dentition status and dental prosthetic needs among …

DENTITION STATUS AND DENTAL PROSTHETIC NEEDS AMONG ELDERLY

IN ERNAKULAM DISTRICT, KERALA, INDIA

DR. MADHU U

DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT

FOR THE AWARD OF THE DEGREE OF MASTER OF PUBLIC HEALTH

ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES (AMCHSS)

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY

THIRUVANANTHAPURAM

KERALA, INDIA

OCTOBER 2009

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ACKNOWLEDGEMENTS

First and foremost, I like to express my whole-hearted sincere thanks to my guide

Dr. Manju R. Nair, Scientist C, AMCHSS, SCTIMST who has guided me effectively and

efficiently at each and every stage of my research. She has also been a sense of inspiration

for me and I would not hesitate to mention here that without her untiring efforts I would not

have completed this piece of work in time.

I shall also express my thanks to Dr. Rakesh S, faculty at Amrita Institute of medical

Sciences, Kochi, for giving me the necessary inputs, ideas and direction regarding the content

of the study.

I like to thank the entire faculty team at AMCHSS: Dr. K.R. Thankappan, Dr. V. Raman

Kutty, Dr. P. Sankara Sarma, Dr. T K Sundari Ravindran, Dr. Mala Ramanathan, Dr K.

Srinivasan, and Dr. Biju Soman for providing their valuable suggestions and guidance to

improve the study.

I am also sincerely thankful to Mr. Sundar Jaysingh, Assistant Registrar, SCTIMST for

providing the administrative and logistic support and to the members in the Project cell at

AMCHSS for their valuable contributions.

I like to extend my whole-hearted thanks to all my colleagues in AMCHSS, and especially

Dr.Praveen P A who has always helped me through out the course of the study.

I am also grateful to the Panchayat authorities and all the respondents who participated in the

study for their extended cooperation and support.

Last but definitely not the least; I like to express my affection and thanks to my parents,

relatives and my wife, Dr.Resmi R Nair in particular for their constant and continuous

support given to me in all times of need.

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DECLARATION

I hereby declare that this dissertation work titled ‘Dentition status and dental

prosthetic needs among elderly in Ernakulam District, Kerala, India’ is an

original work of mine and it has not been submitted to any other institution or

university.

Dr.Madhu U

Thiruvananthapuram

October 2009

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CERTIFICATE

I hereby certify that the work embodied in this dissertation titled ‘Dentition

status and dental prosthetic needs among elderly in Ernakulam District, Kerala,

India’is a bonafide record of original research work undertaken by Dr.Madhu U

in partial fulfillment of the requirement for the award of the degree of Master of

Public Health, under my guidance and supervision.

Guide:

Dr. Manju R. Nair

Scientist C

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram, Kerala. India.

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Table of Contents

ACKNOWLEDGEMENTS................................................................................................ 2

DECLARATION ................................................................................................................ 3

CERTIFICATE……………….............................................................................................4

ABSTRACT……………………………………………………………………………......7

1 INTRODUCTION AND REVIEW OF LITERATURE……………………..……………9

1.1 Introduction…………………………………………………………………………..9

1.2 Review of literature…………………………………………………………………11

1.3 Rationale of the study……………………………………………………………….24

1.4 Objectives…………………………………………………………………………...25

2 METHODOLOGY……………………………………………………………………….26

Objectives…………………………………………………………………………...26

2.1 Study design………………………………………………………………………...26

2.2 Study setting………………………………………………………………………..26

2.3 Sample population………………………………………………………………….26

2.4 Time frame………………………………………………………………………….27

2.5 Sample size…………………………………………………………………………27

2.6 Sample selection procedure………………………………………………………...27

2.7 Data collection techniques………………………………………………………….27

2.8 Study variables……………………………………………………………………...30

2.9 Ethical considerations………………………………………………………………33

2.10 Data storage and analysis…………………………………………………………..34

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3 RESULTS ……………………………………………………………………………….35

3.1 Characteristics of the study population……………………………………………..36

3.2 DMFT and Edentulousness………………………………………………………....46

3.3 Bivariate analysis……………………………………………………………………47

3.3.1 Analysis of factors related to Complete edentulousness…………...………………47

3.3.2 Analysis of factors related to Complete dentate…................................................... 57

3.4 Multivariate analysis………………………………………………………………..61

4 DISCUSSION……………………………………………………………..……………..63

4.1 Discussion……………………………………………………………………………63

4.2 Limitations…………………………………………………………………………...72

4.3 Strengths......................................................................................................................72

4.4 Conclusion………………………………………………………...............................72

4.5 Policy implications......................................................................................................73

REFERENCES………………………………………………………………………….......74

Annexure 1 – Informed consent..............................................................................................81

Annexure 2 – Questionnaire....................................................................................................82

Annexure 3 – Clinical examination-guidelines……………………………………………...90

List of tables…………………………………………………………………………………94

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ABSTRACT

Dentition status and dental prosthetic needs among elderly in Ernakulam District,

Kerala, India

BACKGROUND

Life expectancy is increasing worldwide, with consequent increase in the proportion of

elderly in the population. Among Indian states, Kerala has the highest proportion of elderly

and is projected to have 30 per cent of its population as elderly in 2051. This presents huge

challenges to health care for the elderly and oral health is a critical component of elderly

care.

OBJECTIVE

The study was conducted with objective to assess the dentition status with particular

reference to edentulousness, the factors associated with edentulousness and to assess the oral

health care seeking behaviour among elderly population aged 60 years and above.

METHODOLOGY

A descriptive cross sectional survey was carried among 403 elderly of Alengad Panchayat,

Kerala. Primary data was collected using a pre tested self administered structured

questionnaire that included questions on socio demographic, personal habits, general and oral

health, medical and dental illness, awareness on dental care, financing of dental treatment

and clinical dental examination using DMFT chart of WHO oral health assessment form.

RESULTS

The mean DMFT score indicative of dentition status was 18.14 ±7.5. The prevalence of

complete edentulousness was 12 percent. Less than one third of the elderly were completely

dentate. Complete edentulousness increased with increasing age. Multiple logistic regression

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models showed that elderly who resided in joint/extended family (OR 4.5, CI 1.3-16.0), who

consumed vegetarian diet (OR 8.7, CI 4.4-16.9), who used removable partial dentures in the

past (OR 11.4, CI 5.1-25.0), who were less aware on ideal frequency of dental visit(OR 4.9,

CI 1.2-20.6), who perceived their status of oral health to be below average (OR 6.7, CI 3.4-

13.3) were more likely to be completely edentulous.

CONCLUSION

The findings of this study indicate that dentition status of elderly in Kerala is affected

severely, the oral health care seeking behaviour is poor and dental treatment care of the

elderly is inappropriate, unmet and often neglected.. It is imperative from the study that the

oral health should be a critical element of the geriatric preventive health care. The health

system need to be adequately strengthened to promote, support and protect health and social

well-being of the elderly due in part to lack of human and financial resources.

Key words: Edentulousness, complete dentate, dentition status, oral health, elderly,

community.

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CHAPTER 1

INTRODUCTION AND REVIEW OF LITERATURE

1.1 INTRODUCTION

Life expectancy has risen rapidly in the 21st century. The dramatic change in the life

expectancy of human beings witnessed in the previous century has resulted along with other

factors in an unprecedented growth in the number and proportion of elderly people globally.1

A significant decline in the number of babies born and consequent reductions in numbers of

younger age groups increased the proportion of people aged 60 and over and these led to

considerable shift in the population composition and changes in the demographic profile

referred to as demographic transition.1

Advancement in medical treatment and technology, better medical care, control of

many infectious diseases, improved nutrition, hygiene and sanitation caused a reduction in

death rates resulting in increased longevity and concurrent reduction in fertility rates resulted

in lower birthrates. Hence in almost every country, the proportion of people aged over 60

years is growing faster than any other age group. 2,3

Population ageing has been a global phenomenon that is most prominent in developed

nations but is also occurring in developing countries. This is indicated by the increase in the

proportion of older people worldwide, from 205 million in 1950 to 606 million in 2000 and

projected to increase by more than eight times to approximately two billion by 2050.1

Population ageing is considered one of humanity’s greatest triumphs as is seen as a success

story of public health policies and socioeconomic development. 1. This demographic change

is also on the other hand expected to have considerable impact on the social, economic and

10

intergenerational relationships in all societies.2 Elderly can be a valuable resource who can

contribute to society, within their families, communities and national economy as either a

formal or an informal part of the workforce, or through volunteer work.1,4

However global ageing will put increased economic and social demands on all

countries and challenges society to adapt, so as to maximize the health and functional

capacity of older people.5The demographic transition presents a lot of implications for health

and social sector. It presents public health challenges in terms of health care and social

security of the elderly necessitating extensive adaptation and modification of health care

services. With increasing longevity, care of the elderly will only be exacerbated in the

future. Often, older people are among the poorest, have lived in poverty all their lives and

have been unable to accumulate savings to take care of themselves during their old age. In

both developed and developing countries, the ageing of the population thus raises concerns

about whether existing systems and social support mechanisms will be able to deal with the

emerging issues of the elderly .1

Good health is essential for older people to remain independent and to play a part in

family and community life. Life-long health promotion and disease prevention activities can

prevent or delay the onset of non communicable chronic diseases which form the major

burden of diseases among the elderly2. Oral health conditions constitute a major source of

morbidity that affects the quality of life and general health conditions of the elderly.1,2

However the evidence on increasing oral morbidity with age and its link with general

systemic health conditions are often missing from geriatric health care policies and services.

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1.2 REVIEW OF LITERATURE

Elderly has been referred to as any citizen who is 60 years or above of age .Further

elderly can be grouped into three categories namely young old (60-74 years),old old (75-84

years) and oldest old (more than or equal to 85 years of age).1,4

Global scenario

The world's elderly population that is, people 60 years of age and older is the fastest

growing age group. In all countries, especially in developed ones, the older population itself

is also ageing.1 People over the age of 80 currently number approximately 69 million, the

majority of whom live more in developed regions. Although people over the age of 80 make

up about one percent of the world’s population and three percent of the population in

developed regions, this age group is the fastest growing segment of the older population.1

Ageing seems not to affect all physiological functions to the same degree, so that the

total ageing rate of different organs will differ. As mentioned earlier,the figures show that in

2000, there were 600 million people aged 60 and over; there will be 1.2 billion by 2025 and 2

billion by 2050.1 Today, about two thirds of all older people are living in the developing

world by 2025, it will be 75%. In the developed world, the very old (age 80+) is the fastest

growing population group.2 Women outlive men virtually in all societies, consequently in

very old age, the ratio of women/men is 2:1.2 In 2007, more than half of the world's

population live in cities. By 2030 that figure is expected to rise to more than 60 percent.2

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Ageing in developing countries

Globally, most of the increase in elderly population is occurring in developing

countries. In 2002, almost 400 million people aged 60 and over lived in the developing

world.1By 2025, this will have increased to approximately 840 million representing 70

percent of all older people worldwide. Hence the older person support ratio is declining more

rapidly in developing countries than in the developed countries.1

In terms of regions, Asia contributes to over half of the world’s older and the oldest

people and its share will continue to increase the most in the years to come. 5,6

By 2050 about 80 percent of the elderly will be living in developing countries.1,5

Population ageing is occurring in parallel with rapid urbanization. The general characteristics

of old age are mainly physical and psychological changes.6

Ageing in India

Demographic transition is happening in India also. The life expectancy has increased

from 20 years in the beginning of the 20th Century to 64 years today due the successful

public health interventions.7The proportion of elderly in the population of India has increased

from 5.6 percent in 1961 to 6. 6 percent in 1991 and to 7.5 percent in 2001. 7

In India, life expectancy at birth increased from 58.1 years in 1990 for males to 64.1

in 2000, and 69.9 years is projected for 2010.1 For Indian women, the expectancy rose from

59.1 years in 1990 to 65.4 in 2000, and is projected to become 68.8 years by 2010.1

Concepts about healthy ageing

With increasing ageing across the world, there was a need for societies to think in

terms of enabling people to work according to their capacities and preferences even as they

grow older, and to prevent or delay disabilities and chronic diseases which are costly to

13

individuals, families and the health care system.8 It was in this context that in 1999 a new

concept of ‘active ageing’ evolved by the World Health Organisation during the

International year of older persons.9 The concept of active ageing highlighted the importance

of social integration and health throughout the life course.9

Active ageing is the process of optimizing opportunities for health, participation and

security in order to enhance quality of life as people age. It applies to both individuals and

population groups.1It focuses on ignored resources like that of the societies to meet the needs

of elderly people. Training for health professionals on old-age care; preventing and managing

age-associated chronic diseases; designing sustainable policies on long-term care; and

developing age-friendly services and settings are some of the interventions aimed at active

aging. 9

Health is a precondition for the elderly to continue to make a positive contribution to

the society.9While the numbers are going up, the quality of life is coming down.

