ARTÍCULOS ORIGINALES

Edentulism and dental prostheses in the elderly: impact on quality of life measured with EuroQol - visual analog scale (EQ-VAS)

 

Carlos Cano-Gutiérrez^1,2, Miguel G. Borda¹, Antonio J. Arciniegas¹, Claudia X. Borda³

¹ Aging Institute, Pontificia Universidad Javeriana, Bogotá, Colombia.
² Hospital Universitario San Ignacio, Bogotá, Colombia.
³ Undergraduate Program of Dentistry, School of Dentistry, Pontificia Universidad Javeriana, Bogotá, Colombia.

CORRESPONDENCE Dr. Carlos Cano-Gutierrez Carrera 7 N. 40-62. Hospital San Ignacio, Piso 8, Facultad de Medicina Bogota, Colombia ccano@javeriana.edu.co

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ABSTRACT

The objective of this study was to measure the impact of edentulism and dental prostheses on quality of life (QOL) in older adults in Bogota, Colombia. Edentulism is a frequent condition in older adults and has great impact on their QOL. No epidemiological data are currently available on edentulism among older adults in Colombia. Data were obtained from the SABE-Bogota study, a cross-sectional study conducted in 2012, and used to analyze the EQ-VAS (Visual Analog Scale) from the EuroQol instrument to measure the perception of quality of life (QOL) in relation to edentulism. The study included 2,000 individuals over 60 years old. The Spearman-Rho correlation was used to analyze the correlation between EQ-VAS and edentulism. Chi-Square, ANOVA and t-test were used to study the differences in EQ-VAS scores between edentulous and healthy subjects. Statistical significance was set at p<0.05. Of the 2000 respondents, 98.3% were edentulous, 73.0% reported half or more missing teeth, 76.9% used dental prostheses and 23.7% had related eating problems. Older age, lower social class and lower education were related to edentulism. Individuals with fewer teeth and dental prostheses had lower EQ-VAS scores (p<0.05) and dental prosthesis did not improve EQ-VAS scores (p=0.22). Edentulism also showed a significant negative correlation with EQ-VAS scores (rho= -0.102, p<0.01). In summary, EQ-VAS is a useful tool for measuring the perception of QOL in dental health scenarios. Edentulism significantly affects QOL in older adults and the use of dental prosthesis does not improve the perception of QOL.

Key words: Mouth; Edentulous; Quality of life; Aging; Dental prosthesis.

RESUMEN

Edentulismo y prótesis dentales en el adulto mayor: impacto sobre la calidad de vida medido con EuroQol - escala visual análoga (EQ-VAS)

El objetivo de este estudio fue medir el impacto del edentulismo y el uso de protesis dentales en la calidad de vida de los adultos mayores en Bogota, Colombia. El edentulismo es frecuente en los adultos mayores y afecta profundamente su calidad de vida. Actualmente existen pocos datos epidemiologicos disponibles sobre este tema en nuestro medio. Los datos fueron extraidos del estudio SABE-Bogota, estudio transversal por conglomerados llevado a cabo en el 2012. Se uso el EQ-VAS (escala visual analoga) como instrumento de medicion de la percepcion de la calidad de vida. El estudio incluyo 2.000 individuos mayores de 60 anos. Se uso el test de Sperman-Rho para analizar la correlacion entre el EQ-VAS, el edentulismo y el uso de protesis. Las pruebas de Chi-cuadrado, ANOVA y t-test se usaron para estudiar las diferencias en los puntajes del EQ-VAS entre los sujetos edentulos y sanos. La significancia estadistica se establecio en <0.05. De los 2000 encuestados, 98.3% fueron edentulos, 73.0% reportaron perdida de mas de la mitad de sus dientes, 76.9% reportaron usar protesis dentales y 23.7% problemas relacionados con la alimentacion. La edad avanzada, el estrato social bajo y el bajo nivel educativo se relacionaron con mayor perdida dental. Individuos con pocos dientes y protesis dentales tuvieron puntajes bajos en el EQ-VAS (p=0.22). La presencia de edentulismo tambien mostro una correlacion negativa con los puntajes del EQ-VAS (rho= -0.102, p<0.01). Se concluye que EQ-VAS es un instrumento de gran utilidad para la medicion de calidad de vida en contextos relacionados a salud oral. El edentulismo afecta significativamente la calidad de vida en los adultos mayores y el uso de protesis dentales no mejora la percepcion de la calidad de vida.

