ORAL HEALTH OF INSTITUTIONALIZED ELDERLY IN BELGRADE

Uvod. Povećanje broja starih institucionalizovanih osoba u svetu iziskuje dobru opštu zdravstvenu i stomatološku zaštitu ove grupe ljudi. Cilj rada bio je ispitati nivo oralne higijene, zatim dentalni, parodontalni i protetski status institucionalizovanih osoba starosti preko 65 godina, u tri staračka doma u Beogradu. Materijal i metod. Anketirana je i pregledana 301 osoba. Anketa je obuhvatala sociodemografske podatke, navike u održavanju oralne higijene, subjektivnu procenu opšteg zdravstvenog stanja i stomatoprotetskog statusa. Kliničkim pregledom utvrđen je status zuba i parodontalnih tkiva korištenjem DFMT i CPITN indeksa. Evidentirano je i zdravlje mekih tkiva usta. Postojeće proteze ocenjene su u pogledu retencije, stabilizacije, abradiranosti, higijene i neophodnosti reparature. Rezultati. Od ukupnog broja pregledanih, 16,6% nije održavalo oralnu higijenu. Pomoć u održavanju oralne higijene dobijalo je 2,3% ispitanika, iako je 36,5% bilo zavisno od tuđe nege. Prosečan DMFT iznosio je 26,36. CPITN indeks prosečno je iznosio 2,23. Protetski nije bilo zbrinuto 45,1% pregledanih osoba koje su imale potrebu za protezom. Reparaturu je zahtevalo 55,2% proteza, a higijena proteze bila je loša u 50,0% slučajeva. Od ukupnog broja pregledanih osoba, 11,9% bilo je bezubo i nije imalo totalne proteze. Zaključak. Može se zaključiti da stare institucionalizovane osobe ne dobijaju pomoć u održavanju oralne higijene, iako su u velikom broju zavisne od tuđe nege. Takođe, prisutan je veliki broj nedostajućih zuba i potreba za kompletnom parodontološkom i protetskom terapijom većine osoba. Neophodno je poboljšati stomatološku zdravstvenu zaštitu pacijenata u staračkim domovima. Klјučne reči: oralno zdravlje, stare osobe, institucionalizovani Abstract


Introduction
Due to demographic transformation during last decades, there has been an increase in the number of elderly people, which implies great changes and challenges for health systems and social policy.Therefore, longer lifespan is not always followed by a better life quality.Instead, some elderly need help with activities that used to be simple for them.As the number of institutionalised elderly increases, so do requirements for their general and dental health care, because elderly people live longer if they have natural teeth or dentures. 1t is obvious that there is a link between oral health and systemic disorders that endanger life quality, as well as life itself. 2,3ral health is a reflection of general health, medications, habits, behaviour and diet.Oral and dental diseases have a negative impact on nutrition and sleep. 4,5Furthermore, a connection has been proved between poor oral health and aspiratory pneumonia in patents in nursing homes. 6enerally, poor oral health of the elderly reflects in a large number of lost and decayed teeth, periodontal disease, xerostomia and oral precancerous lesions.Poor oral health decreases the ability to chew properly, and as a result, people choose softer food, usually rich in fatty acids and cholesterol and poor in fibres.Edentulousness is also a risk factor for weight loss, and a social handicap, due to difficult communication. 1 The aim of this research was to determine the oral hygiene level, dental, periodontal and prosthetic status of intitutionalized elderly persons of over 65 years of age, in three residental homes for elderly in Belgrade.
Clinical examination was performed by using dental probe, dental mirror and periodontal probe graduated in millimetres.Participants were examined in their rooms, either lying or sitting in beds, depending on their health condition, with an adequate natural or artificial lighting.
Special questionnaires were used in the research.Sociodemographic data included: education, residency duration, dependence on other people's care and its duration.Also, frequency of oral hygiene maintenance was recorded, as well as denture maintenance and incidence of dental checkups.Furthermore, a subjective assessment of a participant's health, general and oral, was recorded, and graded as very good, good, bad, and very bad.Users of residential homes were also asked whether they thought they needed dental treatment.Moreover, it was important to investigate whether the institutionalized elderly noticed any of common dental symptoms, such as: toothache, pain in/around jaw joint, bad breath, toothache after hot/cold beverage, bleeding gums, inability to chew, toothache during night, or dry mouth.
Within clinical examination any oral soft tissue lesion was recorded.Also, dental and periodontal statuses were noted.

Nivo oralne higijene
Primećeno je da je manje od polovine anketiranih imalo naviku pranja zuba dva ili više puta dnevno.Pomoć pri održavanju oralne higijene dobijalo je 2,3% ispitanika.Navike ispitanika u održavanju oralne higijene prikazane su u Grafikonu 2. of Treatment Needs) index.CPITN index was used to evaluate periodontal status and the need for its treatment.Periodontal pocket depth was measured by a graduated periodontal probe on three points, both on vestibular and oral surface of a tooth.[10] During examination it was noted whether patient had a denture, its type and age.Bearing in mind the denture quality (comfort, stability, ability to chew and taste food, aesthetics, speech), participants were asked to subjectively grade their denture from 0 (very bad) to 10 (excellent).After that, dentists made an objective and expert assessment of denture retention, stabilisation, vertical dimension, artificial teeth attrition and denture hygiene, and therefore a conclusion about the need for denture repair.
Statistical analysis was performed by a computer programme SPSS 22.0 (Chicago, Illinois, USA).Descriptive analysis, i.e. freque-ncy, average values and cross-tabs were calcu-lated, as well as the independent T-test samples.

