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Year : 2020  |  Volume : 31  |  Issue : 4  |  Page : 507-514
Oral health status and care of institutionalized elderly individuals in Lebanon

1 Faculty of Dental Medicine, Lebanese University, Lebanon
2 Paris Descartes University and Hopital Louis-Mourier, France
3 Laboratoire de Recherche Cranio-Faciale, Oral Health Unit, Faculty of Dental Medicine, Saint Joseph University of Beirut, Beirut, Lebanon
4 Former Dean, Faculty of Dental Medicine, Lebanese University, Lebanon

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Date of Submission04-Mar-2020
Date of Decision30-Mar-2020
Date of Acceptance20-May-2020
Date of Web Publication16-Oct-2020


Background: Oral health of the elderly is a major public health challenge. Data on oral health and dental care of the institutionalized elderly is lacking in Lebanon. Aims: (1) Assess the oral health of Lebanese people aged 65 years and over living in residential facilities; and (2) identify factors associated with poor oral status. Materials and Methods: A sample of 526 nursing home residents aged 65 years and older was randomly selected from 46 residential facilities. Information collected were sociodemographic characteristics, degree of autonomy regarding toilet use and nutrition, presence of chronic diseases and medications, dry mouth sensation, dental brushing, access to oral health and reasons of dental visits. A structured oral examination was conducted to gather data on DMFT index, oral hygiene indices modified gingival index, and the unmet need for prosthesis. Statistical methods included bivariate and multivariate analyses. Results: 55.9% of the participants were edentates, 41.4% used partial and/or complete dentures, and the minority used dentures with good hygiene. 15% of the dentate sample reported regular tooth brushing, 7% reported to have visited the dental office in the past 12 months, and 57% presented an unmet need for prosthesis. Oral health status was significantly related to age, smoking, daily tooth brushing, and autonomy (P < 0.05). Subjects with chronic diseases and consuming medications were more likely to have xerostomia. Conclusion: Oral health status is poor in the elderly institutionalized Lebanese population, which should promote a multidisciplinary team sharing responsibility for daily oral hygiene and access to dental treatment.

Keywords: Access to care, institution, Middle Eastern country, older people, oral health

How to cite this article:
Choufani A, Folliguet M, El-Osta N, Rammal S, Doumit M. Oral health status and care of institutionalized elderly individuals in Lebanon. Indian J Dent Res 2020;31:507-14

How to cite this URL:
Choufani A, Folliguet M, El-Osta N, Rammal S, Doumit M. Oral health status and care of institutionalized elderly individuals in Lebanon. Indian J Dent Res [serial online] 2020 [cited 2022 Aug 9];31:507-14. Available from:

   Introduction Top

The world's population is aging; in Europe, more than 19% of the population is older than 65 years, compared to 16.3% in the United States and 27% in Japan.[1] In Lebanon, the proportion of people aged 65 years and older is estimated to be more than 10%.[2],[3] In 2025, this population is expected to include more than 830 million of people worldwide, due to the decline in birth rate and the decrease in mortality rate.[1],[2],[3]

Oral health of the elderly is a major public health challenge. They have important oral health problems with disparities related to socioeconomic conditions, mental impairments, and access to oral health services.[4] A poor oral health status affects the quality of life and the ability to eat, communicate, and socialize. Moreover, pathological microorganisms present in saliva, on denture and teeth may be inhaled and cause pneumonia, the most common cause of mortality in frail people.[5],[6]

Living at home or in long-terms facilities can influence the use of care and the patients' perception of their oral health status.[7] In developed countries, poor oral health of institutionalized older people has been attributed to the inability to achieve proper oral hygiene and to the lack of dental care consumption in comparison to those living at home.[7] A great percentage of institutional residents do not have the functional or cognitive abilities to practice oral care independently and must rely on their nurses to help them maintain good oral health.[8] They corroborate about the need to increase awareness of nursing staff and their responsibilities to assume the daily oral hygiene for patients unable to do so for themselves.[7],[9] This action could decrease the risk of infections, improve the quality of life, and in turn increase the life expectancy.[7],[9]

In Lebanon, most elders are capable of living independently but the number of seniors in long-term facilities although low, is growing. Oral care is perceived as a low priority one in institutions and questions have always been raised about the status of oral health and the quality of oral care provided by institutions caring for elderly.[2],[3]

Some studies have been performed to assess oral health of older people living independently but data on oral health of elderly living in home facilities is still lacking.[10],[11],[12] Therefore, the aim of this national study was to assess the oral health status of institutionalized Lebanese people aged 65 years and over, and to investigate its relationship with social background and health-related behaviors and characteristics.

