oral health assessment of elderly people living in...
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ORAL HEALTH ASSESSMENT OF ELDERLY PEOPLE LIVING IN THE
ARKHANGELSK REGION, RUSSIA
Karina Kunavina
Master’s Thesis
Supervisors:
Arja Rautio, University of Oulu
Andrey Soloviev, Northern State Medical University
Alexander Opravin, Northern State Medical University
Master’s Degree Program in Health and Wellbeing in the Circumpolar Area
Institute of Health Sciences
University of Oulu
2016
UNIVERSITY OF OULU
Faculty of Medicine, Institute of Health Sciences
ABSTRACT
Kunavina, Karina: Oral health assessment of elderly people living in the Arkhangelsk
region, Russia
Pro gradu thesis: 75 pages, 2 appendices
November 2016
_________________________________________________________________________
This thesis analyses the oral health of elderly people living in Arkhangelsk, Russia.
Complex oral health assessment includes objective, standardized dental tests and indices
recommended by WHO. The aim of the study was to determine the alterations in dental,
periodontal, salivary, glossal and immune status of oral health in elderly persons, the
influence of possible unhealthy habits on the health of oral cavity and to compare these
indicators with literary sources. The research focuses on elderly people older than 60 years
old, who reside in a home for the elderly in Arkhangelsk.
Modern world social and health tendencies dictate the necessity of ongoing research of the
aging population problem. Aging is a natural phenomenon and an inevitable process but
when the number of old-aged people exceeds the number of working-age population it
causes serious modifications in health care, economics, social support and so forth. The
socio-demographic situation in the Arkhangelsk region is characterized by a considerable
increase in the number of retirement age people who suffer from severe somatic disorders.
Organs and tissues of the mouth do not represent an exception, so the elderly experience
serious problems with their oral health as well.
The hypothesis of the study has proved to be mostly true: our conclusion is that the young-
old and the old demonstrate poor oral health. We have observed 100% prevalence of caries
and decayed, missed, filled teeth index (DMFT) = 24,5 with predominance of missing
teeth; the level of hygiene equals to 3,4; poor condition of dentures; high prevalence of
periodontal diseases and oral mucosa lesions; low salivary flow rate (0,08 ml/min) and pH
(6,0), high saliva viscosity and deterioration of the oral immunity indicators such as
interleukin-8 (IL-8), immunoglobulin G (IgG), tumor necrosis factor alpha (TNF-α),
secretory immunoglobulin A (SIgA) and cortisol.
This study may be used to formulate recommendations for the elderly, social workers and
health management bodies to improve the oral wellbeing of this group of people. The data
received during this study can be also be of use for other countries of the Barents region in
two similar respects: dental features of the aging population and the influence of living
conditions in the North on oral health.
_________________________________________________________________________
Keywords: population aging, oral health care, the elderly, the young-old, the old people,
dental, periodontal, salivary, glossal and immune status.
ABBREVIATIONS
CI – Confidence Interval
CI-S – Calculus Index Simplified
CPI – Community Periodontal Index
DAS – Dental Anxiety Scale
DI-S – Debris Index Simplified
DMFT – Decayed, Missed, Filled Teeth
DoH – Declaration of Helsinki
ELISA – Enzyme Linked Immunosorbent Assay
FDI – Federation Dentaire Internationale
FU – Functional Units
GOHAI – Geriatric Oral Health Assessment Index
IADR – International Association for Dental Research
IgG – Immunoglobulin G
IL-8 – Interleukin-8
LCDC – Lifestyle Change plus Dental Care
LNU – Level of Living Survey
MCS – Microcrystallization of Saliva
Md, Q2 – median
MPS – Microcrystallization Potential of Saliva
NSMU – Northern State Medical University
OHIP-14 – Oral Health Impact Profile
OHI-S – Oral Hygiene Index Simplified
OHRQoL – Oral Health Related Quality of Life
OIDP – Oral Impacts on Daily Performance inventory
PMA – Papilla, Marginal, Alveolar gingiva
POPs – Posterior Occluding Pairs
Q1 – First Quartile
Q3 – Third Quartile
r – Correlation Coefficient
SD – Sample Standard Deviation
SIgA – Secretory Immunoglobulin A
SST – Salivary Surface Tension
SWEOLD – SWEdish Panel Study of Living Conditions of the Oldest OLD
TNF- α – Tumor Necrosis Factor alpha
x – Arithmetic Mean or Average
WHO – World Health Organisation
WHOQOL-Old – World Health Organization Quality of Life-Old
WMA – World Medical Association
WST – Water Surface Tension
CONTENTS
1. INTRODUCTION ............................................................................................................ 8
2. LITERATURE REVIEW .............................................................................................. 11
2.1. Oral diseases ............................................................................................................ 11
2.2. Comorbidity ............................................................................................................. 15
2.3. Quality of life ........................................................................................................... 17
2.4. Accessibility of dental aid ....................................................................................... 18
2.5. Programs .................................................................................................................. 21
3. AIMS OF THE STUDY ................................................................................................. 26
4. MATERIALS AND METHODS .................................................................................. 28
4.1. Formal permission and adherence to ethical norms ............................................ 28
4.2. Informed consent ..................................................................................................... 28
4.3. Study design, population and duration ................................................................. 28
4.3.1. Inclusion criteria.................................................................................................. 28
4.3.2. Exclusion criteria ................................................................................................ 29
4.4. Examination of patients .......................................................................................... 29
4.4.1. Dental status ........................................................................................................ 29
4.4.2. Periodontal status ................................................................................................ 31
4.4.3. Salivary status ..................................................................................................... 34
4.4.4. Glossal status ....................................................................................................... 36
4.4.5. Immune status ..................................................................................................... 37
4.4.6. Statistical analysis ............................................................................................... 38
5. RESULTS ....................................................................................................................... 39
5.1. Dental status ............................................................................................................ 39
5.2. Periodontal status .................................................................................................... 40
5.3. Salivary status ......................................................................................................... 41
5.4. Glossal status ........................................................................................................... 43
5.5. Immune status ......................................................................................................... 43
6. DISCUSSION ................................................................................................................. 45
6.1. Questionaires, external examination ..................................................................... 45
6.2. Dental status ............................................................................................................ 45
6.3. Periodontal status .................................................................................................... 49
6.4. Glossal status ........................................................................................................... 50
6.5. Salivary status ......................................................................................................... 51
6.6. Immune status ......................................................................................................... 52
6.7. Study limitations ..................................................................................................... 57
7. CONCLUSION ............................................................................................................... 59
REFERENCES ................................................................................................................... 61
APPENDICES
Appendix 1 ...................................................................................................................... 74
Appendix 2 ……………………………………………………………………………..75
FIGURES
Figure 1. CPI index teeth…………………………………………………………………………………… 33
Figure 2. Types of saliva's microcrystallization (Belskaya 2011) .……………………………………...... 36
Figure 3. Saliva microcrystallization, type c………………………………………………………………. 41
Figure 4. Saliva microcrystallization, type d………………………………………………………………. 42
Figure 5. Saliva microcrystallization, type e………………………………………………………………. 42
TABLES
Table 1. Distribution of the population of older age groups in Arkhangelsk region (Arkhangelskstat
2016) …………………………………………………………..……………………………………………... 10
Table 2. Oral conditions observed in elderly patients (El Osta et al. 2012, Porter et al. 2015) ………... 11
Table 3. Contamination degree of natural teeth and dentures …………………………………………... 12
Table 4. Mean DMFT, DT, MT, FT and remaining teeth in the studies of the different countries …… 12
Table 5. Assosiation of periodontal diseases with somatic pathology and conditions ………………….. 16
Table 6. Programs in dental health .……………………………………………………………………….. 22
Table 7. Violations in the oral cavity due to senescence ………………………………………………….. 27
Table 8. Parameters of local immunity ……………………………………………………………………. 43
Table 9. Correlation between oral indices and markers …………………………………………………. 44
Table 10. Necessity of orthopedic treatment ……………………………………………………………… 48
Table 11. Distribution of partial edentia in elderly groups …………………………………………….... 48
Table 12. Distribution of oral hygiene levels among the elderly ………………………………………… 49
Table 13. Distribution of CPI codes ……………………………………………………………………….. 50
Table 14. Severity of hyposalivation among the elderly ………………………………………….………. 52
Table 15. Levels of immunity markers in saliva………………………………………….……………….. 53
8
1. INTRODUCTION
Current health tendencies largely define the directions of health research. One of the most
evident and urgent issues is the problem of population aging. As stated by World Health
Organization (WHO), the world’s population of those aged 60 years and older is expected
to increase from 605 million to 2 billion by 2050, i.e. will nearly double from 12% to 22%
(WHO 2015). Currently both in the developed and developing countries the reduction of
birth and mortalities rates and growth in life expectancy are changing the demographic
profile of the countries’ population (Matsuka et al. 2012, Rodrigues et al. 2012b, Yao &
MacEntee 2014a, Martins et al. 2014). Due to advances in technology and medicine the
proportion of older people will continue to rise worldwide (Srivastava et al. 2012).
The problem of population aging can be approached to from different aspects. It can be a
sign of advancement of social and health care and also represent public health challenge
(Ayernor 2012). On the one hand, the elderly people often play an active role in the
community, labor market and contribute to child upbringing, provide a precious reservoir of
wisdom and thus play a major role in shaping of the wellbeing of future generations
(Kumar et al. 2015). On the other hand, when the number of old-aged people exceeds that
of working-age population it needs major readjustment in social and health services,
economic development with the aim to preserve health and wellbeing of the elderly
(Andrade et al. 2012, Eustaquio-Raga, Montiel-Company & Almerich-Silla 2013, Liu et al.
2013).
At present oral diseases are among the most widespread diseases all over the world.
Though oral pathology does not represent a major mortality threat, it certainly influences
the general health of people and makes a significant impact on quality of life (Srivastava et
al. 2012, Arcury et al. 2013, Gil-Montoya et al. 2015). Geriatric patients require more
complex measures of prevention, intervention and oral health reabilitation. They experience
dramatic physiological, psychological and functional changes by the end of life, which may
limit the capacity to perform proper oral hygiene techniques, while substantially increasing
9
the risk of dental caries, gingival infections and periodontal disease (Velasco-Ortega et al.
2013, Chen et al. 2013b, Cornejo et al. 2013, Gulcan et al. 2014). The oral diseases can
cause or worsen major systemic conditions, such as heart disease, stroke, pneumonia,
diabetes and infective endocarditis. The advanced age combined with a history of smoking
and/or drinking can also put this group at increased risk of developing oral cancers. (Levy,
Goldblatt & Reisine 2013.)
Back in 1982 WHO established the goal to keep functional and aesthetic dentition with at
least 20 natural teeth to 50% of individuals aged between 65 and 74 years by the year 2000
(Ribeiro et al. 2011) and the preference for keeping natural teeth even among older people
exists in some areas (Muirhead, Marcenes & Wright 2014). However, billion of dollars
have been spent on dental care for diseases which can generally be prevented with adequate
oral hygiene. The wide spread myth that oral diseases and edentulousness are typical of the
aging and culturally and so the image of toothless old people persists across cultures.
(Wiener et al. 2012, Cornejo et al. 2013.)
The socio-demographic situation in the Arkhangelsk region is characterized by a persistent
population decline, increase in the number of people of retirement age, increase in the
number of citizens registered as disabled and growth in the number of people with mental
disorders. Thus, starting from 2006 the total number of people in the age groups 60-64, 65-
69, 70 and over has steadily grown (see Table 1). Based on the age structure forecast in
2018 there will be a 10,6% fall of the working population and 8,5% increase in the amount
of elderly people in the proportion. The rise in the number of elderly residents determines a
significant growth in demand for social services and health care, including dental aid.
(Arkhangelskstat 2016.)
Social service provided by 20 state financed hospitals and homes for the elderly with
branches all over the Arkhangelsk region have a capacity of 2696 beds, including 9
neuropsychiatric and 6 gerontopsychiatric boarding homes. Inpatient social services also
support 12 temporary accommodation outlets for senior citizens and disabled cared after by
state social institutions with a total bed capacity of 370 beds. (Ministry of Labor,
10
employment and social development of the Arkhangelsk region 2014.) Also in Arkhangelsk
there is a shelter for homeless with 30 beds. During 2013 the growth of foster families for
the elderly and disabled has been actively encouraged in Arkhangelsk region as one of
inpatient replacement methods.
Table 1. Distribution of the population of older age groups in Arkhangelsk region (Arkhangelskstat
2016).
