Edentulism in the elderly in Montenegro

SUMMARY Introduction For the first time in Montenegro, a survey was conducted to examine the oral health status of the elderly. Materials and methods The study included 170 subjects of both genders, average age 72.32 ± 6.85 years. The research methodology was in line with the WHO methodological guidelines for epidemiological studies of national oral pathology. For statistical analysis of data IBM STATISTICS 20 was used. Descriptive and inferential statistical methods, Tamhane T2 post hoc tests, χ 2 test were applied. The homogeneity of the dispersions was checked by the Leven test. The significance level was set to 0.05. Results The DMFT value was 29.417 ± 3.81 (MT: 26.25 ± 6.95; FT: 2.68 ± 3.98; DT: 0.63 ± 1.56) and it was significantly higher in women, smokers and people who did not visit the dentist regularly. The percentage of edentulous persons was 46.47%. The index of dental rehabilitation - IRD was 73.86%. The average age of dentures was 11 years. Conclusion The state of oral health of the elderly in Montenegro is not at satisfactory level, which is reflected in the high percentage of edentulous people and unfavorable structure of DMFT.


INTRODUCTION
Improving oral health is a basic prerequisite for improving general health [1]. This is especially important for the elderly whose general health is impaired and burdened by chronic diseases. Research in the region [2], Europe [3,4,5] and other continents [6][7][8][9] has influenced the launch of research on the oral health status of the elderly in Montenegro. Studies of the impact of oral health on the quality of life have been conducted worldwide for more than five decades and a high degree of interdependence between quality of life and oral health has been proven [10][11][12][13][14]. These findings have been implemented in a new definition of oral health [15,16]. About 30% of Europeans, aged between 65 and 74, no longer have their natural teeth [17]. There is a recommendation for the implementation of oral health in general health prevention programs, which should result in people up to the age of 65 preserving at least 20 natural teeth [18]. Numerous authors have investigated the influence of oral health habits, socio-economic status and other characteristics on the occurrence of oral diseases and consequent edentulousness [5,6,7,[17][18][19][20][21][22][23]. Demographic data indicate a decades-long trend of population aging [24]. In order to prepare the health system for the increased number of elderly patients in the future, it is necessary to collect data on the state of oral health.
The aim of the research was to examine the state of oral health of the elderly in the central region of Montenegro.

MATERIAL AND METHOD
Prior to the implementation of the research, obligatory measures were taken, such as obtaining approval from the Ethics Committee of the Medical Faculty of the University of Montenegro in Podgorica. A research plan was made, respondents were informed and their consent to participate in the research was obtained.
All clinical examinations were performed by one dentist (a specialist in dental prosthetics, who was trained to analyze oral health data using relevant indices) according to the principles of good clinical practice. Kappa statistics were used to test the reliability of the researcher. The Kappa value estimated after retesting for intra-consistency of the investigator was 0.94.

Sample research
The study included 170 people with an average age of 72.32 ± 6.85. The method of including respondents in the research was based on the following characteristics: 1. Persons aged 65 and over who applied for an examination at the Faculty of Medicine in Podgorica -Study program of dentistry on certain days (Mondays and Wednesdays) in the period from September to December 2016 were included.
2. All users of the services of homes for the elderly "Nana" and "Ljubav spaja" in Spuž and Danilovgrad were included, whose state of general and mental health allowed them to be examined.
All respondents voluntarily agreed to participate in the research after they were explained the purpose of the research, the method of distribution of the obtained data and the anonymity of participation.
The sample was 5% according to the number of inhabitants aged 65 and over in the central part of Montenegro and it was statistically allocated so that the expected coefficient of variation falls between 8 and 11%.
The first research instrument used was a clinical examination of oral health, according to the WHO methodology, using the methodological guidelines for epidemiological studies of national oral pathology [25].
Data related to the number of carious, extracted and filled teeth, data on present dental restorations (fixed and mobile) and the age of dental restorations were analyzed.
The state of oral health was assessed on the basis of relevant indices, showing the following: 1. Caries status was registered using Klein Palmer's DMF system (D -Decaued, M -Missing, F -Filled) [26]. Caries was diagnosed by inspection with the help of a dental probe and a flat dental mirror, in daylight. Dental caries (K) was characterized by lesions with a clearly formed cavity on the tooth surface. Changes in transparency and initial demineralization of enamel with an intact surface that did not lead to disruption of dental tissue continuity were not registered. The term filling (P) included all permanent and temporary fillings of teeth. Extracted (E) teeth were all extractions caused by caries or periodontal disease. This indicator was presented in total for all respondents, in relation to certain characteristics of the respondents.
2. DMFT index -average caries index (DT -average number of carious teeth, MT -average number of extracted teeth, FT -average number of filled teeth).
3. IRZ index -The dental rehabilitation index was used to express (in percentage) how many lost teeth were replaced by making dental prosthetic restorations (fixed and mobile). It was calculated: number of restored teeth / number of extracted teeth + number of restored teeth x 100. 4. The presence of dental prosthetic restorations (fixed and mobile) and their age were recorded.
The second research instrument was a closed-ended questionnaire with 4 questions: Q1 -When was the last time you went to the dentist? Q2 -What are the reasons for your last visit to the dentist? Q3 -Are you a user of tobacco products? Q4 -What do you recognize as the main reason for the loss of your teeth?
During the examination, the respondents were given advice on how to properly maintain oral tissue, teeth and dental restorations. Dental restorations were reviewed and advice was given on how to maintain them.
In statistical processing, the collected data were processed using the statistical program IBM STATISTICS 20. Methods of descriptive and inferential statistics were used. Of the descriptive methods, the arithmetic mean and standard deviation were used. As part of inferential statistics, the t test for two independent samples, the χ 2 test, the Tamhane T2 percent hoc test, and the ANOVA were used. The homogeneity of the dispersions was checked by the Leven test. The significance level was set to 0.05.

