The prevalence of denture wearing and the impact on the oral health related quality of life among elderly in Kota Bharu, Kelantan

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1 Archives of Orofacial Sciences (28), 3(1): ORIGINAL ARTICLE The prevalence of denture wearing and the impact on the oral health related quality of life among elderly in Kota Bharu, Kelantan S. Zainab a, N.M. Ismail b *, T.H. rbanee c, A.R. Ismail b a Dept. of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, 1615 Kubang Kerian, Kelantan, Malaysia. b School of Dental Sciences, Universiti Sains Malaysia, 1615 Kubang Kerian, Kelantan, Malaysia. c Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, 1615 Kubang Kerian, Kelantan, Malaysia. (Received 17 March 28, revised manuscript accepted 1 June 28) Keywords Denture wearing, elderly, oral health related quality of life. Abstract This study aims to determine the prevalence of denture wearing among elderly and to compare the oral health related quality of life (OHRQoL) between elderly with dentures and those without dentures. This cross sectional study involved 56 randomly selected edentulous elderly in the district of Badang, Kota Bharu, Kelantan. Consented participants were interviewed in the Kelantanese dialect at their homes by a single trained interviewer using the short version Oral Health Impact Profile [S-OHIP(M)] which had been translated into the Malay language, tested and validated for use in Malaysian population. Denture wearing and self rated denture status was noted. The prevalence of denture wearing was 46.2% (95% CI=41.83, 5.7). There was a significant difference in sex, smoking status, self perceived treatment need and self perceived satisfaction between denture wearers and non denture wearers. Denture wearers reported better overall OHRQoL compared to non denture wearers (p<.1). They reported better OHRQoL in 3 items namely difficulty in chewing uncomfortable to eat and avoiding food compared to non denture wearers. Thus appropriate measures are required to improve knowledge among the elderly regarding the use of dentures and the importance of proper denture care. Introduction The Global Oral Health Programme 25 revealed that the present oral health of elderly people were far from optimal (Petersen and Yamamoto, 25). A large proportion of the elderly is edentulous with small proportions having few remaining teeth (Petersen, 23). Elderly with severe oral health status had problems with social situations and interpersonal contacts which may lead to depression and affect their well being (Avcu et al., 25). The loss of teeth has been found to affect quality of life (Locker, 1988; Locker, 2; Sheiham et al., 21; Nuttall et al., 21; Oral Health Division, 24). Dentists frequently recommend removable or fixed prostheses to support impaired masticatory function (Dolan et al., 21; Shimazaki et al., 21). The most * Corresponding author. Dr. orliza Mastura Ismail, School of Dental Sciences, Universiti Sains Malaysia, 1615 Kubang Kerian, Kelantan, Malaysia. Fax: address: mastura@kck.usm.my common prosthesis offered to edentulous people worldwide is complete dentures (Roessler, 23). Dentures play a role in the nutritional status of the elderly. Elderly people wearing defective dentures or those who were edentulous but not wearing dentures were associated with malnutrition (Seman et al., 27). A study among community-dwelling elderly aged 7-75 years in Italy noted that there was a close inter-relation between dental status and nutrient intake. The use of dentures can help improve both nutrient intake and the quality of life of the elderly (Appollonio et al., 1997). A local study among edentulous elderly in Tumpat, Kelantan, Malaysia, reported 71.2% complete denture wearers (Seman et al., 27). The National Oral Health Survey of Adults (NOHSA) reported 5.8% elderly aged 6 years and older had some form of oral prostheses and majority (31.8%) were females (Oral Health Division, 24). About 86.% edentulous elderly staying in pondok Kelantan wore complete dentures (Seman et al., 27). 17