Year
Age
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
60-64 37888 37247 42859 50180 61329 69537 73611 77174 81006 82606 85038
65-69 60962 61802 54463 45420 36991 32306 31929 36785 43121 52868 59935
70 and
over
100557 101189 104733 107307 110450 111665 113421 110431 105442 101799 99282
Total 199407 200238 202055 202907 208770 213508 218961 224390 229569 237273 244255
In September 2016 the “Care” home for the elderly was opened with the capacity of 200
beds. Opening of the home for the elderly is a successful example of state-private funded
partnership. The building was renewed and equipped by private investors, with some of the
maintenance costs paid by the pension funds and some covered by the regional budget.
(Government of Arkhangelsk region 2016.)
Concerning dental care there are no special surgeries for the elderly people while there is a
shortage of specialized dental programs for them with the notable exception of the program
which provides free dentures for the Second World War veterans. Dental aid is generally
provided on the same basis as for the rest of the population. It is highly advisable to
conduct a comprehensive research with the aim of accessing the dental health of the elderly
in the Arkhangelsk region. Furthermore, it is important to promote disease prevention when
formulating dental health programs for older adults. It is likely that there will be greater
demand for the treatment aimed at preserving the teeth. The effectiveness of preventive
strategies will require further research and further economic analysis of tooth replacement
programs. (Gerritsen et al. 2010.)
11
2. LITERATURE REVIEW
2.1. Oral diseases
The elderly demonstrate in general poor oral health which should be the object of concern
for doctors, scientists and officials. The most evident mouth disorders of the elderly are
presented in Table 2.
Table 2. Oral conditions observed in elderly patients (El Osta et al. 2012, Porter et al. 2015).
Organs and tissues of oral cavity Disease/problem
Teeth Caries
Sensitive teeth
Low hygiene
Tooth loss
Periodontium Low hygiene
Gingivitis
Periodontitis
Tooth loss
Salivary glands Hyposalivation
Xerostomia
Oral mucosa Candidiasis
Cancer
Temporo-mandibular joint Chronical pain
Alveolar bone Loose or ill-fitting dentures
Oral hygiene is often perceived as an unimportant procedure and the situation is made
worse by the inability of the elderly to perform tooth brushing adequately. In one of the
studies only 28,8% of 61–70 years old subjects used both tooth brush and tooth paste/tooth
powder while 11,8% of them used sea weeds for cleaning their teeth (Aapaliya et al. 2015).
In the research of tooth and dentures hygiene unsatisfactory hygienic conditions of oral
cavity and prostheses have been observed (see Table 3) (Ushnitskyi et al. 2013b). In turn,
the oral care level and destructive oral biofilms are significantly associated with caries,
periodontitis and tooth loss (Wiener et al. 2012, Chen et al. 2013b).
12
Table 3. Contamination degree of natural teeth and dentures.
None Low Moderate Severe
Young-old 4,88 ± 0,48% 22,91 ± 0,39% 42,31 ± 0,29% 29,90 ± 0,35%
Old 0% 12,42 ± 1,33% 67,97 ± 0,49% 19,61 ± 1,22%
As a rule, dental caries is widely spread among senior citizens. DMFT index (DT-decayed,
MT-missing and FT-filled teeth) is a conventional index used by dentists to evaluate caries
intensity. According to the literary sources the meaning of DMFT can fluctuate noticeably,
with a greater number of teeth in DMFT structure presented by extracted teeth while the
amount of remaining teeth is deficient (Table 4).
Table 4. Mean DMFT, DT, MT, FT and remaining teeth in the studies of the different countries.
Study Country DMFT DT MT FT Remaining
teeth
Ribeiro et al.
2011
Brazil 5,49
Rodrigues et
al. 2012a
Brazil 20,19±7,97 0,53±1,50 19,65±8,75 0,92±1,95 8,00±8,63
Cornejo et
al. 2013
Spain 22,8 2,1
20,5
0,2
10,2
Gaszynska
et al. 2014
Poland 27,6±5,2 5,6±7,3
Castrejon-
Perez et al.
2012
Mexico 11,8±9,2
Liu et al.
2013
China 13,9±9,64 2,396±3,29 11,226±9,63 0,296±0,88
Aapaliya et
al. 2015
India 2,08±1,14 1,19 ± 0,93 3,83 ± 1,26 0,13 ± 0,39
Henriksen,
Axell &
Laake 2003
Norway 17
Tegza et al.
2013
Russia, all
territories
22,75 1,72 18,26 2,77
Mkhitaryan
et al. 2015
Russia,
Stavropol
21,3 10,6% 62,4% 27,0%
Yushmanov
a et al. 2007
Russia,
Arkhangel
region
28,83
DMFT, DT, MT, FT and remaining teeth readings are expressed by x±SD or %
More than a half of the elderly have periodontal (gum) disease caused by the accumulation
of a specific bacterial biofilm around the teeth (Muirhead, Marcenes & Wright 2014, Hu et
13
al. 2015). Periodontal status is usually assessed using various periodontal indices which
mostly take into account the presence of bleeding, dental calculus and loss of periodontal
attachment. For instance, 97,4% of women need periodontal treatment in Spain and 90-
100% of elderly people of both sexes in Russia (Yushmanova et al. 2007, Cornejo et al.
2013, Mkhitaryan et al. 2015). Although most seniors claim using brush and floss as
regularly as younger people, several factors contribute to an increased risk of poor oral
health in this age group, such as hypofunction of the salivary glands and difficulty brushing
and flossing with a reduced immunity against infection (Kelsall & O'Keefe 2014).
Teeth and gums diseases lead to permanent tooth loss which increases the occurence of
poor self-rated general health and oral health and the quality of life (Huang, Chan & Young
2013). The prevalence of edentulism ranges from 6,6% to 52,8% (Marin-Zuluaga et al.
2012, Rodrigues et al. 2012b, Eustaquio-Raga, Montiel-Company & Almerich-Silla 2013,
Arcury et al. 2013, Chen et al. 2013a, Gaszynska et al. 2014, Peltzer et al. 2014). Konopka
and colleagues (2015) claim that the lowest number of retained teeth among Europeans
have Hungarians (2004) – 9,1, Greeks (2005) – 11,1 and Danes (2001) – 12,4; a similar
number was found in Germans (2005) – 13,6 and Poles (2015) – 13,7, whereas the highest
is found in Spanish (2005) – 14,2 and Swiss (2002) – 17,6 (see also Table 4). Mean number
of lost teeth in Russia is 16,6±1,2 for men and 12,5±1,5 for women among the young-old
group and 27,3±2,3 for men and 24,8±2,2 for women of old age (Iordanishvili et al. 2013).
According to a report of Andrade et al. (2012) 97,7% of the elderly need oral prosthesis. In
the opinion of El Osta et al. (2012) the sufficient number of dental functional units (FU -
the number of tooth pairs participating in mastication) is more than 4 and it is a better
indicator of masticatory function than the number of teeth present. People who have fewer
than four FUs report difficulties in chewing or swallowing and they tend to avoid hard
foods, including meat, vegetables and bread. They can consequently be at risk of
malnutrition, which may affect their general health and reduce their life expectancy. (El
Osta et al. 2012.) Ribeiro and colleagues (2011) suggest that three to five occlusal units or
functional posterior occluding pairs (POPs) provide sufficient occlusal stability for a
prolonged period of time. In this connection the preservation of natural teeth is very
14
important not only for normal mastication and nutrition but also for general health and
quality of life. Otherwise, dental prosthetics is a way to keep oral health in the situation
when natural teeth have already been lost. In the case of the elderly it is found that they
often do without oral prosthesis, since they believe that the teeth are not the first priority,
prophylaxis will not work well and losing teeth is regarded as normal (Martins et al. 2014).
Consequently, when scientists try to estimate percentage of elderly people who wear
complete or partial denture they often obtain greatly very low percentage (Ushnitskyi et al.
2013b, Kumar et al. 2015, Hiltunen, Vehkalahti & Mantyla 2015).
Non-caries cervical lesions are serious dental problem as well and nowadays more and
more attention is paid to it. Erosion is associated with chemical or electrochemical effect of
“extrinsic” (acidic food, drink, occupational-related erosion) and “intrinsic” (eating
disorders and gastroesophageal reflux disease, vomiting and regurgitation) factors. In turn,
abrasion, attrition, abfraction and wedge-shaped cervical lesions are often connected with
mechanical processes: bruxism, chewing on one side, biting hard objects, overzealous tooth
brushing and exessive occlusal loading. (Oginni & Adeleke 2014.) In the literature review
Johansson et al. (2012) demonstrated that dental erosion is spread throughout the world
with different frequency: United Kingdom 2-77%, Sweden 12-22%, Iceland 1-6%, Saudi
Arabia 26-34% and so on. According to Lai and collegues (2015), who examined a
particular territory – Guangzhou, Southern China, the prevalence of non-caries lesions
(V-shaped, wedge-shaped, or disk-shaped lesions and occlusal attrition) was 81,3%, with a
mean of 4,4 teeth affected amongst 65- to 74-year-olds. About a half of the elderly subjects
have at least one tooth with lesion that needed restoration. (Lai et al. 2015.) At present it
should be taking into account these types of hard tissue lesions not only because of its
increasing prevalence but also because there is some data about unsatisfactory longetivity
of resin-based composite restorations (Oginni & Adeleke 2014). Considering the fact that
elderly prefer tooth extraction as the easier way of treatment than restoration they tend not
to seek restorative dental aid in case of therapeutic treatment failure.
According to a recent report, the prevalence of subjective dry mouth and reduced
stimulated salivary flow rate is significantly higher in older individuals than in younger
15
(Takeuchi et al. 2015). Dry mouth is the most prominent oral health problem among
seriously ill patients and affects more than 90% of hospice cancer patients. This condition
arises in the advanced age not only due to somatic pathology but also because of a large
number of medications taken (non-selective β-adrenoceptor blockers, selective β(1)-
adrenoceptor blockers, antipsychotics, antidepressants, anxiolytics, anticholinergic
medications, drug for the treatment of osteoporosis, diuretics, sedatives/hypnotics, anti-
inflammatory drugs/analgesics) (Ohara et al. 2013, Johanson et al. 2015). Reduction in
salivary flow may be a fundamental factor of oral diseases such as dental caries and
mucosal lesions. Moreover, hyposalivation is associated with dysphagia, halitosis and
affects social activities. (Takeuchi et al. 2015, Chen & Kistler 2015.) However, in study of
Cunha-Cruz et al. (2013) the statistically significant association between dental caries and
salivary flow has not been found.
Another problem is deterioration of taste perception and ability to identify and discriminate
basic taste qualities which may deprive people of the pleasures of eating is the cause of
poor appetite, weight loss and malnutrition. Taste loss associated with poor oral health
could be due to toxins and inflammatory products produced by the oral bacteria (caries,
gum diseases, poor oral hygiene, tongue coating and atrophic tongue). (Solemdal et al.
2012.)
The most three common clinical pathologies of the oral mucosa lesions are leukoplakia and
leukokeratosis that were found in 10,5% of examined people, candidiasis 5,82% and lichen
planus 2,2% (Konopka et al. 2015).
2.2. Comorbidity
Elderly people suffer from different diseases connected with oral health. Dental infections
or loss of teeth can exacerbate chronic diseases such as diabetes, asthma, arthritis, kidney,
cardiovascular (angina pectoris, stroke, hypertension), pulmonary, Alzheimer’s disease and
obesity (Metcalf, Northridge & Lamster 2011, Ribeiro et al. 2012, Saengtipbovorn &
Taneepanichskul 2014, Kelsall & O'Keefe 2014).
16
Poor oral health may also cause inadequate consumption of fruit and vegetables, functional
disability, lower scores on cognitive testing, poorer self-rated level of general health, social
cohesion, self-esteem and quality of life that can significantly undermine a person’s ability
to live a normal life (Ayernor 2012, Peltzer et al. 2014, Gaszynska et al. 2014, Imai &
Mansfield 2015).
Periodontal diseases are among the most prevalent dental diseases. They include dental
calculus, gum inflammation and bleeding, loss of periodontal attachment (shallow and deep
periodontal pockets), tooth mobility and tooth loss. In Table 5 somatic pathology and
adverse conditions connected with periodontal diseases are presented.
Table 5. Assosiation of periodontal diseases with somatic pathology and conditions.