Industrialization, Migration, Urbanization and Westernization are severely affecting the

moral value systems.7 The erstwhile joint family, the natural support system, has started

crumbling. The fast changing pace of life is adding to the woes of the older persons. This is

leading to severe adverse effects on the status and well-being of the elderly. Further more, in

the process, elderly women, especially widowed, are likely to face more problems as

compared to elderly men because of differences in their status and role in the society. At the

same time as the population age structure shifts, the population of older people will increase

in population to that of younger people, especially those of ‘Working age’.7 This shift has

profound policy implications for persons and income support, for job creation and

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employment, for health and elder care system and for economic growth and development in

every country.7,10

It is common to associate old age with disability. Older people are heterogeneous that

is, extreme losses of physical, mental and social functions are often seen in old people.2,5,6

Yet many people continue to maintain high level of function. However, as “young-old” move

in to the “old old” category, they tend to have more health complaints and diagnosed illness.

The elderly people face number of problems and adjust to themselves in varying degrees in

their old age. These problems range from absence of ensured and their dependents, to ill-

health, absence of social security, loss of social role and recognition, and the non-availability

of opportunities for creative use of their free time.5

Factors related to ageing

Factors related to ageing changes can be determined as intrinsic and extrinsic. The

intrinsic factors are related to normal ageing such as genetic, while extrinsic factors include

the environment and the lifestyle. The physiological changes occur in all body systems such

as musculoskeletal, cardiovascular, respiratory, neurological and gastrointestinal systems.

Significantly, these changes lead to diseases.2,3

Not only physiological changes, but also psychological changes occur in the elderly.

These changes are considered to be factors associated with illnesses among the aged.

Depression and anxiety are the most common psychological disorders. 2,3

Active ageing also depends on a variety of influences or “determinants” that surround

individuals, families and nations. Cross-Cutting Determinants of active ageing include

Culture and Gender. Culture, which surrounds all individuals and populations, shapes the

way in which we age because it influences all of the other determinants of active ageing. It

15

also influence health-seeking behaviours.2 Women’s traditional role as family caregivers may

also contribute to their increased poverty and ill health in older age. Men engage in more risk

taking behaviors such as smoking, alcohol and drug consumption and unnecessary exposure

to the risk of injury.2

Determinants Related to Personal Factors include biology and genetics and

psychological factors.2 Ageing is a set of biological processes that are genetically determined.

Psychological factors including intelligence and cognitive capacity (for example, the ability

to solve problems and adapt to change and loss) are strong predictors of active ageing and

longevity.2

Determinants Related to the Physical Environment2

Physical environments that are age friendly can make the difference between

independence and dependence for all individuals but are of particular importance for those

growing older. Safe, adequate housing and neighborhoods are essential to the well being

of young and old. For older people, location, including proximity to family members,

services and transportation can mean the difference between positive social interaction and

isolation.2

Inadequate social support is associated not only with an increase in mortality, morbidity and

psychological distress but a decrease in overall general health and well being. 2 Falls among

elderly are a large and increasing cause of injury, treatment costs and death. Clean water,

clean air and access to safe foods are particularly important for the most vulnerable

population groups.2

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Determinants Related to the Social Environment2

Social Support: Older people are more likely to lose family members and friends and

to be more vulnerable to loneliness, social isolation and the availability of a “smaller social

pool”. Violence and Abuse: Older people who are frail or live alone may feel particularly

vulnerable to crimes such as theft and assault. Education and Literacy: Low levels of

education and illiteracy are associated with increased risks for disability and death among

people as they age, as well as with higher rates of unemployment. Education in early life

combined with opportunities for lifelong learning can help people develop the skills and

confidence they need to adapt and stay independent, as they grow older.2

Economic Determinants2

Income: Active ageing policies need to intersect with broader schemes to reduce

poverty at all ages. While poor people of all ages face an increased risk of ill health and

disabilities, older people are particularly vulnerable. Social Protection: As societies develop

and the tradition of generations living together begins to decline, countries are increasingly

called on to develop mechanisms that provide social protection for older people who are

unable to earn a living and are alone and vulnerable. Work: In all parts of the world, there is

an increasing recognition of the need to support the active and productive contribution that

older people can and do make in formal or informal work.

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Determinants Related to Health and Social Service Systems are as follows: 2

Health Promotion and Disease Prevention: To promote active ageing, health

systems need to take a life course perspective that focuses on health promotion, disease

prevention and equitable access to quality primary health care and long-term care. Curative

Services: Despite best efforts in health promotion and disease prevention, people are at

increasing risk of developing diseases as they age. Long-term care includes both informal

and formal support systems. The latter may include a broad range of community services

(e.g., public health, primary care, home care, rehabilitation services and palliative care) as

well as institutional care in nursing homes and hospices. It also refers to treatments that halt

or reverse the course of disease and disability. Mental Health Services which play a crucial

role in active ageing, should be an integral part of long-term care.2

Behavioural Determinants2

The adoption of healthy lifestyles and actively participating in one’s own care are

important at all stages of the life course. One of the myths of ageing is that it is too late to

adopt such lifestyles in the later years. On the contrary, engaging in appropriate physical

activity, develop healthy food habits, avoid smoking, non use of alcohol and medications

wisely in older age can prevent disease and functional decline, extend longevity and enhance

one’s quality of life. Tobacco Use: Smoking is the most important modifiable risk factor for

non-communicable diseases for young and old alike and a major preventable cause of

premature death. Smoking not only increases the risk for diseases such as lung cancer, it is

also negatively related to factors that may lead to important losses in functional capacity.

Physical Activity: Participation in regular, moderate physical activity can delay functional

declines to a greater extent. It can also substantially reduce the severity of disabilities

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associated with heart disease and other chronic illnesses (U.S Preventive Services Task

Force, 1996). Active living improves mental health and often promotes social contacts.2

Diets high in (saturated) fat and salt, low in fruits and vegetables and providing

insufficient amounts of fiber and vitamins combined with sedentarism, are major risks factors

for chronic conditions like diabetes, cardiovascular disease, high blood pressure, obesity,

arthritis and some cancers. Also important is alcohol: While older people tend to drink less

than younger people, metabolism changes that accompany ageing increase their susceptibility

to alcohol-related diseases, including malnutrition and liver, gastric and pancreatic diseases.

Older people also have greater risks for alcohol-related falls and injuries, as well as the

potential hazards associated with mixing alcohol and medications. Because older people

often have chronic health problems, they are more likely than younger people to need and use

medications– traditional, over-the-counter and prescribed.2

Iatrogenesis : Health problems that are induced by diagnoses or treatments – caused

by the use of drugs is common in old age, due to the interaction of drugs, inadequate dosages

and a higher frequency of unpredictable reactions through unknown mechanisms. 2

Adherence: Access to needed medications is insufficient in itself unless adherence to

long-term therapy for ageing-related chronic illnesses is high. 2

Morbidity among elderly

Increase in the proportion of the elderly is associated with significant physical, social

and economic issues that result in increased vulnerability to increased morbidity especially

chronic non communicable diseases.2 In 60 years of age, about 10 percent of the elderly

above 60 years of age suffer from impaired physical mobility and 10 percent are

19

hospitalized at any given time, both proportions rising with increasing age.8 Among

elderly over 70 years of age, more than 50 percent suffer from impaired physical mobility

and hospitalization at any give time.2 Among elderly chronic non-communicable diseases

constitute major chunk of morbidity.2,3,5 Non-communicable diseases are emerging as the

leading causes of disability and mortality, and they share common risk factors.4 Non

communicable diseases entail high burden of care giving for the families and communities.

Since the impact of non-communicable diseases is not only on the elderly themselves but

also on the family and community, prevention and promotion are advisable.4

Oral health ,a critical component in the geriatric health care is often forgotten and

ignored.2,4 Systemic diseases and/or the adverse side effects of their treatments can lead to an

increased risk of oral diseases, reduced salivary flow, altered senses of taste and smell, oro-

facial pain, gingival overgrowth, alveolar bone resorption and mobility of teeth.4Oral health

is one of the most pertinent factors affecting active ageing but often ignored.2,3,4,7 Poor

oral health, primarily dental caries, periodontal diseases, tooth loss and oral cancer cause

other systemic health problems. They create a financial burden for individuals and society

and can reduce self-confidence and quality of life. Studies show that poor oral health is

associated with malnutrition and therefore increased risks for various non-communicable

diseases. 2,4

Oral diseases and tooth loss may be increased directly or indirectly by the process of

ageing. Globally, poor oral health amongst older people has been evident in high levels of

tooth loss, dental caries, and periodontal disease and the treatment needs are often unmet and

neglected.10

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The health impacts of loss of teeth in the elderly include impairment of the

masticatory function, low dietary intake and impaired nutritional status. Approximately 60%

of the elderly 60 years and above are dissatisfied with their function of mastication because

of loss of teeth.4

The inter-relationship between oral health and general health is particularly

pronounced among the elderly. Poor oral health can increase the risks to general health and,

with compromised chewing and eating abilities, affect nutritional intake. Other relevant

issues include high sugar content diets, inadequate oral hygiene due to poor dexterity, and

alcohol and tobacco use risk factors that are detrimental to oral health.4,10

Among the elderly, high prevalence of co-morbidities and barriers to care are observed,

together with oral health care challenges in relation to changing dentition status,

edentulousness and limited oral functioning, denture related conditions, ill fitting removable

dentures, caries prevalence with unmet need for care, periodontal pocketing/loss of

attachment and poor oral hygiene, oral cancer, xerostomia and craniofacial pain and

discomfort.10

Research indicates that the utilization of dental services by the elderly decreases with

increasing age. 2,11 Not only is perceived need for oral care less, even when need exists, it is

less likely to be translated into action and demand for care. When the elderly do make use of

dental services, it is more likely to be on an emergency rather than a routine basis. Other

research has also indicated that dental visits by older adults are correlated to the possession

of teeth, not with age. As long as older adults maintain their dentition, they will continue to

seek dental services. Failure to seek dental services often results from a lack of perceived

21

need for services. The edentulous elderly often do not seek dental services because they

perceive they have no teeth, therefore are in no need of such services. 11

Dentition status is defined as the number and the disease status of the teeth in the

oral cavity.12 It contributes to masticatory efficiency and exerts potent effects on dietary

intake. The number of occluding teeth especially in the posterior segments of the mouth is

highly correlated with masticatory efficiency. Impaired masticatory efficiency and biting

force are associated with many oral diseases. These include pain and discomfort in the

mouth, trismus, mobility of teeth, gingival enlargement, bone loss, teeth attrition and

generalized periodontal diseases. The loss of mechanical chewing efficiency leads to

preference of easy to chew foods which can inturn increase the risk of nutritional

deficiencies.4,12,13

Edentulousness is defined as the loss of teeth in the oral cavity due to any reason

which also affects the masticatory function and diet choice.13 Tooth loss is an irreversible,

cumulative process that is no longer considered as a natural consequence of aging. Instead it

is the result of two major dental diseases namely dental caries and periodontal disease.12

Nevertheless, teeth loss increases in frequency with age. 10

Globally, the dentition status among elderly as measured by Decayed, missing,

filled index (DMFT) ranges from 23.7 percent to 28.8 percent.14 In India, the dentition

status (DMFT percent) among the elderly ranges from 8.2 to 23.4.15

The prevalence of complete edentulousness among the elderly ranges from 12.8 percent to

74.9 percent across the globe4,5,10,16,17,18 In India, the prevalence of complete edentulousness

of elderly is 19 percent. (That is about one in five of all elderly in India are edentulous.)4

22

Factors associated with dentition status that leads to edentulousness:

Dental morbidity: Dental caries and periodontal diseases are found to be the major

causes of loss of teeth among elderly.14,16,17,19,20,21 Trauma, removal of teeth for prosthodontic

and orthodontic reasons are some of the other factors associated with. 14,16,17,20,21,22,23

Other co-existing morbidities: Medical conditions include GI disorders and

digestion, coronary heart disease(ST segment depression),diabetes, epileptic seizures,

dementia, psychological depression, vision and visual impairment, poor respiratory function,

blood pressure, weight loss, cancer, osteoporosis, renal diseases.21,22,23,24,25,26 Consumption of

medications and drugs (phenytoin, cyclosporin, tetracycline, anti-depressants) and its adverse

effects.20,21, 24,25,26

At the individual level: Major socio-demographic factors are age, sex, socio-

economic status, education, occupation, place of birth/residence and marital status.

