Iftikhar Alam, Fawad Bangash, BDS. N · nutritional status of the subjects was assessed by simple...

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Oral health and nutritional status of the free-living elderly in Peshawar, Pakistan

Iftikhar Alam, BSc, MSc, Fawad Bangash, FSc, BDS.

Nutritional status and nutrient intake are closelyrelated to oral health.1 Unfortunately, elderly

individuals are often victims of poor oral health,1-3

andPakistanisnoexception.Onliteraturereview,wewereunabletofindpreviousstudiesdocumentingthedentalhealthof theelderly inPakistan.Wetherefore,undertook a small cross-sectional study to investigatethenutritionalandoralhealthstatusofthisagegroup,and also to ascertain any relationship between oralhealth,teethcleaning,andnutritionalstatus.

Here,wereportthenutritionalstatusandoralhealthof a total of 130 free-living elderly male individualsof age 60 and above living in Peshawar, North WestFrontier Province of Pakistan. Elderly males whoattendedadentalclinic inPeshawarbetweenApril toJuly 2008 were the subjects of the present study. Aninformed written consent declaring their willingnessto participate in the study was obtained from all theparticipants.Themethodofconvenient samplingwasapplied for sample selection. The inclusion criteriawere set to include otherwise medically fit subjectswith no evident chronic disease (as assessed by theirself-reportedmedicalfitnesshistory),non-smokersandwith no drug addiction. Female subjects seldom visitprivate clinics due to cultural constraints of the areaand therefore, they were not included in the presentstudywithin the existing settings andprovisions.Thenutritionalstatusofthesubjectswasassessedbysimpleanthropometricmeasurements includingweight (Kg),height(cm)andbodymass index:BMI=weight(Kg)/height (m2).Weightwasmeasured to thenearest100gwith the subjectwearing lightclothing.Heightwasmeasured to the nearest 0.1 cm using a microtoise®(FrancisInc.,Lahore,Pakistan)attachedtoawall.Eachsubject stood on a horizontal platform without shoesand with heels together and head in the Frankfortplane. Dietary data were collected using the 24-hourdietaryrecallmethod.Forthispurpose,aquestionnairewas developed, validated and pre-tested by collectingdata from 10 individuals not included in the presentstudy. The respondents were asked what they hadeatenovertheprevious24hourperiodfrombreakfastuntiltheirlastmealatnightjustbeforegoingtosleep,includingsolidfoodaswellasbeverages,butexcludingmedicine, and so forth. The amount of each foodconsumedwasused to calculate themean amountofnutrients taken. For dental health, every subject wasexamined by a single dental physician in the clinic.Given the limitationsof time and resources available,

noradiographicinvestigationswereperformed.Atoothwasregisteredif≥2mmwerepresentabovethegingivalmargin.Cariousdefects(DT),missing(MT)andfillingteeth (FT) were diagnosed. The DMFT scores werecalculated in accordance with the WHO guidelines.4A patient self-assessment form for chewing problemsand bleeding gums was developed and piloted beforethestartofthestudy.Chewingproblemsweredefinedas the inability to chew food easily andwithoutpainor difficulties. Participants were asked whether theyhad any difficulties in chewing and their responseswererecordedas‘Yes’or‘No’.Wedidnotcollectdataon specific causes of chewing problems. However,the participants were asked whether they sufferedfrom mouth dryness or if they observed difficulty inmovingafoodbolusinthemouth.Similarly,dataonbleeding gums were obtained by asking the subjectsquestions like:Doyour teethbleedwhile cleaningoreating? In addition, physical assessment of the gumswasperformedtoconfirmtheresponseofthesubjects.The gums were checked for inflammation, pocketsaroundtheteeth,hypertrophy,discoloration,andgumhyperplasia. The subjects were also interviewed ontheirdaily teethcleaning/brushingpractice.Theteethcleaningpracticesweredefinedas:‘cleanregularly’iftheparticipants brush their teeth 2-5 times or more in aday;‘cleanseldom’iftheparticipantsbrushtheirteeth≤onceaday.BasedontheirBMIvalues,subjectsweregroupedin2categories,namely,normalweight(NW;BMI=18.5-24.9)andunderweight(UW;BMI=<18.5)accordingtoWHOcriteria.5ThedatawerestatisticallyanalyzedusingGraph-PadSoftware(Version5.0.).Thedescriptivestatisticsoftheanthropometricdata,resultsofDMFTscoreandDMT-componentswereprovided(meanvalues,standarddeviation).Student’st-testwasusedforstatisticalcomparisonandcorrelationanalyses.A p-value of <0.05 was considered as statisticallysignificant.