2 Zainab et al. Many older adults have problems with chewing, pain, difficulty in eating and social relationships because of oral disorders (Shimazaki et al., 21; Oral Health Division, 24; Ismail, 1996). Due to these reported problems, researchers have developed interest in quantifying the consequence of disease which affects function, comfort and ability to perform daily activity (Tickle et al., 1997; Slade and Spencer, 1994). The Oral Health Related Quality of Life (OHRQoL) measure was developed to measure psychosocial impact. One such instrument is the short version Malay language Oral Health Impact Profile {S-OHIP(M)} which was validated and found appropriate for use in cross-sectional studies in the Malaysian adult population (Saub et al., 25). This study aimed to determine the prevalence of denture wearing among the elderly and to compare the OHRQoL between elderly with dentures and those without dentures. Materials and methods A cross sectional study was conducted in the district of Badang, Kota Bharu, Kelantan from September 26 until February 27. This district is situated in the north-east of Kelantan state. It consists of 14 sub districts and within each, was several villages. It was one of the most populated district and have about 1887 (33%) of elderly people aged 6 years and older (Department of Statistics, Malaysia, 21). The age of 6 years and older was used to denote elderly people (Mat and Taha, 23). The reference population was community-dwelling elderly aged 6 years and older in Kota Bharu and the source population was communitydwelling elderly aged 6 years and older in the abovementioned district during the study period. The inclusion criteria were Malaysian elderly aged 6 years and older. Sample size was calculated prior to the study using PS Power and Sample Size Calculation Program, version (Dupont and Plummer, 199). The edentulous and dentate elderly formed the two groups. The standard deviation of quality of life was σ=2 (Slade and Spencer, 1994). This reference was chosen for calculating sample size because of the similarity of the population of interest. With anticipation of 2% non response rate, the final sample size was 557 subjects. Study participants was selected by systematic random sampling with sampling interval of 1:2 from a list of names of community-dwelling elderly aged 6 years and older in the district. The sampling interval was determined based on the estimate of elderly population aged 6 years and older in Badang to the estimated sample size required (Department of Statistics, Malaysia, 21). Consented participants were interviewed by a single trained interviewer in the Kelantanese dialect at their homes. Sociodemographic factors, life styles and behaviour, self perceived oral health, self perceived treatment need and self perceived satisfaction as well as responses to the 14-item questionnaire were obtained. For each item, the elderly were asked how frequently they had experienced the impact in the preceeding 12 months. Response items were recorded in a 5- point Likert scale: = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, 4 = very often. Total S-OHIP(M) score ranged from to 56. Higher scores indicate poor OHRQoL. Oral examination was carried out by a single examiner and denture wearing status was recorded after completion of questionnaire. Data were analyzed using SPSS version 12.. Descriptive statistics such as mean and standard deviation (SD) for continuous variables and frequency and percentages for categorical variables were calculated. For independent categorical variables, dummy variables were created with reference category set at zero. In this study, denture wearers were those wearing at least one removable denture in a jaw. It includes those with upper and lower complete dentures, upper complete dentures only, lower complete dentures only and those wearing partial dentures. n denture wearers were edentulous participants without dentures and dentate elderly with less than 2 remaining teeth whereby this criteria had been associated with health related quality of life (Akifusa et al., 25). Elderly people with less than 2 teeth or not wearing dentures were considered as having inadequate rehabilitation (Nevalainen, 24). Level of education was recorded as those with formal education and no formal education. Elderly with formal education included those who attended at least primary level of education. As for general health, independent elderly were those who did not require assistance in their daily activities. Those who ever smoke were elderly who currently smokes and past smokers. In this study, the responses of fairly often and very often were considered as the cut off point to identify those who experienced oral health impacts on a relatively frequent basis (Saub et al., 25). The overall impact experienced by participants over S-OHIP(M) items were described. The difference in S-OHIP(M) score between denture wearers and non denture wearers was determined by independent t test. The level of significance was set at.5. Simple logistic regression analyses were undertaken to determine the relationship of impacts between denture wearers and non denture wearers in each of the 14-items of the S-OHIP(M). The dependent variable was the denture wearing status. Ethical approval was obtained from the USM Research and Ethics Committee in August 26. Results Out of 557 randomly selected participants, 56 (9.8%) consented and participated in the study. n-participants (51, 9.2%) were those not 18