16,17,27,28,29,30,31,32,33,34 Functional status and cognitive status factors include hand grip

strength, swallowing and chewing abilities, communication abilities, behavioral problems,

low original intelligence. 28,29,30,32,33,34,35,36 Life style factors-Most important are diet and

nutrition where vegetarians had a higher level of edentulousness compared with non-

vegetarians.10 Major factors related to personal habits are use of tobacco, alcohol, brushing

technique and habits.16,17,18,19,28,29,30,31,32,33,34,35,36,37,38

A great number of variables are associated with tooth loss, and there is no consensus

whether dental disease related or socio-behavioral factors are the most important risk factors.

There is a direct causal relation between smoking and general and oral health status.

Furthermore, smoking can also be regarded as an indicator of a negative attitude to health.

2,16,28,19,30

23

Brushing habits and technique also affects the dentition status. Poor brushing techniques

can lead to carious teeth and thereby loss of teeth.38,39,40,41,42,43 Awareness of preventive oral

hygiene and care: The perception of felt need of visiting dentist affects the dentition status.

16,17,18,19,28,29,30,31,32,33,34,44,45,46,47

At the house-hold level: The major factors associated with the dentition status which

can lead to edentulousness at the house-hold level are the social support/communication,

financial support, carer involvement, carer burden, affordability of treatment, domestic

violence and poverty.27,34,35,39,48,49,50,51,52 Neighbourhood deprivation is also a key factor

influencing the dentition status of the elderly, which inturn may lead to edentulousness.53,54,55

Access to dentist and dental services, provision of services, and barriers to services are

the other factors associated with loss of teeth among elderly.18,32,33,34,38,39 Awareness,

education, and knowledge regarding the dental problems and dental care among the elderly

are observed to improve their status of dentition and function of mastication there by

improving their oral as well as general health.40,41,42,51,52 The quality of life of older adults is

also affected by poor oral health conditions.9 Quality of life is “an individual’s perception of

his or her position in life in the context of the culture and value system where they live, and

in relation to their goals, expectations, standards and concerns. Since oral health is related to

health and health is related to quality of life tooth loss could have an impact on quality of

life. As people age, their quality of life is largely determined by their ability to maintain

autonomy and independence.56,57,58

24

To study these factors in detail, most of the studies followed the cross-sectional

survey as the study design where they assessed the dentition status (number and disease

status of teeth) with special focus on complete edentulousness and treatment needs.

16,26,27,28,30,31,34,35,36,41,42,43,44

The public health literature contains few analytic studies on risk factors for dental disease

among older community-dwelling populations. Among them, a few studies have used cohort

as the study design which aimed at measuring the incidence of tooth loss and the risk factors

of tooth loss.22,34,41

Decayed, Missing and Filled index (DMFT) was used as the most common tool to measure

dentition status. 27,28,29,30 Modified DMFT index was also used for the same.18, 31,32,33,38,59

Dentition status and treatment needs (DSTN) was another major measurement tool, which

has the advantage of measuring both dentition status and treatment needs.33, 43,44,45,46

1.3 RATIONALE OF THE STUDY

Among the Indian states, Kerala is one of the states having the larger proportion of

elderly population and the growth rate among the aged is increasing higher and higher. The

proportion of aged population in Kerala has increased from 5.8 per cent in 1961 to 10.84 per

cent in 2001. 60 The projected figures indicate that aged populations of the state will be16 per

cent in 2021 and about 30 per cent in 2051.61

Therefore one of the many challenges facing Kerala is its growing elderly population.

It is growing much faster than the overall population itself. With the possibility of declining

birth rate and fewer children in families, there will be lesser and lesser people taking care of

the elderly as the decades roll by. Traditional life guards of family care are dwindling due to

25

our migration, dual career and growing consumerism.61 All these make the well-being of the

elderly, a growing challenge of the 21st century. This accelerated growth of elderly demands

the need for changes in health care system delivery and welfare activities.60,61 Little oral

health epidemiological information is available for the Kerala populations specifically, no

information is available on prevalence of edentulousness in adults and the elderly.

1.4 OBJECTIVES

1. To assess the dentition status with particular reference to edentulousness (complete)

among elderly population aged 60 years and above.

2. To study the factors associated with edentulousness among them.

3. To assess the oral health care seeking behaviour among the elderly.

26

CHAPTER 2

METHODOLOGY

Objectives:

1. To assess the dentition status with particular reference to edentulousness (complete)

among elderly population aged 60 years and above.

2. To study the factors associated with edentulousness among them.

3. To assess the oral health care seeking behaviour among the elderly.

2.1 Study design:

It was a cross-sectional descriptive survey conducted in the Alengad panchayat,

(Gramapanchayat, in Paravur Taluk of Ernakulam District, Kerala) from June 2009 to

September 2009 which studied and documented the dentition status and dental prosthetic

needs of the elderly.

2.2 Study setting:

A cross-sectional survey was conducted in the Alengad panchayat. (Gramapanchayat, in

Paravur Taluk of Ernakulam District, Kerala).

2.3 Sample population:

The STUDY POPULATION included all elderly aged 60 years and above who could

respond independently of Alengad Panchayat, Ernakulam District, Kerala, India.

27

2.4 Time frame:

Data was collected between June 2009 to September 2009.

2.5 Sample size:

(According to census 2001 report, the Alengad panchayat has a total population of 38,564

(males=18,088 and females=18,332) distributed in 20 wards with a total of 7985 number of

households and the elderly population accounts for 5000 people approximately.)

Using Statcalc Epi Info version 6, and taking the expected outcome prevalence of complete

edentulousness of elderly for India as 19 percent4 with worst acceptable result at 14 percent

in the sample frame, the sample size came to 237 at 95percent confidence interval.

Considering the design effect of n ‘ = n X (1+0.5 ) and non-response rate of 10 percent, the

sample size was rounded off to 400.

2.6 Sample selection procedure:

CLUSTER SAMPLING: The study population was split according to wards (1 cluster=1

ward) and the sampling interval was calculated. Here for example- the sampling interval

would be 5000/20=250(approximately).Based on the sample size, all the clusters were

considered. Thus approximately 20 elderly were selected on a random basis from each

cluster(each ward) for the study.

2.7 Data collection techniques

Primary data was collected by the principal investigator using a self administered structured

questionnaire.

28

TOOL

A structured Questionnaire (annexure 2) was constructed in English and translated into

Malayalam and back translated again into English before being administered in the field.

The questionnaire consisted of different sections beginning with demographic educational

and family details followed by economic status details, personal habits, general health and

medical illness, oral health and dental illness, awareness on dental care, present dental

illness, financing of dental treatment and clinical examination to end with. Questions on

personal habits were adapted from WHO STEPS instrument on non-communicable diseases.

Questions on oral health and dental illness were adapted from WHO STEPS instrument- oral

health module. Sensitivity to Culture and selection of appropriate words were considered.

The same was piloted before administration.

CLINICAL EXAMINATION: The dentition status was inspected using sterilized non-

disposable dental mirrors and explorers, and cotton roles were used to control saliva. A full

mouth hard tissue clinical examination was carried out which included examining the crown

and exposed root of permanent tooth, each crown and root were assigned a number based on

the result of that exam. The numbers were recorded in boxes corresponding to each tooth to

provide a DMFT chart.

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

29

Measurement tool: Dentition status assessment was done using validated WHO ORAL

HEALTH ASSESSMENT FORM(1997)62

PERMANENT

TEETH CROWN

PERMANENT

TEETH ROOT

CONDITION/STATUS

0 0 SOUND

1 1 DECAYED

2 2 FILLED WITH DECAY

3 3 FILLED, NO DECAY

4 - MISSING, DUE TO CARIES

5 - MISSING, ANY OTHER REASON

6 - FISSURE SEALANT

7 7 BRIDGE ABUTMENT,SPECIAL

CROWN/VENEER/IMPLANT

8 8 UNERUPTED

CROWN/UNEXPOSED ROOT

9 9 NOT RECORDED

T - TRAUMA(FRACTURE)

Definitions

Dentition status is defined as the number and the disease status of the teeth in the oral

cavity. Complete edentulousness is defined as the complete loss of natural teeth in the oral

cavity due to any reason. Complete dentate: A person is said to be complete dentate if all

the 32 natural teeth are present in his/her oral cavity.

30

2.8 Study variables

Dependent variable- DENTITION STATUS/EDENTULOUSNESS (COMPLETE)

A. Dentition status:

Dentition status is defined as the number and the disease status of the teeth in the oral cavity.

To arrive at a DMFT score for an individual patient's mouth, three values are determined and

added: the number of teeth with carious lesions, the number of extracted/missing teeth, and

the number of teeth with fillings or crowns.

DMFT= Decayed teeth score + Missing teeth (caries+ other reasons) score + filled teeth

score.63

B. Edentulousness:

Edentulousness is defined as the loss of teeth in the oral cavity due to any reason which also

affects the masticatory function and diet choice.

Total number of missing teeth: Calculated by adding the number of missing teeth in the

anterior (front) and posterior (back) regions in the oral cavity. It includes teeth missing due to

caries and teeth missing due to other reasons also.

Complete edentulousness: Completely edentulous if total number of missing teeth equals 32.

Partial edentulousness: Partially edentulous if total number of missing teeth is greater than

zero and less than 32.

Complete dentate: Completely dentate if total number of missing teeth equals zero.

CONCEPTUAL FRAMEWORK: Oral health outcomes are affected by factors which can

be classified into exogenous variables (ethnicity/social milieu, age groups), primary factors

of oral health and oral health behaviour.59

31

Exogenous Primary factors Oral health Oral health

Variable of oral health behavior outcomes

External

Environment Health Related General

Evaluated Health Status Decayed, Missing, Filled Periodontal Status

Ethnicity/social milieu

Personal Practice Tooth brushing Dental Floss use Diet Tobacco use

Dental Care System Policy Resources Organization Financing

Perceived Health Status General Functional Social

Age Cohort 35-44 years 65-74 years

Formal Health Service Use Preventive Treatment Restorative

Personal Characteristics Predisposing Enabling resources Need

Patient Satisfaction Access Communication Quality

32

Independent variables:-

At the individual level:

Socio-demographic factors include Age, sex, education, occupation, place of

birth/residence, marital status and type of family. Age was categorized into age class (young

old (60-74), old old (75-84), oldest old (>=85)).Marital status was re-grouped into two

groups one with currently married and others (never married, widowed, separated, divorced).

Highest level of education was regrouped into four groups (no schooling, primary education,

secondary and Higher secondary education, Graduate/Post Graduation/Professional).

Economic status: Past occupation (self) and past spouse’ occupation were re-grouped into

two groups (self employed/agriculture/others and Institutional (Government/private).

Source of income (current) was re-grouped into two (from children/others and own sources).

Life style: whether personal habits like use of smoke and smokeless tobacco, food habits and

diet and brushing habits influenced the dentition status and edentulousness.

Frequency of cleaning teeth was re-grouped into two groups (once and twice/more than

twice)

Material used for cleaning teeth was re-grouped into two groups namely toothbrush and

toothpaste and others (toothpaste alone, toothpowder, charcoal, lemon and salt, mango

leaves).

33

General health and illness: General health and illness included four questions on perceived

status of general health, medical consultation, co-morbidities and consumption of drugs and

medicines.

Oral health and dental illness: Included 19 questions which focused on perceived status of

teeth, past and present dental illnesses (Dental caries and periodontal diseases, trauma,

removal of teeth for prosthodontic and orthodontic reasons), past visit to dentist and its

reasons, type of facility of dental consultation, whether comfortable with the services

provided, functional status and detailed clinical examination for decayed, missing and filled

teeth.

Oral health care seeking behaviour: Included questions on utilization of dental

services(had ever visited dentist in the past, reasons for last dental visit, type of facility of last

dental visit, reasons for selecting that facility),family support (person who accompanied for

the last dental visit), whether the last dental services provided was comfortable, awareness

on dental care(ideal frequency of dental visit, perceptions on common conditions for dental

visit),and financing of dental treatment(who pays for dental treatment, whether dental

treatment is reimbursable, re-imbursement options) at the household level.

