Year : 2006 | Volume
: 17 | Issue : 1 | Page : 11--21
Oral healthcare for elderly : Identifying the needs and feasible strategies for service provision
Pankaj Goel1, Kanwarjit Singh2, Arundeep Kaur2, Mahesh Verma3,
1 Department of Community Dentistry, Maulana Azad Dental College & Hospital, New Delhi, India
2 Department of Periodontics, Maulana Azad Dental College & Hospital, New Delhi, India
3 Department of Prosthodontics, Maulana Azad Dental College & Hospital, New Delhi, India
Department of Community Dentistry, Maulana Azad Dental College & Hospital, New Delhi
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.
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Goel P, Singh K, Kaur A, Verma M. Oral healthcare for elderly : Identifying the needs and feasible strategies for service provision.Indian J Dent Res 2006;17:11-21
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Goel P, Singh K, Kaur A, Verma M. Oral healthcare for elderly : Identifying the needs and feasible strategies for service provision. Indian J Dent Res [serial online] 2006 [cited 2023 Mar 23 ];17:11-21
Available from: https://www.ijdr.in/text.asp?2006/17/1/11/29897
Aging is a universal process and a normal inevitable biologic phenomenon. With discoveries in medical sciences and improving social conditions the average life span in most parts of the world continues to increase and it becomes the mission of health professionals to not merely increase the life span but also and perhaps more importantly, make later years of life more productive and enjoyable. Hence successful aging has to be considered in the context ofthree important qualities as shown in [Figure 1].
Considering the fact that a sizeable population of India is graying, it is predicted that the elderly population of the country shall be among the highest in the world by the year 2025, i.e. 177 million (80% of them residing in rural areas) . Hence it becomes necessary to collect pertinent information on the oral health of the elderly to serve as baseline data for policy formulation, monitoring and evaluation purposes. In this regard, edentulism is a condition of primary concern. Fdentulism or toothless ness, in the elderly has been traditionally attributed to be a direct outfall of periodontal (gum) diseases and dental caries (tooth decay). Periodontal diseases occur more frequently and severely with advancing age due to a backlog of unmet oral hygiene needs. At the same time secondary dental caries is a major problem and some researchers have suggested that restorations with overhanging margins are a major risk factor for this disease in the elderly. Also current information and findings suggest that there is an increase in the mean member of decayed and filled teeth among dentate elderly as a result of more number of retained (vulnerable) teeth at any given age.
Although historical dental literature used epidemiologic measures to describe individual diseases as components of oral health, more recent concept of successful oral health aging is based on not only acceptable oral health, but also access to professional dental services as well as a positive feelings about the dental care received . The present study is a pathfinder survey in the same direction with the objective:  to identify the oral health practices and patterns of utilization of dental services,  to assess oral health status and treatment needs of the elderly population and  to test alternate strategies for controlling oral health problems among the elderly.
MATERIALS AND METHODS
National capital territory of Delhi, a land area of 1483 square kilometers, has apopulation of 13.4 million, which is amix of people from all the 35 geographical subunits of India, referred to as states or union territories. Eighty-four percent of Delhi's population comprises of Hindus, eight percent Muslims, five percent Sikhs and one percent Christians, which is quite similar to the overall pattern of religious follower-ship in India. However majorities of people (93%) in Delhi reside in urban area, which is in contrast to the national average of urban population (27%).
The rural areas of Delhi were included in the present study and a two stage sampling technique was adopted. In the first stage five rural census enumeration blocks (all having equal population of approximately 5000 each) were randomly selected from a list obtained from office of registrar general and census commissioner of India based on the last (1991) census. The second stage comprised of systematic random sampling of twenty households in each seleced rural census enumeration block. This way a sample of 100 subjects was selected (as suggested in basic oral health survey methodology WHO, 1997)  as representative of the elderly population residing in rural areas ofDelhi.
The index age group of 65-74 years  was selected as being representative of the elderly. Equal number ofmales (n=50) and females (n=50) of the following rural census enumeration blocks of delhi were included in the sample frame:
BijwasanJharoda KalanBarwalaKirari suleman nagarMustafabad
The study was conducted in three phases, namely:
Survey;Community dental health programme operation; Evaluation
Oral Health Assessment Proforma  was utilized for identifying the oral health status and treatment needs of the elderly population. In addition to it and interview of all subjects was conducted to identify their oral health practices and patterns of utilization of dental services. A qualified dental surgeon was selected as "Research Associate" for the study and imparted training in recording both the clinical proforma and questionnaire. A dental hygienist/auxiliary was selected to be the recording clerk and trained to assist the research associate in the study. Pretesting of the recording procedure was done first at the investigators' hospital and subsequently in a nearby slum cluster under the supervision of the investigators. Standardization and calibration of the recorder and recording clerk were achieved during the same sessions.