3 Prevalence of denture wearing and the impact on quality of life among elderly available during data collection, too ill or outright refusals. The prevalence of prosthesis wearing was 46.2% (95%CI=41.83, 5.7). There was a significant difference in characteristics between sex, smoking status, self perceived treatment need and satisfaction between denture wearers and non denture wearers (Table1). Table 1 Characteristics Characteristics of denture wearing and non denture wearing elderly, (n=443) Denture wearing n denture wearing χ 2 (df) p-value (n=234) (n=29) Mean Freq Mean Freq (SD) (%) (SD) (%) Age (years) >8 Sex Male Female Educational level formal education With formal education Occupation Unemployed Employed/ Self employed/ Pensioner Living status Alone With others General health Independent Dependent Presence of chronic disease Dental visit At least once in the past year ne in the past year Smoking status Smoke Never smoke Dental fear Self perceived oral health Good Moderate Poor Self perceived treatment need Self perceived satisfaction te: * = p < (8.25) 71.1 (8.) 113 (48.1) 15 (5.2) 1.5 (2) (33.5) 61 (29.2) 43 (18.4) 43 (2.6) 56 (24.) 14 (48.8) (1) <.1* 178 (76.) 15 (5.2) 162 (69.2) 133 (63.6) (1) (3.8) 76 (36.4) 162 (69.2) 145 (69.4).4 (1) (3.8) 64 (3.9) 32 (13.7) 2 (9.6) (1) (86.3) 189 (9.4) 187 (79.9) 172 (82.3).436 (1) (2.1) 37 (17.7) 11 (47.) 96 (45.9).72 (1) (53.) 113 (54.1) 31 (13.2) 29 (13.9).31 (1) (86.8) 18 (86.1) 59 (25.2) 96( 45.9) (1) <.1* 175 (74.8) 113 (54.1) 58 (3.7) 52 (35.4).765 (1) (69.3) 95 (64.6) 176 (75.2) 149 (71.3) 2.577(2) (23.5) 53 (25.4) 3 (1.3) 78 (3.3) 51 (21.8) 66 (31.6) 5.316(1).21* 83 (78.2) 143 (68.4) 182 (77.8) 144 (68.9) (1).37* 52 (22.2) 65 (31.1) 19

4 Zainab et al. Table 2 described the prosthesis status of denture wearers. Table 2 Distribution of prosthesis status among denture wearer (n=234) Prosthesis status Denture wearer Freq (%) Upper and lower complete denture 82 (77.7) Upper complete denture only 34 (14.5) Lower complete denture only 9 (.4) Upper partial 7 (.3) Both upper + lower partial denture 2 (.1) There was a significant difference in the mean score of S-OHIP(M) between denture wearers and non denture wearers (Table 3). Denture wearers had significantly lower mean S-OHIP(M) score compared to non denture wearers (p<.1). This indicated that they had less impact and better OHRQoL than non denture wearers. Table 4 described the impact on S- OHIP(M) items. Majority of denture wearers and non denture wearers reported having impact in the first 4 domains of S-OHIP(M) which were functional limitation, physical pain, physical discomfort, and physical disability. The most common impact reported by denture wearers were food stuck in mouth while for non denture wearers were avoiding food. Simple logistic regression analysis showed significant associations in the aspects of difficulty in chewing with odds ratio (OR).3 (95%CI=.2,.4), uncomfortable to eat OR.5 (95%CI=.3,.7), avoiding food OR.2 (95%CI=.2,.4) and food stuck in mouth OR 2.2 (95%CI=1.4, 3.5) between denture wearers and non denture wearers towards OHRQoL. Table 3 Comparison of S-OHIP(M) score between denture wearers and non denture wearers (n=443) Characteristics n(%) Mean(SD) 95%CI of mean t stats(df) p- value* Denture wearers 234(52.8) 6.85 (5.75) 1.947, (442).1 n denture wearers 29(47.2) 1.1 (7.6) te: *=p<.5 Table 4 Association between reported impact on S-OHIP(M) items by denture wearers and non denture wearers (n=443) Items Denture Wearers (n=234) n (%) n denture Wearers (n=29) n (%) Odds Ratio (OR) 95% Confidence Interval (CI) p value Functional limitation Q1. Difficulty in chewing Q2. Breadth stale Physical pain Q3. Uncomfortable to eat Q4. Ulcer in mouth Psychological discomfort Q5. Discomfort due to food stuck Q6. Feeling shy Physical disability Q7. Avoid food Q8. Avoid smile Psychological disability Q9. Disturb sleep Q1.Disturb concentration Social disability Q11. Avoid social Q12. Affect daily activity Handicapped Q13. High expenses Q14. Affect confidence 73 (36.3) 4 (3.8) 63 (4.9) 1 (52.6) 7(67.3) 11(39.) 4 (5.) 1(5.) 128 (67.3) 9 (69.2) 91 (59.1) 9 (47.4) 34 (32.7) 5 (1.) 158 (61.) 11 (1.) 4 (5.) 1 (5.) ,.4.2, 1.3.3, , 3.5.2,.4 <.1*.12 <.1*.994.1*.995 <.1* te: 1. Reference level: non denture wearer 2. CI= Confidence Interval *= p<.5 2