2.9 Ethical considerations

Ethical clearance for the study was obtained from the Institutional Ethics Committee, Sree

Chitra Tirunal Institute for Medical Sciences and Technology. Required permission was

taken from the Panchayat authorities. The purpose of the study was explained and Informed

consent for participation (interview and dental examination) was taken in a written format

34

from each respondent in the beginning itself. The privacy of the respondent and the

confidentiality of the information provided by the respondent were strictly maintained.

Participants identified with problems that need treatment were referred or advised to seek

treatment from the nearest health care facility. The basic information on dental problems and

dental care was also imparted to the respondents.

2.10 Data storage and analysis

The original copies of the completed questionnaire will be kept safely with the principal

investigator for a period of five years.

The data collected was entered in SPSS version 17.0 and two extra soft copies in the form of

compatible discs were made.

Primary data was collected, entered and analyzed in SPSS version 17.0 Descriptive analysis was done to study the sample characteristics (baseline characteristics of

the study sample were assessed using descriptive statistics).

Bivariate analysis was done using non parametric Chi square test of significance for

complete edentulousness and complete dentate.

Multivariate analysis using logistic regression was also carried out for complete

edentulousness.

For all the tests, p value of < 0.05 was considered for statistical significance.

35

CHAPTER 3

RESULTS This chapter includes the description of the analysis and the main findings of the cross

sectional survey conducted between June 2009 to September 2009 among 403 elderly in

Alengad Panchayat, Ernakulam District, Kerala. The descriptive characteristics of the study

population are presented first followed by a description of the dentition status and

edentulousness among the elderly. Factors associated with complete edentulousness

followed by factors associated with complete dentate status and finally the factors

significant in multivariate regression model are organized according to the objectives of

the study.

The study population had a mean age of 70.9+/-6.2SD and there was no significant

difference in the mean age between females and males. The maximum age was 93 years and

minimum age was 60 years. More than half of the study population were females (52.1

percent) and the rest were males. These percentages of men and women are almost similar to

elderly sex distribution in Kerala.65

36

3.1 Characteristics of the study population

Table 1 Socio-demographic details of the elderly in Alengad Panchayat, Kerala

About three fourth of the study population belonged to young old group. Among the elderly

who were not currently married (widowed, separated and divorced), 34.5 percent were

widowed and mostly were women. With regard to educational status, more than ninety

percent of the elderly had primary education and more and the proportion of elderly with no

schooling was found to be negligible.

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE

Age 70.9(Mean) 6.2(SD)

Age groups • Young old (60-74) • Old old (75-84) • Oldest old (>=85)

330055 8866 1122

7755..77 2211..33

33 Sex

• Female • Male

221100 119933

5522..11 4477..99

Marital status • Currently married • Others (never married, widowed, separated and

divorced)

225500 115533

6622 3388

Type of family • Nuclear • Joint/extended

339922 1111

9977..33 22..77

Highest level of education completed

• No schooling • Primary education • Secondary and Higher Secondary education • Graduate/Post Graduate/Professional degree

1122 222200 115566 1155

33

5544..66 3388..77 33..77

37

Table 2 Past occupation and present income of the elderly in Alengad Panchayat, Kerala

More than fifty percent of the study population did not have any occupation in the past.

Among those who were employed, more than half had worked in Government or private

institutions. Only 40 percent of the elderly reported that their spouses’ were employed in the

past and among those spouses’ who were employed, almost one-third were either self

employed or agricultural or in other similar jobs. More than half of the elderly presently had

no monthly income. Almost three fourths of the elderly who presently had some income had

their own sources of income.

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Past occupational status of the respondent

• No • Yes

222288 117755

5577 4433

If yes, what was the occupation of the respondent (N=175)

• Government / private institutions • self employed, agriculture, other jobs

110000 7755

5577..22 4422..88

Past occupational status of the spouse • No • Yes

224411 116600

6600 4400

If yes, what was the occupation of the spouse (N=160)

• Government / private institutions • self employed, agriculture, other jobs

110088 5522

6677..55 3322..55

Whether the participant has any present income or not

• No •• Yes

221144 118877

5533 4466

If yes, what is the source of income (N=187) • Own sources • From children, others

113355 5522

7711..22 2277..88

38

Table3 Personal habits of the elderly in Alengad Panchayat, Kerala

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Frequency of cleaning teeth (N=355)

• Once • twice, more than twice

118811 117744

5511 4499

Material used to clean teeth (N=355)

• Tooth brush and tooth paste • Others

115533 220022

4433 5577

Whether the respondent cleans his/her teeth by self(N=355)

• Yes • No

343 12

96.9 3.1

If no, who helps in cleaning teeth • Others • Spouse

10 2

83.3 16.7

Smoking status (N=315) • Never • Current

Daily smoking(N=76) • Yes • No

239 76

76 0

75.8 24.2

100 0.0

Use of smokeless tobacco(N=339) • Never • Current

Daily use of smokeless tobacco • Yes • No

310

29

29 0

91.5

8.5

100 0.0

Time period since stopped daily smoking (N=88)

• ≥ one year • < one year

77 11

87.5 12.5

Type of diet consumed • Mixed diet • Vegetarian diet

228899 111144

7722 2288

Consumption of vegetable • Daily/weekly/occasionally • Never

403 0

100 0

Consumption of pulses • Daily/weekly/occasionally • Never

402 1

99.8 0.2

Consumption of fruits

39

Daily teeth brushing as a habit was performed by all the elderly except those who were

completely edentulous. However, the ideal frequency of brushing twice or more than twice

was practiced by only less than half. More than fifty percent of the respondents used

materials like tooth powder, charcoal, lime and mango leaves for cleaning their teeth and

only 43 percent used toothbrush and toothpaste. Almost all the elderly were capable of

brushing their own teeth.

Tobacco use, a crucial factor that affects oral health was explored in the study. Almost one

fourth of the respondents reported smoking and about one in five of them smoked daily.

Smokeless tobacco use was reported by nine percent and about three fourths of the tobacco

chewers were females.

Regarding diet, another crucial factor of oral health, almost three fourths of the study

population were mixed (non)vegetarians (72 percent). Among those who consumed green

• Daily/weekly/occasionally • Never

397 6

98.5 1.5

Consumption of milk/curd • Daily/weekly/occasionally • Never

389 13

96.5 3.2

Consumption of fish • Daily/weekly/occasionally •• Never

298 105

73.9 26.1

Consumption of egg • Daily/weekly/occasionally • Never

289 114

71.7 28.3

Consumption of chicken/meat • Daily/weekly/occasionally •• Never

282 121

70 30

Consumption of sweets • Daily/weekly/occasionally •• Never

342 61

84.9 15.1

Consumption of tea/coffee • Daily/weekly/occasionally • Never

397 6

98.5 1.5

40

leafy vegetables, about 50 percent consumed it on a daily basis. About three fourths of the

elderly consumed fish, about half of them consumed it daily. Only less than one in five never

consumed sweets. Most of the elderly who consumed sweets did so occasionally and only

about ten percent consumed sweets daily. Almost all elderly drank tea/coffee and majority of

them drank it on a daily basis.

Table 4 Perceived status of health, medical consultation and medications among elderly in Alengad Panchayat, Kerala

Less than one third of the elderly perceived their general health status to be below average.

More than half of the respondents were on regular medications. Almost one in five of the

elderly who were on medications were taking medicines for hypertension and diabetes and

less than 10 percent were taking medicines for hypertension, diabetes and other cardiac

diseases taken together and 13.1 percent were taking medicines for arthritis. During the

survey, a significant proportion of the elderly on medicines for diabetes and arthritis were

females.

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Status of health perceived

• Average/above average • Below average

273 127

67.7 31.5

Whether had any medical consultation • No • Yes

264 132

65.5 32.8

Whether on any medications • Yes • No

238 162

58.8 40

41

Table 5 Perceived status of oral health and teeth related illness among elderly in Alengad Panchayat, Kerala

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Status of teeth perceived

• Average/above average • Below average

263

135

65.3

33.5 Teeth related discomfort in the past six months

• No • Yes

283

120

70.3

28 CHEWING PROBLEMS RELATED TO TEETH

• No • Yes

293 108

72.7 26.8

DIFFICULTY WITH SPEECH DUE TO TEETH • No • Yes

394 9

97.8 2.2

FEEL OF TENSION DUE TO TEETH DISCOMFORT • No • Yes

403 0

100 0.0

FEEL OF EMBARASSMENT • No • Yes

401 2

99.5 0.5

PROBLEMS WITH SMILE DUE TO TEETH DISCOMFORT

• No • Yes

401 2

99.5 0.5

DISTURBANCES IN SLEEP DUE TO TEETH PROBLEMS • No • Yes

338866 1177

9955..88 44..22

PROBLEMS WITH DAILY WORK • No • Yes

400 3

99.3 0.7

PROBLEMS WITH USUAL ACTIVITIES • No • Yes

403 0

100 0.0

LESS TOLERANCE OF SPOUSE • No • Yes

403 0

100 0.0

PROBLEMS WITH SOCIAL ACTIVITIES • No • Yes

403 0

100 0.0

Whether the respondent had ever visited dentist • Yes • No

255 148

63.3 36.7

If yes, the reason for the past dental visit(N=255) • Pain related to teeth/gums

218

86.2

42

One third of the study population perceived their oral health status to be below average. More

than two third of respondents had not perceived any dental illness in the past six months.

Almost all the elderly did not have any difficulty in smiling, sleeping, carrying out usual

work and social activities because of teeth problems. Only 27 percent and 4.2 percent felt

that their chewing and sleep were affected because of teeth problems. More than two thirds

of males had ever visited dentist, whereas only slightly more than half of the females had

ever visited dentist. Among them, only one fourth of the elderly (both men and women) felt

comfortable with the past dental treatment care. Out of 21.1 percent of total who were unable

to visit dentist for any dental problem in the past six months, 40.5 percent didn’t find it

possible to reach to the dentist because of physical distance, 33 percent didn’t find time to

consult a dentist, and 9.5 percent felt that the treatment cost was very high.

• Other reasons 37 13.8 Type of oral health facility for the last dental visit (N=255)

• Private clinic/hospital • Government hospital

236 19

92.6 7.4

Reason for selecting that facility(N=102) • dentist is good, famous, friend • easily available, access, afford

99 3

97 3.0

Person who accompanied for the last dental visit (N=255)

• With others • Alone

158 97

62 38

Whether the last dental treatment care was comfortable (N=255)

• Yes • No

195 60

76.5 23.5

Inability to visit dentist for any dental problem in the past six months

• No • Yes

318 85

78.9 21.1

43

Table 6 Dental prosthetic use among elderly in Alengad Panchayat, Kerala

A very negligible proportion of the elderly who ever visited the dentist had fixed dentures

and only less than one in five had removable dentures (17 percent). More than half of the

elderly who were completely edentulous did not have complete dentures and among them 15

percent of elderly were not using the dentures regularly. Only 10.5 percent of elderly who

were partially edentulous had partial dentures and among them slightly less than half were

not using the dentures on regular basis (42 percent). In short, 65 percent of completely

edentulous elderly and 94 percent of partially edentulous elderly had strong prosthetic needs.

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Use of fixed dentures(N=255)

• No • Yes

253 2

99.2 0.8

Use of removable dentures(N=255) • No • Yes

211 44

83.1 16.9

Whether denture wearing was regular (N=44) • Yes • No

31 13

70.5 29.5

Reasons for not wearing the denture(N=13) • Loose fitting denture, chewing problems • Pain in jaws

9 2

81.8 18.2

44

Table7. Awareness regarding dental care among elderly in Alengad Panchayat, Kerala

Only less than one in five of the elderly correctly reported that the ideal frequency of dental

visit was six months. There was no difference in this awareness between men and women.

More than half of the elderly felt that one needs to consult the dentist only in times of need.

Table 8 Current dental illness among elderly in Alengad Panchayat, Kerala

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Awareness on ideal frequency of dental visit

• Other time periods •• Every 6 months

339 64

84.1 15.9

Perceived reason/reasons for dental visit • When in need • Pain related to teeth/gums

218 166

56.8 43.2

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Presence of any current dental illness

• No • Yes

267 136

66.3 33.7

Nature of current dental illness • Pain • Sensitivity of teeth • Mobility of teeth • Broken teeth

80 30 24 2

59 22 18 1

Whether currently under any dental treatment(N=136)

• No • Yes

118 18

86.7 13.3

45

About one in three had dental problems currently. Among them, dental pain was the major

problem reported by more than half of the respondents (59 percent). Majority of the elderly

who had current dental illness were not presently under any kind of dental treatment.