Study Factors associated with periodontal diseases
Zhang et al. 2014 Periodontitis and diabetes, hypertension, rheumatoid arthritis,
cardiovascular diseases, depression, anxiety, obesity,
malnutrition, smoking, alcohol consumption, socioeconomic
status, stress, adverse pregnancy outcomes
Northridge et al. 2015 Diabetes, cardiovascular diseases
Ansai et al. 2013 Tooth loss and increased risk of all-cause and cancer mortality,
but not of cardiovascular disease
Tooth loss and orodigestive cancer
Eustaquio-Raga, Montiel-
Company & Almerich-Silla 2013
Deficient masticatory function and malnutrition
Psychosocial and emotional problems
Siukosaari et al. 2012 Periodontitis and cardiovascular mortality risk
Periodontitis and cerebral ischaemia
Hu et al. 2015 Tooth loss and all cause mortality include causes such as
cardiovascular disease, stroke and dementia
Again, poor oral health can be caused by various diseases or conditions. Hereby
hypofunction of the salivary glands and its consequence – xerostomia – may be an outcome
of diabetes and the adverse effects of medications or cancer radio-therapy (Chen et al.
2013a, Yao & MacEntee 2013). Mental illness, including schizophrenia, depression,
bipolar disorder and dementia are characterized by inadequate plaque control,
magnification of hyposalivation and dry mouth, impaired ability to provide hygiene
resulting in high caries experience and tooth loss (Velasco-Ortega et al. 2013, Luo et al.
2015, Hu et al. 2015).
17
The following socio-economic factors such as place of residence (urban or rural areas),
institualization, education level, availability of dental insurance, occupation, economic
status and others affect dental health. Poor oral health and poor oral health habits are likely
to be observed among people working in sales/service, skilled/ labor,
agriculture/forestry/fishery or others or those with no occupation than those whose longest
jobs were professional/technical. There are a number of reasons which can explain this
tendency. Firstly, professional workers have more possibility to manage their schedule and
get dental aid. Secondly, occupation type is also related to living place where density of
dentists can vary. Agriculture/forestry/fishery workers are more likely to live in rural areas
and professional/technical workers live in urban areas. The third reason is that the type of
work is linked to dental health awareness. Agriculture/forestry/fishery workers and people
without an occupation pay less attention to their appearance and speech which is usually
associated with the state of their teeth. The fourth point is that large companies which
employ professional/technical workers have their own oral health program while small
companies mostly have not. Therefore, agriculture/forestry/fishery workers have little
possibility to gain dental aid and information about dental health. (Yamamoto et al. 2014.)
2.3. Quality of life
The impacts of poor oral health on the quality of life of the elderly is not always recognized
by dental professionals although good oral health is an integral part of general wellbeing
and a contributory factor to oral health related quality of life (OHRQoL) (Yao & MacEntee
2013, Huang, Chan & Young 2013, Gaszynska et al. 2014, Yao & MacEntee 2014a).
Attention of the entire health care team should be addressed to the maintenance of elderly
individuals’ oral health that will allow them to speak, chew, recognize flavors, live without
pain or discomfort and communicate with others with no lost to their self-esteem
(Rodrigues et al. 2012b).
The concurrence of various oral health problems can have a negative effect on one’s
OHRQoL and cause poor self assessed oral appearance (Vilela et al. 2013, Chen et al.
2013). Key factors of that are the advancing age, living in rural areas, lower levels of
education and health awareness (Kotzer et al. 2012), trust and confidence in their dentist
18
(Muirhead, Marcenes & Wright 2014).
There is a significant evidence that those with low self-rated oral health have the smallest
primary social networks and the largest need of activities intended to improve the quality of
life of the elderly (Arcury et al. 2013, Leon et al. 2014). There are two plausible
relationship mechanisms between social participation and dental health with social network
functioning as a main effect and stress buffering (Takeuchi et al. 2013). Poor oral health
can result in social stigma, with poor dental appearance resulting in low self-esteem, less
social interaction, lower employability, lower life satisfaction and greater mobility
limitations (Andrade et al. 2012).
To evaluate OHRQoL some instruments have been developed. Among available OHRQoL
instruments the Geriatric Oral Health Assessment Index (GOHAI) and the Oral Health
Impact Profile (OHIP-14), self-reported instruments designed to assess the oral health
problems in older adults are regarded as the most comprehensive assessments. (El Osta et
al. 2012, Rodakowska et al. 2014, Leon et al. 2014.) Dental anxiety could be measured
using the four-item Dental Anxiety Scale (DAS) (Bell et al. 2012). The Oral Impacts on
Daily Performance inventory (OIDP) is one of the many self-reported inventories to assess
OHRQoL in terms of adverse impacts that oral conditions can have on everyday life
experiences (Gulcan et al. 2014). In 1999 the WHO drafted the World Health Organization
Quality of Life-Old (WHOQOL-Old) project specifically to measure quality of life in the
elderly population. The aim of the project of Rodrigues et al. (2012b) was to draft and test a
generic quality of life measure for international/cross-cultural use. This tool allows to
assess the impact of social and healthcare services on the quality of life of elderly
individuals as well as to better identify the areas of investment for achieving better gains in
the quality of life. (Rodrigues et al. 2012b.)
2.4. Accessibility of dental aid
A series of studies claim there are some fundamental barriers to deliver dental aid for the
elderly especially for those living in rural areas and those belonging to ethnic groups (Wu
et al. 2011, Yao & MacEntee 2014a).
19
The first and the most solid is a financial barrier. Due to the prevalent attitudes towards
dental procedures as unimportant and unnecessary dentistry has been largely excluded from
health care because of budgetary constraints. For example, in Spain public health service
confines itself exclusively to diagnosis and pain-relief medicines or tooth extraction. Any
other treatment is to be arranged with a private practice and paid for by the patient.
(Eustaquio-Raga, Montiel-Company & Almerich-Silla 2013.) Some employees sponsor
dental services but after an individual is retired he or she must pay out of their own pockets
and the elderly have lower income (Yao & MacEntee 2013, Kelsall & O'Keefe 2014, Herr
et al. 2014). At the same time individuals who use public and/or philanthropic services give
generally a negative assessment of dental services (Martins et al. 2014).
In Russia there is a mandatory health insurance system which includes dental aid as well. It
contains therapeutic and surgical treatment of oral diseases and hygienic procedures but
does not cover prosthetics and orthodontic treatment. It means that each individual who has
insurance policy can receive dental aid in state funded dental clinics. The funds for
mandatory health insurance system are formed by employers’ insurance contributions,
federal and regional budget funds. Dental consultations and/or treatment in private clinics
are also available for those who can afford it. Furthermore, private companies enter into a
contract with private clinics that provide private health insurance service. (ConsultantPlus
2016.) Although there is still low availability of dental aid for some group of people both
within the framework of mandatory health insurance (inadequate time to treat a patient,
dated equipment and materials, shortage of personnel and so forth) and private sector (price
and income disparity) (Official website of the Russian Dental Association 2016).
Behavioral barrier explains the fact that people generally seek dental care only in case of
pain or discomfort (52% of visits) and there are also widespread believe that tooth loss is an
inevitable consequence of aging and those who postpone treatment until they have to
replace all of their remaining natural teeth with complete dentures (43,2% of visits). On the
contrary, only 4,2% of respondents visit the dentist for regular check-ups. (Gaszynska et al.
2014.) Another reason is mental health disorders and theirs manifestations that affect the
20
elderly: memory and independence loss, anxiety, depression and behavioral changes
(Soloviev et al. 2015).
There are also some institutional factors which may have significant implications for public
health. For the institutionalized elderly dental health plays a great role, so the caregivers’
skills in providing dental care is of great importance. Some studies reveal that not all
caregivers are adequately trained to care for elderly individuals, especially in providing oral
hygiene care, not sufficiently aware of the existence of institutional protocols on oral health
among residents and not always recognize the value of dental knowledge. It is considered
important that changing attitudes of caregivers towards the importance of their own oral
health may contribute towards improving the level of oral care for the elderly (Cornejo-
Ovalle et al. 2013, Pihlajamaki et al. 2016.)
Another institutional factor is education of dentists and hygienists. It is well-known fact
that geriatric patients often have several chronic health conditions and/or take some
medications. So this group of patients requires special approach and many dentists feel not
sufficiently prepared to deal with this population due to lack of adequate clinical training
while they were studying in dental school. The reason is that dental schools either do not
have or just declare geriatric component in their curriculum but not all of them fully teach
it. (Levy, Goldblatt & Reisine 2013.) Matsuka et al. (2012) also argue for a need to increase
the numbers of dental schools offering geriatric training courses at nursing care facilities in
order to enable early student contacts with this population and to expand students’ future
choices. For example, in Finland there is a licentiate degree in “suugeriatria”. This special
qualification in geriatric dentistry is offered by Finland Dental Association to better deal
with oral health problems for this growing group of population. (Suomen
Hammaslääkäriliitto 2013.)
Organizational barriers include lack of specialists and limited health care due to living
conditions and difficulties of access to healthcare services, particularly in rural areas
(Ribeiro et al. 2011, Arcury et al. 2013). For instance, in Canada only 10% of dentists,
hygienists, denturists and dental therapists practice in remote areas where one-third of
21
senior Canadians live (Yao & MacEntee 2014a). According to Widström and colleagues
(2010), inhabitants of the Barents region of Norway, Sweden, Finland and to a greater
extent in Russia have more difficulties of access to dental aid than their compatriots living
in the south of these countries. The main reasons are, as listed above, the lack of dental
providers and economic constraints. For example, in Arkhangelsk region there is only one
dentist per 2292 of population, and this is so nationwide – 4 dentists per 10000 of people,
while the figure is almost twice higher than in Norway, Sweden and Finland. (Widstrom et
al. 2010.)
2.5. Programs
Despite increases in medical spending there is still health disparity in special group of
people making it necessary to maintain equity in health care policy. First of all some
legislative measures should be introduced:
encouraging a government-administered universal dental plan supported financially by
redirecting the premiums currently paid for private dental insurance in each province and
territory,
establishing official guidelines for standards of oral care within all dental health facilities to
reduce complications from oral diseases,
reviewing the admission criteria for dental and dental hygiene programs to include the
applicants with mature social and human values sufficiently prepared to deal with chronic
disease and disability problems in aging population. (Yao & MacEntee 2014b.)
Long-term routine dental care is considered as a way to reduce major tooth loss and
improve quality of life at age 65 years and older (Crocombe 2015). With the aim of
maintaining dental health among the elderly some programs were introduced by
governments, scientists and health providers in different countries. Examples of those
programs are presented in Table 6.
22
Table 6. Programs in dental health.
Program Country Aims Results
SWEdish Panel
Study of Living
Conditions of
the Oldest
OLD
(SWEOLD),
since 1992
Sweden,
www.sweol
d.se
To describe and
analyze the
living
conditions of
elderly people
in Sweden
- SWEOLD provides nationally representative data
which can be used to identify age and cohort
effects.
- SWEOLD, together with Swedish Level of Living
Survey (LNU), provide longitudinal interview data
over a 40-year period. Individuals can be followed
through several stages from midlife to later life
and mortality, thus allowing for a life course
perspective.
- Analyses of SWEOLD data have provided
valuable insights into health trends among the
elderly Swedish population and into health
inequalities between women and men and different
socio-economic groups. (Lennartsson et al. 2014.)
ElderSmile
clinical
program, since
2004
USA,
http://aging
.columbia.e
du
To improve
access to and
delivery of oral
health care for
seniors
- ElderSmile successfully incorporated education,
screening, and referral for diabetes and
hypertension into its service delivery offerings.
- ElderSmile provides important care to an often
overlooked population more vulnerable to serious
dental conditions and related diseases such as
diabetes, heart and lung diseases, and stroke.
- Linking primary care and oral health screening in
senior centers help assess disease impact and
identify minority seniors in need of medical and
dental services. (Marshall et al. 2013.)
Lifestyle
Change plus
Dental Care
(LCDC)
program
Thailand
To improve
glycemic and
periodontal
status in the
elderly with
type 2 diabetes
Increasing awareness, changing attitudes and
improving practice in providing oral health and
dealing with diabetes mellitus of the elderly with
type two diabetes (Saengtipbovorn,
Taneepanichskul 2014).
The WHO Oral
Health
Program
Globally To strengthen
the
implementation
of systematic
oral health
programs
oriented towards
better oral
health and
quality of life
for older people
WHO supports countries in establishing appropriate
oral health surveillance systems. It collects essential
oral health data and information on lifestyles to
determine the impact of risk factors for the oral
diseases among older people in each country and to
design intervention programs targeting these risk
factors. WHO encourages public health care
administrators and decision-makers to design
effective and affordable strategies and programs for
better oral health and quality of life of the elderly,
which are integrated into general health programs.