Palabras clave: Boca; Edentulismo; Calidad de vida; Envejecimiento; Protesis dentales.

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INTRODUCTION

The elderly population has increased rapidly worldwide in recent decades due to the demographic transition¹ which is accompanied by an increase in longevity and age-dependent chronic diseases². Oral diseases are among the most prevalent conditions in the elderly^3,4 and affect quality of life (QOL) as a result of infections, functional impairment, poor self-esteem, socialization issues, communication and chewing problems^5,6. Edentulism therefore represents a difficult challenge for public health given that poor oral health leads to a broad spectrum of comorbidities, such as malnutrition, frailty, and deterioration of preexistent chronic diseases, and decreases overall health status^7,8. Most importantly, these conditions increase morbidity and mortality rates ⁹. The most frequent causes of poor dental health are caries, periodontal disease and edentulism; the latter being a consequence and a common outcome of caries and periodontal disease¹⁰. Edentulism is the loss of at least one tooth (partial edentulism) or the loss of all the teeth (total edentulism)⁴. In the elderly, high prevalence rates have been reported for caries (47 to 91.9%), periodontal disease (36 to 89%) and edentulism (20 to 65%)^3,6,11-18.
In clinical practice, oral and dental examinations are the basis for identifying early oral diseases, signs of malnourishment and systemic diseases and infections that could be the result or the cause of dental health issues. Recently developed technology has enabled successful treatment of these diseases. Nevertheless, there are still serious problems involving dental health in the elderly, due to the following reasons: access to oral health services is limited, services are expensive and frequently not covered by insurance companies¹⁹, poor hygiene habits and the lack of dental health information provided to older adults^20,21. Dental prosthesis usage has been shown to increase QOL by improving dental function. However, it has been reported that people are often not aware of the proper use of the prosthesis or simply do not use it despite their need^19,22. Furthermore, a complete nutritional assessment is a priority in edentulous individuals and dental prosthesis users because they typically eat food with low nutritional value to facilitate chewing. Adequate nutritional status in edentulous patients is maintained by proper usage of the prosthesis and health care of the gingiva and remaining teeth. Several approaches have been used to measure QOL²³. One of the most widely used instruments for measuring QOL is the EuroQOL questionnaire²⁴, developed by "The International European Quality of Life Group'' to be applied internationally and standardized to measure QOL in the context of different diseases^25,26. {Leeds, 2004 #850} It has also been used and validated for Latin American countries in standard Spanish. This study used the Spanish version to analyze the relationship between QOL and dental health in the elderly ^27,28. This study evaluates the impact of edentulism and the usage of dental prostheses on the self-perceived QOL of older adults in the city of Bogota, Colombia

MATERIAL AND METHODS

The SABE Bogota study (Health, Wellbeing and Aging) is a probabilistic cross-sectional study. Data were collected from a sample selected by clusters in a multistage process (Sectors, sub-sections of neighborhoods, blocks, and sets of 10 houses); a correction factor was used for a statistical confidence of 95%. The total response rate was 81.9%. The sample of 2000 older adults aged 60 years and older was statistically representative of this population. The Pan American Health Organization designed the SABE survey for Latin American countries including 11 main topics²⁹: 1) identification of the house and the elderly older adults to be interviewed; 2) house and home characteristics; 3) personal and family data; 4) experiences of violence; 5) cognitive status; 6) health status; 7) characterization and causes of disabilities; 8) functional evaluation; 9) medication usage and access to health services; 10) anthropometrics and physical performance tests; 11) health, disease and a social history framework (biological component). Data were collected by fieldwork teams including: 1 supervisor, 3 to 4 interviewers and 1 anthropometrics specialist. The teams were trained by the principal investigator, field researchers, a statistician and a field coordinator. The collected data were digitalized and saved in Microsoft Excel, software version 2011. All respondents signed an informed consent in order to participate in the study, which was approved by ethics committee of the Pontificia Universidad Javeriana.

