Oral health conditions of institutionalized older adults and associated factors

Introduction: The growth of the Brazilian older adult population has influenced the increased demand for institutionalization for this public, which usually has poor oral health conditions such as edentulism. Objective: To characterize the oral health conditions and verify the variables related to the edentulism of institutionalized older adults and verify the relation of the time of institutionalization with oral health. Methods: It was a cross-sectional study conducted with 512 institutionalized older adults in which the sociodemographic profile, general health conditions, and oral health care and conditions were evaluated by clinical exams, consultations of medical records, and structured questionnaires. The data were analyzed in the Statistical Package for Social Sciences using the Pearson Chi-square and Fisher's Exact tests and a logistic regression model using a 95% confidence level. Results: A high DMFT (29.4), high prevalence of complete edentulism (61.3%), high need for maxillary (73.6%), and mandibular oral rehabilitation (56.8%) were observed. Edentulism was associated with older age (p<0.001), lower schooling (p<0.001) and non-retirement (p=0.031). It was found that longer institutionalization time remained associated with edentulism even when adjusted by sociodemographic and general health variables (p=0.013). It was also associated with the absence of brushing (p=0.024) and a lower frequency of tooth, gum, and prosthesis brushing (p<0.001). Conclusion: It is suggested to establish oral health care routines within long-term institutions for the effective maintenance of oral health throughout the institutionalization time.


INTRODUCTION
As in many countries, Brazil's older population has grown exponentially, mainly due to declines in fertility rates, decreased mortality rates, and improved care technologies 1,2 . The increase in the longevity of its population and the consequent aging in the country 2 has generated a greater demand for attention and services for those individuals 3 .
In addition to the growth of the older population, the demand for long-term care institutions (LTCI) for older adults also grows, significantly raising the need for health care for these institutionalized people 4 as consequence. This increase in demand for institutions has also been caused by the reduction in the number of family caregivers and their difficulties in carrying out the care for these older adults in their home 1 .
Aging is a natural process that develops throughout the life of human beings, often tooth loss is seen as a natural part of this process 2 . Besides the results of the latest national oral health survey conducted in Brazil showed the poor oral conditions found in the older adult population 5 , this situation arrives from the model of care centered on extractions throughout the life course of the older adults that existed in the past and the lack of preventive public policies aiming at the older population in the country 1,2 .
The literature has shown that the oral health condition of institutionalized older adults is notoriously precarious and worse than the non-institutionalized population 6-8 , including in the Brazilian northeastern region where they have presented worsened conditions [3][4][5]9 . However, it is not yet clear what is the effect of institutionalization on the oral health of older people. The well-established relationship between oral disorders and their effects on the general health status of older adults makes it even more urgent to improve oral health care 10 . Nonetheless, new public policies capable of improving oral conditions in the institutionalized older population are still needed 2,3 , but to create them, it is necessary to identify the determinants of the oral health status of such population and understand their needs 9 . However, there are no studies on oral health that are representative of the institutionalized elderly population in the city of Fortaleza, Brazil.
Thus, this study aimed to characterize the oral health conditions and to verify the variables related to the edentulism of institutionalized older adults, as well as to verify the relation of the time of institutionalization with oral health.

METHODS
The survey was a census with a quantitative cross-sectional approach. An epidemiological survey on oral health was carried out with older adults residing in LTCI in the city of Fortaleza, Ceará, Brazil. The 14 LTCI of the city were evaluated between April and June 2019.
The inclusion criteria were residents of the listed LTCI, older adults (aged 60 years or more), and being present in the LTCI during the period of the evaluations. The ones who were hospitalized or in palliative care during the data collection period and those in an aggressive state were excluded.
The data collection was performed by four examiners and four note-takers, who participated in a process of training and calibration carried out by consensus technique.
The Kappa indexes obtained in the inter-examiner calibration were 0.80 and 1.00, and in the intra-examiner, they were 0.90 and 1.00, considered an excellent concordance.
Clinical examination and interviews with the older adults were conducted. The collection instrument was divided into sociodemographic aspects; general health evaluation; oral health care evaluation and oral clinical exams.
The older adults were assessed for their cognitive status by using the Pfeiffer Test 11 , an instrument composed of ten questions whose scores range from 0 to 10, based on the number of errors. Such status was classified as undamaged intellectual function (0-2 errors), low cognitive impairment (3-4 errors), medium cognitive impairment (5-7 errors), and several cognitive impairments (8-10 errors). These aging people were considered oriented according to the number of errors presented and an adjustment made by their education level. Thus, it was considered disoriented the older adults with more than 5 errors, in the case of illiterate people, and with more than 4 errors, in the case of literate people. For the analysis, cognition was classified as undamaged intellectual function/low cognitive impairment and medium/several cognitive impairments.