(Petersen & Yamamoto 2005.)
Subsidized
prosthetics
Russia To increase the
availability of
dental care
Manufacturing and repairing of dentures (except for
the cost of precious metals and ceramet) in
municipal health care facilities (Garant 2016)
23
The Columbia University College of Dental Medicine and its partners institute the
ElderSmile clinical program to cover the unmet need for oral health care in older adult
population which currently includes 51 prevention centers. These centers provide general
presentations in English and Spanish of oral health care in later life (e.g. potential oral
health hazards, choosing oral health care products and accessing to oral health care,
including transportation), demonstrations of brushing and flossing techniques and care of
prosthetic devices and oral examinations (including assessment of oral cancers) for older
adults electing to participate. Services are provided by two faculty dentists, program
staffers and dental students, who are trained by the project director. Taking into account
that oral diseases in the elderly are often related to undiagnosed and untreated chronic
health conditions, in 2010 screening for diabetes and hypertension was integrated as a
measure to attract seniors within the ElderSmile program. Thus, 7,8 % and 24,6 % of
diabetes and hypertension respectively were found among ElderSmile participants with no
previous diagnosis by a physician. (Marshall et al. 2013, Marshall et al. 2015, Northridge et
al. 2015.)
In the framework of LCDC program based on the health belief model, social cognitive
theory and cognitive-behavioral theory participants suffering from diabetes mellitus
received a lifestyle and oral health education program, individual lifestyle counseling, oral
hygiene instruction followed by an educational booster by viewing an educational video
covering all of the above mentioned issues (Saengtipbovorn & Taneepanichskul 2014).
Dealing with oral health of the elderly, WHO, Federation Dentaire Internationale (FDI) and
the International Association for Dental Research (IADR) set the following goals to reach
by 2020:
dental caries: reduce the number of teeth extracted because of dental caries at age 65–74
years by X%;
periodontal diseases: reduce the number of teeth lost because of periodontal diseases by
X% at age 65–74 years with special reference to tobacco use, poor oral hygiene, stress and
current systemic diseases;
24
tooth loss: reduce the number of edentulous persons by X% at age 65–74 years, increase the
number of natural teeth preserved by X%, and increase the number of individuals with
functional dentitions (20 or more natural teeth) by X% at age 65–74 years. (Petersen &
Yamamoto 2005.)
In Russia veterans of the Second World War and other wars and as well as old-age
pensioners and disabled are eligible for free dental prostheses, and in some regions free
services in the field of prosthetics (in addition to the above categories) can be obtained by
other groups of people, for instance, heroes of the Soviet Union, heroes of the Russian
Federation and the individuals awarded the Order of Glory, disabled workers and people
with disabilities from childhood (Benefit portal, Russia, 2014).
Elderly receive regular care not only from dentists but also from other medical and nursing
care providers, making it necessary to improve physician-nurse-dentist cooperation to
better address the oral health needs of these individuals. This partnership has a number of
advantages:
assessment of oral health need in controlling various medical conditions and/or geriatric
syndromes including chronic pain, depression, social anxiety and withdrawal, malnutrition,
dysphagia, irregular medication schedule;
assistance to promotion of oral health care;
physicians, nurses and other palliative care providers able to identify oral health needs in
patients with life threatening conditions and to arrange regular medical referrals;
oral health techniques could also be implemented at bedside that reduce the need to transfer
patients to dental offices, thus minimizing the stress for patients and their caregivers and
the potential disruption of homeostasis due to transfer. (Metcalf, Northridge & Lamster
2011, Chen et al. 2013a, Chen & Kistler 2015.)
It also should be mentioned that cooperation between health care providers may become
more effective with the improvement and development of dental technology (Ornstein et al.
2015). Nevertheless, with growing availability of free dental check-ups through mobile
dental units, many people discontinued seeing there dentists and claimed they would not
25
keep dental appointments (Niesten, van Mourik & van der Sanden 2013).
Due to the global threat of dental diseases and population aging there is a need to develop
integrated dental and mental health care with emphasis on prevention of dental problems
among the elderly (Velasco-Ortega et al. 2013). The main directions of dental measures in
the future are education of dentists to work with the elderly and physicians to diagnose
dental problem, organization of help in dental care and check-up facilities, improving
awareness of dental health, enlargement of governmental financial assistance in dental aid
coverage.
26
3. AIMS OF THE STUDY
Object of this research is the worsening of oral health condition due to aging. The research
subject is the oral health status in the elderly residents of the North of Russia.
The aim of the study is the assessment of main oral health indices of a group of elderly
residents of the home for the elderly in Arkhangelsk, Russia.
Research questions are:
1. How does the age affect the oral health of the elderly home residents?
2. What kind of changes in the basic parameters of the oral health of the subjects can
be attributed to old age?
3. Can there be possible links found between the various parameters of oral health?
4. What is the influence of bad lifestyle habits (smoking and alcohol use) on the dental
wellbeing of the elderly home residents?
The practical tasks are:
1. Collecting oral health data of the individuals living in the home for the elderly in
Arkhangelsk.
2. Assessing the oral health changes and comparing the dental, periodontal, salivary,
glossal and immune status of the elderly patients with WHO standards or the data obtained
from other studies.
3. Defining the effects of bad habits (smoking and alcohol use) on the oral health of
the elderly.
4. Making recommendations for the patients and social workers that can improve oral
wellbeing of this group of people and increase awareness of the importance of dental care.
5. Assessment of the dental help needs of this group of patients and making proposals
for further dental care improvements.
27
The research hypothesis is the growing risk of poor oral health increasing with the
advanced age, with the assumption that the older the patient is the further his or her dental
health deteriorates given that senescence affects conditions of dental, periodontal, salivary,
glossal and immune status (Table 7). Contrary to that, the null hypothesis states that oral
health does not deteriorate due to aging.
Table 7. Violations in the oral cavity due to senescence.
Status Manifestations in the oral cavity
Dental Increased level of caries and its complications, non-caries lesions,
edentulousness
Periodontal Gum and periodontium inflammation
Salivary Alteration in physical saliva parameters
Glossal Enlargement of tongue coating
Immune Changes related to the deterioration of immune system
28
4. MATERIALS AND METHODS
4.1. Formal permission and adherence to ethical norms
The study protocol has been approved by the Ethics Committee of Northern State Medical
University (NSMU), Arkhangelsk, Russia and the pertaining ethical permission has been
granted. The written permission has been obtained from the manager of the home for the
elderly, Arknangelsk, Russia.
4.2. Informed consent
Making sure that the purpose and details of the study are understood by the subjects, the
written informed consent has been obtained from all the individuals who were willing to
participate in the study. The consent forms were obtained from the subjects before the
examination and the protocol of the present study was followed in accordance with the
Declaration of Helsinki (DoH) of the World Medical Association (WMA). The written
consent and examination sheets were printed in Russian (Appendix 1) and distributed to
each participant.
4.3. Study design, population and duration
A descriptive cross-sectional survey was conducted to assess the data concerning to dental,
periodontal, salivary, glossal and immune status of the elderly individuals above the age of
60 residing in home for the elderly, Arkhangelsk, Russia during August 2012.
4.3.1. Inclusion criteria
The inclusion criteria were:
1. Subjects who were willing to participate and given the informed consent.
2. Patients aged 60 and above.
3. The individuals residing in the home for the elderly in Arkhangelsk.
29
4.3.2. Exclusion criteria
The exclusion criteria were:
1. Subjects who were not willing to participate.
2. Subjects aged less than 60.
3. Subjects with whom it was not possible to follow the protocol of the study, patients with
reduced cognitive function and those with terminal diseases.
About 80 people lives in the home for the elderly with 26 were included in the study. The
reasons given for relatively low response were such as feeling too sick, too tired, just had
my teeth checked and having dentures only, the same as given in the study of Solemdal et
al. (2012).
4.4. Examination of patients
Dental examination was given in accordance with WHO’s Oral Health Surveys, Basic
Methods, 4th
and 5th
Edition, and the comprehensive assessment was carried out for 26
subjects. A specially prepared questionnaire was used to acquire information on age,
education, individual habits, comorbidity as well as to record relevant information about
dental, periodontal, salivary, glossal and immune status and observations concerning the
general look of patients participating in the research were also recorded (Appendix 2).
The oral examination was conducted by means of Community Periodontal Index (CPI)
probe and dental mirror (WHO 2013). The probe is graduated by every 1 mm at one end
and by sections on the other end up to 3,5 mm, from 3,5 to 5,5 mm, 8,5 and 11,5 mm, and
ends with a ball in diameter of 0,5 mm (Konopka et al. 2015).
4.4.1. Dental status
The evaluation of dental status includes the prevalence of caries, identification of decayed,
missing and filled teeth, type of edentulous arches and the presence of prostheses.
30
The DMFT index is fundamental both in clinical practice and research as oral health-related
quality of life assessment tool. The D component includes all teeth with carious crown,
carious root and filled crown or root with caries. The M component comprises missing
teeth not only due to caries but to any other reason. The F component includes teeth only
with filled crown and without caries, when one or more permanent restorations are present
and there is no caries anywhere on the crown. The basis for DMFT calculations is 32 teeth,
i.e. all permanent teeth including wisdom teeth. Teeth with fissure sealant or fixed dental
prosthesis/ bridge abutment, special crown or veneer/implant are not included in
calculations of the DMFT index.
During visual examination and probing non-carious lesions were noticed (e.g. attrition,
abrasion, erosion etc.).
The number of decayed teeth with crown or root caries (DT), missing (MT) and filled teeth
(FT) were recorded. DT and MT were summed up to obtain the decayed and missing teeth
(DMT) index and subtracted from FT. This index – FT-DMT reflects the attitude towards
dental health. If its reading is more than 0, the attitude is considered as favorable. If the
reading is less than 0 or equal 0, it implies that person does not care much about preserving
oral health (poor hygiene level, rare dental examinations and treatment). (Opravin et al.
2011.)
To access the type of edentulous jaws the classification of E. Kennedy of partially
edentulous arches was used:
Class I – bilateral free ended partially edentulous.
Class II – unilateral free ended partially edentulous.
Class III – unilateral bounded partially edentulous.
Class IV – bilateral bounded anterior partially edentulous. (Wikipedia 2016.)
In case of complete edentia the Oxman’s classification for upper and lower jaws was
applied. According to this classification there are four types of edentulous jaws:
31
Type I – high residual alveolar ridge, high maxillary tuberosities, prominent palatal vault
and adequate attached mucosal base.
Type II – moderately expressed atrophy of alveolar bone and maxillary tuberosities, less
deep palate and lower attachment of the movable mucosa.
Type III – highly expressed but even atrophy of alveolar ridge, flattening of the palatal
vault. Movable mucosa attaches at the top of the alveolar bone.
Type IV – uneven atrophy of alveolar ridge, a combination of features of the previous
types. (Mironova 2012.)
In addition, the presence of removable dentures was recorded for each jaw. The codes were
as follows:
0 – No denture.
1 – Partial denture.
2 – Complete denture.
9 – Not recorded. (WHO 2013.)
4.4.2. Periodontal status
Oral Hygiene Index Simplified (OHI-S), papilla, marginal and alveolar gingiva index
(PMA), CPI were used to establish periodontal status. The level of oral hygiene was
estimated with OHI-S developed in 1960 by John C. Greene and Jack R. Vermillion. OHI-
S’ index teeth are 11, 16, 26, 31, 36 and 46. The index is composed of two components,
one describing the soft (debris index simplified (DI-S)) and one the calcified (calculus
index simplified (CI-S)) deposits present. DI-S and CI-S are measured on the labial
surfaces of teeth numbers 11, 16, 26, 31, and the lingual surfaces of 36 and 46. The criteria
for the DI-S assigning scores of 0-3 are as follows:
0 – No debris or stain present.
1 – Soft debris covering no more than one-third of the tooth surface being examined or the
presence of extrinsic stains without debris regardless of surface area covered.
2 – Soft debris covering more than one-third but not more than two-thirds of the exposed
tooth surface.
3 – Soft debris covering more than two-thirds of the exposed tooth surface.
32
The criteria for the CI-S assigning scores of 0-3 were as follows:
0 – No calculus present.
1 – Supragingival calculus covering no more than one-third of the exposed tooth surface
being examined.