   Materials and Methods Top

Study design

This nation-wide cross-sectional study was undertaken from October 2016 till May 2017 among Lebanese elderly individuals (age 65 years or more) living in residential facilities across the country. The study was approved by the ethical committee of the Lebanese University (ID# 146/242018). A written informed consent was obtained from the participants and a verbal consent was obtained in case of illiteracy.

Sampling and sample size

The sampling frame used was based on the most recent list of nursing organizations published by the Lebanese Ministry of Social Affairs and the United Nations Fund.[13] A total of 55 institutions for older people were identified and 9 were excluded due to lack of information (number of beds, size of establishment). Hence, the random selection was performed on 46 residential facilities including 4,709 beds. Institutions were selected using a stratified random sampling technique with a proportional distribution based on the total number of beds reported in all institutions for each geographical area. In each institution, subjects were randomly selected. Only residents age 65 years or more living in the institution for at least 3 months were included in the study. As provided by the staff of the institutions, participants suffering from a terminal illness or having a severe cognitive impairment preventing cooperation during the dental examination were excluded.

The sample size was calculated according to the formula N = 50 + 8m, where m is the number of independent variables. Given that m is equal to 10, a minimum of 130 subjects had to be included in the study.[14]

Data collection

Data were collected from a questionnaire and a clinical oral examination, performed by the same examiner in each governorate. The examiners were calibrated according to WHO guidelines to ensure that each one was able to follow a standardized plan and to minimize the disparities between the different examiners.[15]

Questionnaire: It was completed in the presence of the geriatrician and the nurse in charge. The information collected were sociodemographic characteristics (age, gender), smoking status (yes/no), frequency of family or friends visitors (1/week, >1/week), degree of autonomy regarding toilet and nutrition (autonomic, partially dependent, totally dependent), presence and number of chronic diseases, number of medications intake per day, dry mouth sensation, and tooth brushing per day. In addition, participants were asked about their access to oral health in the last 12 months and the reasons of their dental visits.

Clinical oral examination: It was performed visually with prepackaged sterilized instruments (single use mirror and probe) and equipment (gloves, mask, and gauze pads) according to WHO standards.[16] The number of teeth with carious lesions at D3 level according the Eckstrand classification, teeth with fillings and missing teeth were recorded.[17] The DMFT Index was calculated according to the World Health Organization criteria. The presence and the types of removable prosthesis used were also recorded (partial, complete).

Oral hygiene was clinically evaluated by assessing plaque index.[18] For subjects using removable prostheses, food deposits were assessed on removable prostheses and coded as described by Cohen et al.[18] For dentate subjects, the Simplified Oral Hygiene Index (OHI-S) as described by Greene and Vermillion was applied with its two components: debris and calculus index.[18],[19] The modified gingival index (MGI) was used to assess periodontal status ranging from 0 = no inflammation to 4 = severe inflammation. It is a non-invasive (no probing), and practical technique for institutionalized elderly.[20]

Statistical analyses

The IBM® SPSS® statistics 24.0 and Stata/SE 11.1 statistical packages were used to carry out all statistical analyses. Statistical significance was set at 0.05.

Student t-tests and analysis of variance (ANOVA) followed by Tukey post-hoc tests were used for continuous variables. Chi-square tests were used for categorical variables. Multiple linear regressions for continuous dependent oral health outcomes and logistic regression analysis for the categorical oral health dependent outcome were carried out. All covariates associated with the outcomes at P < 0.200 at the univariate level were included in the multivariate analyses. Collinearity among independent variables was tested and variables highly correlated were not included in the same model. The results of both univariate and multivariate analyses are tabulated in order to present a comprehensive epidemiological evaluation.

