TMD and GOHAI indices of Brazilian institutionalised and community-dwelling elderly

Original article TMD and GOHAI indices of Brazilian institutionalised and community-dwelling elderly Maria Carolina Abud1, Jarbas Francisco Fernandes dos Santos1,2,3, Vicente de Paula Prisco da Cunha1,2 and Leonardo Marchini1,2,3 1 School of Dentistry, University of Vale do Paraı́ba, SJCampos, Brazil; 2School of Dentistry, University of Taubaté, Taubaté, Brazil; 3State University of São Paulo–UNESP, SJCampos, Brazil doi:10.1111/j.1741-2358.2008.00250.x TMD and GOHAI indices of Brazilian institutionalised and community-dwelling elderly Rationale and objectives: Considering the controversy in the literature regarding several aspects of temporomandibular dysfunction (TMD) in elderly populations and the absence of reliable data on elderly Brazilians in this field, this study consisted of an evaluation of TMD prevalence and the self-perception of oral health among institutionalised and community-dwelling elderly in São José dos Campos, Brazil. Methods: Two hundred and fifteen community-dwelling and 185 institutionalised elderly people were evaluated by the Helkimo anamnestic (Ai) and clinical dysfunction (Di) indices and answered a questionnaire using the Geriatric Oral Health Assessment Index (GOHAI). Results: The major prevalence of TMD symptoms was for the Ai0 (symptom-free) group (69.5%), while the major prevalence of clinical signs was for the DiI (mild) group (56%). Women presented a higher AiII classification than men (v2 test, p = 0.049). Community-dwelling elderly presented a significantly lower Ai0 classification than the institutionalised ones (Two ratios equality test, p < 0.001). There was no relationship between the institutionalised status and the clinical dysfunction index for Di0 and DiIII classification (Two ratios equality test, p = 0.194 and 0.535 respectively). The institutionalised elderly presented greater (One-way ANOVA = 0.005) self-perception of oral health (33.45) than did the community-dwelling group (32.66). There were only weak Pearson’s correlations among the anamnestic ()33.0%) or clinical ()14.7%) findings by the TMD and GOHAI indices. Symptom-free (Ai0) institutionalised elderly presented better scores in all GOHAI dimensions and elderly representing an absence of clinical TMD signs (Di0) presented higher GOHAI physical dimension scores in both groups. Conclusions: The prevalence of TMD symptoms among this sample of elderly individuals was relatively low, self-perception of oral health was reasonable and a weak, inverse correlation was found between TMD signs and symptoms and elderly self-perception of oral health measured by the GOHAI index. Keywords: temporomandibular dysfunction, Helkimo index, GOHAI, institutionalised elderly, community-dwelling elderly. Accepted 21 June 2008 Introduction The growth of elderly populations is a worldwide phenomenon. Brazil’s population of individuals 80 years old or older (called ‘very old’) was 1.1 million in 1991, but by 2000, this population had reached about 1.8 million. In contrast, the population of individuals between zero and 19 years of age increased by only 3% over the same period, while the very old population increased by 65%1. Therefore, oral health caregivers should be aware 34 of the needs of the elderly, aided by local and global epidemiological studies, which present oral health profiles of this population. Physiological changes to oral motor function2,3 and the temporomandibular joint4–6 caused by ageing, as well as pathological changes in teeth and periodontal tissues, with consequent loss of occlusal contacts, could lead to the conclusion that temporomandibular dysfunction (TMD) is prevalent among the elderly. However, in an apparent paradox, recent research on this topic7–10 has Ó 2008 The Authors Journal compilation Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2009; 26: 34–39 TMD and GOHAI among Brazilian elderly 35 revealed that TMD symptoms in the elderly populations are not so prevalent as previously assumed. Earlier reports have indicated that oral function11–13 and quality of life14 are negatively affected in TMD patients. Therefore, we believed, it would be of interest to investigate the prevalence of TMD among the elderly with a view to improving health care for this population. However, no epidemiological studies on TMD in elderly populations have been conducted in Brazil utilising international standards. Therefore, in the absence of TMD studies utilising international standards and considering that TMD negatively affects oral function11–13 and quality of life14, this study evaluated the prevalence of TMD among institutionalised and community-dwelling elderly in São José dos Campos, Brazil, and investigated the possible influence of this condition on the self-perception of oral health in these groups. On the basis of previous findings7–14, we hypothesised that: 1) the prevalence of TMD is relatively low and 2) the presence of TMD negatively affects the self-perception of oral health in elderly patients. 