2 – Supragingival calculus covering more than one-third but not more than two-thirds of the
exposed tooth surface, or the presence of individual flecks of subgingival calculus around
the cervical portion of the tooth.
3 – Supragingival calculus covering more than two-thirds of the exposed tooth surface or a
continuous heavy bank of subgingival calculus around the cervical portion of the tooth.
The DI-S and CI-S scores are obtained by the sum of the debris score for all teeth, divided
by the number of surfaces scored. Then sums of debris and calculus indices were summed
up to derive OHI-S score. At least two of the possible six surfaces have been included in
order to calculate the score, and the adjacent teeth were substituted for the selected teeth if
they were missing. The clinical relevance to the DI-S and CI-S is as follows: 0,3- 0,6 –
good oral cleanliness; 0,7-1,8 – fair; 1,9-3,0 – poor. The interpretation for OHI-S is 0,0-1,2
– good; 1,3-3,0 – fair; 3,1-6,0 – poor. (Wei, Lang 1982.)
To evaluate the gingival inflammation PMA index developed by Schour and Massler in
1944-1947 (Wei, Lang 1981) in modification by C.Parma (1960) was used. The
inflammation presents in the interdental papilla (P) has been assessed as the equavalent of
one point. Then, the spread to the marginal gingiva (M) – two points and ultimately the
attached gingiva (A) – three points. (Rebelo and Correa de Queiroz 2011.) The number of
affected papillary, marginal and attached units for individuals aged over 15 years are 28 to
30 calculated by the following formula (Danylevskiy 2000):
РМА= (Sum of points/ 3* Number of teeth)*100%.
CPI was used for assessment of periodontal bleeding, calculus and periodontal pockets.
Dentitions have been divided into 6 sextants: 18–14, 13–23, 24–28, 38–34, 33–43 and 44–
33
48. Index teeth for adults aged 20 years and older are 17/16, 11, 26/27, 36/37, 31, 46/47. A
sextant is to be examined only if there are two or more teeth present which are not indicated
for extraction. The two molars in each posterior sextant are paired for recording and, in
case of one missing, there is a replacement. If no index tooth is present in a sextant
qualifying for examination, all the teeth that are present in that sextant are examined and
the highest score is recorded as the score for the sextant. (WHO 1997.)
To conduct the examination CPI probe was used with the gingiva of all teeth present in the
mouth was examined by inserting the tip of the WHO CPI probe between the gingiva and
the tooth to assess the absence or presence of bleeding. When the probe was inserted, the
ball tip followed the anatomical configuration of the surface of the tooth root and the full
extent of the sulcus or pocket explored. The index teeth, or all remaining teeth in sextant,
are to be examined and the high test score is to be entered in the appropriate box (Figure 1).
Figure 1. CPI index teeth.
The codes are as following:
0 – Healthy.
1 – The bleeding observed, directly or by using a mouth mirror, after probing.
2 – Calculus detected during probing, but all of the black band on the probe visible.
3 – The pocket of 4-5 mm (gingival margin within the black band on the probe).
4 – The pocket of 6 mm or more (black band on the probe nt visible).
X – Excluded sextant (less than two teeth present).
9 – Not recorded. (WHO 1997.)
17/16 11 26/27
46/47 31 36/37
34
4.4.3. Salivary status
Salivary status involves saliva quality description (color, foamy, presence of impurities)
and evaluation of salivary flow rate, type of saliva microcrystallization, viscosity, surface
tension and pH.
Resting saliva was collected to diagnose a reduction in salivary flow. The collection was
performed between 9 and 11 am and the subjects had been instructed not to eat or drink any
beverages except water, not to smoke and chew gum one hour before the examination. The
patients were advised to rinse the mouth for 5 seconds with 5 mL distilled water and then to
rest for five minutes. The subjects were asked to minimize the movements especially mouth
movements during the collection and to keep eyes open before an initial swallow, to keep
mouth slightly open and allow saliva to drain into the 10 ml sterile tube. At the end of the
collection, participants expectorated the accumulated saliva into a tube. After 5 or 10
minutes, in case of low flow rate, the volume of collected saliva was measured, and the
salivary flow rate was expressed in mL/min. (Yurdukoru, Terzioglu & Yilmaz 2001,
Navazesh & Kumar 2008, Ueno et al. 2014.)
Measurement of salivary viscosity was done using the Hess viscometer graduated in
centipoise (cP). The viscometer consists of two similar graded pipettes fixed in parallel on
the holder. The pipettes have identical capillaries and are jointed with rubber tubes and one
of the pipettes ends with a valve. There is glass tip which is used for suction to create
vacuum in the pipettes. The procedure is as follows: firstly, portion of distilled water fills
the pipette up to 0 level and the access to the pipette is blocked by the valve. Then saliva
fills the other pipette up to 0 level, after which the valve is opened and both liquids go up:
the saliva up to level 1 cP and the water up to the level which registers as saliva’s viscosity
level. Afterwards, the capillary is cleaned with alcohol, ammonia and ether after each
measurement.
For determination of salivary surface tension (SST) three to four drops of saliva are filled
into the pipette and then one drop of saliva is placed on the filter paper from the height of 1
35
cm and in a minute the contour of spot is circled with the pen. The area of the circle is
calculated by the formula:
SST = WST*Ss/Sw,
where WST – water surface tension (72, 72 nanometer/meter), Ss – area of salivary drop,
Sw – area of distilled water drop. Sw for the filter paper is 5,97 cm2. (Goryachev 2011.)
Saliva’s crystal structure is essential for organism homeostasis. The shape of crystals is
determined by the wave gradient between the crystal-forming elements and environmental
factors. When pathology occurs, changes at the molecular and submolecular levels are
taking place, producing an impact on the rate of crystal-forming elements which finds an
expression in a modified form, size and number of facies’ branches. (Dobrenkov 2014.) To
determine microcrystallization of saliva (MCS) samples of oral fluid were collected in
chemically clean test tubes. The same amount of saliva was collected with the pipette and
placed on a glass plate three consecutive times and dried at room temperature. Subsequent
analysis of obtained samples was performed in accordance with the listed below scale and
criteria for evaluating the type of MCS using an electron microscope «Leica DM750»
(Germany) with an 4x-100x magnification. The normal results of MCS are characterized by
a clear pattern of large elongated prismatic crystal structures spreading from the center of
the drop, fusing with each other and forming a tree like or pteridophytes shape (the picture
corresponds to the reading of 5 (Figure 2, a)). The destruction of crystal structure caused by
various adverse factors is assessed to get the results of MCS. The following types of crystal
destruction are identified: large prismatic elongated crystal structures fused together in a
random order are measured as 4 points (Figure 2, b); if the center of the drop shows some
star-shaped crystals form while on the periphery there are enlarged dendrite crystals, the
reading is 3 points (Figure 2, c); if the individual crystals are in the form of rods or twigs
arranged across the field then the reading is 2 points (Figure 2, d); if the entire area of the
drop is taken by a large number of crystal structures of isometrically arranged, stellate,
round or irregular shape, then the reading is 1 point (Figure 2, e); the complete absence of
crystals in the field of view equals 0 points (Figure 2, f). (Belskaya 2011.)
36
Figure 2. Types of saliva's microcrystallization (Belskaya 2011).
The microcrystallization potential of saliva (MPS) was expressed by the mean point of
crystallization of three drops: 0,0-1,0 – very low; 1,1-2,0 – low; 2,1-3,0 – fair; 3,1-4,0 –
high, 4,1-5,0 – very high (Vasilieva 2013).
Resting salivary pH values were measured by dipping pH strips McolopHast TM
pH 4,0 –
7,0 (Merck, Germany) into unstimulated saliva for 10 seconds and comparing them with a
pH reference chart placed on the pack.
4.4.4. Glossal status
Evaluation of glossal status was conducted by using the tongue dorsal surface test which
registrates the presence of coating and hyperkeratosis. By means of tongue dorsum visual
inspection a list of changes are registered according to the following criteria:
37
0 – No changes.
1 – Coating on the tongue dorsum.
2 – Coating on the tongue dorsum and minor hyperkeratosis.
3 – Coating on the tongue dorsum and significant hyperkeratosis of filiform papillae.
(Ivanova 2009.)
4.4.5. Immune status
Assessment of local immunity in the mouth was conducted by studying the amounts of
interleukin-8 (IL-8), immunoglobulin G (IgG), tumor necrosis factor alpha (TNF-α),
secretory immunoglobulin A (SIgA) and cortisol in saliva samples. Samples were stored at
–30C until enzyme-linked immunosorbent assay (ELISA) was done in the biochemical
laboratory of NSMU. For this method manufacturer supplied reagents “Vector-Best”
(Novosibirsk) A-8762 , A-8756, A-8662, A-8668 were used.
The procedure begins with the adding of 100 μl of activating solution into strips wells
incubated for 30 minutes at 37 °C after which washed. Then, in the first two wells of the
strips 100 μl the calibration samples were placed while in the remaining wells 100 μl of test
samples were added and then incubated for 45 minutes at 37 °C after which washed again.
Next, into each well 100 μl of conjugate solution was added and incubated for 30 minutes
at 37 °C, and washed at the end of the incubation. Then in all wells strips100 μl of
orthophenylenediamine solution were put and incubated for 25-30 minutes at room
temperature. The end of the reaction was performed by addition of 50 μl of stop solution to
each well. The analysis results were recorded spectrophotometrically at the wave length of
492 nm. According to the measurement the results the calibration curve was graphed and
immunoglobulin concentrations were assessed. (Vector-best 2016.)
After the comprehensive examination the intervention urgency was determined according
to what is recommended by WHO:
0 – No treatment needed.
1 – Preventive or routine treatment needed.
2 – Prompt treatment including scaling needed.
38
3 – Immediate (urgent) treatment needed due to pain or infection of dental and/or oral
origin.
4 – Referred for comprehensive evaluation or medical/dental treatment (systemic
condition). (WHO 2013.)
4.4.6. Statistical analysis
The data is entered and analyzed with STATA version 13.1.220 (StataCorp LP, Texas,
USA). In the first place the Shapiro-Wilk normality test is applied to test normality. For
normally distributed quantitative variables the sample arithmetic mean or average (x),
sample standard deviation (SD) and confidence interval (CI) are determined. For statistical
analysis of quantitative data which is non-normally distributed, median (Md, Q2), first and
third quartile (Q1 and Q3) and CI are used. Statistical significance is considered if p-value is
0,05. To assess relationships between variables the correlation coefficient (r) is computed.
For parametric data the Pearson’s product-moment correlation coefficient is applied and for
nonparametric equivalents the Spearman's rank correlation coefficient is used. For
qualitative data proportions (ω) and CI are performed. In addition, the linear regression test
is applied to examine the relationship between quantitative outcomes and quantitative
variables.
39
5. RESULTS
As stated above, the response rate was relatively low (32,5%) and during the study 26
patients were examined. After applying inclusion-exclusion criteria we have got 23 patients
aged 60 to 89 years. Three patients were excluded because they were younger than 60.
Thus, the mean age (x(SD)) of the participants of the study (n = 23) equals to 76,9 (8,1)
years.
According to age-related changes, a wide variety of somatic pathology was observed,
including almost all organs and systems of human body (cardio-vascular, gastro-intestinal,
respiratory, urinary tract, musculoskeletal system, neoplasms, undergone operations,
allergies, ear and eye diseases). Moreover, changes in neural system and mental health such
as nervous tics, hand and head tremors, mood swings, lack of trust, unreasonable fears have
been registered.
When individual lifestyle habits were assessed, one patient revealed nicotine addiction
dating back to a few decades, and we observed that this patient developed the following
changes in her appearance and anamnesis: the parchment skin, which was dry and wrinkled
with yellow tint and in the rough quality of voice. She has undergone neoplasm. Another
patient reported a long-term alcohol addiction: her face was hyperemic, edematous and
there were nose telangiectasia.
The appearance of patients who participated in the research is characterized by loss of
turgor and skin elasticity, deep nasolabial and mentolabial folds, reduced height of the
lower third of the face, mesioclusion, cyanosis of the lips and nasolabial triangle, which
may be attributed to heart diseases.
5.1. Dental status
After the visual examination and probing was performed the prevalence of dental caries
was found as 100%. The meaning of DMFT was 24,5 that corresponds to very high caries
intensity which begins when the DMFT equals to 6,6 or higher (x = 24,5, SD = 6,3; 95%
40
CI: 21,8 – 27,3). Besides, missing teeth (86,9%) prevailed over filled (5,5%) or decayed
(7,6%) teeth. In addition, there have been found non-caries lesions, in particular, attrition
(48% of cases) and wedge-shaped defects (22%) have taken place.