Table 9 Financing of dental treatment among elderly in Alengad Panchayat, Kerala

Three fourths of the elderly paid from their own sources for dental treatment. More than 95

percent didn’t have any re-imbursement options for dental treatment. Among those who had

options for re-imbursement, pension schemes dominated and less than one third had

insurance.

VVAARRIIAABBLLEE FFRREEQQUUEENNCCYY PERCENTAGE Source of money for dental treatment

• Self/spouse/insurance • Son/daughter/grandchild/ others

302 100

74.9 24.8

Whether the dental treatment charge were reimbursable

• No • Yes

386 15

95.8 3.7

If yes, options for reimbursement(N=15)

• All pension schemes • Insurance

11 4

73 27

46

3.2 DMFT (Decayed, Missing, Filled Teeth) score and Edentulousness Table 10 DMFT: Decayed, Missing, Filled Teeth score among elderly in Alengad panchayat, Kerala Mean DMFT score(SD) 18.14(7.5) Mean number of decayed teeth(SD) 7.37(6.6) Mean number of missing teeth (SD)

• Mean number of missing teeth due to caries • Mean number of missing teeth-other reason

10.26(11.2)

1.68 8.65

Mean number of filled teeth (SD) 0.44 (1.3) Mean number of sound teeth (SD) 13.73 (7.5) Mean number of teeth-traumatic 0.05 The mean DMFT score of the study population was 18.14+/-7.5SD which denotes severely

affected status of dentition (teeth). The mean number of missing teeth was 10.26 +/-11.2SD,

with no considerable difference between men and women

Table 11 Prevalence of complete and partial edentulousness, complete dentate among elderly in Alengad Panchayat, Kerala Complete edentulousness 11.9 percent

Partial edentulousness 56.3 percent

Complete dentate 31.8 percent

Only less than one-third of the total elderly were complete dentate (had all the 32 natural

teeth). About 12 percent of the elderly were completely edentulous and more than half of the

elderly were partially edentulous.

47

3.3 Bivariate analysis 3.3.1 Analysis of factors related to complete edentulousness Table 12 Socio-demographic factors and complete edentulousness among elderly in Alengad Panchayat, Kerala

Age was found to be a significant factor related to the status of dentition. As age advanced,

the proportion of elderly who are completely edentulous also increased. The type of family

and education of the respondents were also found to be statistically significant. Elderly who

resided in joint/extended family were more likely to be completely edentulous compared to

who lived in nuclear set up. The factors such as sex of the respondent and marital status were

found to be not significant.

VVaarriiaabbllee CCoommpplleettee EEddeennttuulloouussnneessss

NNoo FFrreeqquueennccyy ((ppeerrcceenntt))

CCoommpplleettee EEddeennttuulloouussnneessss

YYeess FFrreeqquueennccyy ((ppeerrcceenntt))

PP VVaalluuee ((cchhii ssqquuaarree))

Age groups • Young old (60-74) • Old, old (75-84) • Oldest old (>=85)

282(92.5) 67(77.9)

6(50)

23(7.5) 19(22.1)

6(50)

0.00**

Sex • Male • Female

170(88.1) 185(88.1)

23(11.9) 25(11.9)

1.00

Marital status • Others (widowed,

separated, divorced) • Currently married

130(85)

225(90)

23(15)

25(10)

0.13

Type of family • Joint/extended • Nuclear

7(63.6)

348(88.8)

4(36.4) 44(11.2)

0.01*


• No schooling • Primary education • Secondary and Higher

Secondary education • Graduate/Post

Graduate/Professional degree

12(100) 194(88.2)

138(88.5)

11(73.3)

0(0.0) 26(11.8)

18(11.5)

4(26.7)

0.006*

48

Table 13 Economic status factors and complete edentulousness among elderly in Alengad panchayat, Kerala

Whether the respondent had any past occupation or not was not statistically significant but,

the occupation was. Elderly who were working in Government/private institutions and who

had present source of income were more likely to be completely edentulous compared to who

were self employed in the past and who didn’t have any income presently. The relation of

past occupation of spouses’ and source of income with edentulousness were not significant.






Past occupational status of the respondent

• No • Yes

199(87.3) 156(89.1)

29(12.7) 19(10.9)

0.60

If yes, what was the occupation of the respondent

• self employed, agriculture, other jobs

•• Government / private institutions

72(96)

84(84)

3(4)

16(16)

0.01*

Past occupational status of the spouse

• No • Yes

216(89.5) 137(85.6)

25(10.4) 26(14.4)

0.23

If yes, what was the occupation of the spouse


•• Government / private institutions

48(92.3)

92(82.9)

4(7.70)

19(17.1)

0.10

Whether the participant has any present income or not

• No •• Yes

195(91.1) 158(84.5)

19(8.9) 29(15.5)

0.04

If yes, what is the source of income

• From children, others • Own sources

43(82.7) 113(85)

9(17.3) 20(15)

0.70

49

Table 14 Personal habits and complete edentulousness among elderly in Alengad






Frequency of cleaning teeth • Once • Twice, more than twice

179(98.4) 175(99.4)

3(1.6) 1(0.6)

0.30

Material used to clean teeth • Others • Tooth brush and tooth

paste

148(98.7) 200(99.5)

2(1.3) 1(0.5)

0.40

Whether the respondent cleans his/her teeth by self

• No • Yes

11(100) 336(99.1)

0(0.0) 3(0.9)

1.00

If no, who helps in cleaning teeth

• Others • Spouse

10(100) 2(100)

0(0.0) 0(0.0)

Smoking status • Never • Current

208(87) 67(88.2)

31(13.0) 9(11.8)

0.79

Use of smokeless tobacco

• Never • Current

269(86.8)

25(86.2)

41(13.2)

4(13.8)

0.56

Time period since stopped daily smoking (N=88)

• ≥ one year • < one year

9(81.8) 70(90.9)

2(18.2) 7(9.1)

0.40

Type of diet consumed • Vegetarian diet • Mixed diet

77(69.4) 278(95.2)

34(30.6) 14(4.8)

0.00

Consumption of vegetable Never Daily/weekly/occasionally

355(88.1)

0(0.0)

48(11.9) 0(0.0)

Consumption of pulses Never Daily/weekly/occasionally

1(100)

354(88.1)

0(0.0)

48(11.9)

0.70

Consumption of fruits Never Daily/weekly/occasionally

4(80)

350(88.2)

1(20)

47(11.8)

0.60

50

Type of diet was statistically significant with complete edentulousness where more than one

third of vegetarians were found to be completely edentulous. Elderly who consumed fish,

egg, chicken/meat and tea/coffee were less likely to be completely edentulous. Frequency of

cleaning teeth, material used to clean teeth, whether the respondent cleans his or her teeth by

self, smoking status and use of smokeless tobacco were not found to be statistically

significant.

Consumption of milk/curd

Never Daily/weekly/occasionally

11(84.6)

343988.2)

2(15.4) 46(11.8)

0.70

Consumption of fish Never Daily/weekly/occasionally

78(74.3) 277(93)

27(25.7) 21(7.0)

0.001

Consumption of egg Never Daily/weekly/occasionally

86(75.4) 269(93.1)

28(24.6) 20(6.9)

0.001

Consumption of chicken/meat Never Daily/weekly/occasionally

90(74.4) 265(94)

31(25.6) 17(6.0)

0.001

Consumption of sweets Never Daily/weekly/occasionally

42(68.9) 313(91.5)

19(31.1) 29(8.5)

0.001

Consumption of tea/coffee Never Daily/weekly/occasionally

3(50)

352(88.7)

3(50)

45(11.3)

0.040*

51

Table 15 Perceived status of health, medical consultation and medications and complete edentulousness among elderly in Alengad Panchayat, Kerala

Self perceived status of health was significant. Those elderly who perceived their health

status to be below average are more likely to be edentulous than others. However, the factors

such as whether they had any medical consultation and whether they were on any

medications were not found to be statistically significant with complete edentulousness.






Status of health perceived • Below average • Average/above average

104(81.9) 248(90.8)

23(18.1) 25(9.2)

0.01

Whether had any medical consultation

• No • Yes

235(89.0) 118(85.6)

29(11.0) 19(14.4)

0.60

Whether on any medications • No • Yes

144(89.4) 209(87.3)

17(10.6) 30(12.7)

0.70

52

Table 16 Perceived status of oral health, teeth related illness and complete edentulousness among elderly in Alengad Panchayat, Kerala VVaarriiaabbllee CCoommpplleettee

EEddeennttuulloouussnneessss NNoo

FFrreeqquueennccyy ((ppeerrcceenntt))




Status of teeth perceived • Below average • Average/above average

100(74.1)

250(95.1)

35(25.9)

139(4.9)

0.001

Teeth related discomfort in the past six months

• No • Yes

243(85.9) 112(92.9)

40(14.1) 8(7.1)

0.20

CHEWING PROBLEMS RELATED TO TEETH

• No • Yes

253(86.3) 100(92.6)

40(13.7) 8(7.4)

0.90

DIFFICULTY WITH SPEECH DUE TO TEETH

• No • Yes

348(88.3) 7(77.8)

46(11.70 2(22.2)

0.30

FEEL OF EMBARASSMENT • No • Yes

358(88.0)

2(100)

48(12.0) 0(0.0)

1.00

DISTURBANCES IN SLEEP DUE TO TEETH PROBLEMS

• No • Yes

340(88.1) 15(88.2)

46(11.9) 2(11.80

1.00

Whether the respondent had ever visited dentist

• No • Yes

135(91.2) 220(86.3)

13(8.8) 35(13.7)

0.04

If yes the reason for the last dental visit

• Other reasons • Pain in teeth/gums

34(97.1) 184(84.4)

1(2.9)

34(15.6)

0.08*

Type of oral health facility for the last dental (N=255)

• Private clinic • Government hospital

202(85.2) 19(100)

35(14.8) 0(0.0)

0.08*

Reason for selecting that facility(N=102) easily available, access, afford dentist is good, famous,

3(100)

83(83.8)

0(0.0)

16(16.2)

1.00

53

Self perceived oral health status was also found to be significant. Those elderly who

perceived their status of oral health to be below average were more likely to be completely

edentulous. However it can be probably the other way round also that elderly who were

completely edentulous perceived their oral health status to be below average. The factors

such as whether the respondent had ever visited dentist and whether the past dental treatment

was comfortable were also found to be statistically significant. Those who have ever visited

dentist and those were comfortable with the past dental treatment are more likely to be

edentulous. Certain factors such as the type of facility of last dental visit, reasons and person

who accompanied for the past dental visit were not statistically significant. The oral health

factors such as teeth related discomfort in past six months were also not found to be

statistically significant.

friend Person who accompanied for the last dental visit(N=255)

• With others • Alone

138(87.3) 82(84.5)

20(12.7) 15(15.5)

0.50

Whether the last dental treatment care was comfortable (N=255)

• No • Yes

57(95.0) 163(83.6)

3(5) 32(16.4)

0.03*


• No • Yes

272(85.5) 83(97.6)

46(14.5) 2(2.4)

0.02*

54

Table 17 Dental prosthetic use and complete edentulousness among elderly in Alengad

On the use of dentures, the use of removable partial dentures was significant than the use of

fixed partial dentures. Elderly who used removable partial dentures in the past were more

likely to be completely edentulous compared to others. There was no statistically significant

difference between elderly who wore the dentures regularly and who didn’t.






Use of fixed dentures • No • Yes

218(86.2) 2(100.0)

35(13.8) 0(0.0)

0.60

Use of removable dentures • No • Yes

196(92.9) 23(53.5)

15(7.1) 20(46.5)

0.001

Whether the denture wear was regular

• No • Yes

10(76.9) 14(45.2)

3(23.1) 17(54.8)

0.06*

Reasons for not wearing the denture

• Loose fitting denture, chewing problems • Pain in jaws

8(88.9)

2(100.0)

1(11.1)

0(0.0)

0.60

55

Table 18 Awareness regarding dental care and complete edentulousness among elderly in Alengad Panchayat, Kerala

There was significant difference between elderly who were aware of the ideal frequency of

dental visit and who were not. Those who were less aware on the frequency of dental visit

were more likely to be edentulous.