   Results Top

Characteristics of the study population

Five hundred twenty-six participants (61.4% women) were recruited from the institutions and were clinically examined. The mean age was 80.7 ± 9.21 years, with more than two-thirds (70.3%) aged 75 years or above. [Table 1]. The majority were non-smokers (84.2%) and almost all presented with one or more chronic disease (92.6%); the mean number of chronic diseases reported being 1.87 ± 1.143. The vast majority of participants reported receiving visits from family members (75.3%). In terms of autonomy, close to half the participants were completely dependent for toilet use (45.2%), whereas almost three quarters were able to feed themselves independently (72.4%).
Table 1: Percent distribution of institutionalized geriatric persons by sociodemographic characteristics, autonomy, chronic diseases and medication (n=526)

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Oral health assessment

The mean number of decayed, missing, filled teeth was 2.5 ± 4.3, 21.9 ± 8.7, 1.1 ± 3, respectively, and the average overall DMFT score was 25.4 ± 4.9. Additionally, oral hygiene and modified gingival indices were measured at 2.0 ± 0.9 and 1.25 ± 0.7, respectively [Table 2]. Almost half of the participants experienced a dry mouth sensation (47.0%).
Table 2: Percent distribution of institutionalized geriatric persons by oral health indicators and access to oral health care (n=526)

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Out of the entire examined geriatric sample, 294 (55.6%) were edentulous and 8.4% had 21 or more teeth. Slightly less than half (42.6%) of the entire sample were using partial and/or complete dentures [Table 2].

Oral health practices and access to dental care

The vast majority of participants did not report practicing regular tooth brushing at least 1/day (85.4%), and among those using removable prostheses more than three quarters (84%) presented with prostheses that had accumulations of deposits (recent, old, or calculus) [Table 3].
Table 3: Percent distribution of institutionalized geriatric persons by oral health practices and access to oral health care (n=526)

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With respect to access to dental care, less than one-tenth of the sample reported having attended the dental office in the 12 months (7%) and half of all these visits were for curative reasons [Table 3]. More than half of the examined sample (57%) presented with an unmet need for a dental prosthesis. Among the edentulous sample, more than 40% did not use any denture and around 10% used only one denture (maxillary or mandibular) when in fact they were in need for both.

Variables associated with oral health indicators

DMFT index and the Number of natural teeth

Both the total DMFT index and the number of natural teeth remaining in the assessed geriatric population were statistically significantly associated with age (P = 0.001), receiving visitors (P = 0.042 and P = 0.014, respectively), practicing daily tooth brushing (P = 0.001 and P = 0.003, respectively), and smoking status (P = 0.026 and P = 0.031, respectively) while controlling for toilet use autonomy and medication intake (P > 0.05). Older subjects (≥ 75 years), smokers, those not practicing daily brushing and those not receiving visitors were all more likely to have a lower number of remaining natural teeth and a higher DMFT index [Table 4].
Table 4: Univariate and multivariate analyses of explanatory variables associated with oral health indicators

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Gingival and hygiene indices

The modified gingival Index was statistically significantly associated with feeding autonomy (P = 0.011) and maintaining the practice of daily tooth brushing (P < 0.001), while controlling for age and medication intake (P > 0.05). Lower gingival indices were significantly predicted among independently feeding subjects and those practicing daily tooth brushing. The oral hygiene index, on the other hand, was only predicted by gender (P = 0.015), while controlling for feeding autonomy and medication intake (P > 0.05). Females were statistically significantly more likely to exhibit lower values. The Prosthetic Hygiene Index was statistically significantly predicted by toilet use autonomy (P = 0.004) and access to dental care during the last 12 months (P = 0.015)while controlling for age, chronic disease, and medication intake (P > 0.05). Independent subjects and individuals who consulted with a dentist in the past year were more likely to present with a lower prosthetic hygiene index.

Dry mouth perception

The perception of dry mouth was statistically significantly predicted by gender (P = 0.036), the presence of chronic diseases (P = 0.003) and the medications intake (P = 0.012) while controlling for toilet use autonomy (P > 0.05).

Men (OR = 1.48, P = 0.036), subjects suffering from chronic diseases (OR = 3.28, P = 0.003), and subjects taking medication (OR = 1.26, P = 0.012) were more likely to present with dry mouth [Table 4].

