57

Volume 47, Number 1, March 2014

Research Report

Oral hygiene and number of oral mucosal lesion correlate with

oral health-related quality of life in elderly communities

Dewi Agustina
Department of Oral Medicine
Faculty of Dentistry, Universitas Gadjah Mada
Yogyakarta-Indonesia

abstract
Background: Quality of life assessment mostly is based on general health. Deterioration of physiologic condition, polypharmacy
and the high occurrence of chronic disease in elderly may manifest in oral cavity that can affect oral function, in turn it will affect
quality of life of elderly. Purpose: This study was aimed to determine the correlation of oral health status and oral health-related
quality of life (OHRQoL) in elderly communities of Yogyakarta city. Method: Seventy three elders were subjects of this study. Data
of OHRQoL and oral health status were obtained from modification of questionnaire of Dental Impact of Daily Living (DIDL) Index
and from intraoral examination, respectively. Intraoral examination comprised oral mucosal lesion amount, oral hygiene, DMFT
index and periodontal tissue status. The data then were analyzed statistically using Pearson Product Moment Correlation. Result:
The results showed that mean of DMFT index was 16.9 and 63% of subjects were found with gingivitis, most subject had moderate
oral hygiene and each subject at least had two oral mucosal lesions. Mean score of quality of life was 27.2 and classified as satisfying.
Oral hygiene and number of oral mucosal lesion had correlation with OHRQoL with r were -0.236 (Sig. : 0.045) and -0.288 (Sig. :
0.013), respectively. Conclusion: The study suggested that oral hygiene and number of oral mucosal lesion correlate with oral health
related-quality of life in elderly communities of Yogyakarta city.

Key words: Oral health, quality of life, elderly

abstrak
Latar belakang: Penilaian kualitas hidup terutama didasarkan pada kesehatan umum. Memburuknya kondisi fisiologis, polifarmasi
dan tingginya kejadian penyakit kronis pada lansia dapat termanifestasi di dalam rongga mulut sehingga dapat mempengaruhi fungsi
mulut yang pada gilirannya akan mempengaruhi kualitas hidup lansia. Tujuan: Penelitian ini bertujuan untuk meneliti hubungan antara
status kesehatan mulut dan kualitas hidup berdasarkan kesehatan mulut pada masyarakat lanjut usia di kota Yogyakarta. Metode:
Tujuhpuluh tiga lansia sebagai subjek dalam penelitian ini. Data kualitas hidup berdasarkan kesehatan mulut dan status kesehatan
mulut diperoleh dari modifikasi kuesioner Indeks Dampak Kesehatan Gigi terhadap Kehidupan Sehari-hari dan dari pemeriksaan
intraoral. Pemeriksaan intra oral terdiri atas jumlah lesi mukosa rongga mulut, kebersihan mulut, indeks DMFT dan status jaringan
periodontal. Data kemudian dianalisis secara statistik menggunakan Pearson product moment correlation. Hasil: Hasil penelitian
menunjukkan bahwa rata-rata indeks DMFT adalah 16,9 dan 63% subjek ditemukan dengan gingivitis, subjek rata-rata memiliki
kebersihan mulut yang cukup dan setiap subjek rata-rata memiliki dua lesi mukosa mulut. Rerata kualitas hidup berdasarkan kesehatan
mulut adalah 27,2 dan tergolong memuaskan. Kebersihan mulut dan jumlah lesi mukosa mulut memiliki korelasi dengan kualitas hidup
berbasis kesehatan rongga mulut dengan masing-masing r adalah -0,236 (Sig. : 0,045) dan -0,288 (Sig. : 0,013). Simpulan: Dapat
58 Dent. J. (Maj. Ked. Gigi), Volume 47, Number 1, March 2014: 57–61

disimpulkan bahwa kebersihan mulut dan jumlah lesi mukosa mulut berkorelasi dengan kualitas hidup berbasis kesehatan rongga
mulut pada masyarakat lanjut usia di kota Yogyakarta.

