Oral Diseases (1995) I, 147-151 b 1995 Stackton Press All rights resewed. 1354-523X/95 112.00

Oral disease in the elderly in long-term hospital care

LP Samaranayake', CA Wilkieson2, P-J Lamey3, TW MacFarlane"

'Oral Biology Unit, Faculy of Dentisiry, University of Hong Kong: 'Department of Geriatric Medicine, Vicioria Infirmap, Glasgow, Scotland: 'Department of Oral Medicine, Queens University of Belfast, Northern Ireland; JDepartrnerit of Dental Sciences, University of Glasgow, Scotland

OBJECTIVE: To obtain baseline information on the prevalence of oral problems and disease in insti- tutionalized elderly in a Scottish hospital. DESIGN: A cross-sectional clinical investigation with complementary microbiological studies as appropriate. SUBJECTS AND METHODS: A cohort of 147 elderly in five long-term care wards; collection of demographic data; clinical examination to determine: i) the dental, and denture status and associated lesions such as Can- dida-associated denture stomatitis and angular cheilitis, ii) oral mucosal disease; swabs as appropriate for micro- biology. MAIN OUTCOME MEASURES: Dental status, root car- ies prevalence; denture status and hygiene, and associ- ated disease; oral mucosal health. RESULTS Median period of institutionalization of I47 patients was 15 months and 65% were aged 80 years or more; the majority were significantly mentally impaired; 52% wore complete dentures, 9% were partially dentate, 19% possessed partial or incomplete dentures; 20% were neither dentate nor had dentures. Of 80 patients who verbalired their complaints, 35% complained of dry mouth and 45% had denture-related problems, princi- pally discomfort. The commonest oral finding was a coated tongue (56%); angular cheilitis was present in 25%, and Candida-associated denture stomatitis in 19%; none had oral ulcers. CONCLUSIONS: There was considerable unmet dental need with significant oral disease and poor levels of oral and denture hygiene in this target group; both dental and medical professionals should act in concert t o deliver curative as well as preventative dental care for the eld- erly living in institutions to improve their quality of life.

Keywords: oral disease; prevalence; elderly; institutionalized; hospital care

Introduction The elderly are particularly predisposed to the development of oral disease as a consequence of their age (Miles, 1972),

Correspondence: Dr LP Sarnaranayake, Oral Biology Unit. Faculty of Dentistry, University of Hong Kong. The Prince Philip Dental Hospital, 34 Hospital Road. Hong Kong Received 13 April 1995; revised 5 June 1995; accepted 26 June 1995

presence of physical (Ekelund, 1988a) and mental disease (Whittle et al, 1987), and often multiple drug therapy (Bahn, 1972). This situation is further exacerbated in insti- tutionalized elderly as a number of these factors may often act in concert to initiate or aggravate such disease. Although there are a number of studies on the prevalence of oral disease in the institutionalized elderly from a variety of countries (Grabowski and Bertram, 1973; Donatsky et al, 1980; Lemasney and Murphy, 1984; Brauer et al, 1986; Stockwell, 1987; Whittle et al, 1987; Ekelund, 1988a,b; Viglid, 1990) such data for a Scottish population are sparse (Neil1 and Phillips, 1970).

In general, all elderly patients admitted to geriatric units in the United Kingdom are assessed and all remediable con- ditions treated. Those severely debilitated and who need frequent medical and nursing care are admitted to long- term care wards where they remain for the rest of their lives. It is easy to appreciate, therefore, that such patients run a high risk of developing oral disease. Although a high standard of oral hygiene encouraged by hospital carers should help offset such a predisposition, several factors, including patient compliance, do not always make this possible.

In particular, these individuals are a high risk group for development of oral mucosal disease. Old age itself, den- ture wearing, antibiotics, corticosteroids, diabetes mellitus, xerostomia and malignancy all predispose to development of oral candidosis (Samaranayake and Lamey, 1988). Simi- larly both coronal and root surface caries may become ram- pant in the neglected, dry mouth of an elderly patient and drug therapy may compromise salivary function.

We therefore set out to define the prevalence of oral problems and disease in the elderly residents of five geri- atric long-term care wards in a Glasgow city hospital.