Oral health care was evaluated through a seven-question questionnaire related to the care performed by the older adults or the caregiver. The hygienization of teeth, gums, and prostheses, as well as the removal of the prosthesis to sleep, were evaluated.
Besides, there was the addition of three questions concerning the use of dental services.
The oral clinical examinations were performed using previously sterilized mouth mirrors and WHO periodontal probe (Hu-Friedy, Chicago, USA). The older adults were examined sitting in a clean environment and the examiners were provided with the same model of head lanterns.
The oral examination included the measurement of dental caries using the DMFT index (indicating the number of permanent teeth decayed, missing, and filled).
The periodontal evaluation was based on the Community Periodontal Index (CPI) in those examined with at least two remaining teeth without extraction indication, considering index teeth. In the absence of one of them, the remaining sextant teeth were examined with the highest index recorded, and, in case of their absence, the sextant was recorded as excluded 5,12 .
The edentulism was evaluated by oral and prosthesis examination in which the use and need for oral rehabilitation were observed and recorded, as well as which type of prosthesis was being used and in which arch. Also, evaluations regarding the presence of possible oral mucosa lesions were performed, recording their condition and location.
For data analysis, the following variables were considered to evaluate dental functionality: presence/absence of edentulism (total tooth loss), number of present functional teeth, number of present molars, presence of 2nd and 5th sextants, and presence of maxillary and mandibular shortened dental arch (SDA). These variables can assess the oral health condition of older adults with extensive tooth loss as well as the functionality of the remaining teeth.  As for general health data, 62.3% of the sample have multimorbidities, while 63.5% use polypharmacy. Regarding cognitive status, the great majority presented several cognitive impairments (46.3%), whereas 21.7% presented undamaged intellectual function. Regarding mobility, 11.9% of the older adults were bedridden and most of them could walk without help (44.7%).
The mean value DMFT was 29.4±4.7, in which the component of missing teeth corresponded to a mean of 27.7±6.9 teeth. Regarding the roots, those people had about 2.1±3.9 exposed roots, of which 0.6±0.6 were decayed. For periodontal disease, it was found a mean of 0.6±1.2 sextants with calculus, 0.7±1.4 with gingival bleeding, 0.3±0.7 for shallow pockets, and 0.1±0.4 for deep pockets (Table 1).
Concerning the use of dental prostheses, 43.2% used a prosthesis in the maxillary arch and 21.9% used a prosthesis in the mandibular arch. But 73.6% of the older adults needed a maxillary complete denture and 66.2% needed a mandibular complete denture. As for dental functionality, only 5.5% of them had 20 teeth or more present in the mouth, 61.3% were edentulous, 92.6% had no 2nd and 5th sextants present, and 77.9% had no molars, and 93.6% had incomplete short dental arch present.
Only 9% of the older adults had some type of oral lesion ( Table 2).
Regarding oral health care, 87.5% reported brushing their teeth and gums; of these, 57.6% had the autonomy to do their brushing Among those who brushed their teeth and gums, 67.6% performed it two or more times a day. Concerning the hygienization of the prostheses, 72.5% of the ones who used them performed it by themselves, mostly twice a day and 52% of the older adults did not remove dental prostheses for sleeping (Table 3).
Regarding the use of dental services, 53.3% of the participants made their last visit to the dentist less than a year. The main, reason for the visit was for prevention, whereas 39.1% said they went to the dentist for the last time in the LTCI (Table 3). Table 4 shows the results of the analysis of sociodemographic variables and their associations with edentulism. It was observed that edentulism was associated with lower education level (illiteracy), older adults with 80 years or above, longer were associated with total loss of teeth (Table 5). When the institutionalization time of the older adults was analyzed with the variables of oral health care, it was observed that a longer institutionalization time was associated with the absence of tooth and gum brushing (p=0.024) as well as a lower frequency of tooth and gum brushing (p<0.001).

DISCUSSION
A high rate of edentulism and low oral rehabilitation was found in this study, which indicates that the oral health situation of institutionalized older adults is worse than non-institutionalized ones in Brazil 5 . The mean DMFT found was 29.4, higher than the values mentioned in other similar studies conducted in developed countries, which ranged from 15.2 to 26.3 8,[13][14][15] . Nevertheless, the mean found was equivalent to the one presented in similar studies in Brazil, ranging from 27.9 to 30.6 9,16-18 , which shows a worse oral health status among institutionalized older adults in Brazil.
