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Table of Contents
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 182-188

Oral health-related quality of life in older people in Kashan/Iran 2015

1 Department of Medical Surgical Nursing, Kashan University of Medical Sciences, Isfahan, Iran
2 Trauma Nursing Research Center, Kashan University of Medical Sciences, Isfahan, Iran
3 Department of Epidemiology and Health Statistic, Kashan University of Medical Sciences, Isfahan, Iran
4 Department of Periodontology, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication18-Dec-2017

Correspondence Address:
Negin Masoudi Alavi
Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Ghotb Ravandi Highway, Kashan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nms.nms_55_17

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Background: Oral health-related quality of life (OHRQOL) means the subjective perception of oral health and its impacts on the quality of life. It is an important indicator in oral surveys. Objectives: The aim of this study was to evaluate OHRQOL in older people in Kashan city (Iran) in 2015. Methods: In this cross-sectional study, 500 elders aged <60 years were evaluated. The Geriatric Oral Health Assessment Index (GOHAI) was used for data collection along with demographic and oral cavity characteristics. Mann–Whitney U, Kruskal–Wallis test, and multiple logistic regression were used for data analysis. Results: The 58.6% of participants were male. Mean age was 73.79 ± 10.13 years. The 284 (56.8%) participants were edentulousness. The GOHAI total score was 43.08 ± 8.35 that showed the above average scores of measurements. Statistical tests showed that the OHRQOL was significantly better in married persons, with negative history of smoking, and those who used mouthwash, toothpicks, regular tooth brush, and tooth floss (P < 0.05). In multiple regression analysis, the age, gender, education, the history of smoking, color of gum, number of decayed teeth, the firmness of gum, having denture, and frequency of tooth brushing could explain 38.7% of OHRQOL. Conclusion: The physical indicators of the oral cavity in older people of Kashan were not satisfactory although the OHRQOL was above medium level. In Kashan, it seems that use of full dentures is more common than other treatments such as filling caries or using implants.

Keywords: Dental health surveys, Geriatric dentistry, Oral health, Quality of life

How to cite this article:
Khosrozadeh H, Alavi NM, Gilasi H, Izadi M. Oral health-related quality of life in older people in Kashan/Iran 2015. Nurs Midwifery Stud 2017;6:182-8

How to cite this URL:
Khosrozadeh H, Alavi NM, Gilasi H, Izadi M. Oral health-related quality of life in older people in Kashan/Iran 2015. Nurs Midwifery Stud [serial online] 2017 [cited 2023 Mar 24];6:182-8. Available from: https://www.nmsjournal.com/text.asp?2017/6/4/182/221006

  Introduction Top

Aging and mouth problems have a long interrelated history. Conventionally, oral diseases and edentulousness were typical of aging.[1] Although this belief has been changed, still the mouth problems are common in older adults.[2] Oral health is a key component of general health; the World Health Organization (WHO) has emphasized the importance of oral health as a major component of general health and quality of life.[3] Mouth problems (e.g., dental caries, periodontal disease, tooth loss, dry mouth, and oral cancer) can predispose older people to different health conditions such as malnutrition and pneumonia.[4],[5] A study in Iran showed that losing teeth was significantly related to ischemic heart disease.[6] Besides oral health is a part of healthy aging.[3],[7]

The systematic data which allow assessment of oral health in Iran is limited. A study in 2002 showed that the DMFT (Decayed, Missing, Filled Teeth), in Iranian adults was 14.8.[8] In the North of Iran, 60%–78.8% of old people had no teeth.[8],[9] Studies show that oral health is not satisfactory in older people.[10] The WHO report in 2003 showed that edentulousness in people aged >65 years was 58% in Canada, 27% in Denmark, 11% in China, and 6% in Gambia.[11] This different statistics showed that poor oral health is an international problem. It also showed that there is a significant difference in oral health in different countries.