2004/CEP) and all the subjects gave their informed consent. All the interviews and clinical examinations were conducted by a single examiner. Material and methods The oral health self-perception was based on the Geriatric Oral Health Assessment Index (GOHAI). This index contains 12 questions about oral health, which are scored from 1 to 3, giving a total sum ranging from 12 to 36. The higher the final score, the greater the individual’s perception about oral health, and vice-versa. Self-perception was classified as ‘negative’ when the total score was 30 points or less. The questions referred to three dimensions: the physical dimension (the individual’s chewing, swallowing and vocal abilities), social dimension (satisfaction with the appearance of teeth; concern about teeth, gums or dentures; social limitations caused by oral appearance; self-consciousness about oral health, uncomfortable about eating in public); and concern dimension (ability to eat without discomfort, use of medication to relieve oral discomfort, sensitivity to cold, hot or sweet foods). The version used in this study was the Brazilian validated GOHAI version, which presented a 0.65 Cronbach’s alpha16. Subjects Four hundred individuals aged 60 or more were enrolled in this study. Of these, 185 were residents of institutions for the elderly and 215 were community dwellers. This sample represents 1.69% of the entire elderly population of São José dos Campos, Brazil1, according to the last census (2000). All the institutions for the elderly (n = 18) in the city, involving all levels of care, were invited to participate in the study, but 27.7% of them (n = 5) declined. All the residents of the participating institutions, who were able to answer the questions, were enrolled in this study. The community-dwelling elderly were recruited among the social groups for independent elderly of the city. The most representative groups (n = 11) participated and all the participants in these groups were enrolled in the study. Using the MinitabTM power and sample size tool (Minitab Inc., State College, PA, USA) and considering the aforementioned percentage of the city population (1.69%), the sample’s power was given a score of 0.9793, indicating that the sample was fairly representative of this city. The study was previously approved by the institutional review board (protocol number L092/ TMD evaluation The prevalence of TMD was evaluated by the Helkimo Index15, which was also used to evaluate patients’ complaints (anamnestic index – Ai) and clinical symptoms (clinical dysfunction index – Di) of TMD. The anamnestic index (Ai) evaluates the patients’ subjective complaints of TMD and ranges from Ai 0 (absence of subjective symptoms of TMD) to Ai II (severe TMD symptoms). The clinical dysfunction index (Di), which evaluates clinical (objective) symptoms of dysfunction on the basis of oriented clinical examination, ranges from Di 0 (absence of clinical symptoms of TMD) to Di III (more than one severe symptom combined with any of the mild symptoms). Oral health self-perception Statistics Possible relationships between evaluated variables were analysed by the chi-squared test when variables were qualitative and by Pearson’s correlation when variables were both quantitative and Ó 2008 The Authors Journal compilation Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2009; 26: 34–39 36 M.C. Abud et al. qualitative. One-way ANOVA was used to check a possible relationship between the GOHAI indices of the groups. A two ratio equality test was applied to check possible relationships between the Helkimo indices and the institutionalised status. The Helkimo indices of each GOHAI dimension for the two groups were also compared by ANOVA. The anamnestic dysfunction indices (Ai) obtained for the two groups are shown in Table 1. Community-dwelling elderly presented a significantly lower Ai0 classification (free of symptoms) than the institutionalised ones (two ratio equality test, p < 0.001). Considering both groups together, women presented a higher AiII (severe TMD symptoms) classification than men (v2 test, p = 0.049, v2 = 6.02). Table 2 indicates the clinical dysfunction indices (Di) recorded for the two groups. No relationship was found between institutionalised status and the clinical dysfunction index for Di0 (absence of clinical signs of TMD) and DiIII (severe symptoms of TMD) classification (two ratio equality test, p = 0.194 and 0.535 respectively), or between gender and the clinical dysfunction index (v2 test, p = 0.333, v2 = 3.41). An important correlation (v2 test, p < 0.001, 2 v = 62.21) was found between clinical and anamnestic TMD findings in our sample of elderly individuals. Table 3 lists the results of