Actual field survey was undertaken during the month of march 2003. Armamentarium used was: mouth mirrors, community periodontal index (CPI) probes, disposable surgical gloves, mouth masks, cotton swabs, instrument carrying trays, torch, copies of clinical proforma as well as questionnaire, relevant maps of the area and literature for distribution. All examinations were conducted in the front porticos of individual households under natural illumination. Use of artificial illumination (using torch light) was made only if required. Not more than ten subjects were examined in one day using sterile dental instruments. At the end of each day's work all data was coded and instruments were sterilized at the investigators' hospital.
The second phase of the study comprised of developing and executing a community dental health programme starting apri1 2003. The programme was developed on the basis of the results of the survey, i.e. identification of treatment needs of the elderly. The Directorate of Health Services (Delhi) was requested to allow the dental team to operate the programme from the primary health center/dispensary located in the study areas. However, due to non-availability of the sane in some of the study areas the investigators made liaisons with the department of preventive and social medicine, Maulana Azad medical college, New Delhi and one social organization to provide their centers for operating the programme. A visit was arranged to meet the medical officers/incharges of these centers wherein the aim of the study was explained and tentative dates for the programme operation were fixed. The medical officers/ in-charges were requested to give wide publicity to the programme using necessary publicity material, i.e. posters, pamphlets (hand outs) and banners that were developed in the local languages by the investigators. Also a lecture cum training workshop on oral health was delivered to the multipurpose health workers, i.e. primary health care workers, of these centers to enable them to answer any queries the general public might have regarding the same. All costs incurred on the publicity were home by the investigators and the community dental health programme was operated free of cost
In order to test various strategies for service provision, the study areas were randomly allocated into various test and control groups as follows:
Jharoda Kalan was chosen as the control site and no intervention was taken up in this area.Bijwasan was chosen as the site for group oral health education that was imparted during a two-days long community dental health programme conducted at the health center. Elderly patients requiring treatment were referred to a tertiary care center (i.e. investigators' hospital) on a priority basis under the programme. The salient features ofthis programme were:
1. Oral health check-up;
2. Group oral health education;
3. Dissemination of information, education and communication material on oral health;
4. Provision of referral services.Barwala, Kirari Suleman Nagar and Mustafabad were chosen as sites for community dental health programme that included group oral health education as well as primary and rehabilitative dental care provision. No referrals were under this programme since rehabilitative care was provided on the site. The salient features of this programne were:
1. Oral health check-up
2. Group oral health education;
3.Disemination of information, education and communication material on oral health;
4. Primary dental care provision, i.e. oral prophylaxis, extraction of diseased teeth, restoration of decayed teeth, intra-mal radiography and medication;
5. Rehabilitative dental care provision, i.e. complete denture fabrication through multiple recall visits and follow-up.
Under this programme a two-days long group oral health education programme was first held and followed by service provision by weekly visits to each site for a period of two-and-half months (ten visits per site). All dental care was provided using a mobile dental clinic having two dental chairs, one autoclave and intra oral radiograph machine. Various portable dental equipment and material was also installed within the premises of each health center and used for service provision. A team of resident dental surgeons, dental hygienists and dental chairside assistants working in the investigators' hospital accompanied the investigators and the research associate on every field visit. Patients requiring multiple recall visits for denture care were followed up for additional few weeks.
One month after the end of the intervention, i.e. August 2003, the original sample populations residing in all the five study areas were revisited. A post-intervention questionnaire was administrated to those study subjects who were aware of the community dental health programme conducted in their area Questions pertaining to utilization made of dental care, reasons for nonattendance at the programme and recommendations for future were asked from the subjects. The questions were designed by the investigators themselves after through review of literature on similar studies.
The data gathered from clinical proforma, questionnaire, service records and post-intervention evaluation was coded, cleaned and entered in MS-EXCEL computer software. Data analysis was done on epi-Info6 statistical package. Risk factors associated with predominant oral health problems) of the elderly were analyzed using Chisquare and Fissure-exact tests. A risk factor was considered to be statistically significantly associated at 95% level of confidence (p>0.05).