Results
Sociodemographic features of participants are shown in Table 1, and their most common general diseases in Figure 1.

Oral hygiene level
It was noticed that less than half of the interviewed had the habit of brushing teeth two or more times a day.Two point five percent of people received help with oral hygiene maintenance.Habits concerning oral hygiene are shown in Figure 2.
Nine percent of the interviewed visit a dentist at least once a year, while 53.1% did that more than five years ago.
Dental and periodontal status Clinical examination revealed 41.1% participants to be edentulous.Average number of missing teeth was 25.18, while there was an average of 0.84 decayed and 0.58 filled.Average DMFT was 26.36.
The highest value of CPITN was 2.23 on average.Eighty-one point eight percent of the examinees had no sextant with CPITN=0, while 9.1% had one such sextant.CPITN was 2 in one sextant in 23.8% of examinees, and in two sextants in 14.0% of institutionalized elderly.One sextant had the value CPITN=3 in 25.4% of examinees, and CPITN=4 in 4.2%.The number of excluded sextants most frequently was 5 (34.4% of institutionalized elderly).
Clinical examination revealed 18.6% to have angular cheilitis, while gingivitis was present in 14.6% of cases.Denture-related stomatitis could be seen in 11.6% of participants.Extreme alveolar atrophy was noted in 10.6% of the institutionalized persons, and glossitis in 5.6%.
During subjective evaluation of one's own health, examinees complained mostly of dry mouth (59.9%), and almost half thought they needed a dental treatment.
Details of subjective evaluation of one's own oral health are shown in Figure3.

Prosthetic status
Examined institutionalized elderly mostly used complete dentures.Frequency of different types of prosthetic restorations is shown in Figure 4.
Prosthetic restoration was not applied in 45.1% of participants who needed it.Eleven point nine percent were edentulous, and had no dentures.Average age of a denture was 11.9 years.Examinees graded their dentures with 7.42 on average.
Results of an objective assessment of a denture quality are shown in Figure 5, and it can be seen that almost all dentures that institutionalized elderly used needed some kind of correction.
The method applied has limitations in comparison to other methods described in the literature, when control group of healthy patients is concerned. 4Apart from frequency analysis, average values and cross-tabs, which were a part of our method, some research used other analysis, such as variance and regression. 4,15nstitutionalized elderly in our research were examined in their rooms, sitting or lying in bed, depending on their health condition, and under good natural or artificial lighting.As no residential home for elderly where the research was performed had a dental office, clinical examinations were done in a previously described way.In other surveys, dentists were able to use well-equipped dental offices within residential homes, including general anaesthesia for mentally disabled patients who refused necessary treatment. 15t is important to emphasize that during the interview some participants gave dishonest answers about dependence on other people's care and oral hygiene maintenance.To be more precise, a number of the interrogated said to be independent of other people's care, and they were accommodated in a section for half-dependent or dependent.In such cases, researchers corrected answers in questionnaires on their own.Furthermore, it was noticed that many refer to rinsing mouth with water as "toothbrushing".Same persons said that they do not use toothbrush or toothpaste.Their answer that they do brush teeth was corrected into "do not brush teeth".
Bearing in mind the studies that show a high correlation between denture usage and death rate of elderly people in residential homes, it can be stated that more than half of the examined people are endangered by decreased number of teeth and existence of dentures. 20o be more precise, 67.8% of examined institutionalized persons use mobile dentures, and the average number of missing teeth is 25.18, which strongly emphasizes the necessity to preserve natural teeth in this group of people.It is possible to compare 45.3% of edentulous institutionalized people, stated by a research from our region, with our result of 41.1% of edentulous participants, although that research was performed on a two times smaller sample (139) than ours. 12he same research noted the average DMFT of 27.0.Our result is almost identical: 26.36.
Another research from our region found that 70.0% of residential home users were edentulous, after clinical examination of 274 persons, which is similar to the number of our participants (301). 11Such various results can be explained by different levels of dental care among countries, even within one country. 11,12Although our results match ones of a research that shows somewhat better oral health of institutionalized elderly, even such results stress the need for improving dental health care in residential homes for elderly.

Conclusions
Elderly institutionalized do not receive help with maintaining oral hygiene, despite the fact that many are dependent on other people's care.Also, this group of people has a large number of missing teeth and the majority need a complete periodontal and prosthetic treatment.It is necessary to improve dental health care of patients in residential homes for elderly.

Table 1 .
Sociodemographic features of participants