Source 16

The aim of the present study was to assess the oral health practices, status and treatment needs of the rural elderly in national capital territory of Delhi. An effort was also made to identify patterns of utilization of dental services and test alternate strategies for service provision. A total of 96 elderly subjects (47 males and 49 females) in 5 rural areas were interviewed and clinically examined using Basic Oral Health Survey criteria of W.H.O. This was followed by a community trial in which the 5 villages were divided into control and test groups. Results of the survey found that both traditional as well as modern oral health practices co-exist in the rural community. Dental services were available to a majority (mostly through private sector), and edentulousness was a condition of primary concern among the elderly as a result of unmet treatment needs for dental caries and periodontal diseases. Age was a variable that was statistically significantly associated with edentulousness (p=0.005). Results of the community trial showed that higher utilization of care can be achieved by providing on-site dental care as compared to referring cases to tertiary care centers. Nevertheless provision of treatment alone is not a suitable policy recommendation since many elderly did not avail care even at on-site community dental health programmes that were operated free of cost. This emphasizes the need of health education over treatment in order to empower the elderly, especially the non-ambulatory patients, to practice prevention and develop favourable attitudes towards accepting prompt treatment at primary health care level.

The demographic distribution of the sample was similar to the actual profile of the rural population in Delhi, which implies that findings of this study have a generalization value.
The predominant oral hygiene aid reported was toothbrush (43.7%) although a number of subjects (21.9%) also reported using Datun, which is a scientifically accepted indigenous oral hygiene aid used widely in many rural parts of India Datun or chewing sticks, are derived from the Neem tree (Azadirachtaindica, family Meliaceae) that has antipyretic, antiseptic and insecticide properties as described by Elvin Lewis M and Lewis ALI. Azadirachta indica is also used to treat skin diseases, manufacture soap and toothpaste. No other oral hygiene aid was reportedly being used by the subjects, which is an observation similar to that reported in Chinese population by Schwarz LP and Lo ECM who found that the use of dental floss was very uncommon, only 21 subjects reported using fluoridated toothpaste and a little over half the subjects (52%) changed their toothbrushes within 3 months. These findings reflect paucity of proper information on contemporary plaque control devices. However most subjects (87.5%) reported rinsing their mouth with water always after meals, which is a healthy cultural practice followed in India Over half the subjects (58.3%) reported snacking in-between meals, which is an unsafe dental health practice as documented by Murray JJ.

History of smoking tobacco was reported by one-quarter (27.1 %) of the subjects, both males and females. Of these, 92.4% reported using traditional Indian forms of smoking, viz. hooky (smoking pipe) and / or bidi (tobacco rolled in tembomi leaf). Such traditional forms of smoking have been associated with oral pre-cancer and cancer and have a higher relative risk as compared to cigarettes as documented by Jafarey who found the relative risk for smoking to be 5.7 for men and 12.9 for women in Pakistan. Among different smoking habits (compared to no smoking or / and tobacco chewing habits) cigarette or cigar smoking increased the risk by 6 times, hooka and pipe by 16 times and bidi smoking by 36 times.

Few subjects of both sexes (7.3%) reported chewing tobacco with betel leaf or betel nut. Chewing tobacco is another risk factor associated with oral pre-cancer and cancer as documented by Paymaster who observed in his study that 81% of 4212 oral cancer patients in India used tobacco of which 36% were chewers, 23% smokers and 22% practiced both chewing and smoking. Simarak conducted a study in Thailand and reported, using multivariate regression analysis, that the relative risk estimate for the betel-tobacco chewing habit was significant for both men and women.

Private practitioners were the main source of availability of dental treatment for majority of subjects (61.5%). This observation can be associated with the fact that dental surgeons are not posted at the level of primary health center/dispensary in most rural areas of India, including Delhi and hence a majority of population is dependent upon private practitioners, a good number of whom may be quacks.