Table 19 Current dental illness and complete edentulousness among elderly in Alengad Panchayat, Kerala






Awareness on ideal frequency of dental visit

• Other time periods •• Every 6 months

293(86.4) 62(96.9)

46(13.6) 2(3.1)

0.02*

Perceived reason/reasons for dental visit

• When in need • Pain in teeth/gums

194(89.0) 146(88.0)

24(11.0) 20(12.0)

0.80






Presence of any current dental illness

• No • Yes

219(82.0) 136(100.0)

48(18) 0(0.0)

0.00*

Whether currently under any dental treatment(N=403)

No Yes

338(87.8) 17(94.4)

47(12.2) 1(5.60)

0.40

56

There was statistically significant difference between elderly who had current dental illness

and who didn’t. Those elderly who did not perceive any dental illness presently were more

likely to be completely edentulous compared to others.

Table 20 Financing of dental treatment and complete edentulousness among elderly in Alengad, Kerala

Factors such as source of money for dental treatment and re-imbursement options did not

show any statistical significance with complete edentulousness.

** P value-linear by linear association * P value- Fischer exact






Source of money for dental treatment

• Son/daughter/grandchild/ others

• Self/spouse/insurance

88(88.0)

266(88.1)

12(12.0)

36(11.9)

1.00

Whether the dental treatment charges were reimbursable

• No • Yes

341(88.3) 14(86.7)

45(11.7) 2(13.3)

0.90

If yes, options for reimbursement

• Insurance • All pension schemes

5(55.6) 13(81.3)

4(44.4) 3(18.8)

0.20

57

3.3.2 Analysis of factors related to complete dentate status:

In further Bivariate analysis, we tried to compare those elderly who were complete dentate

(who had all the 32 natural teeth) with those who were edentulous (either complete or

partial).The factors which were statistically significant in the analysis are presented below.

Table 21 Socio-demographic factors and complete dentate among elderly in Alengad Panchayat, Kerala

VVaarriiaabbllee CCoommpplleettee DDeennttaattee NNoo


CCoommpplleettee DDeennttaattee YYeess



Age groups • Young old (60-74) • Old, old (75-84) • Oldest old (>=85)

197(64.6) 68(79.1) 10 (83.3)

108(35.4) 18(20.9) 2(16.7)

0.006**

Marital status • Others (widowed,

separated, divorced) • Currently married

117(76.5)

158(63.2)

36(23.5)

92(36.8)

0.005

Type of family • Joint/extended • Nuclear

10(90.9) 265(67.6)

1(9.1)

127(32.4)

0.08*


• No schooling • Primary education • Secondary and Higher

Secondary education • Graduate/Post

Graduate/Professional degree

12(100) 155(70.5) 97(62.2)

11(73.3)

0(0.0) 65(29.5) 59(37.8)

4(26.7)

0.031*

58

Table 22 Economic status factors and complete dentate among elderly in Alengad panchayat, Kerala

Table 23 Personal habits and complete dentate among elderly in Alengad panchayat, Kerala






what was the past occupation of the respondent


• Government / private institutions

55(73.3)

61(61.0)

20(26.7)

39(39.0)

0.08






Material used to clean teeth • Others • Tooth brush and tooth

paste

111(74.0) 117(58.2)

39(26.0)

84 (41.8)

0.002

Consumption of egg Never Daily/weekly/occasionally

87(76.3) 188(65.1)

27(23.7) 101(34.9)

0.029

Consumption of chicken Never Daily/weekly/occasionally

94(77.7) 181(64.2)

27(22.3) 101(35.8)

0.008

59

Table 24 Perceived status of health, medical consultation and medications and complete dentate among elderly in Alengad Panchayat, Kerala

Table 25 Perceived status of oral health, teeth related illness and complete dentate among elderly in Alengad Panchayat, Kerala






Status of health perceived • Below average • Average/above average

104(81.9)

169(61.9)

23(18.1)

104(38.1)

0.001




FFrreeqquueennccyy ((ppeerrcceenntt


Status of teeth perceived • Below average • Average/above average

114(84.4) 158(60.1)

21(15.6) 105(39.9)

0.001

Difficulty with speech due to teeth problems

• No •• Yes

267(69.2) 8(47.1)

119(30.8) 9(52.9)

0.055

Reason for the last visit •• Other reasons •• Pain in teeth/gums

21(60.0) 166(76.1)

14(40.0) 52(23.9)

0.043

Person who accompanied for the last dental visit

• With others •• Alone

110(69.6) 79(81.4)

48(30.4) 18(18.6)

0.036


• No • Yes

230(72.3) 45(52.9)

88(27.7) 40(47.1)

0.001

60

Table 26 Dental prosthetic use and complete dentate among elderly in Alengad, Kerala

Table 27 Financing of dental treatment and complete dentate among elderly in Alengad, Kerala

Factors such as age, type of family, perceived status of general and oral health and use of

removable partial dentures which were statistically significant with complete edentulousness

were found to be statistically significant with complete dentate also. Age was again a crucial

factor which showed significance. As age advanced, the proportion of elderly who were

completely dentate decreased. Elderly who resided in nuclear family, who perceived their

status of general and oral health to be average/above average and who did not use removable

partial dentures in the past were more likely to be completely dentate. Factors such as marital




FFrreeqquueennccyy ((ppeerrcceenntt))))


Use of removable dentures • No •• Yes

148(69.8) 41(95.3)

64(30.2) 2(4.7)

0.001*

Whether the denture wear was regular

• No • Yes

11(84.6) 31(100.0)

2(15.4) 0(0.0)

0.082*






Source of money for dental treatment

• Son/daughter/grandchild/ others

• Self/spouse/insurance

78(78.0)

196(64.9)

22(22.0)

106(35.1)

0.015

61

status, material used to clean teeth, person accompanied for past dental visit and source of

money for dental treatment were found to be statistically significant with complete dentate

only. Elderly who were currently married, who used toothpaste and toothbrush, who did not

go alone for past dental visit and who had own source of money for dental treatment were

more likely to be completely dentate.

** P value-linear by linear association * P value- Fischer exact 3.4 Multivariate analysis (Logistic regression)

We tried to build up a logistic regression model to find out the independent factors affecting

complete edentulousness (as it was a binary variable)

Among twelve factors affecting complete edentulousness kept in the final model of logistic

regression analysis, five factors came significant finally. The factors which did not show

significance were age class, sex, present income, perceived status of health, inability to visit

dentist for any dental problem, current dental illness and whether the last dental treatment

was comfortable.

The factors affecting complete edentulousness which came significant in logistic regression

analysis are discussed below.

62

Table 28 Factors affecting complete edentulousness significant in logistic regression

analysis

The factors which came significant in the final model of the logistic regression analysis were

type of family, type of diet, use of removable partial dentures in the past, awareness on the

ideal frequency of dental visit and perceived status of teeth. Elderly who resided in

joint/extended family are more likely to be completely edentulous compared to who lived in

nuclear set up. Elderly who consumed vegetarian diet are more likely to be completely

edentulous compared to others. Elderly who used removable partial dentures in the past were

more likely to be completely edentulous. Those who were less aware on the ideal frequency

of dental visit were more likely to be edentulous. Those elderly who perceived their status of

teeth/oral health to be below average were more likely to be completely edentulous.

Dependent

variable

Independent

variables

Reference

category

P value Odds ratio 95% CI

Complete

edentulousness

Type of

family

Nuclear family 0.006 4.5 1.3-16.0

Type of diet Mixed diet 0.003 8.7 4.4-16.9

Use of

removable

dentures

Non user 0.0001 11.4 5.1-25.0

Awareness

on ideal

frequency of

dental visit

More aware 0.006 4.9 1.2-20.6

Perceived

status of

teeth

Average/above

average

0.001 6.7 3.4-13.3

63

CHAPTER 4

DISCUSSION

4.1 Discussion

The study was done in the context of the growing proportion of elderly population

due to demographic transition and the challenges that it presents in terms of ensuring their

health and well being. Kerala has the largest proportion of the elderly in the country and is

raising public health concerns regarding general and oral health care and wellbeing of elderly

population. The quality of life of elderly is dependent on good oral health which is integrally

related to their general health. One of major morbidity of the elderly is loss of teeth, affecting

their mastication, dietary intake, nutritional status and quality of life.

In this context this study tried to assess the dentition status with particular reference

to edentulousness, to study the factors associated with edentulousness and to assess the oral

health care seeking behaviour among elderly population aged 60 years and above of Alengad

Panchayat, Ernakulam district, Kerala India. The findings are discussed in this chapter.

The study population had a mean age of 70.9+/-6.2SD and there was no significant

difference in the mean age between females and males. The maximum age was 93 years and

minimum age was 60 years. Slightly than half of the study population were females (52.1

percent) and the rest were males similar to the sex distribution among the elderly in Kerala.65

Dentition Status: Dentition status among the elderly was assessed using the DMFT

score and the mean score in the study population was 18.14+/-7.5(SD) which implies that the

status of dentition/teeth is affected severely (A mean DMFT score of greater than 6.1 is

indicative of severely affected status of dentition).63,64 This high mean DMFT score in the

64

study population means that the status of teeth is very poor and indicates unhealthy dental

and periodontal conditions.

The mean number of missing teeth was 10.26 +/-11.2SD, with no considerable difference

between men and women.

Edentulousness: The prevalence of complete edentulousness in the study population

was 12 percent. This finding falls within the range of complete edentulousness as reported

by earlier studies.66,67,68 Edentulousness is found to increase with increasing age. Since about

three fourths of the elderly in this study population was in the young old(60-74 years)

category, the prevalence might have been a little lower. Adding to that, the proportion of

elderly in 60-64 age group was found to be almost 16 percent in this study population. The

only comparative data available from India indicates a prevalence of 19 percent in the age

group 65-74.4

The prevalence of partial edentulousness was 56.3 percent which denotes that more

than half of the elderly did have missing natural teeth due to caries, periodontal diseases,

trauma to teeth and other reason suggestive of a long history of poor oral health. This is also

in tune with the review of literature.10

Factors affecting complete edentulousness:

Age was found to be a significant factor related to the status of dentition and

edentulousness. As age advanced, the proportion of elderly who are completely edentulous

also increased and this was in tune with the findings of earlier research in this area.10,16,17

This also indicates the future increase in the burden of edentulousness that would arise with

continuing increase in years of survival among the elderly in the State.

65

Type of family and educational status of the elderly were also found to be statistically

significant. Elderly who resided in joint/extended family were more likely to be completely

edentulous compared to who lived in nuclear families. Similar finding was reflected in earlier

studies69 also and this could be attributed to the fact that the elderly who lived in nuclear

families could devote more time and take better care of themselves compared to those who

resided in joint or extended family where there were other competing priorities and personal

domestic commitments.

Sex has been documented as a factor associated with being completely edentulate

among elderly.16,17 However in the present study, sex of the respondent and marital status

were not found to be significantly related to edentulousness. The mean number of missing

teeth also showed no difference between the two sexes.

Whether the respondent had any past occupation was not significantly related to being

completely edentulous among the elderly. However, elderly who were employed in the

formal sector either in government or private institutions and who had current source of

income of their own were more likely to be completely edentulous. This was in comparison

to those who were employed in the non-formal sector in the past and who didn’t have any

source of income at present.

Personal brushing habits are known to affect oral health status

considerably.10,16,17,20,69 Among the elderly who took part in this study daily teeth brushing as

a habit was practiced by all (except those who were completely edentulous.) Almost all the

elderly were capable of brushing their own teeth. However only less than fifty percent

practiced the ideal frequency of brushing which is twice or more per day. This indicates the

66

need to stress on the ideal brushing frequency which might serve to promote better oral

health care among the elderly in the future.

More than fifty percent of the respondents used materials like tooth powder,

charcoal, lime and mango leaves for cleaning their teeth and only 43 percent used toothbrush

and toothpaste. Proper brushing technique using toothbrush and toothpaste reduces likelihood

of oral morbidity.38,39,40,41,69 The fact that more than half of the elderly were not using

toothbrush and toothpaste presents an opportunity for future interventions right from younger

ages stressing on proper brushing techniques. Such interventions would serve to bring down

oral morbidity in older age groups.

Tobacco use which is a crucial factor that affects oral health was explored in the

study. Almost one fourth of the elderly reported smoking and about one in five of them

smoked daily. Nine percent of the elderly reported use of smokeless tobacco. Almost three

fourth of the respondents who reported using smokeless tobacco were females. Tobacco use

has been identified as significant modifiable risk factor for poor dental health among older

adults.31,32,33,34 However in this study the use of smoke and smokeless forms of tobacco were

not significantly related to complete edentulousness and complete dentate. The prevalence of

current use of tobacco in the form of smoking was (24.2 percent) and smokeless tobacco use

was (8.5 percent). Therefore, though it was not related to dentition status and edentulousness

in this study, this is a risk factor that predisposes the elderly to chances of developing

different forms of oral cancer. This indicates the need to sensitize dental practitioners and

public health practitioners actively identify and intervene among elderly on tobacco use.