Kata kunci: Kesehatan mulut, kualitas hidup, lansia

Correspondence: Dewi Agustina, c/o: Bagian Ilmu Penyakit Mulut, Fakultas Kedokteran Gigi Universitas Gadjah Mada. Jl. Denta I,
Sekip Utara Yogyakarta 55281, Indonesia. E-mail: [email protected]

introduction given in this index is easier to be understood compared with

other indexes that usually using Likert scale.
Proportion of elderly (older than ≥ 60 years) worldwide The aim of this study was to determine the correlation
dramatically increased recently. The reasons for this is between oral health status and oral health related quality
increasing of life expectancy because of quality of life of life in elderly communities of Yogyakarta city. The
improvement and development of health aspect.1 Problems significance of this study were: (a) giving inputs to
of elderly health are various either as results of physiologic competent institutions to increase the elderly health
or pathologic process. To cope with those problems, the management based on the oral disorders found in this study;
best thing to do is improving quality of life of elderly by (b) can be used as a basic reference for the oral health related
giving an adequate health management. So far the quality quality of life studies in elderly.
of life assessment is mostly based on general health of
people. Quality of life itself can not be separated from the
whole condition of human being that consists of general materials and methods
and oral health. Deterioration of physiologic condition,
polypharmacy and the high occurence of chronic disease Seventy three elderly from five elderly communities
in elderly may manifest in oral cavity that can affect oral (Gowongan, Tegal Panggung, Danurejan, Suryatmajan
function. and Universitas Negeri Yogyakarta) in Yogyakarta city
Health and function of mouth deteriorate as long as were subjects of this study. The subjects received intraoral
getting older.2 Several oral findings could be detected in examination to observe: the number of oral mucosal lesion,
elderly population. All these findings would give badly periodontal tissue condition using modified Periodontal
impact for daily life of elderly. However, maintenance of Index from Russel, general oral hygiene and DMFT index
oral health is still ignored by elderly. The ignorance of oral (dental caries/decay, missing and restored teeth). All data
health results in decreasing of self confidence and social were recorded in Oral Health Status Form. Assessment of
life that eventually affect the quality of life. Research quality of life based on modified DIDL was performed
correlated between oral health and oral health-based quality and recorded in OHRQoL Form. Principally, DIDL is an
of life in elderly is essential to conduct in Indonesia since instrument to describe the quality of life based on perception
Indonesian population can be categorised into old structure towards oral health. There are 36 alternative statements that
because of the percentage of elderly has reached up to 7%. can be met with the perception of oral health. Someone
Yogyakarta is a province in Indonesia with the highest should judge the statements with "yes" or "no". The score
amount of elderly (13.20%).3 Yogyakarta is a city with of quality of life is determined by amount of score that
the longest life expectancy in Indonesia, so many elderly should be had by someone with satisfied quality of life.
communities grow rapidly here. The community is a place The total score of the statements determines grading of
for elders to share ideas, thoughts and is a pleasure place OHRQoL with the following classifications: (a) score of
to intensively communicate each other with a goal to get a 25-36 is satisfied; (b) score 13-24 is relative satisfied; and
better quality of life. (c) score 1-12 is unsatisfied.
To assess quality of life is something so difficult since The data were descriptively and statistically analysed
concept of quality of life is elusive and abstract. Quality using Pearson
�����������������������������������������������������
Product Moment Correlation test to determine
����������
of life assessment is full of life values.4 There are many the correlations between independent variables (number
parameters to assess the quality of life related to elderly. of oral mucosal lesion, oral hygiene, periodontal tissue
However, from 20 instruments available, only 7 instruments condition, DMFT index) with dependent variable (oral
meet with criteria of measurement, quantification and health related quality of life). If the correlation existed, so
qualification including DIDL.5 In fact, parameters used in the simple linier regression analysis was conducted with CI
those instruments are not always suitable if applied in every = 95% (�α = 0.05) to ���������������������������������������
determine the influence of independent
country. Therefore, in this study DIDL parameters6 has been variables towards dependent variable or to determine the
modified based on the preliminary study. Dental Impact of correlation using software
��������������������������������
of SPSS of 16 version.
Daily Living was chosen since the alternative statements
Agustina: Oral hygiene and number of oral mucosal lesion correlate with oral health-related quality of life 59