Recently, the oral health-related quality of life (OHRQOL) has received more attention than physical indicators of the oral cavity. This variable evaluates the subjective perception of the oral health and its impacts on the quality of life.[1],[12] OHRQOL is easy to obtain compared to collecting clinical data. It is also a valid tool to assess the personal experiences of physical symptoms such as one's feelings, perceptions, and pain.[13]

A study in Spain showed that 68.1% and 64.3% of older men and women, respectively, had low OHRQOL.[1] Locker found that 53% of elders had problem in OHRQOL.[14] Some studies showed the improvement of OHRQOL after using dentures and other interventions.[2],[15],[16]

OHRQOL of Iranian adults has been studied in limited studies with inadequate samples. A study in Iran showed that 64.9% of Iranian adults reported the negative impact of oral health on their daily performances.[17] In another study in Tehran, the perceived oral health was satisfactory in adults.[18] These limited studies had controversial findings.

Cultural, social, and economical conditions can influence the OHRQOL.[19] Age, sex, smoking, education, and some chronic conditions such as diabetes and depression had significant relation with OHRQOL.[17],[18],[20],[21],[22] It seems that OHRQOL, like QOL is a complex concept. Iran is a country in Middle East, where dentistry is mainly private and adult patients must pay the total cost of dental care. This can limit the accessibility of dental care. Nurses have crucial role in evaluating and improving QOL and its dimensions such as oral health-related QOL in older people. Oral health is important in nutrition and general well-being that are the focus of nursing care in older people.


The aim of this study was to describe the oral health status and OHRQOL in people 60 years and older in Kashan (Iran) in 2015.

  Methods Top

Design and study population

This population based cross-sectional study was conducted in people aged over 60 years living in Kashan, center of Iran. Data collection was conducted from May to July 2015.

Sampling and selection of subjects

The sample size was calculated with the confidence level of 95%, the estimation of OHRQOL to be 38.2 ± 10.2,[6] and the error of 0.03. With the following formula:

(1.962 × 10.22)/(0.032 × 38.22) = 305

The 305 was multiplied by 1.5 for the cluster sampling effect. The sample size was 457 after multiplication then it was increased to 500 for higher accuracy. The cluster sampling was used in this study. The Kashan city was divided to 5 areas according to municipal map. One health center of every area was selected randomly. The sample size of every health center was determined according to the population of that area. The streets of the area were chosen randomly, and in every street the alleys were included in the study. The researcher went to the houses in the alleys to find the participants. The inclusion criteria were community-dwelling people with age over 60, living independently in urban areas of Kashan city, the ability to communicate, negative history of cognitive problems, and willingness to participate in the study. In the process of data collection, if the patient was not able to complete the questionnaire he/she was excluded from the study. The process continued till all the participants entered the study.

Data collection

The assessment tool had three parts:

  1. The demographic data including age, sex, socioeconomic status, education, marital status, current smoking, and history of smoking. This part was completed with the interview
  2. Oral situation including the number of natural, decayed, or filled teeth, having dentures, frequency of brushing, visiting a dentist in the past year, use of mouthwash, dental floss or toothpicks, existence of mouth sores, the color and consistency of gum. The examination on soft tissues of the mouth, presence of teeth, and use of dentures were classified in a simple dichotomous manner, with the aim of minimizing the possibility of observation errors. This part was completed with interview and examination by the first author
  3. The OHRQOL questionnaire: Geriatric Oral Health Assessment Index (GOHAI) is one of the tools that try to evaluate the OHRQOL. This tool has been designed by Atchison and Dolan in the United States in 1990 and has been translated and used in different countries such as China, France, Japan, Germany, and Saudi Arabia.[23],[24]

The Persian version of the GOHAI, which was translated and validated in the previous study [22] was used for this part. The GOHAI includes 12 questions, each with a score between 1 and 5, and a total score ranging from 12 to 60. A higher score indicates a better perceived oral health status. GOHAI is divided into three categories of physical function (4 questions), psychosocial function (5 questions), and pain and discomfort (3 questions). The reliability was calculated to be 0.92.[22] The questionnaires completed with the interview.

Ethical considerations

This study was conducted as master degree thesis. The protocol of the study was approved by the Ethical Review Board of the Kashan University of medical sciences with the ethical code No. IR.KAUMS.REC.1394.65. The research process and its objectives were explained to the participants, and all participants signed informed consent before data collection. The participants were assured about the data confidentiality, and the questionnaires were anonymous. The Helsinki Declaration was respected in the research process.

