Impact Profile in elderly Chileans in southern Chile

Cite as: Yobánolo-Hoffmann M, Valentin-Hoyos J & Aravena PC. Oral Health Impact Profile in elderly Chileans in southern Chile. J Oral Res 2015; 4(6): 365-370. Abstract: Aim: To evaluate the impact of oral health on the quality of life of elderly patients (EP) in the public health system of Valdivia, Chile in 2015. Methods: A descriptive study was conducted using the “Oral Health Impact Profile Spanish version” (OHIP-14Sp), in a population of 387 EP (71.8±7.5 years old; 53% women). The impact of oral health on the quality of life was determined by the mean scale score that ranged beween 0 points (good quality of life) and 56 points (poor quality of life). In addition, oral health problems reported by EP population as having a greater inf luence on their quality of life were also included in this study. Results: The mean score of OHIP-14Sp was 20.1±7.6 points. Items showing problems more frequently associated with quality of life were: “toothache” (32.8%), “appearance of the teeth” (32.8%), “sensitive teeth” (32.3%) and “difficulty for chewing food” (25.8%). Conclusion: The impact of oral health on the quality of life of the EP population was considered low when compared to the median score of OHIP-14Sp. Functional and aesthetic aspects showed the highest impact on the quality of life of EP in the city of Valdivia.


INTRODUCTION.
The elderly population (EP) over 60 years of age has shown a progressive and rapid change in its population pyramid.Globally, data from the United Nations predict that by 2050 one in five people will be over 60 years, estimating a rate higher than 24.1% in Chile, with a life expectancy of up to 80 years 1 .However, these figures are associated with dramatic oral health problems caused by the loss of teeth in EP due to the lack of appropriate measures to prevent and treat oral health problems throughout their life 2 .
In 2003 less than 1% of the Chilean population over 65 years old had all their teeth and a third of them was totally toothless, demonstrating a perceived need for dental prosthesis use in 55.3% of the EP, affecting various aspects of their quality of life 3 .The interest in evaluating diseases that affect quality of life has been increasing gradually.To quantify quality of life in relation to oral health, scales such as Oral Health Impact Profile-49 (OHIP-49), Oral Health Impact Profile-14 (OHIP-14), Oral Impact of Daily Performance (OIDP), Geriatric/General Oral Health Assessment Index (GOHAI), among others 4 , have been used and validated.
In Chile, a group of researchers at Universidad de Talca validated the OHIP-14Sp scale in a group of Chilean elders obtaining a high internal consistency (α=0.91) 5 .As a result, this instrument allows to quantify quality of life in relation to the perceived state of oral health in EP from different regions of Chile.Local evidence suggests that EP usually consider poor oral health condition as a normal consequence of the aging process 6 .Thus, the analysis of quality of life associated with oral health yield epidemio-logical data that can be compared with data from other Latin American regions, facilitating the implementation of public health policies to improve the quality of life of EP 1 .
The aim of this study was to evaluate the impact of oral health on the quality of life of EP according to the OHIP-14Sp scale in the public health system of the city of Valdivia in southern Chile, 2015.

Study design
A descriptive study of EP patients treated in the public health system of the city of Valdivia was performed in 2015.The research protocol was approved by the Research Ethics Committee of the Health Service of Valdivia (No. 073/2015).