results From linear regression analysis of variables with

correlation i.e. oral hygiene and number of oral mucosal
This study involved 73 elderly from five elderly lesion, the following equations were obtained: ŷ = 29,451
communities (Gowongan, Tegal Panggung, Danurejan, – 2,337x (ŷ = OHRQoL and x = oral hygiene) dan ŷ =
Suryatmajan and Universitas Negeri Yogyakarta) in 29,418 – 1,500x (ŷ = OHRQoL and x = number of oral
Yogyakarta����������������������������������������������
city. The subjects consisted of 11 males and mucosal lesion).
62 females aged 61-80 years. Fifty three subjects with The mean score of DMFT index in all subjects was
educational qualification of less than senior high school 16.9. These indexes were catagorised as moderate to high,
and twenty subjects with that of higher than senior high since classification of DMFT index i.e. DMFT index >13.9
school. Seventy subjects were married and the other three is high and 9.0-13.9 is moderate. 11 In this study, there was
were unmarried. Seventy one subjects were Javanese and no correlation between DMFT index with quality of life
the other two were other ethnics. Sixty seven subjects were (Table 2).
independent for activity daily living (ADL) and the other
six required some help when doing ADL. Occupational
backgrounds were house wife (30 subjects), merchant discussion
(4 subjects), employee (4 subjects), retired (25 subjects),
entrepreneur (4 subjects) and others (6 subjects). The Although the status of oral health of elderly generally
results of oral health examination can be demonstrated was not good enough (Table 1), however, they had satisfying
on Table 1. quality of life. This results probably were affected by aging
According to Table 1, it was clear that 82% of elders concept. In this concept, principally elderly will sincerely
had oral mucosal lesion. In this study, fissured tongue is the accept this decreasing condition that is assumed as natural
most found lesion, 51% of all elders with this lesion. Other process and it always happens for all elders.7 This concept
oral mucosal lesions found in these subjects were ulcerative makes elderly never look for solution and it does not much
lesions (20.5%), keratosis (17,8%), coated tongue (8.2%) influence the quality of life perception. One thing needs
and other lesions (2.5%). to be considered is parameters or indicators used to assess
the status of oral health. On the other hand, validity for
quality of life measurement is difficult to determine. So far,
Table 1. Summary of intraoral examination from all subjects instruments used to measure quality of life is determined by
professionals based on their own standard and definition.
No. of Whereas perception of quality of life is subjective and
Aspects Percentage Mean
subjects what someone deems that it is important for his/her life,
Oral mucosal lesion : 2.02 not always true for someone else.8
- Present 60 82% The result showed on Table 1 was supported by a
- Absent 13 18% finding that fissured tongue is the most common tongue
Oral Hygiene : condition (5.24%) compared to other tongue abnormalities.9
- Good 14 19% On the other hand, another study also found that fissured
- Fair 47 64% tongue was the most common tongue lesion diagnosed
- Poor 12 16% in 11.5% of the subjects comprised of 2,000 dental out
Periodontal tissue : patients that have been screened for tongue lesions.10 The
- Healthy 13 18% older someone the more fissured tongue may be found that
- Gingivitis 46 63% might be caused by reduction of elastic fibers in oral tissue.
- With tooth mobility 14 19% This lesion is benign and does not need special treatment,
DMFT Index 16.9 only required to increase tongue hygiene.10
Score of OHRQoL 27.2

Table 2. Summary of correlation analyses between oral hygiene, number of oral mucosal lesion, DMFT and periodontal status with
OHRQoL in all subjects

Oral hygiene Σ of oral���������������

�������������������
mucosal lesion DMFT P�����������������
eriodontal�������
tissue
Coefficient Correlation -0����
.���
236 -0����
.���
288 -0����
.���
026 -0����
.���
066
of������������
Pearson (r)
P-value (Sig) 0����
.���
045 0����
.���
013 0����
.���
828 0����
.���
580
Conclusion Weak correlation and Weak correlation and No correlation No correlation
negative negative
60 Dent. J. (Maj. Ked. Gigi), Volume 47, Number 1, March 2014: 57–61

