Introduction
With the onset of care-dependency, oral health tends to get neglected as priorities shift, with more time being dedicated to care for needs that are considered to be more important (HOEKSEMA ET AL. 2017). It is well reported in literature, that dependent elderly people tend to have poor oral health (CHALMERS ET AL. 2002; MATTHEWS ET AL. 2012; YOON ET AL. 2018). Impairments of mobility, manual dexterity and cognitive function, together with barriers related to dental care delivery, all contribute to the oral health problems generally experienced by dependent elders (WU ET AL. 2007). The main dental diseases, dental caries and periodontal disease, are behavioural diseases with bacterial involvement i.e. diseases whose onset and progression can be suppressed by effective oral health care behaviour namely, diet control, regular tooth brushing and denture cleaning, and regular utilisation of dental services (FRENCKEN ET AL. 2012; NIESTEN ET AL. 2017).
In Switzerland, dental health care is not covered by the compulsory health care insurance and dental treatment charges, with exceptions as stated in article 31 in the federal law of health insurance (KVG), are out-of-pocket expenditures (DI BELLA ET AL. 2018). Dental care is generally provided in private dental practices. Some dentists and dental hygienists also provide mobile dental services to treat people who, due to physical or cognitive impairments cannot attend the dental practice. The majority provide these service at less than 20% of their total workload through the use of portable equipment (BORG-BARTOLO ET AL. 2020). Besides portable equipment, other models exist for the delivery of mobile dental care namely mobile dental vehicles, hybrid models (a combination of a mobile dental vehicle together with portable equipment) and the delivery of dental care in-situ i.e. the setting up of a fully-equipped dental clinic on the premises of either nursing homes or targeted institutions (ASSOCIATION OF STATE AND TERRITORIAL DENTAL DIRECTORS 2007). For the purpose of this study, the hybrid model and the portable equipment model were used. They were the two models most readily available to conduct the study and were suitable to reach the care-dependent elders residing both in nursing homes or in the community.
The objective of this pilot study was to provide data on the present oral health status and the oral health behaviour of care-dependent elderly people in the rural canton of Uri. The study aimed at assessing whether age and duration of living in a nursing home is associated with dental attendance, whether there is a relationship between age and the DMF-T index, and how high the risk was for participants to develop oral health problems. The null hypotheses for this study were: 1) the frequency of dental attendance is not dependent on a) age b) the duration of living in a nursing home, 2) there is no difference in the DMFT-index as age increases.
Materials and Methods
Ethics approval was obtained in May 2018 (EKNZ ID 2017-07013) prior to the start of the study. The managers of the nursing homes and the local community domiciliary services provided by ‘Spitex’ in the canton of Uri were informed about the study via information leaflets and personal discussions, with the care givers being responsible for the recruitment of the participants. Informed consent was obtained from the patients or their legal guardians, who signed a consent form after being provided with information regarding the scope of the study and their participation in the study. The inclusion criteria were care-dependent elderly people who resided either in nursing homes or were community dwellers in the canton of Uri. Those who fulfilled the inclusion criteria were examined and none of the participants were excluded retrospectively. The first phase of data collection took place between June 2018 and December 2018 while the second phase took place between October 2019 and January 2020. The dental examinations were carried out by three dentists and one dental hygienist, who conducted dental visits in the participants homes or nursing homes using portable dental equipment or the hybrid model. The dental examinations were offered free of charge. The study protocol was conducted according to the Declaration of Helsiniki. The study sample consisted of 56 participants (47 resided in nursing homes, 9 were community dwellers). The nursing home group (NHG) consisted of 24 females and 23 males, aged 86 ± 7.36 years. The community dwellers group (CDG) consisted of 7 females and 2 males, aged 76 ± 12.8 years.
Data collection
A questionnaire was filled by the patients themselves or with the help of their care givers. Data was collected on demographics; age, gender, location, duration in nursing home (when applicable), medical history: heart and circulation, diabetes, cholesterol, anticoagulants, painkillers, respiratory, thyroid, antiepileptics and immunosuppressants, current status; presence of pain, ability to eat, oral health behaviour; daily intake of sugar, daily use of fluoride through toothpaste, mouthwash and/or fluoride tablets, daily oral hygiene, the last visit to the dentist and the last visit to the dental hygienist (appendix 1).