Data analysis

The data were transferred to SPSS version 13.0 (SPSS Inc., Chicago, Illinois) for statistical analysis. The normality of the quantitative variables such as age or the GOHAI score were evaluated using Kolmogorov–Smirnov test. The difference of GOHAI score in dichotomous variables such as sex and having dentures were studied using Mann–Whitney U-test, and the difference in categorical variables such as education was analyzed using Kruskal–Wallis test. Spearman's correlation coefficient was employed to test the correlation between numerical variables such as age, and GOHAI score. Multiple logistic regression was used to study the variables that could predict the GOHAI score. The level of significance was set at P < 0.05.

  Results Top

The 500 elders recruited to the study that 58.6% were male, and 41.4% were female. Mean age was 73.79 ± 10.13 years (range 60–110). The 284 (56.8%) of participants were edentulousness. The number of remained teeth was 6.68 ± 9.17. Only 62 (12.4%) participants had >20 teeth. The GOHAI questionnaire showed the average scores of measurements of the scale in all dimensions [Table 1]. The detail characteristics of the participants and the differences in GOHAI score can be seen in [Table 2].
Table 1: Geriatric Oral Health Assessment Index and decayed, missing, filled teeth among older people (Kashan, Iran, 2015)

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Table 2: Mean scores and standard deviations of Geriatric Oral Health Assessment Index (GOHAI), according to demographic and clinical characteristics (Kashan, Iran 2015)

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The OHRQOL was significantly better in married persons, with negative history of smoking, and those who used mouthwash, toothpicks, regular tooth brush, and tooth floss. The complete denture significantly had a better result in OHRQOL compare to partial dentures. The people with higher education had higher GOHAI score. Visiting dentist in the previous year had no significant relation with OHRQOL. Overall, the mouth care was poor and only 77 (15.3%) participants used regular tooth brush.

The GOHAI score had significant negative correlation with age (r = −0.353, P = 0.0001), and the number of decayed teeth (r = −0.127, P = 0.004). It had positive correlation with the number of filled teeth (r = 0.225, P = 0.0001).

Having trouble in biting and chewing, discomfort when eating, having sensitive teeth, and feeling worried about the teeth, were most common problems. The psychosocial impacts were limited, and only 48 participants had limited their contacts with others because of oral health. The details of the answers can be seen in [Table 3].
Table 3: Frequency distribution of the participants' answers to each of the questions on Geriatric Oral Health Assessment Index (GOHAI) questionnaire

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In multiple regression analysis, the age, color of gum, number of decayed teeth, education, the firmness of gum, gender, the history of smoking, having denture, and frequency of tooth brushing made a meaningful model with OHRQOL. These variables could explain the 38.7% of GOHAI score (R = 0.662, R2 = 0.387, adjusted R2 = 0.376). [Table 4] shows the details of multiple regression analysis. The age had the greatest beta coefficient in GOHAI score.
Table 4: The results of multiple regression analysis with Geriatric Oral Health Assessment Index score as dependent variable

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  Discussion Top

The study showed that only 12.4% had >20 natural teeth. The positive mouth care attitudes such as regular tooth brush or mouth wash was not frequent. GOHAI scores have no reference values, so maybe it is not proper to interpret it as high or low. In this research, the GOHAI score showed above the medium level of OHRQOL. In a study in the elders in Brazil, the GOHAI score was much higher than current study.[25] In Japan also, the GOHAI scores in physical and psychosocial and pain were much higher than our study.[26] In a study in Israel in hospitalized adults, the 31.3% of the patients were edentulous, and only 14% had partial or full dentures. The mean number of residual teeth was 11.35.[27] These results showed that in comparison to some other countries, the ORHQOL was lower in Iran/Kashan. It might be related to the poor oral health care that can be seen in the study, and also to the reality that primary health services in Iran do not provide any education or dentistry services to the elder population.