Analysis of the oral health status of the respondents
Out of 170 examined persons, 79 (46.47%) were edentulous. DMFT was 29.417 ± 3.81 (min 15; max 32). The structure of DMFT showed that the subjects had an average of 26.25 ± 6.95 extracted teeth -MT, 2.68 ± 3.98 filled teeth -FT, while the number of carious teeth per subject was on average 0.63 ± 1.56 (damaged teeth DT). Subjects had an average of 2.39 ± 3.66 healthy teeth and 7.14 ± 9.19 prosthetically unrehabilitated teeth.
The presence of remaining natural teeth expressed according to the segments of dentition (which was important for the planning of prosthetic therapy) showed that the subjects had on average a higher number of teeth in lower dental arch (1.14) compared to the upper dental arch (0.73). In the anterior segments of dental arches, the number of preserved natural teeth was higher than in the posteror. In the lower anterior segments, the average number of natural teeth was the largest and it was 2.22, while in the upper anterior segment it was 1.29. The presence of the first permanent molars was on average 0.41 per subject (25.88% of persons had between 1 and 3 first permanent molars).

DMFT analysis according to the characteristics of the respondents
The study showed that females had statistically higher value of DMFT compared to males (t = -2.593; p = 0.011) ( Table 1).
Persons who were users of tobacco products had significantly higher value of DMFT compared to persons who did not use tobacco products (t = 2.279; p = 0.024) ( Table 1).
The data showed statistically significant difference in the value of DMFT according to the time elapsed since the last visit to the dentist. People who have visited dentist in the last 12 months had significantly lower DMFT value compared to subjects who have not seen dentist longer (between 1 and 5 years; more than 5 years) (ANOVA; F = 4.805; p = 0.009). Leven's test indicated heterogeneity of dispersions (p < 0.001) (Tamhane test, p = 0.009) ( Table 2).
There was no statistically significant difference in the values of DMFT in the subjects in relation to age (t = -1.147; p = 0.253).

Presence of dentures
The dental rehabilitation index -IRD was 73.86%. It was found that in 83 (48.82%) persons there were mobile dental restorations in both jaws. Thirty-four (20.00%) subjects had dentures in one jaw and no dental restorations in the other jaw. There were 16 (9.41) persons with fixed prostheses. The number of persons who had dentures in one jaw and a fixed prosthesis in the other jaw was 10 (5.88%) ( Table 3).