Material and methods

A total of 147 patients resident in five thirty-bedded long- term care wards for the elderly in StobhilI Hospital were approached and their permission sought for inclusion in the study. Where appropriate, permission was also obtained from relatives and nursing staff.

All interviews and clinical examinations took place at the institutions by one examiner. Prior to clinical examination demographic and medical data were collected from the nursing and medical notes. The demographic variables included age, sex, and length of stay in any form of hospital

Oral disease in elderly s LP bmannayake et al

I48 care and length of stay in their current long-term ward. The medical variables comprised the number of prescribed drugs, past medical and dental history. The current medical problems were obtained from the nursing and medical notes. Details of drug therapy were obtained from the drug prescription sheet and the drug recording sheet was checked for patient compliance.

The presence, nature and age of dentures was established and patients were asked about wearing habits, denture- related problems and denture care. Their last dental consul- tation was established by interviewing patients, relatives and staff and referring to case records.

A short, simple oral health questionnaire was applied asking about symptoms relating to salivary flow, angular cheilitis and mouth ulcers. Mental state was assessed using the Abbreviated Mental Test (Hodgkinson, 1972). Patients with a score of less than 7 out of 10 were considered to have significant mental impairment.

Oral examination was carried out in a thorough standard- ised manner by one examiner using a plain dental mirror and a blunt probe with illumination from a hand-held light. The whole oral mucosa was inspected and only clearly vis- ible abnormalities and changes were recorded. Angular cheilitis was defined as erythematous cracks or fissuring at the comers of the mouth. Candida-associated denture stomatitis was recognised as areas of pinpoint or uniform erythema on the upper denture bearing mucosa. Swabs and smears of the palatal and the denture surfaces were taken and analyzed to confirm such diagnosis. Tongue coating was a subjective assessment, and was defined as being,pre- sent on the dorsum of the tongue with a uniform distri- bution of papillae.

Results

Study population The age distribution of the 147 patients studied is shown in Table 1. There were 44 male and 103 female aged 62 to 97 years. The majority had been in some form of hospital care for some time and on average had been resident in their current ward for more than a year (median = 15 months). Cerebrovascular disease was the most common physical disease present (54%), followed by ischaemic heart disease (28%) and arthritis (22%) (Table 2). All pati- ents were receiving drug therapy, with 15% receiving four or more drugs; 88% took at least one drug (Figure 1). Fifty

Table 1 Age distribution of the study population

Age groups Number

60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99

Total

2 9

11 31 42 35 12 5

147

Table 2

Diseuse N o of putienrs (%)

The disease prevalence among 147 long btay geriatric patients

Cerebrovascular disease lschaemic heart disease Arthritis Congestive cardiac failure Parkinsons disease Diabetes mellitus Chronic obstructive airways disease Depression Anaemia Cancer

79 41 32 20 14 12 I I 9 6 5

Figure 1 147 patients surveyed in the study

The number of different types of drugs taken by the cohort of

two per cent of the subjects took drugs with hyposalivatory side-effects.

Significant mental impairment, as determined by the Abbreviated Mental Test score of less than 7 out of 10 was present in 98 (67%) patients, while 29 (20%) had little or no impairment (score, > 7 out of 10). The remaining 20 patients (13%) were either unable to answer the questions as a result of speech impairment or simply declined to do so.

Dental care delivery and dental status The last dental consultation could only be established with certainty in 75 (51%) patients as summarised in Table 3. The majority had not consulted the dentist for more than two years. Most of those seen in the previous 1 to 2 years had been visited by the hospital dentist at the request of the patient or nursing and medical staff, principally for denture- related problems.