Population and sample size
The target population was EP patients over 60 years old who were regularly treated at the General Hospital of Valdivia and at the Dr. Jorge Sabbath Family Health Centre in the same city.A convenience sample was selected according to the number of EP patients who received dental treatment at each health centre according to their scheduled appointments between March and June 2015.
The number of EP was established according to the score of the OHIP-14Sp scale presented by Leon et al. 5 , considering a standard deviation of 31.4 points, a confidence interval of 95% and a desired precision of 3.5 points; an approximate number of 310 EP patients participated in the study ("EpiTools Epidemiological Calculators".Australian Biosecurity Cooperative Research Centre).
EP patients selected were those who, after a verbal explanation of the purpose of the study, accepted and approved their participation by reading and signing the informed consent.EP suffering from alcoholism, cognitive impairment, illiterate or those who were dependent on others were excluded from the study.
"Oral Health Impact Profile" in Spanish (OHIP-14Sp) The OHIP-14Sp scale validated in Chile 5 was used in this study.This scale has 7 domains (Functional limita-tion, Physical pain, Psychological discomfort, Physical disability, Psychological disability, Social disability, and Handicap) distributed in 14 items.Each item corresponds to oral health problems associated with quality of life and valued by frequency in a Likert scale of four points: "Never" (0 points), "Almost never" (1 point), "Sometimes" (2 points), "Frequently" (3 points) and "Always" (4 points).The sum score of the OHIP-14Sp scale ranges between 0 points (good quality of life) and 56 points (poor quality of life).Before using the scale, a validation face test was conducted with a pilot study of 30 patients at the General Hospital of Valdivia.As a result, font size was increased because most EP had difficulty reading the questionnaire.These participants were not included in the study sample.
Two researchers (J.V.H; M.Y.H) applied the scale to patients in the waiting rooms of the services already mentioned.The questionnaire was printed on a letter-size paper using size 12 "Century Gothic".Patients were briefly explained the purpose of the questionnaire and asked to read and sign the informed consent.Then patients received the document along with an ink pen.They were given a maximum of 20 minutes to answer the instrument.Once completed, researchers gave the participating patients their contact information.
For each patient, the following independent variables were registered: age (age range every 5 years), sex (male, female), area of residence (urban, rural), smoking (yes, no) and frequency of visits to the dentist for check-ups (one or more visits per year, less than one visit per year).The sum score of the OHIP-14Sp scale was registered as the dependent variable.

Data analysis
Surveys were coded in a Google Drive spreadsheet (Google Inc.Mountain View, CA, USA).The impact of oral health on quality of life was assessed according to the average of the sum of scores obtained from each EP participant.It was considered a low impact if the mean score was lower than the median of the OHIP-14Sp scale (28 points).In addition, those problems in which over 25% of the EP selected the options "Frequently" and "Always"

RESULTS.
Three hundred eighty-seven EP participated in the study between April and June, 2015.They had an average age of 71.8±7.5 years.Of these, 53% were women, mostly residents of urban areas (p<.001).The mean score of the OHIP-14Sp scale was 20.1±7.6 points (minimum=3, maximum=47).There were no significant differences in relation to sex (p=.18), age range (p=.1) and area of residence (p=.16).The variables "smoker EP" and "visits less than once a year to the dentist" showed statistically higher scores on the OHIP-14Sp scale (p<.001).
The distribution of sociodemographic variables and the mean score of the OHIP-14Sp scale in each one of them is shown in Table 1.

DISCUSSION.
The impact of oral health on quality of life in a sample of EP over 60 years in Valdivia proved to be low in relation to the median of the OHIP-14Sp instrument.However, it was observed that conditions such as being a smoker and visiting the dentist less than once a year showed significantly higher scores.It was also noted that the problems associated with food, tooth sensitivity, toothache and cosmetic appearance were the most frequently observed.
These findings are consistent with results from seven other countries including Canada, Mexico 8 , Colombia 9 and Japan 10 , whose mean score in the OHIP-14 scale was lower than the median of the instrument (28 points) and where the domains "Physical pain" and "Psychological discomfort" showed more problems in relation to oral health condition.In turn, the use of the instrument GO-HAI in EP from Latin American countries such as Colombia 11 , Peru 12 and Chile 13 complements these results, showing that a high percentage of respondents (74.1%, 77% and 76%, respectively) perceived a high impact of oral health on their quality of life.
Regarding socio-demographic variables, "frequency of visits to the dentist" stands out over the rest, as most of the participants in the study visit the dentist less than once a year (73.6%), having an mean OHIP-14Sp higher than those who do it more than once a year.These results are consistent with those described by Quinteros et al. 6 showing an association between the number of dental visits and higher rates of cavities and missing teeth due to the lack of dental care provided by the Chilean public health system and to the fact that the EP population over 60 years does not have any type of private dental health insurance and is restricted to only one dental care program.Private dental care is unaffordable for most people, whose retirement pensions are usually very low 6 .
Our results showed that the domains "Functional Limitation", "Physical pain", and "Psychological discomfort" were chosen by 25% of EP respondents as a problem affecting their quality of life frequently or always.These results are similar to previous reports 5,6,7,10,14 mainly conditioned by the lack of access to and maintenance of oral health care during the life of the EP patient 2, 6 .
With respect to age, the mean scores of OHIP-14Sp obtained were similar in all age ranges.This finding differs from the results presented by Leon et al. 5 , in which older people had a lower impact on the OHIP-14Sp scale, indicating a greater acceptance by this age group to deteriorating health and lower life expectancy.One of the effects seen in this data is the increased loss in the number of teeth in older ages, even with one third of the population over 65 years 3 being edentulous due to lack of dental care during childhood, and poor oral health promotion and prevention actions, which are currently available 6 However, this limiting condition can be significantly improved by using implant prosthetics.Reports by Jofre et al. 15 have shown through the OHIP-14 scale a significant improvement in the quality of life in those elderly patients with mandibular implants and implant-retained, muco-supported implants, sggesting a basic or preliminary rehabilitation approach for this group of patients.
One of the limitations concerning convenience sam-