Therewere74(56.9%)NWand56(43.1%)UWelderlysubjects.Theresultsshowmostofthesubjectswereilliterate(76%UW,43%NW)andeconomicallydependent(81%UW,53%NW).Theelderlysubjectsofthisstudybelongedtothelowtomiddlesocioeconomicsegmentofthecommunity.Themeanage,BMI,DMFTscore, and DMFT-components of the study subjectsareshowninTable 1.Therewasasignificant(p=0.001)differencebetweentheDMFTscoresofNWandUWindividuals.Table 2 shows thepercentageofNWandUW elderly according to their general dental statusandnutrientintake.DataongeneralteethhealthstatusshowedmoreelderlyUWsubjectswithbleedinggumsandchewingproblems.Thefindingsonnutrientsintakeshowed NW subjects had significantly higher energy,protein, calcium, and vitamin C intake as compared

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Table 1 - Meanage(years),BMI,DMFTscore,andDMFT-componentsof the normal weight (NW) and underweight (UW) elderlysubjects.

Variables NW UW P-value

MeanageinyearsMeanBMIMean DMFT and DMFT-componentsDTMTFTDMFT

67.4(5.7)23.5(1.9)

2.3(0.21)9.3(3.1)

1.4(0.23)13.0(0.51)

65.2(6.3)16.1(2.5)

4.2(1.21)19.1(6.41)2.9(0.27)26.2(1.3)

0.0320.001

0.0030.001

0.040.001

BMI-bodymassindex,DT-decayedteeth,MT-missingteeth,FT-filledteeth,DMFT-decayed,missing,filledteeth

to the UW elderly. There was an inverse correlationbetweenBMI andDFMT score (r=-0.211,p=0.001).Data shows a significant inverse correlation betweenDMFTscoresandnutrientintake,DMFTscoresandenergy(r=-0.201,p=0.002),DMFTscoresandprotein(r=-0.196, p=0.001), DMFT scores and calcium (r=-0.203,p=0.001)andDMFTscoresandvitaminC(r=-0.191,p=0.001).Theresultsonteethcleaningpracticesshow those who cleaned their teeth regularly (2-5 ormore times a day) had relatively healthier oral healthcomparedtothosewhocleanedtheirteethveryseldom(≤onceaday).

MalnutritionishighlyprevalentinPakistan.6Thereis no separate data on nutritional status of Pakistanielderly.Thenutritionalsurveysconductedinthepast,however, show very marginal nutritional status andhigh nutrient deficiencies in the general population.In this context of higher prevalence of malnutritioninPakistan, it canbe assumed that the elderlymighthaveanevenmoreimpairednutritionalstatus.Thisfactnecessitatesinvestigationofthecausesandcontributingfactors of malnutrition in elderly. The present pilotstudy documented nutritional and dental status ofPakistani elderly individuals. The study showed asubstantial number of elderly with nutritional anddental problems. The correlation between BMI andDMFTscore(r=-0.211)wasonlyslightlypronounced,buttheseresults indicatethathighDMFTscoredoeshavepossiblenegativeconsequences.Thesefindingsareincloseagreementwithsomerecentstudies,2,3inwhichitisshownthatthereisanegativerelationshipbetweennutritional status and dental problems. On literaturereview, we were unable to find any published dataconcernedwithcorrelationsbetweenBMI(nutritionalstatus)andDFMTscoreinPakistanielderlysubjects.

The present study also reported very poor dentalhygiene practices in the UW elderly in particular.Poor oral hygiene is the most important risk factorin the development of periodontal diseases,4 which

subsequentlyleadtopoornutritionalstatus.2,3Oneveryimportant question that may arise from the currentstudy and needs to be answered is: does nutritionalstatusandnutrientintakeleadtopoordentalhealthorisittheotherwayaround?Unfortunately,ourfindingscannotdifferentiatebetweenthese2possibilitiesasweuseda smallpilot studywithacross-sectionaldesign.Nevertheless, we did show an inverse relationshipbetween BMI and the DFMT score and nutrientintakeandDFMTscore.Aperson’sabilitytoeatcanbeaffectedbycompromiseddentition-decayedormissingteeth.Theseoralhealthproblemscansubstantiallylimitaperson’sfreechoice,properchewing,mastication,anddigestionof food.A lowBMI iseasilyexplainableonthebasisofrealfunctionaldifficultiesthatcanpreventnormaleatinginsomecases.Whilethisdoesnotalwaysholdtrue,itmaypartlyexplaintherelationshipbetweenBMIandoralhealth.3