67

Diet is another pertinent factor for good oral heath. 2 Almost three fourths of the study

population were non vegetarians (72 percent) and a quarter were vegetarians. Type of diet

was statistically significant with complete edentulousness where elderly who consumed

vegetarian diet were more likely to be completely edentulous. Another study done among

elderly in India also showed similar results.10This could be due to the fact that vegetarian diet

is said to be protective against caries and not for edentulousness. Another possible

explanation is that more levels of macronutrients especially calcium and micronutrients in

the non-vegetarian diet protect against edentulousness.10,13,31 However this result needs to be

interpreted with caution since the elderly who were completely edentulous could have been

forced to shift to vegetarian diet. However, further analytical studies need to be performed to

establish association and temporality.

The self perceived status of general health by elderly was significantly related to

edentulousness. Less than one third of the elderly perceived their general health status to be

below average Those elderly who perceived their health status to be below average were

more likely to be edentulous than others. This is also in tune with the review of

literature.70This could be taken as an indication that elderly who were edentulate perceived

their general health status to be poorer due to the difference that it makes to their quality of

life and is a field of further exploration.

Self perceived oral health status was also found to be significantly associated with

edentulousness, a finding which has been reported by earlier studies. 70 Those elderly who

perceived their status of oral health to be below average were more likely to be completely

68

edentulous. However it can also be the other way round also that elderly who were

completely edentulous perceived their oral health status to be below average.

This is crucial evidence that self perceived oral health and general health is related to

chances of being edentulate. It could also be that people who were edentulate perceived that

their oral health and general health were below average. Either ways, it is crucial evidence

that there is significant difference regarding poor perception of general health and oral health

and edentulousness and reflects the need to include oral health as a key factor to improve the

quality of life of the elderly.

More than two third of respondents had not perceived any discomfort due to teeth within six

months. Self perception of the discomfort and recall could be affected by the culture.50,55

Almost all the elderly did not have any difficulty in smiling, sleeping, carrying out usual

work and social activities because of teeth problems. Only 27 percent and 4.2 percent felt

that their chewing and sleep were affected because of teeth problems. As mentioned earlier,

this can also be due to the cultural acceptance of the elderly that falling of teeth is a normal

phenomenon in old age and that edentulousness and elderly are synonymous. Nearly one in

three of the elderly had reported to have teeth problem in 6 months.

Oral health care seeking behaviour:

More than two thirds of men had ever visited dentist, whereas only 56.7 percent of

women had ever visited dentist. This may be due to the fact that more than one third of the

widowed were women. In a situation where women outlive men and form a larger proportion

of the elderly, special focus on geriatric health care needs to be focused on women since they

are also less likely to have any independent sources of income. Among them, only one fourth

69

of the elderly (both men and women) felt comfortable with the past dental treatment services.

The factors such as whether the respondent had ever visited dentist and whether the past

dental treatment was comfortable were also found to be statistically significant. Those who

had ever visited dentist and those felt comfortable with the past dental treatment were more

likely to be edentulous. Certain factors such as the type of facility of last dental visit, reasons

and person who accompanied for the past dental visit were not statistically significant.

A very negligible proportion of the elderly who ever visited the dentist had fixed

dentures and only less than one in five had removable dentures (17 percent). Sixty five

percent of completely edentulous elderly and 94 percent of partially edentulous elderly had

strong prosthetic needs. The use of removable partial dentures among elderly was significant

than the use of fixed partial dentures.10 Elderly who used removable partial dentures in the

past were more likely to be completely edentulous compared to others. This is owing to the

dental condition of ‘combination syndrome’ attributed to long term use of upper full denture

opposing lower partial denture and presence of lower front teeth There was no statistically

significant difference between elderly who wore the dentures regularly and who didn’t.

The awareness on ideal frequency of dental visit is another important factor affecting

edentulousness.16,17,18 Only less than one in five of the elderly correctly reported that the

ideal frequency of dental visit was six months. There was no difference in this awareness

between men and women. There was significant difference between edentulousness and

elderly who were aware of the ideal frequency of dental visit and who were not. Those who

were less aware on the frequency of dental visit were more likely to be edentulous.

70

About one in three had dental problems currently. Among them, dental pain was the major

problem reported by more than half of the respondents (59 percent). Majority of the elderly

who had current dental illness were not presently under any kind of dental treatment. There

was statistically significant difference between elderly who had current dental illness and

who didn’t. Those elderly who did not perceive any dental illness presently were more likely

to be completely edentulous compared to others. This was also in tune with earlier studies

conducted among elderly.16,19

Financing for dental treatment is another major factor affecting edentulousness.55,56

Three fourths of the elderly paid from their own sources for dental treatment. More than 95

percent didn’t have any re-imbursement options for dental treatment. Factors such as source

of money for dental treatment and re-imbursement options did not show any statistical

significance with complete edentulousness.

Only 32 percent of the total elderly were complete dentate (had all the 32 natural

teeth in their oral cavity).However the oral health care seeking behaviour of the study

population was poor. About one in three of the elderly had dental problems currently but

majority of them were not presently under any kind of dental treatment. Only less than one in

five of the elderly correctly reported that the ideal frequency of dental visit was six months.

These issues raise serious public health concerns.

In further bivariate analysis, we tried to compare those elderly who were complete

dentate (who had all the 32 natural teeth) with those who were edentulous (either complete or

partial). Factors such as age, type of family, perceived status of general and oral health and

use of removable partial dentures which were statistically significant with complete

71

edentulousness were found to be statistically significant with complete dentate also. Age was

again a crucial factor which showed significance. As age advanced, the proportion of elderly

who were complete dentate decreased which was in tune with literature.10,16,17 Elderly who

resided in nuclear family, who perceived their status of general and oral health to be

average/above average and who did not use removable partial dentures in the past were more

likely to be completely dentate. Factors such as marital status, material used to clean teeth,

person accompanied for past dental visit and source of money for dental treatment were

found to be statistically significant with being complete dentate. Elderly who were currently

married, who used toothpaste and toothbrush, who did not go alone for past dental visit and

who had own source of money for dental care were more likely to be completely dentate

indicating that social support, financial independence and care of the self were important

factors related to elderly being dentate.

The factors which were taken into consideration in the final model of the logistic

regression analysis were type of family, type of diet, use of removable partial dentures in the

past, awareness on the frequency of dental visit and perceived status of teeth. Elderly who

resided in joint/extended family (OR 4.5, CI 1.3-16.0), who consumed vegetarian diet (OR

8.7, CI 4.4-16.9), who used removable partial dentures in the past (OR 11.4, CI 5.1-25.0),

who were less aware on the frequency of dental visit (OR 4.9, CI 1.2-20.6), who perceived

their status of oral health to be below average (OR 6.7, CI 3.4-13.3) were more likely to be

completely edentulous. The type of diet and perceived status of teeth need to be interpreted

with caution due to the fact that those who were completely edentulate could have shifted to

vegetarian diet and perceive their status of oral health to be poorer. Being a cross sectional

study, temporality cannot be established.

72

4.2 LIMITATIONS

The study population only included elderly aged 60 years and above who can respond

independently. Information on diet was not captured in detail -only general questions adapted

from World Health Organisation oral health survey were included in the questionnaire.

Information on brushing technique was also not captured. This study has all the limitations of

a cross sectional survey such as establishing association and temporality.

4.3 STRENGTHS

There is a need for data on edentulousness and oral health problems in free living

populations of elderly people and very few studies like this have been done before in India.

The strengths of this study also include single investigator, oral health assessment by

principal investigator himself and use of validated tools.62

4.4 CONCLUSION

The findings of this study indicate that dentition status of elderly in Kerala is affected

severely, the oral health care seeking behaviour is poor and dental treatment care of the

elderly is inappropriate, unmet and often neglected.. The high mean DMFT score in the study

population means that the status of teeth is very poor and indicates unhealthy dental and

periodontal conditions. Complete absence of natural teeth, a poor public health outcome

substantially affects oral and general health status, as well as quality of life. The self

73

perception of poorer general health and oral health was significantly related to being

edentulate. This indicates that oral health is an important but often overlooked public health

issue especially for the elderly.

It is evident from the study that the oral health should be a critical element of the

geriatric preventive health care. The importance of preserving teeth in good condition not

only may be restricted to quality of life in the elderly but also may be an indicator of general

health because edentulousness is associated with general health.

4.5 POLICY IMPLICATIONS

The increasing proportion of elderly in the state implies high burden on the health

system. The health system need to be adequately strengthened to promote, support and

protect health and social well-being of the elderly due in part to lack of human and financial

resources. Health promotion activities on oral health care and accessibility to dental services

for the elderly should be strengthened at the Government level. Financing options of dental

treatment for elderly should be included in the oral health policy since having own source of

income is seen related to having better oral health care. In the long term, any attempt

focussing on public health interventions should start from children of young age, continue

through all stages of their life cycle to reduce oral morbidity, improve dentition status and to

reduce edentulousness among the elderly.

74

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81

Annexure 1

Achutha Menon Centre for Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology,

Thiruvananthapuram, Kerala.

CONSENT FORM

I am Dr.Madhu U, a student of Achutha Menon Centre for Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala. As part of my dissertation work, I am planning to conduct a study on “Dentition status and dental prosthetic needs among elderly in Ernakulam, Kerala, India”. This is a community-based study carried out under the guidance of my Guide Dr.Manju R Nair. This study is purely academic in nature, and I would be interested to interview you and examine your teeth using the instruments. The information provided by you will be kept strictly confidential and the results of this study will be used exclusively for research purpose. This research will not provide you with immediate benefits but the findings of this study might be helpful in initiating and developing strategies to improve the Oral health care of the elderly and might be useful to you as well as the policy makers in the long run. If you are willing to participate in this study, kindly provide your consent in this form for the data collection and oral examination. Your participation will be purely voluntary in nature and you can withdraw at any point of time from the study unconditionally. The data on the above mentioned subject will be collected by me. If you have any queries/clarifications, kindly feel free to contact me on Ph-94472 70664,or by Email: [email protected] or Dr.Anoop Kumar Thekkuveetil, IEC member secretary, SCTIMST, Thiruvananthapuram on Phone -0471 2520256/7 or by email- [email protected] If you are interested, the questionnaire can be provided to you any time you want. Thanking you for providing vital information and sparing your valuable time Signed by investigator Signed by respondent (Full name, Address) (Full name, Address) Date: Date: Place: Place: Witness’ Signature: 1…………………….. 2…………………….

mailto:[email protected]�

82

Annexure 2 Questionnaire

Serial. No:

Ward No: Name of the ward:

Date: House hold No:

Name: Address: Q.No: Question Responses Skip to DEMOGRAPHIC EDUCATIONAL

AND FAMILY DETAILS:

1 Age of the respondent in completed years 2 Sex of the respondent

male female

3 Place of residence 4 For how long have you been residing in

this Panchayat?(in Years)

5 What is your current marital status?

never married currently married separated divorced widowed

6 Type of family

Joint Extended Nuclear

7 Total number of members in the family who are currently residing here

8 Who all are they? 9 What is the highest level of education that

you have completed?