Dependent Variables
To characterize edentulism, we used related questions: 1. How many missing teeth do you have? (None, 1 to 4, 4 to half, more than half, all the teeth); 2. Do you use dental prosthesis? (Yes/no); 3. During the last 12 months, have you experienced any difficulties in eating related to issues with your teeth or dental prosthesis? (Yes/no). To measure QOL we used the EuroQol instrument, which has two main components: 1. EQ-5D, which evaluates 5 dimensions (Mobility, self-care, usual activities, pain/discomfort and anxiety/depression) and 2. EQ-VAS (Visual Analog Scale) which is a scale of 0 to 100 that allows individuals to place themselves according to how they perceive their overall health status (0 is the worst and 100 the best health status). For the purposes of this study we used the EQ-VAS as a tool for measuring healthrelated QOL in edentulous older adults. Independent Variables Socio-demographic variables: Age (age groups); Sex (male or female); Social class [Social class in Colombia is divided into strata (1-6, with 1 being the lowest and 6 the highest). We created three categories using the 6 classes 1-2 (Lower), 3-4 (middle) and 5-6(upper).³⁰]; and Educational level [evaluated as years of education (0, 1-5, ≥6)]. The questions related to edentulism were also used as independent variables when we evaluated EQ-VAS scores.

Statistical Analysis
We performed a descriptive analysis of edentulism and the socio-demographic variables with Chi- Square test to find differences between groups. Then we used the EQ-VAS as a continuous dependent variable to evaluate perceived QOL. This variable followed a normal distribution and we performed parametric analyses. Results are presented as mean scores } SEM (standard error of the mean); One Way-ANOVA or t-test was used to find statistically significant differences between edentulous and healthy subjects. When appropriate, a post-hoc test (LSD-Fisher) was used to determine significant differences between groups. Statistical correlations were estimated with Spearman-Rho correlation test given that the distribution for edentulism categorical variables was not normal. Statistical significance was accepted for p-values less than 0.05. Data analysis was performed using the software IBM SPSS Statistics version 21 for Mac and for figure preparation Sigma Plot by SYSTAT Software Inc. version 12 for Windows.

RESULTS

General Demographics and Prevalence of Edentulism
Of the 2000 respondents, 62.4% were female and 37.6% were male. Age (in years) groups had similar frequencies: 60-64 with 25.3%, 65-69 with 22.7%, 70-74 with 19.9%, and ≥75 had the highest frequency (32.1%). For socioeconomic status, the highest proportion was in the lower social class (51.9%), followed by middle social class (44.9%) and upper social class (3.3%). A total 98.3% were edentulous, 73.0% had lost more than half their teeth and 1.7% had complete natural teeth. 77.0% used dental prosthesis, 23.0% were edentulous and did not use dental prosthesis. Individuals with eating problems related to teeth or dental prosthesis were 23.7% (Table 1).

Table 1: Socio-demographic data Demographics about of the elderly population in the SABE Bogotá-study.

Table 2 shows the prevalence of edentulism by categories. Individuals who have lost more than half their teeth showed higher prevalence among women (76.6%), older age (82.5% over 75 years), lower social-class (78.9%) and lower educational level (84.5%). The frequency of complete teeth decreased from younger to older age groups (2.4% for 60-64 ys., 2.0% for 65-69 ys., 1.5% for. 70-74 ys. and 1.1% for individuals ≥ 75 ys), from higher to lower social class (6.2% for upper class, 2.5% for middle class and 0.8% for lower class) and from higher to lower educational level (2.3% for more than 6 years education, 1.6% for 1-5 years education and 0.8% for 0 years education). Statistically significant values were obtained for all categories.

Table 2: Missing teeth by sex, age groups, social classes and educational level.

Quality Of Life in Edentulous Older Adults Measured with EQ-VAS
Fig. 1 shows the differences in EQ-VAS scores between edentulous groups and subjects with complete teeth. EQ -VAS scores for those with complete teeth were 81.2 2.7 and significantly lower in edentulous groups. EQ-VAS scores decreased as the number of missing teeth increased with a significant negative correlation for edentulism and EQ-VAS, (rho= -0.102, p<0.01). (Data not shown).

Fig. 1: Quality of life (EQ-VAS) scores for groups with missing teeth and healthy subjects. One-way ANOVA, (LSD-Fisher). *p<0.05. (n= 2000).

EQ-VAS scores for edentulous groups that used dental prosthesis (70.1 0.5) did not differ significantly (p= 0.22) from those that did not use dental prosthesis (72.9 2.2). However, the presence of eating problems related to issues with the teeth or dental prosthesis was significantly lower 65.3 1.0 than no eating problems 72.2 0.5 (p<0.05, Table 3).

Table 3: Visual analogue scale by for eating problems related to issues with natural teeth or prosthesis.

