INTRODUCTION
According to the WHO, oral health is considered as an integral part of general health.1 Poor oral health can act as a risk factor for various physical illnesses and it can also be a consequence of poor physical health. Periodontal diseases and loss of teeth have been shown to be independent risk factors for cardiovascular diseases, cardiac events, presence of hypertension, and peripheral vascular diseases.2-7 There is bidirectional relationship between diabetes mellitus and periodontal diseases.8 Subjects with diabetes mellitus are more likely to have periodontal diseases and these are now considered as the sixth complication of diabetes mellitus.9 Presence of periodontal disease among patients with diabetes mellitus has also been linked to higher risk of end-stage renal disease.10 Severe periodontal disease has been shown to increase blood glucose levels, poor long-term control of blood glucose levels, and higher number of cardiovascular complications.11 Poor oral health has also been linked to hospital-acquired respiratory infections12 and increased risk of death due to respiratory diseases.13 Increased risk of stroke is seen in patients with periodontal diseases.14 Loss of teeth due to any cause is associated with presence of Alzheimer's disease and dementia.15 Periodontal disease and poor oral health are significantly associated with preterm birth,16,17 preeclampsia,18 aspiration pneumonia,19,20 stomach ulcers,21 cancers of head, neck, and esophagus,22 and obesity.23
Awareness of medical doctors about oral health conditions was investigated in a study where more than four-fifths of the physicians were unaware of oral health problems in their patients and had inadequate knowledge to refer the patients for dental treatments.24 There is credible evidence to suggest that physicians do not refer patients to seek dental care.25
Today, 68.4% of population is still living in rural areas,26 who have high unmet general and oral health needs, which is attributed to scanty distribution of medical and dental workforce serving in rural areas. Thus, to meet the unmet systemic and oral health problems suffered by people in rural areas remains a challenge. Hence, there is a need to increase the awareness among clinicians with regard to the high prevalence of dental problems among people with various physical illnesses and association of poor oral health status with adverse physical health outcome. A preliminary step in this direction can be by carrying out a survey in easily assessable patients, such as in patients admitted to various medical/surgical wards in order to estimate the magnitude of their dental health problems. Moreover, there are limited data in terms of oral health among inpatients, admitted for diverse reasons.27,28
Review of some of the important studies that have addressed the oral health status of patients with physical illnesses (Table 1) reveals that such studies have been done in different patient settings, have used different study designs, and have not comprehensively addressed together the oral hygiene practices, dentition, and gingival and periodontal status.10,28-33
Thus, this study aimed to assess oral health status and treatment needs of hospitalized patients, who were treated for various systemic conditions.
METHODOLOGY
This study was conducted among medically ill patients admitted in various medical—surgical wards of Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, India. This hospital mainly attends to patients drawn from rural areas. The study was approved by the Ethics Committee of the Institute and all the patients were assessed after obtaining written informed consent. Patients were recruited from the inpatient units of General Medicine, General Surgery, Orthopedics, Otolaryngology, Pulmonary Medicine, Oncology, Ophthalmology, and Gynecology and Obstetrics.
Conscious and cooperative patients were examined in the presence of their attendants at the bedside. Those admitted to various intensive care units were excluded from the study. A total of 346 patients were recruited. Patients who were found to have dental problems were advocated suitable dental treatment.
Demographic details and reason for hospital admission were obtained using a self-designed questionnaire. Assessment of dental parameters included collection of information on dentition, gingival disease, and periodontal pockets using WHO Format34 and performing American Dental Association Type III examination.35 Data collection was carried by one of the authors (AA), trained for clinical examination during several clinical sessions in the Department of Public Health Dentistry.
Data so obtained were assessed by using Statistical Package for the Social Sciences version 17.36 Categorical variables were analyzed in the form of frequency and percentages. Continuous variables were assessed in the form of mean and standard deviation. Comparisons were done by t-test or Chi-squared test, wherever appropriate.
RESULTS
The study included 346 subjects with mean age of 40.77 years (SD 14.4; 14—80), with two-thirds of the participants aged up to 45 years. Two-third (67.1%) of the study participants were educated beyond matric. About one-third (33.2%) of patients had both diabetes mellitus and hypertension, 10.4% of patients were admitted for pregnancy-related issues, 6.4% had hypertension only, 6.6% had fractures, 5.2% had renal complaints, and the remaining one-third (38.2%) had other systemic conditions. About one-fourth (26.3%) of the study sample were either smokers (18.2%) or (8.1%) chewed tobacco. About two-thirds (64.2%) had consulted a dentist in their lifetime (Table 2).