The complete edentia of both jaws have been observed in 6 patients, edentulous upper or
lower jaw found in 5 patients, while in the rest of the patients partial edentia registered. In
the completely edentulous jaws type II of the Oxman’s classification has been observed in 7
jaws, type III – in 5 and type IV – in 5. To access the type of edentulous jaws the
classification of E. Kennedy of partially edentulous arches was used: class I was observed
in 14 jaws, class II – in 9 and class III – in 6. There were 18 jaws with no denture (code 0),
9 with partial denture (code 1), 14 with complete denture (code 2) and 5 were not recorded
(code 9). Thus, 15 subjects were found to be in need of prosthetic care. In seven patients we
have registered defective dentures while eight patients had adequate dentures.
In our study 21 participants had negative reading of FT-DMT index (91%) and only two of
them had FT-DMT above zero (9%). The median of that index was -16 (Q1= -28; Q3= -4;
95%; CI: -20 – -11 ) that testified to negligence among study participants towards their
dental health.
5.2. Periodontal status
The level of oral hygiene with OHIS was found equal 3,4 (SD = 1,0; 95% CI: 3,1 – 4,0)
that indicates the poor oral hygiene. The mean value of PMA index was 25,2% (SD = 19,3;
95% CI: 15,3 – 35,1) that corresponds to mild inflammation rate. The CPI code 0 (healthy
periodontal tissues) was not observed, code 1 (bleeding) in 12,3% (95% CI: 0,08 – 0,19),
code 2 (calculus) – 8,0% (95% CI: 0,04 – 0,14), code 3 (shallow pockets) – 10,1% (95%
CI: 0,06 – 0,16), code 4 (deep pockets) – 8,0% (95% CI: 0,04 – 0,14) and code X (excluded
sextants) in 61,6% of cases (95% CI: 0,53 – 0,69).
41
5.3. Salivary status
The examination of saliva samples showed the following saliva quality characteristics. In
majority of cases saliva was foamy, had yellow or brown colour and a lot of impurities. The
salivary flow rate was calculated as 0,08 mL/min (Q1= 0,04; Q3= 0,15; 95% CI: 0,07 –
0,13), viscosity – 3,0 cP (Q1= 2,5; Q3= 4,0; 95% CI: 2,7 – 4,0), pH – 6 (Q1= 6,0; Q3= 7,0;
95% CI: 6,1 – 6,7) and surface tension – 95,8 nanometer/meter (Q1= 86,5; Q3= 108,8; 95%
CI: 78,5 – 103,9).
In the evaluation of MCS type c was determined (Figure 3) in 17,3% of all the cases, type d
(Figure 4) and e (Figure 5) in 37,3% and 45,3% respectively. The mean value for MPS was
found 1,72 (SD = 0,63; 95% CI: 1,46 – 1,98) that corresponds to low microcrystallization
potential of saliva.
Figure 3. Saliva microcrystallization, type c
42
Figure 4. Saliva microcrystallization, type d
Figure 5. Saliva microcrystallization, type e
43
5.4. Glossal status
According to the tongue dorsal surface test the code 0 was found in 38% of cases (95% CI:
0,16 – 0,65), code 1 in 56% (95% CI: 0,3 – 0,8), code 2 in 6% (95% CI: 0,01 – 0,39) and
code 3 was not found at all.
5.5. Immune status
The results of evaluation of immune status are represented in Table 8.
Table 8. Parameters of local immunity.
Index, number of samples Meaning 95% CI
IL-8(pg/ml) n=16 x = 420,85 (SD = 50,52) 313,16 – 528,53
TNF-α(pg/ml) n=18 Md = 0,93 (Q1= 0,01; Q3= 3,53) 0,94 – 4,15
IgG (mg/ml) n = 21 Md = 26,57 (Q1= 13,12; Q3= 34,64) 19,61 – 29,55
sIgA (mg/l) n=21 x = 390,16 (SD = 40,54) 305,6 – 474,72
Cortisol (nmol/l) n=22 Md = 22,81 (Q1= 21,04; Q3= 24,93) 20,72 – 27,94
After examination the urgency of intervention was determined: code 1 was observed in 2
patients, code 2 in 16 cases, code 3 in 4 subjects and 1 patient was referred for specialist
treatment.
Statistically significant correlation was found after the Pearson’s and Spearman’s
correlation criteria had been applied: strong positive correlation between age and DMFT,
strong negative correlation between age and FT-DMT, strong negative correlation between
age and TNF, very strong negative correlation between DMFT and FT-DMT, very strong
negative correlation between DMFT and surface tension, moderate positive correlation
between OHIS and PMA, strong positive correlation between OHIS and IL-8, strong
positive correlation between surface tension and FT-DMT, strong negative correlation
between surface tension and PMA, strong positive correlation between sIgA and IgG
(Table 9).
44
Table 9. Correlation between oral indices and markers.
Regression analysis showed the two year aging and growth TNF- on 1 pg/ml increase
DMFT on 1 point, one year aging is connected to decrease of FT-DMT almost on 1 point
(regression coefficient (b) – -0,89) and one point enlargement OHIS results in 10% PMA
index rise.
Age FT-DMT Surface
tension
PMA IgG IL-8
DMFT rs = 0,62; p
= 0,002
rs = - 0,89; p
= 0,001
rs = - 0,85; p
= 0,004
FT-DMT rs = - 0,71; p
= 0,03
rs = 0,9; p =
0,0009
TNF rs = - 0,78; p
= 0,01
OHIS rs = 0,49; p
= 0,004
rs = 0,79; p
= 0,002
PMA rs = - 0,69; p
= 0,04
IgA rs = 0,73; p
= 0,02
45
6. DISCUSSION
Facing the challenge of steady growth of the proportion of the elderly worldwide the
International Assosiation of Gerontology singled out gerodontology as a separate scientific
branch back in 1983. Currently the proportion of the elderly is continuing to increase
demanding broader access to dental care. (Samsonov et al. 2011.)
The data we have obtained is compared with the results achieved by multiple research
groups in Russia and abroad taking into account comorbidity, external examination, indices
of dental, periodontal, glossal, salivary and immune status of the elderly.
6.1. Questionaires, external examination
In our study all patients are characterised by suffering from at least one chronical condition
(cardio-vascular, neural, gastro-intestinal, respiratory, urinary, musculoskeletal, ear and eye
diseases, allergies, neoplasms and mental health problems) or having undergone operations,
which corroborates very well with the study of Ovsyannikov (2010) taken place in Moscow
where it was found that 100% of respondents had a few long term somatic illnesses
(Ovsyannikov 2010).
Visual oral examination allowed to reveal petechiae (8,7%) on hard palate surface 2-3 mm
in diameter in two cases that can be a sign of hypertension. Varicous veins in the sublingual
area and cyanosis of nasolabial triangle and lips evidence cardio-vascular diseases.
papilloma under the tongue was detected in one patient while we have not observed various
disorders of skin or oral mucosa such as leukoplakia, hyperkeratoses, cheilitis, scalded
mouth syndrome, oral lichen planus, chronical aphthous stomatitis, lingua geographica
which were noted among the elderly in other studies (Kopyl 2011).
6.2. Dental status
Dental caries has high prevalence among the elderly. In foreign literary sources the
46
prevalence of caries fluctuates from 66,03% to 90% (Liu et al. 2013, Yao & MacEntee
2013). In our study we have found that 100% of participants have dental caries that is much
higher than that in foreign studies, but it complies with studies carried out in this country.
For instance, in a Moscow study 100% caries prevalence was found in all three age groups
(60-69, 70-79 and 80 and over). (Apresyan 2005.)
The most common index to determine dental health is DMFT index and meaning of DMFT
in elderly group varies from 15,7 to 29,59 (Apresyan 2005, Andrade et al. 2012, Rodrigues
et al. 2012a, Rodrigues et al. 2012b, Cornejo et al. 2013, Yao & MacEntee 2013). We
found a very high caries intensity (DMFT = 24,5) in Arkhangelsk that corresponds to other
locations in Russia: 24,61 in Moscow (Apresyan 2005), 25,4 in Izhevsk (Zinchenko 2008),
29,4 in Kemerovo (Kiseleva 2009). Also Apresyan (2005) reveals that DMFT steadily
grows with aging that results in extremely high level of caries among young-old and old
persons (Seccombe & Ishii-Kuntz 1991).
On closer examination of the DMFT index we have found that the mean reading of missing
teeth almost always prevailed over decayed teeth, which indicates that decayed teeth are
usually extracted because of the pain or abscess they caused, so restorative procedures are
rarely performed in the elderly (Srivastava et al. 2012). The mean weight of extracted teeth
is the highest in DMFT structure and grows with the aging up to 97%. Other elements of
DMFT index, such as decayed and filled teeth, amount to 2,7% and 4,1% respectively and
tend to decrease with aging. Mean proportion of caries complications is also very low – less
than 1%, and at the age at 80 and over it was not discovered at all. Mean proportion of teeth
with caries complications which are to be extracted is relatively low (0,6% and 4,8%). It
means that urgency of dental surgical aid is not very high because the majority of teeth had
already been extracted. (Apresyan 2005, Ovsyannikov 2010.) Our results generally
coincide with findings from other studies: proportion of missing teeth is the predominant
factor in DMFT structure (86,9%), followed by decayed teeth proportion (7,6%), and filled
teeth are the lowest factor (5,5%). In our study there was a patient who had 14 teeth with
caries complications and thus the proportion of periodontitis among the whole group
amounted to be 4,9% and also there were found 3,7% of teeth roots to be removed.
47
There are found some peculiarities of dental caries and its complications among the elderly.
Caries lesions are generally found on the tooth neck with wide access and they are
characterized by rough ridges and pigmented dentin, with the diameter of lesion more than
the depth and this lesions and are found painless during the probing. Among the elderly
pain is a very rare reason to seek dental aid because of involution of pulp tissue due to
systemic diseases such as cardio-vascular, musculoskeletal, connective tissue, endocrine
diseases. Furthermore, multiple cases of root caries were found and caries is one of the
major causes of periodontitis. Though acute pulpitis was observed in 2% of cases and acute
periodontitis in 3,2% in a Stavropol study in our study we did not discover such forms of
caries complications at all. (Bragin & Timoshenko 2013.)
Thus, analysis of the DMFT structure in our study showed that the number of missing teeth
in the examined patients prevailed over the number of decayed and filled teeth which
testifies to extremely high necessity of prosthetic care due to chewing deterioration and
relatively low expectations of therapeutic dental aid. According to the results of other
studies there is about 95% of 60 to 69 year olds who were in need of prosthetic care at the
moment of examination and about 5% who had good quality dentures, and 99% and 89% of
patients who need dentures in the other age groups such as 70 to 79 and 80 and over,
correspondingly. (Apresyan 2005, Ovsyannikov 2010.) The need of prosthetic aid was
found in about 75% of all cases in other studies (Kuzmina 2009, Soldatov 2011). In our
study group we found that there was significantly lower need for prosthetic treatment
(65%) than in the studies of any age group (Table 10). We have observed complete edentia
in 6 patients (26%) that corresponds to study results of Ushnitskyi and colleagues (2013b)
(29,03 ± 0,74%). However, Kuzmina (2009) provides data about 5% of participants with
complete edentia of both jaws and Unell et al. (2015) found complete edentia in 3% of
cases among 70 year olds and 7% among 80 year old subjects in Sweden.
48
Table 10. Necessity of orthopedic treatment.
Study Age
(years)
Number
of
persons
Not in need of
prosthetic aid
In need of prosthetic aid
numbers % numbers % have defective
dentures
do not have
dentures
numb
ers
% number
s
%
Present
study
60-90 23 8 35 15 65 7 30 8 35
Ushnitsk
yi et al.
2013
21 86
Apresya
n 2005
60-69 138 7 5,1 131 95 92 94,8 31 22,5
70-79 155 2 1,3 153 99 147 86,1 6 3,9
80 and
over 79 9 11 70 89 68 2 2,5
Type II of Oxman classification of completely edentulous jaws has been discovered in
41,2% of cases of our study participants, type III and IV – in 29,4% of cases, while type I
has not been found at all. Our findings vary slightly from those reported by Ushnitskyi and
colleagues (2013b): type I – 0%, type 2 – 2,5%, type III – 33,7% and type IV – 7,5%. It is
worth observing that classes I and II of the Kennedy classification of partially edentulous
arches predominate not only in ours but in other studies as well and these classes are the
most difficult to treat (Table 11).