DISCUSSION

Dental health progressively deteriorates in the elderly, leading to a complex scenario for overall health in this population. The most frequent dental health problems include caries, periodontal disease, pathological tooth migration, loss of alveolar supportive tissue and finally, partial and total edentulism^31-33. The aging process may contribute to these problems, but does not cause them^21,34. The main etiologies are lack of hygiene and appropriate dental health habits, as has been widely discussed and reported in the literature.^20,33,35 Previous studies of the Colombian population (ENSAB III) reported data on individuals up to 69 years of age and did not characterize edentulism.³⁶ This is the first study that provides epidemiological data for edentulism and its impact on QOL in the elderly in the city of Bogota, Colombia.
We found that the prevalence of edentulous individuals is close to 100% and most of them have lost more than half their teeth, representing a relevant public health problem. This prevalence is highest in women, those in lower social class, individuals with lower educational level and those over 75 years of age. Edentulism also showed a deleterious impact on QOL, as shown by significantly lower scores in EQVAS in edentulous individuals. As expected, the highest scores corresponded to older adults with complete teeth, and although their perceived QOL was higher, it did not differ significantly from those with up to four missing teeth. However, QOL was considerably affected in individuals with a greater number of missing teeth, who reported significantly lower scores in the edentulous groups that have lost less than half or more than half of their teeth, suggesting that the loss of more than four teeth affects the perception of QOL as much as the loss of more than half of the natural teeth. On the other hand, an important measure for improving health and QOL in edentulous people is the use of dental prostheses, although users must know how to use and handle them¹⁹. We found that 23.1% of individuals with edentulism did not use prostheses and those who did use them did not report an improvement in their perceived QOL. This is not surprising, given that dental prosthesis implementation requires a complete oral rehabilita - tion process, including continuous follow-up, patient education, special care and adaptation or change of the device if necessary, all of which are limited in this population. Furthermore, the presence of eating problems related to issues with the natural teeth or prosthesis has a significant detrimental effect on QOL compared to the absence of eating problems. The fact that QOL does not improve in older adults with the use of dental prostheses suggests that they are missing out on important advantages and benefits. Further studies on this population are needed in order to better understand why these dental health measures do not have the intended impact. It is a priority to increase the coverage of dental health care in older adults and improve their understanding on how to use these devices properly, through prevention and education campaigns focused on the oral health of the elderly.³⁷ Despite the complexity of measuring QOL, the EuroQol (EQ-VAS) instrument provides a very good tool which is easy to use at a very low cost and can be implemented routinely in these dental health studies.
This study has some limitations. It was a crosssectional study and it was not possible to evaluate the precise sequence of events and factors leading to edentulism. It was not possible to determine either the causes of or factors related to missing the benefits of dental prosthesis. Despite these limitations there are also several strengths. It is the first study to examine dental health, the prevalence of edentulism and prostheses and their impact on QOL of the elderly in Colombia. Finally, there is high prevalence of edentulous individuals among the older adults of Bogota, many of whom do not use dental prostheses. Most of these individuals had lost more than half their teeth and we found a clear increased association with sex (females), older age groups, lower social-classes and lower educational levels. These vulnerable groups in the older adult population are at high risk of having poor dental health, which in turn is widely reported to be associated with a wide range of illnesses such as malnourishment, chronic diseases and disability4,38. These findings highlight the importance of creating public policies to improve dental health in populations that are less able to afford dental healthcare or do not have enough knowledge about dental hygiene and health, as is the case in lower social classes and lower educational levels. Studies are also needed to identify the reasons why women are more edentulous than men. Most importantly, such public policies should focus on a continuous educational oral rehabilitation process, especially in elderly people who require dental prostheses.
EQ-VAS is a useful tool for measuring the perception of QOL in dental health scenarios. Herein we report that edentulism significantly affects QOL in older adults and that strikingly, dental prosthesis usage did not improve the perception of QOL, possibly due to the lack of knowledge on their appropriate use. It is imperative to collect new epidemiological data about the current status of oral health in the elderly population.

ACKNOWLEDGEMENTS

We thank Rafael Samper Ternent for his valuable discussions on this project and for editing assistance in the preparation of the manuscript. This project was supported by grants from the Administrative Department of Science, Technology and Innovation - Colciencias, Code 120354531692 and the Pontificia Universidad Javeriana.

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