There is compelling evidence to suggest thatperiodontal disease progresses more rapidly inundernourishedpopulations.2Mostobviously,theoralcavityisthefirstpointofentryoffoodintothebodyand serves in the chewing, tasting, and swallowingoffood. Additionally, edentulous individuals prefer softand processed foods, avoiding fruit, vegetables, andmeats that are considered difficult or impossible tochew,andpresentalowerintakeofvitaminC,calcium,non-starch polysaccharides, and protein. The lowerintakeofvitaminCisrelatedtoalowerconsumptionofkeyfoodsthatareconsideredhardtochewbymostindividualswithhighlyimpaireddentition.2

In conclusion, the present study identified aninverse relationship between oral health (as assessedbyDMFTscore)andthenutritionalstatusofthefree-livingelderly.Impaireddentitioncanaffectindividualsbycausingdietaryrestrictionsviadifficultyinchewing,possibly compromising their nutritional status andwell being. The results of the present study, however,cannot be generalized to all elderly populations in

Nutritionalstatusandoralhealthoftheelderly... Alam & Bangash

Table 2 - Percentofnormalweight(NW)andunderweight(UW)elderlyaccordingtotheirgeneraldentalstatusandnutrientintake.

Variables NW UW P-value

Teeth health statusBleedinggumsChewingproblemsNutrients intake % of RDA (sd)EnergyProteinCalciumVitaminC

3441

79(19.4)56(24.1)74(23.5)81(22.3)

5169

56(24.1)41(11.7)34(17.2)42(16.5)

0.0010.001

0.050.002

RDA-recommendeddailyallowance,sd-standarddeviation

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Pakistan.Asstatedearlier,thiswasasmallpilotstudywith limited resources and other constraints. A moregeneralizedstudy isneededtoaddress theproblemofpoororalanddentalhealthinrelationtodeterioratingnutritional statusof theelderly inorder toprepare tofacetheagingchallengeincomingdecades.Wesuggeststudies adopting a prospective epidemiological designtofurtherelucidatetheproblem.

Received 17th November 2009. Accepted 26th January 2010.

From the Tübingen Aging and Tumor Immunology Group (Alam), Tübingen University, Germany, and the International Dental Clinics and Laboratories (Bangash), Peshawar, Pakistan. Address correspondence and reprints request to: Iftikhar Alam, Tübingen Aging and Tumour Immunology Group, Sektion für Transplantationsimmunologie und Immunohämatologie, University of Tübingen, Zentrum für Medizinische Forschung, Waldhörnlestraße 22, 72072 Tübingen, Germany. Tel. +49 (7071) 2981269. Fax. +49 (7071) 294677. E-mail: ialamk@yahoo.com

References1. deAndradeFB,deFrançaCaldasAJr,KitokoPM.Relationship

betweenoralhealth,nutrient intake andnutritional status inasampleofBrazilianelderlypeople.Gerodontology2009;26:40-45.

2. GaiãoLR,deAlmeidaMEL,FilhoJGB,LeggatP,HeukelbachJ. Poor Dental Status and Oral Hygiene Practices inInstitutionalizedOlderPeopleinNortheastBrazil.International Journal of Dentistry2009.doi:10.1155/2009/846081

3. LocherJL,RitchieCS,RobinsonCO,RothDL,SmithWestD,BurgioKL.Amultidimensionalapproachtounderstandingunder-eating in homebound older adults: the importance ofsocialfactors.Gerontologist 2008;48:223-234.

4. WorldHealthOrganization.Oralhealthsurveys:BasicMethods.4thed.Geneva(CH):WHO;1997.

5. WorldHealthOrganization.Obesity:preventingandmanagingthe global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i-xii,1-253.

6. Pakistan Institute of Development Econcomics. NationalNutritionSurvey2001-2002.Islamabad:PlanningCommission,GovernmentofPakistan;2003.

Nutritionalstatusandoralhealthoftheelderly... Alam & Bangash

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