A majority of subjects (81.3%) did not elicit any history of oral health problems in the last one year, which was in contrast to a cent-percent prevalence of normative needs as observed during the clinical examination. This is in accordance with findings of Hell MW and Gethort GH who reported similar observations from Florida regarding lack of congruence in self-perception and actual needs. Furthermore, in the present study, mainly those subjects who reported a history of suffering from gum disease and tooth decay also reported utilizing dental care for alleviating their oral health problem, of whom most were females. This observation is in accordance with findings reported by Vargas CM in their study on oral health care utilization by US residents who concluded that inhabitants in rural areas go for problem oriented treatment and not for comprehensive treatment/ rehabilitation. Hence it can be inferred that felt needs are an important determinant of utilization of care, as suggested by KiyakI IA and Miller RR. In addition, Tennstedt SL reported that women as compared to men are more likely to visit a dentist.

Periodontal examination revealed that few dentate subjects (22.58%) had healthy periodontitrn, with fewer males (17.24%) as compared to females (27.27%). A majority of subjects had calculus deposits (2.03 ± 2.10 sextants) and bleeding from gums (1.05 ± 1.81 sextants). Only 2 (male) subjects (0.08 ± 0.52 sextants) had shallow pockets 4-5mm deep and none of the subjects had deep pockets > 6nnn. These findings are in agreement with a study done by Holmgren CJ who folmd that most elderly subjects in Hong Kong had bleeding from gums and calculus deposits around one or more teeth. However greater numbers of subjects were found to have shallow pockets (51%) or deep pockets (15%) in the same study.

About a third of the dentate subjects (33.87%) did not have any loss of periodontal attachment was almost similar in both males (31.03%) and females (36.36%). Most subjects had 4-5mm loss of attachment (1.60 ± 1.84 sextants) followed by 6-8mm loss of attachment (0.40 ± 0.95) and 9-11mm loss of attachment (0.13 ± 0.42 sextants). None of the subjects had loss of 12mm attachment. These findings are in agreement with a study done on Chinese elderly by Baelum et al [16] who found that 50% subjects had loss of attachment of 4-5mm and 10-30%had loss of attachment of 6-8mm.

A cent percent dental caries experience was observed in the dentate elderly. The mean DMFT was higher for females (10.18 ±7.09) as compared to males (8.86±8.06) the M component (8.61 ± 7.86) contributed the major portion of the DMFT(9.56±7.53) in both sexes. Not even a single filled tooth was found in any of the subjects. In addition about one-quarter of dentate subjects (22.58%) of both sexes had decayed roots (0.69 ± 1.69). These findings are similar to those reported by Lo ECM and Schwartz in a study of the elderly in Hong Kong who found mean number of decayed teeth to be 1.4 (1.7 for males and 1.3 for females); mean number of missing teeth to be 17.0 (14.8 for males and 17.8 for females); and mean number of filled teeth to be 0.5 (0.6 males and 0.5 females). The mean number of decayed roots was 0.4 (0.5 for males and 0.4 for females) and mean number of filled roots was 0.1. In another study Christensen J surveyed the Oral health status of 65-74 yr old persons in Denmark and found the mean DMFT to be 30 with an average of 1 decayed tooth, 28 missing teeth, 1 filled tooth and 2 sound teeth.

A majority of dentition treatment needs for dental caries presented as one surface filling (0.8511.30) followed by extractions (0.76). Need for two or more surface filling were negligible (0.03±0.18) and were required by male subjects only. Lo ECM reported a similar distribution of dentition treatment needs on elderly subjects in Hong Kong where 29% needed one surface filling, 21% needed two or more surface filling and 29% needed extractions due to caries.

A majority of subjects were partially or completely edentulous in one or both arches and most of them were not having any prosthetic replacement for lost teeth, i.e. 92.59% in upper arch and 92.50% in lower arch. The most common oral prosthesis wom by the edentulous subjects was complete dentures (3 in upper arch and 4 in lower arch). One subject each was wearing a removable partial denture and both bridge and removable partial denture in upper and lower arches. Complete dentures constituted a major proportion of prosthetic needs among subjects of both sexes (38.27% in upper arch and 41.25% in lower arch). In a similar study of elderly by Christensen J in Denmark, it was documented that 66% of the population was edentulous of which 14% reported wearing denture in one arch and 74% in both arches. Of the population who were wearing denture, 8% were in need of prosthetic treatment and 79% who had at least one removable denture needed prosthetic treatment due to ill fitting or faulty dentures. Hence 87% of old age population was in need of prosthetic treatment. Another study done by Corbet EF and Lo ECM among 537 elderly in Hong Kong found that 12% of the subjects were completely edentulous. Overall 29% of the elderly had no prosthesis, 52% had a denture or dentures, 33% had a bridge or bridges and 13% had both.