The dental status of the patients is shown in Table 4. One in five patients (20%) were edentulous and did not possess dentures. Many of these patients previously pos- sessed dentures but either lost them or found them

Oral disease in elderly LP Samaranavake ct 01

Table 3 The time since last dental consultation in patients in geriatric long-term care wards

Years Number of patients (%)

0-1 24 (16) 2-3 17 (12) 4-5 6 (4) 6-10 12 (8) 1 1-20 9 (6) 21-40 4 (3) 41-60 3 (2) Unknown 72 (49)

Total 147 (100)

149 Table 6 summarises the prevalence of other oral symptoms, the most common being of dry mouth.

Table 6 Oral symptoms in patients in geriatric long-term care wards

No of putients (%) Sv,nptotn

Dry mouth Bad taste Excess saliva Coated tongue Loss of taste Burning sensation Mouth ulcers Unablelunwilling to respond

28 (19) 17 (12) I0 (7) 10 (7) 6 (4) 6 (4) 3 (2)

67 (46)

Table 4 Dentition of 147 patients in geriatric long-term care wards

Nuttdxr of putients

Age (yrsl Dentare Derit t D Cutnplere D LID on!). LD otily Neither Totd

60-69 I 0 4 2 0 I 8 70-79 3 2 27 5 I 6 44 8 6 8 9 4 1 37 18 0 18 78 90-99 0 I 9 2 0 5 17 Total 8 4 77 27 f 30 147 (90’0) (6) (3) (52) (18) ( 1 ) (20) ( I 00)

D = Dentures Dent = Dentate UD = Upper denture LD = Lower denture

uncomfortable and so abandoned them some years pre- viously.

Ward policy dictated that dentures should be worn by day and soaked in an alkaline peroxide solution (registered trade mark Steradent) overnight. The majority (94%) of pat- ients appeared to comply with this; five patients wore the dentures constantly and four only occasionally. A further five patients wore their maxillary dentures by day, taking them out at night but never (three cases) or only occasion- ally (two cases) wore their mandibular dentures.

Only 80 patients were willing and able to answer the simple oral health questionnaire and of these 36 complained of denture-related problems, mainly discomfort (Table 5).

Table 5 Denture-related problems in patients in geriatric long-term care wards

Number of patients (%)

No problems 44 (30) Problems appearance 3 (2)

discomfort 18 (12) unable to eat 10 (7) food under denture 5 (3)

Unable/unwilling to respond 67 (46)

Clinical jindings Of the 147 patients included in the study only 137 permit- ted detailed oral examination. Most had more than one oral lesion and the range of diseases noted are shown in Table 7. Angular cheilitis, Candidn-associated denture stomatitis, fissured tongue and atrophic glossitis were most frequently found, and perhaps surprisingly oral ulceration was not

Table 7 care wards

Oral examination findings in patients in geriatric long-term

Finding No of patients (%)

Coated tongue Angular cheilitis Fissured tongue Denture stomatitis Atrophic glossitis Dental caries Root caries Geographic tongue Denture induced hyperplasia Damaged dentures Nicotinic stomatitis Retained roots Median rhomboid glossitis Unablelunwilling to respond

83 36 31 28 23 12 8 8 7 4 3 2 1

10

Oral disease in elderly LP Samaranayake ef 01

observed. All those who were dentate had active root caries, some with advanced disease.

Discussion

The elderly in long-term hospital care were a very debili- tated group with both physical and mental impairment which necessitated the frequent use of drug therapy, and also compromised their personal oral hygiene routines. They were, therefore, at risk of developing oral problems. Balanced against this was the ward policy which should have encouraged good oral hygiene although i t was difficult to determine how efficiently such policies were implemented, particularly in the face of other more pressing demands on staff, and uncooperative patients.

The present results, where three quarters of the study group were edentulous, contrast with another Scottish study conducted more than 20 years ago, where 90% of insti- tutionalized elderly were edentulous (Neil and Phillips, 1970). However, our results are almost identical to those of Stockwell (1987) and Viglid (1987) from Australia and Denmark respectively, who reported 74% prevalence of edentulous in institutionalised elderly. Further, Rise and Heloe (1978) from Norway, and Lemasney and Murphy (1984) from Ireland reported 80% and 78% prevalence rates of edentulous respectively, in similar population cohorts. Nonetheless, other data from Italy (Angelillo et al, 1990), Norway (Rise, 19821, Israel (Mersel et al, 1984; Mann et al, 1985), Finland (Yli-Urpo et al, 1985) and Denmark (Brauer et al, 1986) indicate lower prevalence rates of edentulous elderly, ranging from 54 to 61%.