REFERENCES.
pling and patient recruitment aimed specifically at a health centre is the fact that they could cause information bias associated with a chronic illness, which may condition the outcome of this instrument.Furthermore, the use of scales with multiple-choice items may cause response bias induced by random answers or the effect of overestimating the real health condition of the participating patients.Despite these limitations, we believe that these results could be relevant and have an influence on decision-making regarding public health policies, considering the current state of demographic transition towards an aging population in Chile, which is directly related to the availability of intellectual, social, biological and material resources required by the elderly population 2 .In conclusion, it was shown that the impact of oral health on the quality of life of a group of EP over 60 years of the city of Valdivia was low in relation to the median score of the OHIP-14Sp instrument.However, the conditions of being a smoker and visiting the dentist less than once a year obtained significantly higher scores; showing a higher frequency of EP with impaired quality of life caused by feeding problems, tooth sensitivity, dental pain and aesthetic appearance.
We suggest conducting new studies that could establish the influence of various inherent risk and causal factors on the quality of life indices through case-control or prospective cohort studies, including results of previous studies 2 and those obtained with the use of the OHIP-14Sp instrument for measuring the effectiveness of therapies and interventions in community geriatrics and related medical specialties 1 .

ACKNOWLEDGMENTS.
The researchers would like to thank Dr. Sonia Piñeiro, director of the Department of Oral Health at the Municipality of Valdivia and Dr. Fernando Salinas, director of the Dental Department at the General Hospital of Valdivia.
The authors also wish to thank patients registered in the GES Elderly Program of the city of Valdivia for their voluntary participation in this study.This study is part of the requirements of JVH and MYH to obtain their Dental Surgery Degree at the Dental School of Universidad Austral de Chile.
Impacto de la salud oral en la calidad de vida de adultos mayores en el sur de Chile.
Oral Health Impact Profile in elderly Chileans in southern Chile.

-Hoffmann M, Valentin-Hoyos J & Aravena PC.
Oral Health Impact Profile in elderly Chileans in southern Chile.Oral Health Impact Profile in elderly Chileans in southern Chile.

DOI:10.17126/joralres.2015.071Table 1 .
Variables of patients and mean score of the OHIP-14Sp scale in elderly adults of the city of Valdivia, Chile.2015.Percentage of elderly adults who classified the frequency of the problem in the OHIP-14Sp scale.Problems chosen as "Frequently" and "Always" are highlighted in red.All values were calculated using descriptive statistics, showing the mean score of the OHIP-14Sp scale.In addition, for each independent variable the proportion of EP participants and the mean score of the OHIP-14Sp scale by chi square test and Student's t test, respectively (p<0.05), was calculated.Figures and tables were made in Microsoft Excel 2011 (Microsoft Corporation, Washington, USA) and the analytical statistical analysis in STATA 10.0 (StataCorp, WA, USA).Oral Health Impact Profile in elderly Chileans in southern Chile.