The study population comprised of 96 elderly individuals (65-74 years old), of whom 47 were males and 49 were females. Most of the study population (71.9%) was illiterate. A majority of subjects were Hindus (85.4%) followed by Muslims (14.6%). A majority of males were either farmers (19.1 %) or unskilled workers (17%) and a majority of females (27.8%) were housewives. Most subjects (80.2%) were vegetarians and a little over half of them (59.4%) had access to piped water supply.
Oral Health Practices
The most prevalent oral hygiene habit practiced by the subjects was rinsing with water after eating. Majority of subjects reported using toothbrush (43.7%) as their main oral hygiene aid while others reported using Datun (21.9%) or finger (17.7%). Most subjects had a habit of snacking on sweets, of which 36 (37.5%) subjects had sweets during meals, 27 (28.1%) in-between meals, 29 (30.2%) during and in-between meals. Twenty six (27.1%) subjects had a history of smoking, of whom 21 were males (44.7% of males) and 5 were females (10.2% of females). Seven (27.0% of smokers) subjects reported smoking 'hooka', 9 (34.6% of smokers) 'bidi' and 8 (3.8°./0 of smokers) both 'hooker' as well as 'bidi', One (3.8% of smokers) subject reported smoking cigaratee and another one 'chillum'. Seven (7.3%) subjects had a history of chewing tobacco with betal leaffbetel nuts, of whom 5 were males (10.6 of males) and 2 were females (4.1% of females).
Utilization of dental services
Most subjects (79.2%) reported availability of dental services in their area, of which a major proportion was being provided by the private sector (61.5%) [Table 1]. Eighteen (18.7%) subjects reported having suffered from oral health problems, of whom 9 (19.1%) were males and 9 (18.4%) were females. Among those who reported suffering from oral health problems, 11 (61.1%) subjects reported visiting a dentist while 7 (38.9%) did not avail any dental care [Table 2].
Oral health status and treatment needs.
Fourteen (22.58%) subjects had healthy gingival and periodontal tissues while 48 (77.42%) had one or more signs of gingival and periodontal disease. The total number of sextants without loss of attachment >0-3mm was 150 (mean 2.42, standard deviation 2.38) while sextants with loss of attachment> 4nun were 132 (mean 2.13, standard deviation 2.0) [Table 3]. The periodontal treatment needs of the subjects, based on Community Periodontal Index (CPI), were indicated for a total of 196 sextants (mean 3.16, standard deviation 2.31) that were diseased, viz. bleeding, calculus and pockets [Figure 1].
All 62 (100%) dentate subjects had experienced dental caries and their total number of decayed, missing or filled teeth (DMFT) was 593 (mean 9.56, standard deviation 7.53). Total number of dentate subjects having root caries was 14 (22.58%), of whom 7 (24.14%) were males and 7 (21.21%) were females. The number of teeth with decayed roots was 43 (mean 0.69, standard deviation 1.69). [Tables 4 and 5] show sex-specific distribution of DMFT components in denate subjects. A total of 102 (mean 1.64) teeth were in need of treatment for dental caries, of which one surface fillng was needed the most (n~53) followed by extraction (n -sub -47) and 2 surface filling (n=2). [Figure 2] depicts sex-specific distribution of dentition treatment needs for dental caries in dentate subjects.
Seventy five (92.59%) edentulous subjects were not having any oral prosthesis in upper arch and 74 (92.50%) in their lower arch. No prosthetic replacement was needed for those who were already wearing oral prosthesis while a majority of edentulous subjects not having any oral prosthesis required complete dentures (full prosthesis) and removable partial dentures (multi unit prosthesis) in one or both arches.
[Table 6] analyzes the association of dentate status with demographic variables and oral health practices. A statistically significant association was found between age and edentulousness (p=0.005). Association of other variables with dentate status was of no statistical significance.
Strategies for service provision
Overall 475 patients attended the community dental health programme in the four rural areas where intervention was done after the survey, i.e. during Phase-II of the study, with differing levels of attendance from each study area, despite the fact that all rural areas comprised of approximately equal population and equal publicity was given to the programme in all areas. The most commonly availed care was consolation of diseased teeth (10.53%) oral rehabilitation with complete dentures (7.79%) and other care (3.58%) [Table 7].