The clinical examination collected data on the oral mucosa (presence and location of oral lesions), oral hygiene status (no plaque or calculus, grade 1 = up to one third of the tooth covered in plaque/calculus, grade 2 = between one and two thirds of tooth surface covered in plaque/calculus, grade 3 = more than two third of tooth surface covered in plaque/calculus) (WORLD HEALTH ORGANIZATION 2013), denture status; status of dental prostheses, denture hygiene status (no plaque/calculus, grade 1 = up to one third of the denture surface covered in plaque/calculus, grade 2 = between one and two thirds of the denture surface covered in plaque/calculus, grade 3 = more than two thirds of the denture surface covered in plaque/calculus), periodontal status; presence of bleeding on probing, presence of at least one tooth with a periodontal pocket which was 4mm deep or more, and the presence of at least one tooth with furcation involvement, dental status; the Decayed, Missing and Filled teeth index (DMF-T index) was used as a measure of dental caries. Active decay in either crown or root was reported as the D component, missing teeth were reported as the M component and restored teeth due to caries were reported as the F component.
Outcome measures
DMF-T index: The DMF-T index is the summation of the number of decayed (D), missing (M) and filled (F) teeth and was calculated over 32 teeth i.e including third molars.
‘Teamwerk’ index: The ‘Teamwerk’ index was used to further describe the oral health status of the patients (BENZ & HAFFNER 2009). The index is the summation of the scores given to each of the following nine parameters: DMF-T index; scores from 0 = low DMF-T (DMF-T index 0 – 22 for people aged 65 years and over) to 2 = high DMF-T (25 and over for people aged 65 years and over). The grading is according to the ‘Teamwerk’ index graph which plots age (x-axis) vs DMF-T index (y-axis) in a normal population. (BENZ & HAFFNER 2009), caries; scores of 0 to 4 depending on the total number of carious teeth present i.e. 0 = no carious teeth, 4 = 4 carious teeth or more, pain; scores of 0 = no pain or 4 = pain present, sugar intake; scores of 0 = sugar intake less than three times daily or 2 = sugar intake three times or more daily, fluoride contact; scores of 0 = fluoride contact more than once daily, 2 = once daily, 4 = less than once daily, oral hygiene; scores of 0 = optimal to 4 = poor, periodontal pocketing; scores of either 0 = no periodontal pockets or pockets < 4mm in depth or 3 = periodontal pockets ? 4mm, bleeding on probing; scores of 0 = no bleeding on probing or 3 = bleeding on probing present, furcation involvement; scores of 0 = no furcation involvement or 3 = furcation involvement present. In cases where data for a parameter was missing, the highest possible score was given for that missing parameter. For edentulous patients only the parameters DMF-T index, pain and oral/denture hygiene were taken into consideration (GEIGER 2011). The final score is divided into three categories: 0 to 8 = low risk, 9 to 14 = medium risk, 15 to 29 = high risk. The risk levels are linked to recommendations for the frequency by which patients should receive dental care namely: low risk: six-monthly, medium risk: four-monthly and high risk: three-monthly (GEIGER 2011).
Data analysis
Descriptive statistics included the total number (n) and percentage (%) for daily sugar intake, daily fluoride contact, frequency of daily brushing, medications, overall dental status, findings of the oral mucosa, presence of dental pain, oral hygiene status, overview of the periodontal status, denture hygiene status. The total number (n) and percentage (%), means and standard deviations (SD), and minimum and maximum values (min-max) were included for decayed, missing and filled teeth, DMF-T index, DMF-T grading and the risk of developing an oral health problem. Median tests were conducted to assess the relationship between age and i) last dental visit ii) duration of living in a nursing home, and linear regression models were performed to assess the relationship between age and the number of decayed, missing, filled teeth and DMF-T index. No statistical analyses were carried out for the CDG due to the very small sample size available. Statistical significance was established at p-value < 0.05. Statistical analysis was carried out using StataSE 16.
Results
The number of participants who took part in this pilot study was low. 56 participants were examined in all with 47 participants, 24 females, 23 males, residing in nursing homes while nine participants, seven females, two males, lived at home. The average age of the participants in the nursing home group (NHG) was 86.3 ± 7.36 years and that of community dwellers group (CDG) was 76 ± 12.8 years (Tab. I). The average stay in a nursing home was 882 days. The most common type of medication being taking by the participants in both groups was for heart and circulatory conditions. A relatively high number of participants in the NHG were on anti-depressants (n=24, 51%) or painkillers (n=23, 49%) (Tab. II).