Moreover, this finding, added to the greater expression of the missing component in DMFT and a lower average of healthy teeth and molars present, can be seen as a reflection of the old reality in which oral health was not a priority in public health in our country 19 that market the life course of older adults.
Complete edentulism was detected in 61.3% of the participants, a value similar to that found in other regions of Brazil, which varies between 43.1-69.2% 1,19-21 . Thus, it can be seen that edentulism is still one of the major public health problems faced by the population studied and other similar populations in the country 1,[19][20][21] . A large number of toothless people in the sample was also reflected in the evaluation of periodontal disease, in which an average of 5.1 excluded sextants were found, but most of the remaining sextants were affected by such disease in its various levels of progression.
Other indicators of dental functionality also showed worse conditions, mainly affected by the high percentage of edentulism, such as several participants with at least twenty functional teeth, with the presence of the 2nd or 5th complete sextant and shortened dental arch (SDA) in at least one arch. Furthermore, considering that the majority did not use any prosthesis, and needed oral rehabilitation, the rates related to oral rehabilitation were also inadequate. The data are similar to the national values in which the prevalence of prosthesis use and need reached 78.2% and 68.7% respectively 5 .
Thus, the absence of functional teeth in the oral cavity, as well as a high need for oral rehabilitation, have negative impacts on the masticatory and phonetic functions of older adults, altering their ability to feed and socialize, which directly affects the nutritional status and well-being of these population 22 .
Moreover, the social functions of the mouth and its subjectivity such as eroticism, self-esteem, and social relationships, for example, have a direct influence on the quality of life of human beings 23 . Thus, it becomes necessary to maintain the oral health of these older adults, respecting the role that the mouth and teeth represent, not only as part of the human body but also as the symbolism of their socio-cultural insertion.
Even with the expansion of specialized dental and public health services in Brazil, such as the Dental Specialty Centers, which include oral rehabilitation 6,24 , the evaluated population is not having access to this service. Thus, these rehabilitation actions offered by the public service do not seem to reach the institutionalized population adequately, making this group still present a high demand for oral rehabilitation consequently.
It was observed that more than half of the older adults went to the dentist in less than 1 year, most of them having as the main reason for the prevention and carried it out in the LTCI. It is believed that these findings are because one of the largest institutions evaluated is state-owned and provides dental care services. In addition, most of the LTCI evaluated receive extension groups of dentistry schools that perform oral health prevention actions with the residents.
Even so, many factors may have contributed to this difficulty in accessing oral health services in the population studied, for instance, difficulty perceiving the need for dental care by the older adult or by the LTCI 13,15 low levels of schooling and income 15,17 , scarce availability of public oral health services or difficulty in access 17 and organizational difficulties such as lack of transportation of the older adults to the place of care 25 . Moreover, other authors suggest an association between sensitivity to pain and negative self-perception of oral health where individuals seek more dental services because of painful or uncomfortable experience 26 , showing that those who do not attend the dentist present twice as much need for rehabilitation, history of disease and tooth loss 17 . Thus, these results found evidence of the demand for new actions and public policies of oral health that include the institutionalized older adults and can transform this reality.
As for the presence of oral lesions, some authors claim that angular cheilitis and stomatitis associated with the use of dental prostheses and poor oral hygiene habits are the most prevalent oral lesions in institutionalized older adults [27][28][29] . However, there was a low prevalence of oral lesions in the findings of the research, which was similar to others studies 20,30 . A possible explanation for this fact would be the lower percentage of older people in the sample who wear a prosthesis, which may be related to fewer cases of stomatitis.
When related to the sociodemographic characteristics of older adults, edentulism has been associated with aging, in line with the literature that states that tooth loss tends to progress with advancing age 17,31 . In addition, the relationship between poverty at any time in life and tooth loss has been proven 32 . However, one must take into account the cumulative effect of oral diseases over the years, and that edentulism should not be considered just a consequence of the aging process.
The results also showed that edentulism in the institutionalized older adults was associated with worse socioeconomic conditions, according to the literature 2,5,17,33 , which could be minimized with better provision of resources and organization of dental services 2,32 . Thus, qualified oral health care actions to solve the main repressed demands of this population, such as the need for prosthetic rehabilitation, are still necessary.