5 Prevalence of denture wearing and the impact on quality of life among elderly Discussion The prevalence of elderly denture wearers in this study was 46.2% (95%CI=41.83, 5.7). This prevalence was lower than those (81.%) living in pondok (Seman et al., 27). However the prevalence was comparable to the findings of Oral Health Division of Malaysia (24) which was 5.8%. Denture wearers and non denture wearers in this study did not differ in terms of age, socio-economic status, living status and general health with the exception of gender (p<.1) and smoking status (p<.1). There were more female denture wearers then males. Similar findings were also reported by Ismail (1996) and Seman et al. (27) and the Oral Health Division of Malaysia (24). This was in agreement with findings of Esan et al. (24) among patients who were treated in a removable prosthetic unit of a teaching hospital in the rural south west of Nigeria whereby more females demanded for dentures compared to males. It is possible that there may be a difference in perception between sex regarding the use of dentures. According to Mason et al. (26) the life course influences on OHRQoL differed between men and women. In this study there were more female denture wearers than males and the females were more satisfied with their present oral health. The most common type of oral prosthesis used among edentulous elderly was complete dentures. Similar findings were reported by Seman et al. (27). A higher proportion of dentate elderly having less than 2 teeth in this study did not use dentures. Similar findings were seen in Japan, where more elderly people who have lost many teeth did not use dentures in spite of coverage by the public health insurance system (Shimazaki et al., 21). In this study, some reasons for not wearing dentures included feeling nauseated at the sight of dentures, influence by negative experience of others and perceived that wearing dentures will cause discomfort. Some elderly had financial inability to pay for dentures. Overall, the common impacts reported by both denture wearers and non denture wearers were functional limitation, physical pain, psychological discomfort, and physical disability. There was a significant difference in the mean S-(OHIP(M) score between denture wearers and non denture wearers. Denture wearers reported lesser impact on OHRQoL compared to non denture wearers. Roessler (23) stated that people with fewer than optimal number of teeth or without dentures may have problems with avoiding certain foods, pain, distress and problems with relaxation. Sheiham et al. (21) also noted that elderly without dentures were found to avoid food, reported difficulty in chewing and majority changed their meal composition and methods of cooking to facilitate chewing. Our findings showed that denture wearers had significantly less impact in difficulty in chewing, uncomfortable to eat and avoiding food. This finding was consistent with Shimazaki et al. (21) where elderly people using full dentures had significantly less impact on daily functions. Denture wearers had high impact of food stuck in mouth compared to non denture wearers. This was most probably due to the poor condition of present dentures as some complained of loose and worn out dentures. However, a small proportion (2.7%) of denture wearers were unsatisfied with their dentures and perceived they needed treatment, while 37.5% of non denture wearers were not satisfied with their present oral condition and perceived they needed treatment. Thus both denture wearers and non denture wearers required assistance in oral health intervention and health promotion. Further research is needed to evaluate the change in responses to OHRQoL after some form of assistance. Although denture wearers perceived that they do not need treatment and were satisfied with their oral health, a small proportion of denture wearers were not satisfied with their dentures. Thus it is reasonable to intensify efforts in the provision of dentures to both groups of elderly people because each had their own set of problems. Community dentists in their domiciliary visits could improve knowledge and skills regarding use and care of dentures among elderly and their caretakers to improve OHRQoL. Conclusion A high proportion of elderly in the study area were denture wearers (46.2%). They had significantly better OHRQoL compared to non denture wearers with less difficulty in chewing, feeling less uncomfortable to eat and less avoidance of food. However denture wearers had significantly more impact in food stuck in mouth. A small proportion of both denture wearers and non denture wearers perceived the need of dental treatment. 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