No schooling Primary Secondary H. secondary Grad/Post graduate Professional

ECONOMIC STATUS DETAILS: 10 Did you have a wage earning job in the

past? yes No

11 12

83

11 What was that job? Govt service in private institutions Agriculture self employment excluding agriculture Others_______

12 Were your spouse employed in the past? yes No

13 14

13 What was his/her job?

Govt service in private institutions Agriculture self employment excluding agriculture others_______

14 What was your total monthly income from all sources?

< 750 750-1500 1500-3000 3000-6000 >6000

15 Do you currently have any permanent source of income?

yes No

16 17

16 What is/are the source of income? Pension deposits assets from children others_______

17 Presently what is your average monthly income from all sources?

< 750 750-1500 1500-3000 3000-6000 >6000

PERSONAL HABITS:(adapted from WHO STEPS instrument-NCD)

18 How often do you clean your teeth daily?

once twice more than twice

19 What do you use to clean your teeth? tooth brush and tooth paste tooth paste alone tooth powder Charcoal mango leaves

84

others___________ 20 Do you clean your teeth yourself?

yes No

22 21

21 Who helps you in cleaning your teeth? spouse son/daughter Grand son/grand Daughter Homenurse/servant others_______

22 Do you currently smoke any tobacco products?

yes No

23 24

23 Do you currently smoke tobacco products daily?

yes No

24 Do you currently use any smokeless tobacco such as snuff, chewing tobacco, betel?

yes No

25 26

25 Do you currently use smokeless tobacco products daily?

yes No

26 How old were you when you first started smoking daily?

Age (in years)__- Don’t know

27 In the past, did you ever smoke daily?

yes No

28 30

28 How old were you when you stopped smoking daily?

Age (in years)__- Don’t know

29 How long ago did you stop smoking daily?

Years ago months ago weeks ago

30 In the past, did you ever use smokeless tobacco such as snuff, chewing tobacco, betel?

yes No

31 Type of diet consumed vegetarian mixed

32 How often do you eat? a. leafy vegetables

b. pulses/beans

daily weekly occasionally never others____________ daily weekly occasionally never others____________

85

c. Fruits

d. Milk/curd

e. Fish

f. Egg

g. Chicken/meat

h. Sweets

i. tea/coffee/ sweetened drinks

daily weekly occasionally never others____________ daily weekly occasionally never others____________ daily weekly occasionally never others____________ daily weekly occasionally never others____________ daily weekly occasionally never others____________ daily weekly occasionally never others____________ daily weekly occasionally never others____________

GENERAL HEALTH AND MEDICAL ILLNESS:

33 How would you describe the state of your Excellent

86

health?

Very Good Good Average Poor Very Poor Don't Know

34 Do you consult any medical doctor regularly?

yes No

35 Are you taking any medicine presently? yes No

36 37

36 What are the diseases for which you are taking medicines?

hypertension diabetes cardiac problems arthritis others_______

ORAL HEALTH AND DENTAL ILLNESS(adapted from WHO STEPS instrument-Oral health module):

37 How would you describe the state of your teeth?

Excellent Very Good Good Average Poor Very Poor Don't Know

38 During the past six months did your teeth cause any discomfort?

yes No

39 Have you experienced any of the following problems during the past 6 months because of the state of your teeth? Difficulty in chewing foods Difficulty with speech/trouble pronouncing Felt tense because of problems with teeth or mouth Embarrassed about appearance of teeth Avoid smiling because of teeth problems

yes No yes No yes No yes No yes No

87

Sleep is often interrupted due to teeth problems Days not at work because of teeth or mouth problems difficulty doing usual activities Less tolerant of spouse or people close to you Reduced participation in social activities

yes No

yes No yes No yes No yes No

40 How long has it been since you last visited a dentist?

Less than 6 months 6-12 months More than 1 year but less than 2 years 2 or more years but less than 5 years 5 or more years Never received dental care

41 51

41 What was the main reason for your last visit to the dentist?

Consultation / advice Pain or trouble with teeth Pain or trouble with gums or mouth trauma/accident Treatment / Follow-up treatment Routine check-up treatment Others ________

42 Where did you consult the dentist? Govt.Hospital Private hospital Private clinic others ________

43 Why did you prefer to consult the dentist? is good and famous is near-by

88

is easily available treatment is cheap any other reason______

44 Who accompanied you to consult the dentist?

spouse son/daughter Grand son/grand Daughter Home nurse/servant others_________

45 Did you feel comfortable with the services provided?

yes No

46 Do you have any fixed dentures? yes No

47 Do you have any removable dentures? yes No

48 51

48 Which of the following dentures do you have?

full denture An upper jaw denture A lower jaw denture An upper jaw partial denture A lower jaw partial denture

49 Do you wear the denture regularly? yes No

51 50

50 What are the reasons for not wearing the denture?

pain in the jaws loose fitting chewing discomfort always produce saliva gagging others_______

51 During the past 6 months, have you had a dental problem which you would have liked to see a dentist about but you didn't see?

yes No

52 53

52 Why didn't you see the dentist?

Didn't have time Would cost too Much Couldn't get an Appointment Would have to travel too far Didn't have a way

89

to get there Didn't have anyone to care for children or other family members any other reasons________

AWARENESS ON DENTAL CARE : 53 According to you, how often should one

visit a dentist? Once in a month Once in 6 months Once in a year Once in 2 years Others _________

54 What do you feel are the common conditions for which one should visit a dentist?

Consultation / advice Pain or trouble with teeth Pain or trouble with gums or mouth trauma/accident Treatment / Follow-up treatment Routine check-up treatment Others ________

PRESENT DENTAL ILLNESS: 55 Do you currently have any dental

problems? yes No

56 58

56 What is your present dental problem? 57 Are you still under any dental treatment? yes

No

FINANCING OF DENTAL TREATMENT:

58 Who pays for your dental treatment? spouse son/daughter Grand children Self Others_____

59 Do you have re-imbursement options for dental illness?

yes No

60 End

60 What is the kind of reimbursement? Pension plan Insurance Old age Pension others _________

90

Annexure 3

CLINICAL EXAMINATION: The dentition status was inspected using sterilized non-

disposable dental mirrors and explorers, and cotton roles were used to control saliva. A

full mouth hard tissue clinical examination was carried out which included examining the

crown and exposed root of permanent tooth, each crown and root were assigned a number

based on the result of that exam. The numbers were recorded in boxes corresponding to

each tooth to provide a DMFT chart.

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Measurement tool: (Dentition status assessment using WHO ORAL HEALTH ASSESSMENT FORM(1997)

PERMANENT TEETH CROWN

PERMANENT TEETH ROOT

CONDITION/STATUS

0 0 SOUND 1 1 DECAYED 2 2 FILLED WITH DECAY 3 3 FILLED, NO DECAY 4 - MISSING, DUE TO CARIES 5 - MISSING, ANY OTHER REASON 6 - FISSURE SEALANT 7 7 BRIDGE ABUTMENT,SPECIAL

CROWN/VENEER/IMPLANT 8 8 UNERUPTED

CROWN/UNEXPOSED ROOT 9 9 NOT RECORDED T - TRAUMA(FRACTURE)

91

Numbers(zero to nine) and T are assigned as follows:

• 0: A zero indicates a sound crown or root, showing no evidence of either treated

or untreated caries. A crown may have defects and still be recorded as 0. Defects

that can be disregarded include white or chalky spots; discolored or rough spots

that are not soft; stained enamel pits or fissures; dark, shiny, hard, pitted areas of

moderate to severe fluorosis; or abraded areas.

• 1: One indicates a tooth with caries. A tooth or root with a definite cavity,

undermined enamel, or detectably softened or leathery area of enamel or

cementum can be designated a 1. A tooth with a temporary filling, and teeth that

are sealed but decayed, are also termed 1. A 1 is not assigned to any tooth in

which caries is only suspected. In cases where the crown of a tooth is entirely

decayed, leaving only the root, a 1 is assigned to both crown and root. Where only

the root is decayed, only the root is termed a 1. In cases where both the crown and

root are involved with decay, whichever site is judged the site of origin is

recorded as a 1. These criteria apply to all numbers.

• 2: Filled teeth, with additional decay, are termed 2. No distinction is made

between primary caries which is not associated with a previous filling, and

secondary caries, adjacent to an existing restoration.

• 3: A 3 indicates a filled tooth with no decay. If a tooth has been crowned because

of previous decay, that tooth is judged a 3.

• 4: A 4 indicates a tooth that is missing as a result of caries. Only crowns are given

4 status

92

• 5: A permanent tooth missing for any other reason than decay is given a 5.

Examples are teeth extracted for orthodontia or because of periodontal disease,

teeth that are congenitally missing, or teeth missing because of trauma.

The "D" of DMFT refers to all teeth with codes 1 and 2.

The "M" applies to teeth coded 4. (MISSING DUE TO OTHER REASONS ARE NOT

INCLUDED IN DMFT CALCULATIONS FOR SUBJECTS UNDER 30 YEARS OF

AGE)

However for subjects 30 years and older, the M component comprises of teeth coded

4 or 5.That is MISSING DUE TO OTHER REASONS ARE also INCLUDED for

elderly population.

The "F" refers to teeth with code 3.

Those teeth coded 6, 7, 8, 9, or T are not included in DMFT calculations.

To arrive at a DMFT score for an individual patient's mouth, three values must be

determined and added: the number of teeth with carious lesions, the number of

extracted/missing teeth, and the number of teeth with fillings or crowns.

DMFT score=Decayed teeth score + Missing teeth score + filled teeth score.

• 6: A 6 is assigned to teeth on which sealants have been placed. Teeth on which

the occlusal fissure has been enlarged and a composite material placed should also

be termed 6.

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• 7: A 7 is used to indicate that the tooth is part of a fixed bridge. When a tooth has

been crowned for a reason other than decay, this code is also used. Teeth that

have veneers or laminates covering the facial surface are also termed 7 when there

is no evidence of caries or restoration. A 7 is also used to indicate a root replaced

by an implant. 8: This code is used for a space with an unerupted permanent tooth

where no primary tooth is present. The category does not include missing teeth.

Code 8 teeth are excluded from calculations of caries. When applied to a root, an

8 indicates the root surface is not visible in the mouth.

• 9: Erupted teeth that cannot be examined—because of orthodontic bands, for

example—are scored a 9.

• T: Indicating trauma, a T is used when a crown is fractured, with some of its

surface missing but with no evidence of decay.

http://www.healthline.com/galecontent/tooth-development-primary�

http://www.healthline.com/galecontent/orthodontics-1�

http://www.healthline.com/adamcontent/broken-bone�

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LIST OF TABLES

Table 1 Socio-demographic details of the elderly in Alengad Panchayat, Kerala………36

Table 2 Past occupation and present income of the elderly in Alengad Panchayat, Kerala…………………………………………………………………………...37

Table 3 Personal habits of the elderly in Alengad Panchayat, Kerala…………………..38

Table 4 Perceived status of health, medical consultation and medications among elderly in Alengad Panchayat, Kerala………………………………………….40

Table 5 Perceived status of oral health and teeth related illness among elderly in Alengad Panchayat, Kerala…………………………………………………….41 Table 6 Dental prosthetic use among elderly in Alengad Panchayat, Kerala…………...43 Table 7 Awareness regarding dental care among elderly in Alengad Panchayat, Kerala…………………………………………………………………………...44 Table 8 Current dental illness among elderly in Alengad Panchayat, Kerala……………………………………………………………...44 Table 9 Financing of dental treatment among elderly in Alengad Panchayat, Kerala…………………………………………………………………………...45 Table10 DMFT: Decayed, Missing, Filled Teeth score among elderly in Alengad panchayat, Kerala……………………………………………………..46 Table11 Prevalence of complete and partial edentulousness, complete dentate among elderly in Alengad Panchayat, Kerala…………………………………..46 Table12 Socio-demographic factors and complete edentulousness among elderly in Alengad Panchayat, Kerala…………………………………………………..47 Table13 Economic status factors and complete edentulousness among elderly in Alengad panchayat, Kerala…………………………………………………….48 Table14 Personal habits and complete edentulousness among elderly in Alengad……..49 Table15 Perceived status of health, medical consultation and medications and complete edentulousness among elderly in Alengad Panchayat, Kerala………51 Table16 Perceived status of oral health, teeth related illness and complete

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edentulousness among elderly in Alengad Panchayat, Kerala…………………52 Table17 Dental prosthetic use and complete edentulousness among elderly in Alengad………………………………………………………………………...54 Table18 Awareness regarding dental care and complete edentulousness among elderly in Alengad Panchayat, Kerala………………………………………….55 Table19 Current dental illness and complete edentulousness among elderly in Alengad Panchayat, Kerala…………………………………………………….55 Table20 Financing of dental treatment and complete edentulousness among elderly in Alengad, Kerala……………………………………………………………..56 Table21 Socio-demographic factors and complete dentate among elderly in Alengad Panchayat, Kerala…………………………………………………….57 Table22 Economic status factors and complete dentate among elderly in Alengad panchayat, Kerala…………………………………………………….58 Table23 Personal habits and complete dentate among elderly in Alengad panchayat, Kerala………………………………………………………………58 Table24 Perceived status of health, medical consultation and medications and complete dentate among elderly in Alengad Panchayat, Kerala………………..59 Table25 Perceived status of oral health, teeth related illness and complete dentate among elderly in Alengad Panchayat, Kerala…………………………………59 Table26 Dental prosthetic use and complete dentate among elderly in Alengad, Kerala………………………………………………………………………….60 Table27 Financing of dental treatment and complete dentate among elderly in Alengad, Kerala………………………………………………………………..60 Table28 Factors affecting complete edentulousness significant in logistic regression analysis…………………………………………………………….62

dentition status and dental prosthetic needs among …

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