   Discussion Top

Our findings revealed that older people living in residential facilities in Lebanon present a poor oral status with bad oral health conditions and inadequate oral hygiene practices corroborating the results of several global studies showing poor oral health in the institutions.[21],[22] The lack of oral hygiene and dental services, systemic diseases and medications, disabilities and incapacities for oral hygiene and non-giving priorities for oral care could increase dramatically the risk of oral diseases.[4],[21],[22]

The DMFT index was high (25.4 ± 4.9) with a predominance of the M-component (21.9 ± 8.7). Moreover, DMFT was considerably elevated in participants aged 75 and more (25.82 ± 4.54). The number of remaining natural teeth followed the same trend with 4.27 ± 7.23 for the older category in comparison with the younger one 6.88 ± 8.69 and these numbers are similar to other studies.[23],[24],[25],[26]

Higher DMFT were reported for the individuals who did not use to practice daily tooth brushing. This fact is aggravated when the sanitary system in the institution is inadequate, or the team is not trained for controlling the oral hygiene, especially with persons lacking autonomy. Smoking was another factor for oral health problem since it affects the different structures of the mouth; 15.4% of older people were smokers and they were more predisposed to dental caries compared to non-tobacco users; these results were confirmed by different studies.[27],[28]

Our results also showed that only 8.4% are still keeping more than 21 teeth, necessary for good masticatory function.[10],[11],[29],[30] It is scientifically proven that the effect of smoking on tooth loss results from the aggravation of periodontal diseases. In fact, lower numbers of remaining teeth were reported for smokers and the frequency of visits. Moreover, elders receiving visitors could be more interested about their appearance and their oral hygiene.

Dental treatment mainly consisted of tooth extractions, with very low percentage of dental/prosthetic treatments (Filled teeth: 1.1 ± 3), which is the same finding in other studies.[22],[31] This may be due to many reasons such as the tendency for emergency extractions (because of delayed seeking of treatment), difficulties in behavioral management during dental procedures favoring measures that are less technique sensitive such as the extraction of teeth rather than their restoration,[32] and the lack of dental services available in the institutions.

Out of the entire examined geriatric sample, 55.6% were edentulous of whom 42.9% do not use dentures. This percentage is higher in comparison to many studies in other countries.[33] This could decrease the number of dental functional units and in turn decrease the masticatory efficacy and affect the nutritional status and the oral health related quality of life of older people living in institution.[11],[12]

On the other hand, xerostomia was common among participants. It has been attributed to the use of medications and chronic diseases. Xerostomia may cause dental caries, periodontal disease, fungal infections, fitting dentures, and taste alterations. It can seriously impact quality of life and affect nutritional status.[11],[34],[35],[36] Staff in institutions should thus be aware of xerostomia and its treatment in order to enhance oral health status.

In our study, the mean OHI was relatively high (around 2), indicating a poor oral hygiene among participants. These results are concordant to similar studies.[37],[38] OHI index was lesser among those practicing tooth/prostheses brushing and those with total autonomy. Bad oral hygiene is a major risk in prevalence of respiratory infections and pneumonia due to anaerobic bacterial inhalation in older people living in institutions, increasing the risk of death in elderly.[5],[6]

Institutionalized seniors are at greater risk of oral problems; the causes are generally cumulative and progressive and several factors prevent the use of dental care services.[39],[40]

The unmet need for dental and prosthetic treatment was detected in 57% of the assessed sample. 7.0% reported having visited the dental office in the past 12 months and dental clinic was only found in one from the overall 23 Lebanese institutions. Moreover, elderly living in institutions are more prone to suffer from inadequate oral conditions compared to those living in their homes, and may have greater difficulties accessing oral health services.[4],[9] It is imperative to mention that in all institutions, no attention was made for oral care[2],[3]; this could be due to the lack of awareness and training of nurses and geriatrician concerning the oral and prosthetic hygiene. Moreover, oral problems are not considered a priority in comparison to other systemic diseases. This could be related to some popular believes in our traditional societies that teeth should be extracted and replaced with a removable prosthetic when aging.[2],[3]

Inference to the non-institutionalized elderly population in Lebanon based on our results is difficult. Outcomes of studies that have compared health and quality of life differences between the institutionalized and the non-institutionalized have ranged from reporting poorer outcomes for the institutionalized to no difference to better outcomes for the institutionalized.[40] In reality, general (and oral) health outcomes are likely to vary across various institutions and between difference countries, depending on the level of care provided and the qualifications of the caretakers, geographical location (urban/rural), the specific characteristics of the elderly being examined, and the general medical status, to name but a few factors.[40],[41] Additionally, comparisons of institutionalized to non-institutionalized populations are also often biased due to the institutionalized population often being skewed toward older ages. It may therefore be argued that a possible limitation of this study may be the inability to generalize to the non-institutionalized geriatric Lebanese population, in addition to the inability to establish a cause-and-effect association between being institutionalized and the poor oral health outcomes reported. However, we argue that the data presented in this research sufficiently support the main objective of our study, which was to present a cross-sectional survey of the current oral health situation of the targeted population. Our study is not only the first-of-its-kind in Lebanon, but is also truly reflective of the institutionalized geriatric population owing to the high level of institution participation (46 out of 55; 84%), the stratified and randomized nature of the sampling technique and the representation of the various geographical regions of Lebanon. Nonetheless, further studies to assess the oral health status of the non-institutionalized geriatric population in Lebanon are warranted in order collect data that is representative of the entire Lebanese geriatric population.