89% of the NHG participants reported brushing their teeth two or three times daily. The majority of the patients living in nursing homes presented with either grade 1 (40%) or grade 2 (40%) oral hygiene levels while the majority of the community dwellers (55%) had a grade 1 level of oral hygiene. 29 (76%) NHG participants and 8 (89%) CDG participants presented with bleeding on probing (Tab. II).
Twelve (27%) nursing home participants and six (67%) community dwellers reported that they had never visited a dental hygienist. All participants in both groups had been seen at least once by a dentist. 34 participants from both groups had their last dental visit more than a year prior to the study dental check-up. The median duration of living in a nursing home for those who had their last dental visit in less than one year was 15 months. In contrast, the median was almost double for those who had their last dental visit over a year prior to the performed study dental check-up (Tab. II). No statistically significant differences were reported in the frequency of dental visits as age increased (p = 0.35) or as duration of living in a nursing home increased (p = 0.55).
38 (80%) participants living in nursing homes were dentate while nine (20%) were edentulous. All the patients in the CDG were dentate. There was an increase in the number of decayed teeth (p=0.005), missing teeth (p=0.01), and the DMF-T index (p < 0.001) together with a decrease in the number of filled teeth (p=0.02) as age increased (Fig.1 a, b, c, d) with these findings being statistically significant. After the calculation of the risk profile using the ‘Teamwerk-index’ 18 (49%) participants in the NHG who were dentate and six (67%) participants from the CDG had a medium risk of developing dental problems (Tab. III).
Discussion
The objective of this pilot study was to provide data on the oral health behaviour and the present oral health status of care-dependent elderly people in the rural canton of Uri. We fail to reject the null hypothesis for the first aim i.e. the frequency of dental attendance is not dependent on a) age b) the duration of living in a nursing home while the second null hypothesis i.e. that there is no difference in the DMFT-index as age increases has been rejected. The results of this pilot study give a first insight into the oral health status of care-dependent elderly people in the rural canton of Uri. The sample size was small, especially for the community dwellers, thus making it difficult to generalize the findings to the general population. During the course of the study considerable efforts were made to obtain as many participants as possible. This proved to be very difficult especially among the community dwellers. Studies have reported on the difficulties that are at times encountered when recruiting elderly community dwellers (WU ET AL. 2010; KAMMERER ET AL. 2019)). Four dental examiners carried out the dental examinations at different times during the study period, making inter-observer variability a limitation of the study, especially in the detection of caries and the grading of oral and denture hygiene. Two indices, the DMF-T and the ‘Teamwerk-index’ were used as outcome measures, adding to the strength of this study. The DMF-T index is a well-established measure of the lifetime accumulation of dental caries experience (VELASCO-ORTEGA ET AL. 2013). However, it has its limitations as the index gives equal weight to missing, decayed and well-restored teeth and it doesn’t take into account teeth lost for reasons other than caries, such as periodontal disease (LO 2019). The ‘Teamwerk-index’ on the other hand takes into account parameters that cover oral health behaviour, dental caries and periodontal status.
Several studies have reported scenarios of inadequate oral hygiene for patients in nursing homes (CHALMERS ET AL. 2002; STUBBS & RIORDAN 2002; BRÄNDLI-HOLZER 2012), with bleeding on probing being a common finding in dependent elderly patients (GEIGER 2011; JORDAN & MICHEELIS 2016). Studies have reported ranges of 33% to 75% of patients having at least one periodontal pocket that was 4mm or deeper (GEIGER 2011; MATTHEWS ET AL. 2012; JORDAN & MICHEELIS 2016). Periodontal disease is a common chronic oral inflammatory disease that is often found in older adults (BOEHM & SCANNAPIECO 2007). In the present study, the oral hygiene status does not correspond to the reported frequency of daily tooth brushing. It is not known whether tooth brushing and/or denture cleaning was done solely by the patients, whether they received assistance or whether it was done completely by the care givers. The findings indicate that more attention needs be given to oral hygiene by either helping the patients more with their daily brushing and/or to provide more training to the carers.
The Swiss health survey reported a reduction in frequency in dental visits as one gets older (SCHNEIDER ET AL. 2019). A study in Nova Scotia, Canada, reported that almost 75% (n=313) of the participants residing in nursing homes hadn’t had a dental visit in twelve months (MATTHEWS ET AL. 2012), while another study in France, reported that there was a discrepancy between dental visits among community-dwellers (n=9962) and institutionalized elderly patients (n=4167) (MAILLE ET AL. 2017). The present study did not report significant differences in dental attendance as age increased or as duration of living in a nursing home increased. Furthermore, it did not draw comparisons between the two groups due to the difference in the sample sizes. The overall sample size of the study (56 participants) was small, thus additional research with higher statistical power is recommended to further analyse the association between the frequency of dental attendance and i) aging, ii) the duration of living in a nursing home.