Table 1
Studies that report oral hygiene practices, dentition, periodontal and gingival status in patients with physical illnesses
| Study | Study design, number of participants | Results |
|---|---|---|
| Shutlis et al10 | Longitudinal cohort study in Gila River Indian Community of Arizona (USA), 529 participants | Age, duration of diabetes, hemoglobin A1c status, and hypertension at baseline associated with severity of periodontitis |
| Ziebolz et al28 | Case—control study on 33 acute coronary syndrome subjects in University of Medical Centre Gottingen (Germany) | Mean DMFT 14.5 ± 6.8 in subjects < 44 years |
| Gautam et al29 | Cross-sectional study on 206 chronic renal failure hospitalized patients in Andhra Pradesh with mean age 46.79 ± 12.78 | 92.7% Brushing teeth once a day, 45.1% visited a dentist. Lower educational level had high DMFT score. 44.2% with pocket depth of 4—5 mm |
| Carriho Neto et al30 | Cross-sectional study on 82 hospitalized patients in Londrina (Brazil) with mean age 45.7 ± 20.1 | Mean sound teeth 21.6 ± 09.7, mean periodontal pockets 8.7 ± 12.3; 49.4% had felt need of oral prophylaxis. Advanced age led to poor oral hygiene, gingival inflammation was associated with physical illness and medication usage. |
| Rai et al31 | Cross-sectional study involving 300 inpatients, of which 52 (17.3%) patients were in age range of 41—50 years at SDM College of Medical Sciences, Dharwad, Karnataka | Mean decayed teeth 1.91 ± 8.53 Mean missing teeth 5.12 ± 10.36 Mean filled teeth 0.16 ± 9.15 Mean DMFT in < 40 years and those > 40 years was statistically significant. |
| Commisso et al32 | Cross-sectional study on 118 type II diabetic patients admitted in Diabetes Day Hospital, Italy with mean age 60.6 ± 14.2 | 48.8% Brushing teeth twice a day 16.5% Brushing teeth once a day 50% visited a dentist |
| Yunus and Itagi33 | Cross-sectional study on 239 cerebrovascular accident survivors, of which 20.5% were in age range of 41—50 years in Maharashtra. | 81.7% Brushing teeth once a day 16.3% in 41—50 years had >6 mm deep pocket Mean DMFT (41—50 years) was 6.10 ± 5.24. DMFT and Periodontal status significantly increased with increase in age of the subjects. |
| DMFT: Decayed, missing, or filled teeth | ||
Table 2
Demographic status, deleterious habits, and self-expressed need of the study sample
Table 3
Oral hygiene practices of the study sample
The majority (77.2%) of the patients reported using toothbrush. However, a small proportion of patients either used finger for cleaning (16.2%) or tree stick (5.5%). Three-fourths (75.7%) relied on toothpaste, and this was followed by use of toothpowder (17.3%), and very few participants were using charcoal (0.3%). The majority (91%) of the participants were brushing their teeth at least once per day, and this was accompanied by cleaning of tongue in three-fourth (77.7%) of the participants (Table 3).
Dental Health Status
In the whole study sample, the mean number of sound teeth was 23.3 (SD 7.4). The mean number of unerupted teeth was 1.78 (SD 1.68) and the mean number of missing teeth due to caries was 3.1 (SD 3.17). Additionally, the mean number of missing teeth due to any other reason was 0.87 (SD 3.48). Very few patients had filled caries teeth, filled teeth with no caries, and fixed prosthesis (Table 4). The mean number of teeth with gingival bleeding for the whole study sample was 2.24 (SD 4.19). The mean number of patients without gingival abnormality in the study sample was 24.1 (SD 7.49).The comparison of dentition status with education is shown in Table 4, which clearly demonstrates that the less educated had significantly higher number of mean caries teeth, missing teeth due to caries, and significantly lower mean number of sound teeth. The less educated had significantly higher mean number of missing teeth and significantly lower mean number of teeth without gingival abnormality; significant onset of periodontal disease with pocket depth of 4 to 5 mm; greater number of missing teeth; and significantly lower number of teeth without periodontal abnormality.