Table 11. Distribution of partial edentia in elderly groups.
Study I class II class III class IV class
Present study 48,3% 31% 20,7% 0%
Timoshenko & Bragin 2013 42,3% 44,8% 9,2% 3,7%
Ushnitskyi 2013b 55,56 ± 0,46% 21,15 ± 0,92% 6,09 ± 0,98% 3,58 ± 1,01%
During our study we observed non-caries lesions which arise after teeth eruption. Teeth
attrition was found in 48% of cases and it was mainly in the spread form. Other studies also
show high prevalence of abnormal attrition from 29,74% to 35,3% in this age group.
According to Iordanishvili et al. (2014) men suffer more often from abnormal attrition than
49
women and this phenomenon intensifies with age. Furthermore, wedge-shaped lesions
which affect mostly canines and premolars are observed in 22% of cases.
Since the FT-DMT index is not yet widely used for all population we resorted to the
existing data of adolescents with and without history of the psychoactive substances use.
Adolescents who have not used psychoactive substances had the FT-DMT index above zero
in 39% of all cases and for the adolescents who had used the substances the index was 61%
(Opravin 2012). In our study the FT-DMT index was 91%. These findings suggest that
dental wellbeing is an issue of acute interest for all age groups but in the elderly it becomes
the most urgent.
6.3. Periodontal status
According to the studies periodontal diseases in the young-old and old persons vary from
37,1% to 91,2% (Vahromeeva 2008, Kuzmina 2009, Soldatov 2011, Bragin & Timoshenko
2013). Healthy periodontal tissue was not observed in our study at all, while 17% of
gingivitis and 83% of parodontitis were found.
Estimating hygiene level by using OHIS-index we have received the mean value of 3,4±1,0
which indicates poor oral hygiene level. During the examination the abundance of soft and
calcified deposits was found. Other studies also indicate that the elderly have inadequate
level of oral hygiene (Zinchenko 2008, Kuzmina 2009, Soldatov 2011, Bragin &
Timoshenko 2013). Table 12 compares studies of oral hygiene level. It should be noted that
good hygienic level was not found in our study. Poor oral hygiene can be attributed to
somatic and psychological disorders, deterioration of fine motor skills and low motivation
toward maintenance of dental health.
Table 12. Distribution of oral hygiene levels among the elderly.
Study Good Fair Poor
Kiseleva et al. 2009 20,4% 25,8% 53,3%
Present work 0% 41% 59%
50
The evaluation of inflammatory process was done by using the PMA index. Our results
showed milder inflammation rate (25,2%) than was found in another study where more
moderate level of inflammation was observed (41,1%) (Vahromeeva 2008).
Data of CPI index vary from study to study (see Table 13). It should be noted that in some
studies the sum of all codes did not equal to 100% and the reason has not been explained in
the studies (Kiseleva et al. 2009Bragin & Timoshenko 2013, Aapaliya et al. 2015).
Generally these results show a sign of wide spread of severe form of parodontitis.
Table 13. Distribution of CPI codes.
Study Code 0 Code 1 Code 2 Code 3 Code 4 Code X
Present study 0% 12,3% 8% 10,1% 8% 61,6%
Aapaliya et al.
2015
4,8% 0% 12,3% 0% 52,6% 66,7%
Cornejo et al.
2013
1,9% 3,1% 27,1% 18,5% 5,2% 44,2%
Bragin &
Timoshenko
2013
67% 25,1%
Kiseleva et al.
2009
0%
22,1% 19,7% 11,3% 14,6% 2,6%
Inflammatory processes in periodontal tissues are primarily the consequence of debris and
supragingival and subgingival calculus presence. Traumatizing factors, such as
overhanging fillings, low-quality contact point due to poor therapeutic treatments and
damaging constructional elements of removable dentures can be other reasons of
periodontal pathology. Moreover, hyposalivation, alterations of physical saliva parameters,
immune imbalance and comorbidity result in development of gum and parodontium
diseases.
6.4. Glossal status
In the study of the people aged 18 to 56 from the Izhevsk research group the readings of the
tongue dorsal surface test spread from 1,19 to 1,66 depending to the degree of oral cavity
dysbiosis (Ivanova 2009). The value of the tongue dorsal surface test in our study was 0,73
which is substantially lower than that of the younger group in the previously quoted study.
51
Without bacteriological tests it is hard to explain unambiguously why such low value has
been obtained. Microbial landscape in our case might have been balanced or in some way
connected with the immune status changing (increasing of local immunity markers).
6.5. Salivary status
In our study there were two purposes for collecting the saliva samples. First, they were
collected in order to evaluate physical saliva parameters as well as markers of oral cavity
immunity. Examination of the samples was conducted right after the collection and
included determination of salivary flow rate, viscosity, pH and surface tension for it is
important that saliva does not loose its characteristics with time and temperature changes
which could distort pH or viscosity data.
It is general knowledge that aging causes overall degeneration which in turn affects
anatomical integrity of salivary glands leading to cell atrophy, hyperplasia of lypocites and
connective tissues and functional violations such as hypersalivation, or slalorrhea,
hyposalivation, or oligosialia. Among the young-old and old age groups salivary flow
deterioration occurs in 55,5 % and 26,7% respectively. (Iordanishvili et al. 2012.) Other
studies show percentage of patients with the high degree of hyposalivation – xerostomia –
in 35% and 14%, respectively. (Ohara 2013, Novitskaya 2014.)
Ohara and colleagues (2013) claim that xerostomia and hyposalivation are two different
conditions: xerostomia is the subjective feeling of oral dryness while hyposalivation is
connected with the decreased salivary flow rate. They analyzed the data obtained from
previous studies and found that not those who have hyposalivation report xerostomia and,
contrary, those who report xerostomia may have normal or high salivary flow. On the
whole, there are several reasons of hyposalivasion, the most frequent being medication:
80% of the commonly prescribed medications are found to cause xerostomia and more than
400 medications are associated with hyposalivation as an adverse effect. Female patients
have hyposalivation more often but the cause-and-effect relationship is yet to be found. The
studies of menopausal change may help eliminate the gender differences. (Ohara 2013.)
52
The present study did not find patients with normal level of salivation while there were
found cases with no salivation at all and the data were matched with the results of an
Ukrainian study (Table 14). We concluded that salivation disturbance found in our study
was more pronounced because xerostomia prevailed among the participants (52,1%) while
in the above quoted study the second stage of hyposalivation was the most common.
(Novitskaya 2014). It is worth noting that in an Yakutian study the participants of two age
groups, those 65 to 74 and 75 and over had normal salivation rate (0,57±0,04 and 0,61±0,08
respectively) (Ushnitskyi et al. 2013a).
Table 14. Severity of hyposalivation among the elderly.
Salivation flow rate (ml/min) Novitskaya 2014 Present study
Number of
participants (%)
Mean
value
Number of
participants (%)
Mean
value
Normal (> 0,5) 2 (2,6%) 0,61 0 0
Hyposalivation, 1 stage (0,49-0,35) 4 (5,2%) 0,38 1 (4,4%) 0,37
Hyposalivation, 2 stage (0,34-0,25) 34 (43,6%) 0,32 0 0
Hyposalivation, 3 stage (0,24-0, 1) 27(34,6%) 0,15 10 (43,5%) 0,15
Xerostomia (< 0,1) 11 (14 %) 0,08 12 (52,1%) 0,05
Zinchenko (2008) demonstrates that saliva viscosity in the elderly (mean age 61,7±0,4
years) is 1,8 times higher than in adults (mean age 36,2±0,3 years) and this correlates with
the data obtained in our study. Moreover, Ushnitskyi and colleagues (2013a) demonstrates
viscosity level even higher than that obtained in the present study: 3,84±0,13 in 65 to 74
age group and 3,73±0,18 in 75 and over age group.
We identified pH mean value (6,0) that is lower than pH mean found among population of
central and southern Russia aged 18 to 65: 7,0 and 6,5 respectively (Dobrenkov 2014).
6.6. Immune status
The study of Malezhik and collegues (2011) suggests the following explanations of local
immunity changes: the elderly suffer frequently from various gum and oral mucosa
inflammatory diseases which are exacerbated by degenerative processes and
atherosclerosis. Concominant atherosclerosis and myocardial dysfunctions aggravate the
course of local inflammatory processes in parodontiun and limit its adaptational and
53
compensatory capacity making the preservation of normal functions the most immediate
problem for the dentist. Some studies point out the necessity of further investigation of
adaptational resources of the body, including the oral immunity, even in advanced age in
order to help restore and maintain normal functioning. (Malezhik 2011.) It should be noted
that so far there does not exist age norm of oral immunity markers which can be influenced
by many factors such as places of residence, climate conditions, geomagnetic field and
nutrition.
Following our study protocol we have examined a set of oral immune status markers such
as SIgA, IgG, TNF- α, IL-8 and stress-hormone cortisol level in saliva samples of the
participants. Table 15 compares results obtained in our study with the data from other
studies.
Table 15. Levels of immunity markers in saliva.
Marker Malezhik et al. 2011
Young-Old
60–74
n=96
Soldatov 2011
Young-Old
60–74 n=47
Old
75–88 n=37
Lobeyko et al. 2015
Young-Old
61–74
n=20
Old
75–90 n=15
Present study
Young-Old
60–74
Old
75–90 n=23
IL-8(pg/ml) Young-Old
234,5 (113,4; 284)
Young-Old
11,2±2,2
Old
10,7±2,2
Young-Old
411±44
Old
342±31
Young-Old
537,1±262,3
Old
368,0±
154,7
TNF-α
(pg/ml)
Young-Old
11,0±1,7
Old
9,5±1,9
Young-Old
18,3±2,9
Old
29,6±3,2
Young-Old
0,83 (0,686; 0,88)
Old
2,5 (0,095; 4,2)
IgG (mg/ml) Young-Old
36 (0,15; 0,45)
Young-Old
9±0,02
Old
8±0,03
Young-Old
25,0±11,4
Old
24,4±11,1
sIgA (mg/l) Young-Old
308,5 (293,9; 323,1)
Young-Old
920±0,07
Old
720±0,07
Young-Old
416,1±176,3
Old
377,2±195,4
IL-8, TNF-α, IgG, sIgA readings are expressed by x±SD or Md (Q1; Q3)
The saliva examination may indicate the presence of broad range of substances reflecting to
54
the state a person’s health so the present study used the modern laboratory method, such as
ELISA, to determine the levels of various immune parameters and their biological activity
in the saliva found even in low concentrations.
SIgA constitutes the predominant immunoglobulin isotype in secretions including saliva
and maintains integrity of oral mucosa through several mechanisms. It limits
microorganisms and viruses adhesion on the surface of mouth epitelium and dental hard
tissues such as Streptococcus mutans (Dobrenkov 2014), it neutralizes pathogens’ enzymes
and toxins and functions concomitantly with other antibacterial factors such as lysozyme,
lactoferrin and saliva peroxidases. Moreover, SIgA plays a crucial role in pathogens
penetration prevention in oral mucosa. This fact is of extremely importance because there is
a lack of complement system subcomponents and effector cells (monocytes, lymphocytes,
and polymorphonuclear leukocytes) in saliva. (Agaeva 2010.) SIgA, as well as other
immunoglobulines, belongs to immune humoral factors. Though the humoral immunity
map is very individual the normal thresholds of physiological concentrations have been
found for adult and children. Thereby, normal levels of SIgA in saliva fluctuate from 115,3
to 299,7 mg/l according to manufacturer of test-systems for ELISA. Simultaneously, it has
been advised to use this range only as an approximate and determine the range of SIgA
concentration for each laboratory. (Vector-best 2016.) It is pointed out that SIgA
concentration depends on salivary flow rate, dietary factors and the state of psychological
and physical health (Miletic et al. 1996, Malathi, Mythili & Vasanthi 2014). In our study
we have found the level of SIgA to be 390,16 mg/l which exceeds approximate norm of the
manufacturer. Lobeyko et al. (2015) found concentrations of SIgA to be 2,2 and 1,9 times
higher than those found in our study in the group of young-old (60 to 74) and old (75 to 90)
patients, respectively. However, the decreasing trend of SIgA has been observed as in our
study.
