quality of life . Dental caries and periodontal determined. The Oral Health Impact Profile (OHIPdiseases are the major oral health burdens amongst 14) Questionnaires response was classified using the 7,8 the elderly all over the world . They have high Likert scale with six options ranging from; Never-0, prevalence rate, wide geographical spread and Hardly ever-1, Occasionally-2, Fairly often-3, Very 9 graded severity . often-4, Don't know-5. There were 7 main domains in which two questions each were derived from. The aim of the study is to determine the pattern of These included functional limitation, physical pain, oral health and the impacts oral health has on the psycho discomfort, physical disability, psycho quality of life of the elderly patients attending Orile disability, social disability and handicap. The score for Agege General Hospital, Lagos. each response is summed up for the fourteen questions and the mean score is calculated for all Methodology respondents, dichotomizing responses into "no The study was a descriptive cross-sectional study impact" versus "some impact" where "no impact" is which employed a quantitative study method. Verbal the score lower than mean sum and "some impact" 11 consent was taken for inclusion in the study. Patients indicates mean score and above . The scores that were above 60 years who could understand assigned to the responses to the 14 questions are English and those who did not understand English 12 added to obtain values between 0 and 14 . were communicated to through an interpreter. The study population consisted of 269 elderly patients Ethical Considerations attending Orile Agege General Hospital, Lagos, Ethical approval was obtained from the Health Nigeria. Systematic sampling technique was also Research and Ethics Committee of the Lagos used to recruit respondents from each unit that University Teaching Hospital, Lagos with an assigned participated in the study. Oral examination was done identification number of ADM/DCST/HREC/APP/197. and data was collected using a semi-structured, interviewer administered questionnaire which addressed the socio-demographic information, self-Results reporting of an individual's oral health using the WHO 10 Table 1 shows overall responses of the elderly to the Oral Health Questionnaires for the Adult, and the statements assessing their oral health quality of life. impact of oral health conditions on the quality of life The questions were asked to know if they had certain of the elderly patients using Oral Health Impact difficulties because of problems associated with Profile-14 (OHIP-14). During the intra-oral teeth, mouth or dentures. Although 3 (1.0%) of the On whether the respondents had been self-conscious respondents did not indicate if they had trouble of their mouth because of problems with teeth, mouth pronouncing words, 3 of every 5 of the respondents or dentures, 121 (41.2%) stated "never". One hundred stated they never had trouble pronouncing words. and fifty-nine (54.1%) respondents indicated they On whether sense or taste had worsened, 143 never had unsatisfactory diet because of problems with (48.6%) of the respondents never experienced such mouth, teeth or dentures. difficulty. Concerning having pain or ache in the Majority of the respondents (197, 67.0%) said they mouth, approximately one-tenth of the respondents had never been irritable with other people when they indicated that they either had pain very often (31, had problems with their mouth, teeth and dentures. 10.5%) or fairly often (30, 10.2%) due to problems The other responses of the respondents to the with teeth, mouth or dentures while (115, 39.1%) statements assessing their oral health quality of life experienced it occasionally. are as shown in Table 1   proportion of respondents with full lower/upper Lagos. The most dominant domain was "Physical removable dentures (71.4%) assessed to have some pain" (148, 50.3%) followed by "Psychological impact on OHQoL was significantly higher than those discomfort" (131, 44.6%) and "Functional limitation" with either partial removable dentures (47.8%) or no (127, 43.2%). The least frequent domain was removable denture (26.8%) (F. exact= 19.539, "Handicap" (71, 24.1%). Table 3 shows the P<0.001). Also, a significantly higher proportion of association between oral health quality of life respondents who brushes twice daily (42.9%) was (OHQoL) and pattern of oral health among the assessed to have some impact on OHQoL when elderly attending Orile-Agege General Hospital, compared with those that do not brush their teeth 2 Lagos. A statistically significant association was times/day (29.8%) (χ2 = 5.401, P = 0.026). observed among elderly patients with less than 20

Domain
Mean ± SD Impact n (%)    Table 4 showed that after controlling for other removable upper/lower removable dentures were 3 variables, elderly with <20 natural teeth were 5 times times more likely (OR = 2.732, p = 0.001) and those more likely to have some impact on their oral health with removable partial removable dentures 2 times quality of life when compared to those with 20 or more likely (OR = 2.494, p = 0.001) to have some more natural teeth (OR = 5.417, p<0.001). Elderly impact of oral health quality of life. with discomfort in the mouth were 2 times more Also, elderly who washed mouth 2 times or more likely to have some impact on oral health quality of daily had about 2 times likelihood of having some life when compared to those without discomfort in impact of oral health quality of life (OR = 1.770, p = their mouth (OR = 2.128, p = 0.002). Elderly with 0.021).