When similar comparisons were done for patients aged <45 years and those > 45 years, participants > 45 years had significantly higher number of missing teeth due to caries, missing teeth due to reasons other than caries, and significantly lesser number of sound teeth (Table 5). Those aged > 45 years also had significantly higher number of missing teeth, lower number of teeth without gingival abnormality, higher number of teeth with periodontal pocket depth of 4 to 5 mm, and lower number of teeth without periodontal abnormality (Table 5).
When the dentition, gingival, and periodontal status of subjects were compared with those who had ever visited a dentist in their lifetime or never visited dentist; those practicing or not practicing sound oral hygiene like use of toothbrush and toothpaste for cleaning teeth, regular brushing of teeth, and practicing tongue cleaning; those with and without hypertension and/or diabetes mellitus; those using or not using tobacco; no significant differences emerged, but for the fact that those who were using proper cleaning aids had significantly higher number of unerupted teeth [1.191 (SD 1.7) vs 1.34 (1.56); t-value 2.68 (p = 0.008)].
Table 4
Comparison of dentition, gingival and periodontal status with education status of study sample
Table 5
Comparison of dentition, gingival and periodontal status of subjects in the age groups
DISCUSSION
The present cross-sectional study assessed the dentition, gingival disease, periodontal disease, dental hygiene, and felt needs of medically ill hospitalized patients. The sample size of the study was reasonably large when compared with some of the earlier studies.30-32 The study was conducted in a medical college setup, which mainly caters to the rural population. The finding of lack of use of toothbrush by one-fourth of the study sample is comparable with previous studies.32,37 Overall, the majority of the participants brushed their teeth only once, which is in consonance with previous studies in the Indian population.25,29,33 This suggests that there is a need for large mass media campaigns to improve the awareness of rural population in sound oral hygiene practices.
In the present study, the mean numbers of sound teeth were only 23.3 (SD 7.4), indicating that the oral health status is poor among patients with various physical disorders. This finding is supported by the existing literature, which suggests the association of poor oral health status with various physical illnesses.9-14,31-33 This finding reiterates the point that all patients with physical illness must receive proper oral health evaluation and education. However, in this study, no particular physical condition was found to have a specific association with oral health status.
In the present study, it was evident that lower education was associated with poor dental health. Previous studies also support the findings of the present study in terms of association of poor dental health and lower education level.29,38,39
The present study also revealed that compared with patients aged < 45 years, those aged > 45 years had significantly higher number of missing teeth due to caries, missing teeth due to reasons other than caries, and significantly lesser number of sound teeth. Those aged >45 years also had poorer gingival and periodontal health. These findings are similar to the previous studies and suggest that with increasing age, the oral health condition worsens, perhaps, especially, among those with various physical illnesses.7,14,15,31 Although this study did not evaluate the cause—effect relationship, previous studies have shown association of poor oral health and development of myocardial infarction, infective myocarditis, chest infection, stroke, etc.7,12-14 Accordingly, it can be said that oral health should be given due importance in evaluation of every patient with physical illness. All patients, especially those aged more than 45 years must be routinely screened for their dental status and they must be properly informed about the proper oral health hygiene and practices.
The present study has certain limitations. The study involved recruitment of inpatients by purposive sampling. Hence, the findings cannot be directly generalized to the community samples. The study included a heterogeneous group of subjects in terms of type of physical comorbidity, did not evaluate the relationship of oral health status and physical condition, and did not evaluate the cause—effect relationship. The present study was cross-sectional in nature and it did not evaluate the longitudinal course of dental health status of the patients. The present study also did not evaluate the attitude and practices of physicians and surgeons in terms of their advice and referral to dentist. No association was explored for effect on oral health with medication usage; however, this association had been explored previously in certain studies.30,40 Another shortcoming could be the nonevaluation of the association of length of time of stay in hospital with the oral health. The oral examination performed in hospital bed could have led to the underestimation of problems of oral cavity. Future studies must try to overcome these limitations.
To conclude, the present study reveals that patients with physical illnesses have poor dentition status, especially those with poor educational attainment and those >45 years or above. Further, oral health practices are poor in patients with various physical illnesses. Accordingly, there is a need for routine screening for dental problems in patients with various physical illnesses. There is a need to develop oral health protocols with the objective of providing preventive, curative, and rehabilitative services to hospitalized patients. Considering the fact that the referral rates from various medical wards are poor,24,41,42 there is a need to increase the awareness of physicians regarding association of the poor dental health status and various physical illnesses.