After the intervention (in phase III of the study) the original sample subjects were revisited to identify those who did or did not attend the community dental health programme conducted in their respective villages. Subjects cited "health workers, friends/relatives and print media" as the commonest source of information about the community dental health programme. The most often cited reasons for not visiting the community dental health programme were "Ill health/disability and lack of time due to work commitments." "Unavailability of an accompaniment, preference for home remedy and fear of dental treatment" were some of the other reasons given by the subjects.
The subjects suggested ways to improve community dental health programmes and ways to impart geriatric dental care services, based on their personal experiences. These recommendations were preferentially summarized and are presented in [Tables 8 and 9].
The present study was done on a sample of 100 elderly subjects, of whom 96 (47 males and 49 females) were incorporated in the statistical analysis after cleaning the data 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 thatthe 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 et al  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 et al  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 et al  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 et al  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 et al  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  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 et al  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 et al  and Angelillo IF et al .
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 et al  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 SouthAfricashowed 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 subj ects 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;
CONCLUSIONS AND SUMMARY
The present study was conducted on a sample of 96 elderly (65-74 years old) subjects (47 males and 49 females) residing in five rural areas of Delhi in the year 2003. The objectives of the study were to assess oral health practices, status and treatment needs of the elderly. The study also attempted to identify factors influencing utilization of dental services and test alternate strategies for dental care provision to the elderly. The first phase of the study comprised of a survey in which an interview and a clinical examination (using basic Oral Health Survey Proforma of WHO) of the subjects were done by a pre-calibrated recorder and recording clerk. Modem and traditional oral health habits were found to co-exist among the rural elderly. For example, subjects used toothbrush as well as indigenous oral hygiene aid i.e datum. Similarly smokers used cigarettes and traditional Indian forms of smoking i.e, hooka/bedi. A cent percent prevalence of one or more oral health problems was observed among the subjects during clinical examination. In contrast, less than a quarter of the subjects, when asked, perceived these needs. Few subjects availed dental care although dental services were reportedly available to majority of them (mainly in private sector). Felt needs and female gender were two variables that appeared to be associated with utilization of dental care.
A predominant oral health problem observed was edentulousness (35.4% completely edentulous and 56.3% partially edentulous elderly) with most subjects requiring oral prosthesis. Age, as a variable, was statistically significantly associated with edentulous ness. All dentate subjects had experienced dental caries. Restoration of decayed crowns and extraction of decayed root stumps comprised the bulk of dentition treatment needs. Periodontal treatment needs were observed in most dentate subjects as oral hygiene instructions alone or in combination with oral prophylaxis. Periodontal problems appeared to be more prevalent in male subjects as compared to their female counterparts.
In the second phase of the study a community trial was conducted by dividing the 5 study areas into 3 groups, i.e. control, education + referral and education + on-site treatment. A team of dental surgeons assisted the investigators in providing dental care services using a mobile dental clinic and portable dental equipment at the primary health center/dispensary located in the study areas. A total of475 patients utilized the services.
At the end of intervention (trial) that was held for 3 months, a post intervention assessment of original subjects was done to determine reasons for utilization/ non-utilization of services provided (phase 3 of the study). It was observed that negligible proportion of subjects utilized private dental care (in control group) or availed free referral facilities (in education + on-site treatment group). In such study areas where treatment was provided on-site, reasons given by subjects as barriers to accessing care were related to a lack of priority for oral health (attitudes) and their dependent status (non ambulatory/disabled elderly). 'These findings emphasize the need to change patient perception on oral health through health education; and incorporate domiciliary dental care in gerontology. When asked, even the subjects' ranked need for awareness and domiciliary care higher than provision of treatment alone.
Within the limitations of the present study, it can be recommended that provision of dental care in rural areas should not be limited to the rubric of treatment alone but, more importantly, should focus on empowering the community through information, education and communication activities. This dual strategy will aid in not just controlling oral diseases by improving dental literacy (preventive care) but also change attitudes so as to increase acceptability of services leading to greater utilization of curative care. Incorporating primary as well as rehabilitative dental care services, through on-site programs (at grass root level) and domiciliary visits (for non-ambulatory patients), under the existing rural health infrastructure would be one way to remove the barriers to equitable access to routine care for promoting oral health of the elderly in developing countries such as India.
This study was conducted by Maulana Azad Dental College and Hospital and supported by the Govt. of India W.H.O. Collabtative program. The authors wish to acknowledge the contributions of Dr. Rakesh Kumar, Research Associate, towards fieldwork of the study.
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