Worldwide, populations are aging and the percentage of institutionalized individuals is increasing.[42],[43] The sociopolitical context in Lebanon has translated into significant emigration of the younger generation, often leaving older individuals without care from family members and therefore vulnerable to institutionalization, especially in rural areas.[44],[45] We have shown that the institutionalized geriatric population in Lebanon presents with significant morbidity. On average, individuals had 2.5 carious teeth when they were examined; signifying active disease that needs immediate treatment. Oral and prosthesis hygiene levels are on the average unacceptable, more than half of the population have an unmet need for a prosthesis and the vast majority do not have access for dental care. Oral and dental pain, dry mouth and non-replaced missing teeth are associated with significant morbidities relating to nutrition and function in additional to social and emotional well-being of the elderly. This is in direct contradiction with the concept of active aging which encourages the continuing participation of aged people in daily activities and the maintenance of favorable perceptions of the elderly with regards to their positions in life and within their cultural context.[40],[41] Our results sufficiently support the need for raising the level of oral health in the assessed population, especially at the preventative level. The poor oral and gingival indices reported, in addition to the low prevalence of daily brushing highlight a very important window of prevention. The importance of the reported multivariate associations that identify the relationships between the lack of consistent daily tooth brushing and the DMFT, number of natural teeth remaining and the modified gingival index lies not in the reinforcement of the well-known etiology of these oral indicators. The significance is rather in emphasizing the potential of tackling this major risk factor on alleviating the oral morbidities experienced by this specific population.

Given the dependence of the institutionalized geriatric population on caretakers for feeding and toilet use, it is imperative that these caretakers become significantly involved in daily tooth brushing habits and maintenance of oral health. At the very least, this would necessitate training and raising awareness on the importance of oral health and hygiene in addition to hands-on training on the practical method of tooth brushing and plaque removal (from teeth and prostheses) and the possible use of additional aids to toothbrushing such as chlorhexidine and fluoridated mouthwash.[46],[47] Additionally, these same caretakers must be able to assist in providing relief for dry mouth and in identifying the presence of active oral diseases in order to refer for appropriate treatment.[46],[47] On the curative aspect, individuals with active disease and individuals with an unmet need for prosthetics deserve to receive the necessary treatment. Given the financial restraints that often present as obstacles to receiving such treatment, several authors have emphasized the importance of the allocation of funds for this population as part of the state budget.[46],[47],[48],[49],[50]

   Conclusion Top

Our study is the first to evaluate oral and dental conditions in the institutionalized elderly people in Lebanon at a national level. This study has shed the light on the high prevalence of both oral and dental problems. Thus, an integrated approach is needed, and oral health education should include all stakeholders. Additionally, it is necessary to implement curative and rehabilitation measures in institutions for older people populations to reduce the need for future dental treatment. Future studies on the non-institutionalized geriatric population in Lebanon are warranted.

Ethical approval and consent to participate

The protocol of the study was approved by the Committee of Ethics at Lebanese University, (Code: 146/242018). Written and verbal informed consent was obtained from the participants.


The views expressed in the submitted article are our own and not an official position of the institution or funder.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Authors' contributions:

AC, MF, MD contributed with conception and design.

AC contributed with acquisition of data.

AC, NEO contributed with analysis and interpretation of data.

AC, NEO involved in drafting the manuscript.

AC, NEO, MF, MD revised critically the manuscript for important intellectual content. All authors read and approved the final manuscript.

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Correspondence Address:
Dr. Antoine Choufani
Pediatric and Public Health Dentistry Department, Faculty of Dental Medicine, Lebanese University, Hadat, Beirut
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_208_20

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  [Table 1], [Table 2], [Table 3], [Table 4]


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