Table 2 results was not in line with the previous It was assummed that diabetes mellitus type-2 might initiate
study that found there was a weak correlation between or worsen peridontitis and vice versa. A study support
DMFT index with quality of life measured by WHOQOL- that appropriate treatment for periodontitis will improve
OLD with r = 0.135 and with mean score of DMFT was glycemic control in diabetes mellitus type-2 patients.25,26
15.24.12 Oral hygiene itself can be caused by decreasing of oral self
There was a strong correlation between oral hygiene cleansing that it can be associated with xerostomia. It is
and OHRQoL with r = -0.236 (Table 2) and it was well known that many antihypertension medications have
highest correlation compared to other correlations, so it xerogenic effect.27,28
indicated that role of oral hygiene as a contributory factor From above discussion can be withdrawn some points
for OHRQoL is essential. That is why education and as follows. Although the OHRQoL of both group of elders
information about oral hygiene for frail elders should be could be still categorised satisfying, however, based on the
intensified, since many oral diseases are originated from bad oral findings in this study, improvement of elders’ condition
oral hygiene. Bad oral hygiene in elderly is life-threatening was compulsory since oral condition can affect general
condition since it may indirectly cause malnutrition and health. Someone with oral problems tend to consume
dehidration,13 brain abscess,14 arthritis,15 cardiovascular soft and non-fibre foods that make inadequate nutritional
disease16,17 and pneumonia18 those are originated from fulfillment. Finally, it can be correlated with stroke and
periodontal disease. This statement was supported by malignant risks.17, 29 Dentist and dental hygienist should be
studies at many institutions of elderly in Scotland.19 They recruited as part of elderly health team. Almost majority of
found that majority of elders had bad oral hygiene especially oral problems come from bad oral hygiene. Besides that,
elders with denture, even the denture wearers sufferred from bad oral hygiene makes someone prones to oral infection
denture-induced pathology. By regularly increasing of oral that can be focal infection for other parts of body. Therefore,
hygiene in institutionalised elderly can minimise incidence communication, information and education about oral
of pneumonia.20 hygiene is very essential and need to be intensified that it
The two most oral diseases are dental caries and expectedly may increase oral health-based quality of life
periodontal disease. These two diseases are originated from in elders.
bad oral hygiene. It is assumed that development of dental There are two main suggestions arised from this study
plaque is faster in elderly compared to young people.13 One i.e.: (a) it needs to create an instrument for OHRQoL
contributory factor for this bad oral hygiene is xerostomia, measurement that it is suitable for Indonesian elders; (b) it
since the prevalence of xerostomia in elderly is higher than needs to create standard parameters to determine oral health
in young people.21 It is caused as well by systemic disease status for Indonesian elders. The study suggested that oral
and side effect of medication.22 About 500 medications of hygiene and number of oral mucosal lesion correlate with
42 categories contribute to xerostomia in elderly.21 oral health related-quality of life in elderly communities
In this study not all indicators had correlation with of Yogyakarta city.
OHRQoL. Only number of oral mucosal lesions and oral
hygiene correlated with OHRQoL. It is need to be studied
further whether these indicators above are representative acknowledgement
enough to asses OHRQoL. Probably, needs a study to
determine standard indicators that are representative The authors gratefully acknowledge the funding
to assess OHRQoL for each population. According to provided by Dana Masyarakat Faculty of Dentistry,
systematic review carried out towards 1.726 articles about Universitas Gadjah Mada and sincere gratitude to Drs. B.
OHRQoL, only four studies showed significant correlations Esti Chrismawaty and Sri Budiarti for their involvement
between oral health status with OHRQoL.23 So, it is clear in subject’s examination.
that currently no adequate instrument available for oral
health assessment. The results met with Locker’s idea
that quality of life was elusive and abstract. Assessment references
of quality of life was full of life values in which vary for
1. Yellowitz JA. Providing oral cancer examinations for older adults.
each person.4 Quality of life is a perception of life related J Calif Dent Assoc 1999; 27(9): 718-23.
with culture and rules that it is suitable with a place where 2. Peterson PE, Yamamoto T. Improving the oral health of older
someone lives and associated with aim, expectation, people: the approach of the WHO Global Oral Health Programme.
standard and care of life.11 Community Dent Oral Epidemiol 2005; 33: 81-92.
3. Badan Pusat Statistik. Available from: http://www. etd.eprints.ums.
In this study was observed also that hypertension, ac.id/14760/4/03_BAB_I.pdf. Accessed November 8, 2011.
diabetes mellitus and gastritis were the three most found 4. Locker D. Concepts of oral health, disease and the quality of life.
systemic diseases/conditions in elders. The occurence of In: Slade GD, editor. Measuring oral health and quality of life. USA:
diabetes mellitus itself may be associated with effect of bad Dept. of Dental Ecology, School of Dentistry, University of North
Carolina; 1997. p. 11-24.
oral hygiene that leads to high prevalence of periodontal 5. Hebling E, Pereira AC. Oral health-related quality of life: a critical
disease. Periodontitis is more common and severe among appraisal of assessment tools used in elderly people. Gerodontology
patients with diabetes mellitus type-2 than healthy patients.24 2007; 24(3): 151-61.
Agustina: Oral hygiene and number of oral mucosal lesion correlate with oral health-related quality of life 61