Discussion
Oral health impact profile (OHIP) assessed the impact of oral health on the quality of life of the The study assessed the pattern of oral health and oral elderly in this study. It was not surprising that the hygiene practices among the elderly. It also most dominant domain of oral health quality of life determined the oral health quality of life and the among the elderly in this study was physical pain. The association between oral health and the quality of life experience of pain affects the ability to perform many of the elderly. It was observed in this study that 42.9% 17 different physical activities . This result is in tandem of the respondents brushed their teeth twice or more with the finding in the report of an aging Canadian a day and 15.0% of the respondents used dental 11 population study , in which the most commonly floss. This is lower than the findings in the study done reported dominant domain was 'physical pain'. 13 by Armitage and Robertson which reported that Physical pain was also reported to be the most about 60.0% of the respondents brushing their teeth dominant domain of oral health quality of life in the twice daily. Oral hygiene practices of the respondents study that assessed the relationship between oral in this present study seemed ineffective in meeting health and oral health related quality of life among oral health needs and preventing oral diseases. 7   aging Canadian population in which psychological traumatic ulcer . discomfort was also reported as a dominant domain 11 Frequent tooth brushing was found to affect oral of oral health quality of life . However, in contrast to 18 health QoL. A higher proportion of respondents who the finding in this present report, a Spanish study brush their teeth more than 2 times/day was assessed reported functional limitation as the second most to significantly have some impact on OHQoL in dominant and physical pain as the third most comparison to those who brush less than 2 dominant domain. These differences could be due to times/day. Self-esteem and self-perception (54.1%) the method of OHIP adopted and the lifestyle of could explain why regular tooth brushing could be respondents in each study location. In this study, 'additive mean score' method was used while the seen in an elderly. It could be in response to the way study in Spain adopted the "occasional threshold he perceives his oral health. 12 method" . Social disability was the least dominant 7 After controlling for other variables, those domain in Masood et al's study while handicap was respondents with natural teeth of less than 20 in the least dominant in this study and in a study 12 number were 5 times more likely to have some conducted in Spain .
impact on their oral health quality of life when In this study, number of natural teeth related to oral compared to those with 20 or more natural teeth (OR health quality of life. While the elderly with less than = 5.417, p<0.001). Respondents with discomfort in 20 natural teeth were assessed to have some impact mouth were 2 times more likely to have some impact of oral health on their quality of life, while those of oral health on their quality of life (OR = 2.128, p = having 20 or more standing teeth have lesser impact 0.002). Elderly with full upper/lower removable of oral health on their quality of life. This finding is dentures were 3 times more likely (OR = 2.732, p = similar to the report in a study done in United 0.001) and those with partial removable dentures, 2 7 Kingdom which observed that the elderly population times more likely to have some impact of oral health had poorer OHQoL when the number of missing on their QoL. teeth was between 6-17. It is perhaps unsurprising that the experience of discomfort in mouth has some impact on oral health quality of life among the elderly, Conclusion a significant proportion of respondents with Based on the finding of this study, a large number of discomfort in mouth (44.5%) assessed to have some the respondents were assessed to have some impact impact on OHQoL was higher when compared with of oral health on quality of life with the most those elderly without discomfort in mouth. This dominant domain of OHIP-14 being physical pain finding is similar to the study conducted in United and least dominant domain was handicap. The 7 Kingdom , which observed that pain originating from pattern of oral health that was assessed to have some the mouth extends further and causes physical, impact on quality of life was number of natural teeth, discomfort in mouth, removable dentures and psychological and social disability among older frequency of tooth brushing. people. Re-orientating the elderly on oral health services could be key to helping them eliminate pain 19 in the mouth .
References Wearing of dentures was found to affect oral health 1. National Population Commission. Population quality of life among the respondents in this study.
and Housing Census of the Federal Republic of Those with full lower/upper removable dentures Nigeria National and State population and assessed to have some impact on OHQoL were Housing Tables: Priority Tables. 2009; pg 1. significantly higher than those with either partial 2. Ahmed T, Haboubi N. Assessment and removable dentures or no removable dentures. This Management of Nutrition in older People and its finding is similar to the study in which there was importance to health. Clin Interv Aging. 2010;(5): association between wearing dentures with higher