Analysis of the answers to the questions from the questionnaire
Reasons for teeth loss: 108 (63.52%) reported caries, while 61 (35.88%) reported periodontitis. One respondent (0.58%) cited trauma as the cause (Table 4). It was noticeable that women had decay more often (63, 71.59%) compared to periodontitis 25 (28.40%). For males, approximately the same number of subjects had decay 45 (54.87%) or periodontal disease 37 (45.12%) as a reason for teeth loss.
The last visit to the dentist in 58 (34.11%) was more than 5 years ago. In 37 (21.76%) subjects 2-5 years have passed since the last visit. In 30 (17.64%) subjects the visit   Mobile prosthesis in one jaw and a fixed prosthesis in the other U jednoj vilici mobilna, u drugoj fiksna nadoknada 10 (5.88%) 5 5 Mobile dental restorations in both jaws U obe vilice mobilna zubna nadoknada 83 (48.82%) 29 54 Mobile prostheses in one jaw and no prosteses in the other jaw U jednoj vilici mobilna nadoknada, u drugoj nenadoknađeni ekstahovani zubi 34 (20.00%) 14 19 to the dentist was 1-2 years ago. It has been 6-12 months since the last visit for 16 (9.41%) subjects, and less than 6 months for 29 (17.05%) persons (Table 4). As the reason for the last visit to the dentist, the majority of respondents 101 (59.41%) reported pain or a problem with teeth, gums or dental prosthesis. The need for consultations as the reason for the last visit to the dentist was stated by 26 (15.29%) respondents. Treatment was the reason for 22 (12.94%) subjects and regular checkup for 21 (12.35%) subjects ( Table 4).

DISCUSSION
Research by Petersen PE et al. [8,27] showed that number of edentulous people age 65 and over in the world is high. Also, WHO data from 2016 [9] showed that about 30% of Europeans (prevalence varies from 5% to 51%) between the ages of 65 and 74 do not have natural teeth. If this is compared with data from Montenegro (46.47%), it can be seen that the situation in Montenegro is worse than the European average. According to Peterson et al. [8], the situation in Europe in 2010 was as follows: in Poland, the prevalence of edentulousness in elderly was 43.9%, in Slovakia 43%, in United Kingdom 37.5%, in Hungary and Denmark 27%, in Austria 15% while in Lithuania it was lower than 13%. On other continents, the percentage of edentulousness among elderly was: in the USA 26%, in India and Indonesia 19%, in Lebanon 20%, while in China the situation was significantly better (11%).
Numerous factors influence the values of DMFT such as demographic and other characteristics of the population, behavior related to oral health, development of health systems [22] and others. In Europe, periodontal disease is the number one problem when it comes to oral health, while the caries rate has decreased significantly compared to previous decades [1,3]. The reduction in the incidence of caries in these countries is largely the result of decades of continuous use of oral health programs. In Montenegro, caries is the dominant cause of teeth loss. The analysis of the structure of DMFT supports the fact that dental services are available to the population. However, they are much more curative than preventive, and extracted teeth predominate in structure. The existing dental service should be further improved and directed towards preventive and prophylactic methods. Continuity in the promotion of oral health should be insisted on and directed towards all population groups. Emphasis must be placed on health literacy, information and education.
Prosthetic rehabilitation expressed by the rehabilitation coefficient in this study (73.86%) indicated similarity with the results of research in the elderly in Republika Srpska [2] where 31% had an upper complete and 18% had a lower complete dentures. There were 4.6% of persons who had removable denture in one jaw and a fixed one in the other, while a fixed prosthesis was present in 10% of the subjects. In a study by Haikol et al. in Finland [28], fixed prostheses were present in 23.7% of sixty-year-olds and 38.6% of eighty-year-olds (60% of the elderly had mobile dental restorations). Thus, in Montenegro and RepublikaSrpska, the presence of dentures was higher compared to fixed dental restorations, while in Finland the presence of fixed dental restorations was higher.
The value of DMFT observed in relation to the gender of the subjects in this study was consistent with the results in the study of Baumgartner et al. [4] and Pan et al. [5] and was significantly higher in women than men.
Numerous studies [20,21,23] have proven the negative impact of using tobacco products on the increasing incidence of oral diseases, which is in line with the results in Montenegro. A statistical association between the frequency of dental visits and the value of DMFT present in examined subjects was also demonstrated in the study of Nguyen at al. [6], Popović at al. [7], as well as in numerous other studies [17,20,22]. DMFT values were lower in individuals who have responsible oral health behaviors.
The significance of this research is that for the first time the state of oral health of the elderly in Montenegro was examined. The obtained results can be considered representative for the elderly living not only in the central part of Montenegro, but in the whole territory, because close to two thirds of the country's population is concentrated in the central part. In search of a specialist dental service, patients from the other two regions are gravitating towards dental practices, most of which are concentrated in Podgorica and Nikšić.

CONCLUSION
The state of oral health of the elderly in the central region of Montenegro is not at a satisfactory level. The loss of natural teeth and its consequences may become a significant public health problem in the future given the increase in the number of older people. Oral health care needs to become an integral part of state general health care and treatment programs. The promotion of healthy lifestyles and the concept of active aging should also contribute to improving oral health status of the entire population, especially the elderly.