The 75% edentulous in our cohort is greater than the 65% edentulous reported in community dwellers, aged 65 years or more living in the United Kingdom (Todd and Lader, 1991). However, differences in oral health status between community and institution dwellers are difficult to interpret as the former population is typically older and has a higher proportion of women, confounding any association between institutionalization and disease levels (Todd and Lader, 1991). In general, our findings tend to support those of a Canadian study (where the data were adjusted for the aforementioned confounders) in which the institutionalized were more likely to be edentulous than the community dwellers.

Surprisingly, 20% of our cohort had neither teeth nor dentures and it is likely that the inability adequately to chew food would have affected their nutrition (Neil1 and Phillips, 1970). While some would probably be unable to cope with dentures, others had merely lost their dentures which were not replaced. Perhaps regular dental review would have avoided this remediable problem. Dry mouth, seen in many patients, and poor fit may have contributed to the denture- related discomfort experienced by 28% of those denture wearers who answered the questionnaire. It is interesting that only three patients were concerned about the appear- ance of their dentures suggesting that the cosmetic value of dentures was a low priority.

In addition to overnight soaking of dentures in antisep- tics, partially dentate patients were encouraged to brush their teeth twice daily but the absence of a tooth brush or toothpaste from their toilet bags would suggest that some

of those with mental impairment may not have attended to their oral hygiene. This most probably contributed to high incidence of dental caries. Further, it has been shown that many of the elderly mentally impaired patients are unwill- ing to allow the staff to assist in daily oral hygiene (Viglid, 1990). A contributory reason for this may be that the nurs- ing staff do not know how to deliver specialised oral care for such patient groups (Viglid, 1990). It is therefore important that the staff not only be motivated to help, but also trained appropriately in assisting such patient groups.

The fact that the majority of the patients were not seen by a dentist for more than two years is not surprising as dental consultation was available on an ‘on demand’ basis only, with no provision for regular oral examination. None- theless, it should be noted that only 30% of British adults, 65 years or over, visit a dentist at least once in two years (Todd and Lader, 1991). Another contributory factor for the gross oral neglect seen in this population is the likeli- hood that the majority were either ill, immobile andor mentally impaired before hospital admission. All these highlight the crucial necessity of regular prophylactic den- tal review before admission to the ward and on subsequent occasions. Whether or not the relatively low utilization of dental services by the elderly (both institutionalized and community dwelling) presents a significant problem that deserves public intervention is an unresolved question. There is little political pressure by society, in general, and the elderly, in particular, to establish special dental finan- cing or delivery programs for this age group, in most West- em countries (Cohen and Gift, 1995).

The high prevalence of coated tongue was compatible with a population with variable oral hygiene who appeared not infrequently to have a dry mouth. It is possible that xerostomia precipitated by drugs with hyposalivatory effects regularly administered to 52% of patients in the study may have contributed to this condition. It is widely known that Candida-associated denture stomatitis is the most common oral mucosal lesion in elderly denture-wear- ing populations (Ritchie, 1973; Ambjornsen, 1985; Kandel- man et al, 1986; Budtz Jorgensen, 1990) and this study is no exception as 28% of full maxillary denture wearers had this condition, Similar numbers were found in other compa- rable studies (Viglid, 1987; Budtz Jorgensen, 1990). The prevalence of angular cheilitis was perhaps higher than expected from other studies (Viglid, 1987; Ekelund, 1988b) but this may merely reflect different diagnostic criteria. Due to the nature of the study population with mental agility ranging from normal to severe impairment, it is difficult to rely completely on the verbal responses of the participants. Nevertheless, the data indicate that significant, remediable oral problems such as Candida-associated denture stoma- titis, angular cheilitis and dental caries existed in this insti- tutionalized elderly population.

To conclude, results of this investigation support the findings of other studies that the dental and oral health status of the institutionalized elderly is poor and neglected (Lemasney and Murphy, 1984; Mann et al, 1985; Brauer et nl, 1986; Kandelman ef al, 1986; Stockwell, 1987; Ekelund, 1988a; Viglid, 1987; Angelillo et al, 1990; Viglid et al, 1993). These findings emphasize the necessity of improving the dental health service programs for this sector of the

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