Upon analysis of risk factors associated with edentulousness, a statistically significant difference was observed in relation to age. This observation that edentulousness increases with age is in agreement with the finding of Shetty P and Angelillo IF.

A total of 475 patients were examined at community dental health programmes conducted in the study areas. A majority of dental treatment provided in Barwala, Kirari Suleman Nagar and Mustafabad (study areas where treatment was provided on-site) during the programme was tooth extractions (10.53%) and complete dentures (7.79%). It was observed that in Jharoda Kalan (control area where no services were provided), just 1 subject availed dental care at a private clinic during the period of study. Even in Bijeasan (study area where treatment was provided only through referral services), just 1 subject reported to the tertiary center for availing the referral facility. These findings suggest that more number of elderly utilize care when it is provided through on-site community dental health programmes as compared to referral services or private offices. Furthermore, since all the rural areas were located in different part of Delhi, they were separated by space and thus there was little possibility of subjects from one study area availing care at the programme conducted in another study area.

A total of 26 sample subjects reported being aware of the community dental health programme conducted in their area, of which 12 attended the programme and 14 did not. Health workers (46.15%) and neighbours / relatives (42.31%) were the principal sources of information regarding the programme, followed by printed information (34.61%). This finding emphasizes the relative importance of inter-personal communication and print media in health promotion activities.

The most common reasons cited by the sample for not attending the programme were "ill-health/ disability" (42.86%) and "busy with work commitments" (42.86%). "Unavailability of attendant", "preference for home remedy" and "fear of dental treatment" were some of the other reasons cited for the same. Chattopadhyay A in New York State Minority Health Survey found cost, distance or unavailability of dentist in the vicinity as the main reasons reported for non-attendance at dental programme. A study by BhayatAand Cleaton Jones P in rural Zulu population of SouthAfrica showed cost as the main barrier for the same. Andersen R and Newman JF, who developed a popular model of health services utilization, view the use of health services as function of predisposing, enabling and need characteristics of the individual. However none of the traditional barriers to accessing care (as mentioned in other studies) were reasons for non-attendance by any of the subjects in the present study since the numbers of the subjects who availed dental care were too few for any meaningful analysis. Nevertheless the reasons cited by the subjects for not attending the community dental health programme indicates that they do not prioritize their oral health over other issue which is reflective of their attitude. Attitudinal factors further interact in a complex manner with other variables, especially socio-demographic, service related and ill health related factors as suggested by Schou. Also, given the non-ambulatory status of many elderly, non-provision of domiciliary visits (using portable dental equipment) for the homebound patients in the present study could have been another barrier to accessing care by the subjects, as suggested by Fiske J.

Recommendations for improving community dental health programmes were ranked by the subjects in the following order of preference:

Depute more number of dental health workers:
Provide all types of dental treatment;
Hold dental health programmes more frequently;
Give more time to each patient; and,
Give more publicity to the programme.


The order of these recommendations was keeping in line with the ranking of problems reported by the subjects, i.e. long waiting time (33.34%), all types of treatment facilities not available (33.34%), multiple recall visits (16.67%) and painful procedure(8.33%).

Subject ranked their recommendations for imparting geriatric dental care services in the following order of preference;

Hold regular dental awareness campaigns at primary health centres;
Ask health workers to make domiciliary visits to disseminate information on prevention of oral diseases;

This paper is cool because it discusses the condition of elderly people in India. This is nice because I don't know much regarding the oral condition of the elderly. This article was also nice because it talked about a lot more than the oral condition of the elderly, it also talked about the sociodemographic condition.