IgG is a glycoprotein which is secreted by plasma cells (B-cells). It is a predominant
immunoglobulin in normal serum (70-75%, approximately 10 mg/ml). (Divya &
Sathasivasubramanian 2014). IgG is a nonsecretory immunoglobulin which enters the oral
cavity by passive diffusion through the bloodstream but it can be produced in the oral
55
cavity by plasmocytes after specific stimulation. Then it proceeds to the place of an
immune conflict in the submucosal and mucosal layer. The factors which may increase
delivery of serum immunoglobulins into secrets are inflammation of the oral mucosa and its
trauma and local allergic reactions. In such cases, the arrival of a large number of serum
antibodies to the place of antigen conflict is a biologically appropriate mechanism for
strengthening local immunity. Accordingly, it can be assumed that in the young people the
barrier function of the mucous membranes of the mouth is optimal, that is why the
penetration of nonsecretory immunoglobulin in the saliva in this group of persons is less
pronounced. IgG-class antibodies have pro-inflammatory properties and can acquire
immunopathologic role when the elimination of antigen is impossible. (Lobeyko 2015.) We
have received the IgG values which were lower than in the study of Malezhik (2011), but
much higher than in the study of Lobeyko et al. (2015) although the tendency of lowering
of the marker with aging is common. The increase in salivary IgG may be due to increased
permeability leading to passive diffusion of IgG from the vascular and extravascular
compartment into the saliva. This may be suggestive of the active inflammatory process.
(Balakrishnan & Aswath 2015.)
IL-8 is a protein and chemoattractant cytokine produced by a variety of tissue and blood
cells such as monocytes, T-cells, neutrophils, fibroblasts, endothelial cells, keratinocytes,
hepatocytes, chondrocytes and astrocytes as a response to various stimuli including
proinflammatory cytokines (IL-1, TNF-α), bacteria, viruses and the results of their
metabolism. Unlike many other cytokines, it attracts and activates neutrophils in
inflammations. Neutrophils represent the major population of immigrant cells in
periodontitis and its response to IL-8 is characterized by migration of the cells, the release
of granule enzymes and other intra- and extracellular changes. (Bickel 1993.) Besides, IL-8
takes part in stimulation and degranulation of leukocytes, angiogenesis, promotes the
migration of phagocytes in the inflammation focus and causes the synthesis of adhesion
molecules. Increased levels of IL-8 were found in patients with tumours (the markers for
oral squamous cell carcinoma, head and neck squamous cell cancer), bowel, muscle and
joint, kidney, lungs diseases and sepsis. (Rathnayake et al. 2013, Vector-best 2016.)
Comparison of our results with the data provided by Lobeyko (2015) shows relatively high
56
values of IL-8 and the tendency of concentration reduction from the young-old to old age
group. Apparently, the decreased concentration of IL-8 with aging leads to a decrease in
neutrophils chemotaxis into inflammation centers in the oral cavity and the increased level
of bacterial complications.
TNF-α is a proinflammatory cytokine and has several biological effects which are
beneficial for host organisms in inflammation and in protective immune responses against a
variety of infectious pathogens. TNF-α promotes gene transcription and cell activation
perform thereby its anti-tumor activity towards some neoplastic cells, inducing tumor cell
apoptosis and cachexia. It activates granulocytes, macrophages, endothelial cells,
hepatocytes (acute phase proteins production), osteoclasts and chondrocytes (cartilage and
bone tissue resorption), the transcription of other proinflammatory cytokines. This cytokine
along with other cytokines from TNF superfamily stimulates differentiation and
proliferation of neutrophiles, fibroblasts, endothelial cells (angiogenesis), hematopoetic
cells, T- and B-cells and reinforces entrance of neutrophils from bone marrow to
bloodstream. TNF-α plays a crucial role in infections, sepsis and autoimmunity processes
as well as the pivotal involvement of these molecules in the development of secondary
lymphoid organs. (Pfeffer 2003.) Data presented by Soldatov (2011) and Lobeyko (2015)
was considerably higher than obtained in our study while a study conducted in Sweden
referred to TNF-α concentration below the detection level in more than 50% of the samples.
And again, there is the same tendency of increasing concentration from the young-old to
the old group (Soldatov 2011, Rathnayake et al. 2013, Lobeyko 2015).
Cortisol is a steroid hormone (glucocorticoid) secreted by the adrenal cortex from
cholesterol. Cortisol releases as a response to physical activity and acute stress. It also
regulates energy by selecting the right type and amount of substrate (carbohydrate, fat or
protein) the body needs to meet the physiological demands placed on it. Chronic elevation
of cortisol can have detrimental effect on weight, immune function and lead to increased
chronic disease risk. (Aronson 2009.) A research has shown that high morbidity among
athletes during high work load could be related to increased levels of cortisol which has an
immunosupression effect in the body (Afanaseva 2009).
57
Hormone level has distinct circadian rhythm and normal concentration in the blood samples
is between190-690 nmol/l in the morning and between 55-250 nmol/l in the evening.
Secretion in saliva where cortisol exists in unbond form is also rhythmical: 4,11-20,39
nmol/l in morning hours and 0,6-7 nmol/l in evening hours for females of 51 – 70 years.
(Salimetrics 2016.) The results of cortisol concentrations in saliva in our study are slightly
higher (22,8 nmol/l for a.m. hours) than the data from assay-kit manufacturer which can be
used as a guide only, and there is a trend to cortisol concentration growth from the young-
old group to the old. Potentially, it could be a sign of chronic stress influence associated
with increased levels of salivary cortisol, salivary IgA and lysozyme (Malathi, Mythili &
Vasanthi 2014). This elevated cortisol level can be a marker of a number of conditions.
There is factor which influences on cortisol concentration in saliva - gum micro bleeding
can cause elevated results due to presence of blood in the saliva. (Kiev and Ukraine
Laboratories, 2009.)
In our study we have found some imbalances in the local immune responses to the
pathogens. The changes in immunological parameters are to be further examined to
determine the relationships between markers and diseases. Likewise, there can be an
assumption made about the existence of inflammoaging – chronic, low-grade, “sterile”
inflammation, due to several causes, including age-related changes of the immune system.
Apparently, the increased levels of local immunity markers could be a symptom of
inflammoaging in the oral cavity. (Franceschi & Campisi 2014.)
6.7. Study limitations
In our study we used a list of various methods and parameters to estimate the oral health of
the elderly. This type of approach is the advantage of our study, but due to the large amount
of tests not a sufficient number of patients have been examined and so the obtained data can
be transferred to the whole elderly population of Arkhangelsk with reservations because our
study focused on the persons living in the home for the elderly. Modern methods, such as
electron microscopy of saliva droplets or ELISA, were applied while some are out-of-date
(Hess viscometer). Furthermore, the medical status data was construed on the participants’
58
self-assessment and so no verification to the answers from the anamnestic data was
possible. Therefore, there is no proven relationship found between systemic diseases and
oral cavity conditions. The immune markers analyzed in this study are general while more
specific markers are required to achieve the necessary specificity.
59
7. CONCLUSION
The primary aim of the study was to determine the level of the main oral health indices in
the elderly residing in the home for the elderly in Arkhangelsk, Russia. The oral health
markers were divided into dental, periodontal, salivary, glossal and immune status. An
attempt to evaluate each status by modern methods has been made and the research
hypothesis that the older people have worse dental health has been found true.
After comprehensive examination of the group of the elderly we have concluded that aging
affects all the basic parameters of oral health. Dental status of the patients is characterized
by 100% prevalence and very high intensity of caries with predominance of extracted teeth,
the presence of untreated non-caries lesions and neglect towards dental health according to
FT-DMT index results. All the participants of the study were partially or completely
edentulous and 65% of them needed prosthetic care. We have observed poor oral hygiene
level and prevalence of parodontitis with mild levels of inflammation. Deterioration in
salivary status manifests by a decrease in salivary flow rate and pH and increase of saliva
viscosity and surface tension. The study of MCS shows low MPS. The tongue dorsal
surface test reveals the presence of coating on the tongue dorsum. The changes in immune
status consist of elevated of SIgA, IgG, IL-8 and cortisol levels and a decrease in TNF-α
level in saliva samples.
Furthermore, significant links between various parameters of oral health have been found
such as DMFT and FT-DMT, OHIS and PMA and others (see RESULTS). However, the
influence of bad lifestyle habits on the dental wellbeing of the elderly has not been detected
in our study because smoking and alcohol use/drinking predominantly were not reported in
our study group.
Further investigation of the elderly living in the North of Russia is necessary because of the
present study limitations. We believe that we have found important oral health tendencies
which prevail globally and at the same time reflect the specificity of Russia’s population
60
and climate. The algorithm of oral examination developed in this study can be used as a
comprehensive method of oral health assessment in different groups of patients.
The data obtained in this as well as other relevant studies can form a sound foundation for
the formulation of comprehensive social and health care policy for the elderly. As
Rodrigues and colleagues (2012) claim promotion, prevention, treatment and rehabilitation
are key parts of the health care. The analyses of oral health condition of the elderly,
education of dentists in different countries and special programs to preserve oral health in
this group of patient lead to the conclusion that there is an urgent need of policy
modifications in relation to the elderly. At present it is clear that dental aid is to be made
fully available for the elderly both economically and logistically; as well as comprehensive
training programs on geriatric dentistry are to be developed.
At the same time it is very important to underline that health care improvements can not be
restricted to this age group. Continuous efforts by health and state authorities to educate
younger generation and improve the lifestyle with the aim to maintain oral health are to be
made. (Rodrigues et al. 2012.)
Until the comprehensive data on the topic is obtained to make generalized proposals, it is
difficult to formulate recommendations for patients and social workers which can improve
oral wellbeing of this group of people by increasing motivation for seeking dental help.
Still, the following can be stated:
maintenance of oral hygiene is a leading factor in prevention of dental diseases which can
be related to systemic disorders or quality of life deterioration;
dental check-ups should be done regularly, at least twice a year;
tooth extraction should not be longer accepted as a preferable method of dental treatment;
replacement of missing teeth with dentures should be regarded as a normal procedure with
a view to prevent further deterioration of dental health.
61
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74
Appendix 1
ИНФОРМИРОВАННОЕ СОГЛАСИЕ ПАЦИЕНТА
на участие в клиническом исследовании
Вас приглашают принять участие в научном исследовании, посвященном изучению
стоматологического здоровья населения Северо-Западного региона России.
Конфиденциальность:
Информация, полученная лично от Вас в ходе этого исследования, останется
конфиденциальной. Доступ к Вашим документам будет ограничиваться уполномоченным
персоналом в соответствии с законодательством, рекомендациями и стандартами
профессиональной деонтологии. Результаты данного исследования могут быть
опубликованы на научных собраниях и в публикациях, информация также может быть
предоставлена государственным официальным инстанциям – в любом случае без указания на
Вашу личность.
Я, _______________________________________________________________
(ФИО участника)
информирован(а) о целях и задачах проводимого исследования стоматологического здоровья
населения и согласен(на) на участие.
Я информирован(а) о том, что могу в любое время по моему желанию отказаться от
дальнейшего участия в исследовании, и это не повлечет отрицательных для меня
последствий.
Я добровольно соглашаюсь, чтобы данные, полученные в ходе исследования,
использовались в научных целях и были опубликованы с условием соблюдения правил
конфиденциальности.
Дата «____» ___________ 201 г.
Подпись участника __________________________
В моем присутствии участник ___________________________________ подписал(а)
информированное согласие на участие в исследовании
Подпись исследователя ___________________
75
Appendix 2
Date №
Examination card of dental patient
Surname _____________________________________________ Name__________________________________
Age_________________________________ Place of residence_____________________________________________________________________
Dental diagnosis
____________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Comorbidities
Respiratory system_______________________________________________ Gastrointestinal tract ____________________________________________
Urinary system __________________________________________________ Cardiovascular system __________________________________________
Nervous system _________________________________________________ Undergone surgery _____________________________________________
Allergy _________________________________________________________ Pernicious habits ______________________________________________
Others ______________________________________________________________________________________________________________________
Dental part
Last visit of a dentist
_________________________________________________________________________________________________________________
Complaints
_________________________________________________________________________________________________________________________
External examination data
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Oral cavity examination
Dental formula
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Occlusion _____________________________________ DMFT ______________________________________ Hygiene index _____________________
PMA______________________________________________________________ CPI ___________________________________________________
Saliva characteristic, microcrystallisation type
_____________________________________________________________________________________________________
Salivation rate _______________________ Saliva viscosity ___________________ Saliva surface tension _________________________ pH _________
IgA____________________ IgG _______________________TNF-α______________________ IL-8____________________ Cortisol _______________