In 2003, the World Dental Federation approved that maintenance of at least 21 teeth as the condition for functional dentition.[25] Hence, the threshold of 20 teeth is regarded as a functional and nutritional adequacy of dentition.[28] In a study in Poland, only 5.1% of respondents had >20 natural teeth that were less than our study. In Poland, the mean number of teeth was 6.2, and 89.0% had partial dentures.[28] The mean number of teeth was similar to our study, but in Iran, the use of full denture was much higher. It seems that in Iran most of the older people and dentists prefer to use full dentures. In Brazil, the mean of filled teeth was 1.82, and the mean of decayed teeth was 0.7.[29] In our study, the average of filled teeth was much less that might reflect the poor dentist services in our country.

In Kashan, the 284 (56.8%) participants were edentulousness. Complete edentulism in elders has been reported 21.9% in the United States and 39.6% in New Zealand, and 7% in Sweden.[30] The peak of severe tooth loss in both developed and developing countries reported to be around 65 years.[30] Dental prostheses can preserve the mastication function in edentulousness older people. In spite of high rate of edentulism in elders in our study, most of the participants had full dentures that can be an advantage. Dentures need care, hygiene, and routine dental control. Unfortunately, in our study, the mouth care attitudes were not satisfactory that can predispose participants to oral cavity problems. In Japan, approximately 40% of the older participants in a community-based study reported poor oral health.[21] It seems that health services should emphasize on oral health education in older people. This basic and necessary action has been forgotten in many countries.

Implant treatment can increase the OHRQOL. In a study, the mean GOHAI increased from 47.6 to 54.5 after implant therapy.[31] None of the participants in the current study reported implant therapy. The high price of this treatment in Iran might explain this result.

In Brazil, education was likely to have positive effects on GOHAI score. The average GOHAI score was 32.8 for illiterate people.[29] This was much lower than score of illiterate elders in our study. In Brazil, there was a contradiction between the actual oral health status of the older people and their perception of oral health. The high percent of the participants considered their oral health moderate or good, but their GOHAI score was low.[29] We can see the same trends in our study that physical indicators of oral health and healthy attitudes were low but still the GOHAI score was above the medium level. This contradiction shows that older people may miss-judge their real clinical conditions. That's might be a reason why our participants had poor teeth condition but acceptable GOHAI score. This high estimation of GOHAI and poor oral physical indicators might explain why most of the participants did not visit any dentist in the previous year.

In Corenjo study in Spain women had lower GOHAI score than men. Only 3.6% of men and 8.8% of women visited a dentist in the past year. The visit to dentist did not associate with poor OHRQOL.[1] In the current study, multiple regression analysis showed that GOHAI score had positive relation with education, male gender, having denture, frequency of tooth brushing, and the firmness and normal color of the gum. On the other hand, it had negative relation with age, number of decayed teeth, and the history of smoking. The mentioned variables are well documented in other studies.[22],[23],[24],[25],[26],[27],[28] The age had the greatest contribution in GOHAI score. The importance of age can be seen in other studies.[23],[25] The history of smoking is another factor on negative OHRQOL.[26],[27],[28] The multiple regression also showed that regular tooth brushing, stopping smoking, and better dental services for the treatment of decayed teeth can improve the OHRQOL.

This study had some limitations. The number of female participants who refused to take part in this study was higher than expected. This might threaten the generalizability of the findings. The researchers tried to overcome this problem with increasing the sample size. The number of mouth sore was less than expected. This condition might need more specialized evaluation and there might be an underreport of this condition in this study.

  Conclusion Top

The health and OHRQOL and physical indicators of oral cavity in elders of Kashan were not satisfactory. In recent years, in most of the developed countries, a very important trend to keep teeth has appeared. In Iran, it seems that people and health services are more eager to use full dentures instead of other treatments such as filling caries or using implants. The oral cavity condition is decisive when making assessments of the preventive and curative care needs of older population. The oral health-care services should receive more attention in Iran. Oral health condition in older people is an important issue, so we suggest comparative studies in other cities of Iran. The relation between OHRQOL with QOL and the nutrition status and mental health of the older people need more investigation. We also suggest the interventional studies to evaluate the effect of education and dental services on the improvement of OHRQOL.


The authors express their gratitude to the personnel of health centers in Kashan province and the people who kindly participated in our study. We also are thankful of deputy of research in Kashan University of Medical Sciences that approved and funded this study with the grant number 94065.

Financial support and sponsorship

The manuscript has been funded by Kashan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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