Moreover, belonging to less favored social classes, with less schooling, income and lack of health plan insurance are some of the factors that are determinant in the decision of exodonty 33 . Thus, it is also necessary to emphasize the fact that tooth extraction has long been considered the only option in dental practice in Brazil, which has made this procedure to be considered the most viable solution for dental problems.
Possibly, due to cultural remnants, the search for exodontia may still be a way out for individuals with less education and access to information. Moreover, it is a lower-cost procedure than other conservative treatments in dentistry, which causes people with worse socioeconomic conditions to seek this type of assistance. This situation, when added to the difficulty of access these older adults have to public oral health services 2 , where they could be performing more conservative procedures, may have aggravated this situation.
Association with higher rates of edentulism was also found with the longest time of institutionalization, other studies with institutionalized older adults also indicate a worsening of oral health conditions with the advance of institutionalization time 33,34 .
The absence of teeth can often be interpreted as a more desirable situation because of the lack of intercurrence that dental problems can cause 4 ; thus, it would possibly explain this situation, in which being without teeth would facilitate the care of these older adults in LTCI, especially those who are more care dependent.
Regarding oral health care, it was identified that a part of the sample did not perform any type of cleaning of teeth and gums. The large number of edentulous teeth in the sample may have influenced these findings, since their absence may have caused these older adults or their caregivers to view oral hygiene as something unnecessary.
Another considerable part of this population also proved to be lacking the autonomy to perform oral hygiene. One of the explanations for this finding is the high rates of older adults with mobility and cognition problems found in the evaluated population. Several studies claim a positive and significant association between poor oral hygiene and oral health conditions with these and other limitations such as reduced functional capacity and Alzheimer's and Parkinson's diseases 3,16,25,35 .
Although the design of this study does not allow us to establish whether edentulism occurred before institutionalization or if it was caused and aggravated by the internment. An association was observed between a longer period of institutionalization and the absence of tooth and gum brushing, as well as a lower frequency of such brushing. In addition to some factors already discussed, it is necessary to highlight the proven relationship between the process of institutionalization with the decrease in functional capacity 34,36,37 and autonomy 38,39 of older adults, which will have a direct influence on the care of their oral health. Thus, it is possible that, after the institutionalization and with its advancement, those individuals have lost the ability to care for themselves and, consequently, their oral health, leading to worse oral health conditions and greater edentulism. Therefore, the role of the caregiver also deserves to be highlighted when it comes to oral health care for this population. Neglect with oral hygiene can also be pointed out by the absence of adequate care with the institutionalized older adults 40 as a result of not having sufficient knowledge, organization, and planning for the work 25 and time to perform it 1,25 . The presence of older adults with greater limitations, the various functions accumulated by caregivers, and the reduced staff in LTCI may be related to neglect of oral hygiene. Thus, institutionalization has a strong impact on the oral health conditions of these older adults, which is aggravated by the lack of adequate care in LTCI, leaving them at the mercy of oral problems that may worsen over time and impact their general health 6 .
Even so, it was observed that most of the evaluated older adults had a higher frequency of brushing their teeth, gums, and prostheses. Nevertheless, despite these findings, one must be cautious about the proper performance of oral hygiene of these individuals. A study carried out in Poland found in its sample that 26% of older adults who performed hygiene independently at least twice a day; though insufficiently, which was also observed in almost half (45.8%) of the older adults who received help to perform this action 25 . Thus, it is still necessary not only to check the frequency of brushing in institutionalized older adults, but also to check its quality and, consequently, understand how oral hygiene impacts the oral health of these older adults.
Therefore, it is corroborated by some authors who point out that the improvement of oral health care provided by LTCI caregivers depends on the development of education and organization strategies to train them 16,25,35 , as well as better working conditions and more time to perform oral care tasks 25 . Moreover, introducing a continuity of care and surveillance of these conditions may facilitate, when necessary, the dentist's intervention in the prevention of the main diseases that may affect these older adults 35 , and contribute to controlling the influence that oral health diseases possibly cause on their general health 10,16 .
As a limitation of this study, beyond cross-sectional design, there is the memory bias of the interviewees, however, the information was checked with the caregivers, as well as in the medical records when it was not possible to remember.
The results presented in this paper portray an irreversible and cumulative process, which is faced by the institutionalized older adults, in addition to indicating the invisibility of this population to dental services. The need to check the oral health care routine performed by caregivers in LTCI is pointed out. Thus, the results highlight the demand to develop and strengthen public policies that generate a reformulation of dental care provided to institutionalized older adults. So that the institutionalization time does not worsen the oral health of the sample.