6. Leao A, Sheiham A. Relation between clinical dental status and 18. Scannapieco F. Role of oral bacteria in respiratory infection. J
subjective impacts of daily living. J Dent Res 1995; 74(7): 1408- Periodontol 1999; 7097): 793-802.
13. 19. Ettinger R, Manderson R. Dental care of the elderly. Nursing Times
7. Iversen TN, Larsen L, Solem PE. A conceptual analysis of ageism. 1975; 10: 1003-6.
Nordic Psychology 2009; 61: 4-22. 20. Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H,
8. Xavier FMF, Ferraz MPT, Marc N, Escosteguy NU, Moriguchi EH. Hoshiba K, Ihara S, Yanagisawa S, Ariumi S, Morita T, Mizuno Y,
Elderly people’s definition of quality of life. Rev Bras Psiquiatr 2003; Ohsawa T, Akagawa Y, Hashimoto K, Sasaki H. Oral care reduces
25(1): 31-9. pneumonia in older patients in nursing homes. J Am Geriatr Soc
9. Gaphor SM, Abdullah MJ. Prevalence, sex distribution of oral lesions 2001; 50(3): 430-3.
in patients attending an oral diagnosis clinic in Sulaimani University. 21. Ship JA, Pillemer S, Baum B. Xerostomia and the geriatric patient.
J Bagh College Dentistry 2011; 23(3): 67-73. J Am Geriatr Soc 2002; 50(3): 535-43.
10. Darwazeh AMG, Almelaih AA. Tongue lesions in a Jordanian 22. Schwartz M. The oral health of the long-term care patient. Ann
population: prevalence, symptoms, subject’s knowledge and Long-Term Care 2002; 8: 41-6.
treatment provided. Med Oral Patol Oralo Cir Bucal 2011; 16(6): 23. Naito M, Yuasa H, Nomura Y, Nakayama T, Hamajima N, Hanada
e745-9. N. Oral health status and health-related quality of life : a systematic
11. Peterson PE. Priorities for research for oral health in the 21st century- review. J Oral Sci 2006; 48(1): 1-7.
the approach of the WHO global oral health programme. Community 24. Taylor GW, Borgnakke WS. Periodontitis prevalence and severity in
Dent Health 2005; 22: 71-4. Indonesia with type 2 diabetes. J Periodontol 2008; 82(4): 550-7.
12. Wangsarahardja K, Dharmawan OV, Kasim E. Hubungan antara 25. Darré L, Vergnes JN, Gourdy P, Sixou M. Efficacy of periodontal
status kesehatan mulut dan kualitas hidup pada lanjut usia. Universa treatment on glycaemic control in diabetic patients: a meta-analysis
Medicina 2007; 26(4): 186-94. of interventional studies. Diabetes Metab 2008; 3495): 497-506.
13. Shay K, Ship J. The importance of oral health in the older patient. 26. O'Connell PA, Taba M, Nomizo A, Foss Freitas MC, Suaid FA,
J Am Geriatr Soc 1995; 43(2): 1414-22. Uyemura SA, Trevisan GL, Novaes AB, Souza SL, Palioto DB,
14. Andrews M, Farnum S. Brain abscess secondary to dental infection. Grisi MF. Effects of periodontal therapy on glycemic control and
General Dentistry 1990; 38: 224-5. inflammatory markers. J Periodontol 2008; 79(5): 774-83.
15. Bartzokas C, Johnson R, Jane M, Martin M, Pearce P, Saw Y. 27. Scully C. Drug effects on salivary glands: dry mouth. Oral Dis 2003;
Relation between mouth and haematogenous infection in total joint 9(4): 165-76.
replacements. Br Med J 1994; 309(6953): 506-8. 28. Scully C, Bagan JV. Adverse drug reactions in the orofacial region.
16. Fiehn NE, Gutschik E, Larsen T, Bangsborg JM. Identity of Crit Rev Oral Biol Med 2004; 15(4): 221-39.
streptococcal blood isolates and oral isolates from two patients with 29. Terry P, Giovannucci E, Michels KB, Bergkvist L, Hansen H,
infective endocarditis. J Clin Microbiol 1995; 3395): 1399-401. Holmberg L, Wolk A. Fruit, vegetables, dietary fiber, and risk of
17. Joshipura KJ, Rimm E, Douglass C, Trichopoulos D, Ascheriio A, colorectal cancer. J Natl Cancer Inst 2001; 93(7): 525-33.
Willett W. Poor oral health and coronary heart disease. J Dental Res
1996; 75(9): 1631-6.