The Swiss health survey reported that 6.5% of the people aged 65-74 years were edentulous with the figures increasing to 15% for persons aged 85 years and over (SCHNEIDER ET AL. 2017). The present study reported that 20% of the participants in the NHG were fully edentulous. Studies have reported rates of edentulism among the elderly in nursing home or geriatric hospitals of 20% (BRÄNDLI-HOLZER 2012), 41% (MATTHEWS ET AL. 2012), 52% (GLAUSER-POPAJ 2009; KATSOULIS ET AL. 2012) and 66% (CHALMERS ET AL. 2002). The present study reported that there was an increase in the number of decayed (p=0.005) and missing teeth (p=0.01), a decrease in the number of filled teeth (p=0.02) and an increase in the DMF-T index (p < 0.001) as age increased. A high prevalence of dental caries was found in both groups (NHG=65%, CDG=55%), with 56% of the NHG participants presenting with root caries (average = 2.1 teeth). Studies of elderly patients in nursing homes have reported the presence of root caries in 37% (BRÄNDLI-HOLZER 2012) (mean=2.5 teeth), 44% (mean=1.3 teeth) (MATTHEWS ET AL. 2012) and 77% (mean=1.4 teeth) (STUBBS & RIORDAN 2002) of the patients examined. Studies world-wide have demonstrated that overall, elderly people who are care-dependent tend to have poor oral health, with reported DMF-T findings ranging from 23.6 to 30.8 (CHALMERS ET AL. 2002; GLAUSER-POPAJ 2009; VIDZIS ET AL. 2011; BRÄNDLI-HOLZER 2012; MATTHEWS ET AL. 2012; PETELIN ET AL. 2012) (Tab. IV i, ii). Studies in Switzerland have reported average DMF-T findings ranging between 26.8 (BRÄNDLI-HOLZER 2012) to 29.1 (GLAUSER-POPAJ 2009). The present study reported DMF-T findings that fall within these ranges (Tab. IV i, ii).
After taking into account the nine risk parameters as proposed by the ‘Teamwerk-index’, 22% of the dentate patients in the nursing homes were at a high risk of developing oral health problems while the majority of the patients had a medium risk. On the other hand, most of the community dwellers had a medium risk of developing dental problems even though most of them had a low DMF-T index. Recommendations for the frequency of dental visits were based on the ‘Teamwerk-index’ depending on whether the patient had a high, medium or low risk of developing dental problems, with three, four- or six-monthly visits being recommended, respectively. The Teamwerk study also noticed that following the initial phase of the project, patients who received four to six monthly visits were often found to be worse off than the high-risk patients, thus it was recommended that all patients should be seen every three months (GEIGER 2011). The frequency of dental visits should be tailored according to the needs of the patients, with the oral health status monitored at every visit and the frequency of dental visits modified accordingly. Most of the patients in the community were referred for dental treatment by the caregivers of the community domiciliary care services ‘Spitex’, highlighting the key role played by collaboration between the care givers, both in nursing homes and in the community, in enabling the elderly to receive dental care (CHALMERS ET AL. 2001). Through good organisation between the different stakeholders, dental care to the patients both in nursing homes and the community could be organised through mobile dental services, as demonstrated during the course of this study. The training of the caregivers, both formal and informal, in the oral hygiene maintenance of the care-dependent elderly patients, would also ensure an increase in the number of care providers that will be able to address the basic dental needs of these elderly patients.
Our pilot study in rural Switzerland provides first results of the oral health status in dependent elderly people, even though the sample size was small. As people age, oral health deteriorates. More attention should be given in order to achieve better oral hygiene maintenance and more regular dental visits, to ensure a better oral health status in dependent elderly people.
Acknowledgements
We would like to thank the nursing homes in the canton of Uri, together with Spitex Uri and the patients who participated in the study. This article is based on a revised version of the Masters’ thesis “The provision of mobile dental services to the dependent elderly in Switzerland” submitted to the Faculty of Humanities and Social Sciences at the University of Lucerne, in 2020. The thesis was prepared by Roberta Borg-Bartolo under the supervision of Prof. Armin Gemperli and Dr. Stefan Essig.