the GOHAI evaluation for both groups. The institutionalised elderly showed a greater self-perception of oral health than the community-dwelling group (one-way ANOVA, p = 0.005, F = 7.82, d.f. = 398). Results The respondents were 400 elderly individuals, 215 community-dwelling and 185 institutionalised. The response rate of the institutionalised and community-dwelling elderly was 86.8% and 100% respectively. The mean age of the respondents was 72.3 (SD = 8.1) years and 75.2% of this population comprised females. Institutionalised and community-dwelling elderly presented with a mean age of 75.46 (SD = 8.66) years and 69.6 (SD = 6.5) respectively. A statistical difference in age was found between the groups (ANOVA, p < 0.001, F = 3.87, d.f. = 398). The groups also presented a different profile in terms of gender (two ratio equality test, p < 0.001). Females comprised 60.5% of the institutionalised group and 87.9% of the community dwellers. Table 1 Comparison of institutionalised and community-dwelling groups against the Helkimo Anamnestic Index (Ai). Institutionalised Community-dwelling Helkimo Anamnestic Dysfunction Index (Ai) Quantity % Variation (%) Quantity % Variation (%) p-value Ai 0 (absence of subjective TMD symptoms) Ai I (mild subjective TMD symptoms) Ai II (severe subjective TMD symptoms) 145 27 13 78.4 14.6 7.0 5.9 5.1 3.7 133 47 35 61.9 21.9 16.3 6.5 5.5 4.9 <0.001a 0.062 0.005a TMD, temporomandibular dysfunction. a Statistically significant relationship. Table 2 Comparison of institutionalised and community-dwelling groups against the Helkimo Clinical Dysfunction Index (Di). Institutionalised Community-dwelling Helkimo Clinical Dysfunction Index (Di) Quantity % Variation (%) Quantity % Variation (%) p-value Di Di Di Di 78 101 3 3 42.2 54.6 1.6 1.6 7.1 7.2 1.8 1.8 77 123 13 2 35.8 57.2 6.0 0.9 6.4 6.6 3.2 1.3 0.194 0.599 0.024a 0.535 0 (absence of clinical TMD signs) I (mild clinical TMD signs) II (at least one severe TMD sign) III (more than one severe TMD sign) TMD, temporomandibular dysfunction. a Statistically significant relationship. Ó 2008 The Authors Journal compilation Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2009; 26: 34–39 TMD and GOHAI among Brazilian elderly Verifying the possible relationship between the Helkimo anamnestic (Ai) and clinical dysfunction (Di) indices and GOHAI index, only weak Pearson correlations were found in the anamnestic index (p < 0.001, Pearson’s correlation = )33%) and clinical findings (p = 0.003, Pearson’s correlation = )14.7%) on TMD and GOHAI indices (Table 4). As the Pearson’s correlations were negative, an inverse correlation was found between the Helkimo and GOHAI indices. When comparing the anamnestic Helkimo index for each GOHAI dimension in both groups, statistically significant differences were found only in the institutionalised group (ANOVA, p < 0.001) and the GOHAI scores were higher among patients with Ai0 (absence of subjective symptoms of TMD) classification. A comparison of the clinical dysfunction Helkimo index for each GOHAI dimension in the two groups revealed statistically significant differences Table 3 Comparison of institutionalised and community-dwelling groups against the GOHAI, using the oneway ANOVA test. GOHAI Institutionalised Community-dwelling Mean 33.45 ± 0.36, 95% CI 34 2.52 32.66 ± 0.41, 95% CI 33 3.07 36 21 36 185 33.09 33.81 0.005a 7.82 398 36 22 36 215 32.25 33.07 Median Standard deviation Mode Minimum Maximum Scale Lower limit Upper limit p-value F-value d.f. GOHAI, Geriatric Oral Health Assessment Index. a Statistically significant relationship. Table 4 Pearson’s correlation between GOHAI and Helkimo indices. GOHAI Correlation (%) p-value Helkimo Anamnestic Dysfunction Index (Ai) Helkimo Clinical Dysfunction Index (Di) )33.0 <0.001a )14.7 0.003a GOHAI, Geriatric Oral Health Assessment Index. a Statistically significant relationship. 37 in the Helkimo classification only in the physical dimension in both groups (ANOVA, p = 0.003) and GOHAI scores were higher among patients with Di0 (absence of clinical symptoms of TMD) classification. Discussion Our results corroborate recent reports7–10 showing a relatively low prevalence of TMD symptoms among the elderly and confirmed our first hypothesis. Similarly, the higher prevalence of TMD symptoms among women observed in our study is consistent with some previous studies17–19, although others8,10 found no gender-linked relationship. Our study also found a strong statistical relationship between anamnestic and clinical dysfunction indices in a sample of elderly individuals. This relationship, albeit apparently intuitive, seems to be unusual in other samples8,20. These results allow clinicians to expect low incidences of TMD in the elderly population in this city. Likewise, clinicians should also find a strong correlation between subjective and objective symptoms of TMD in this population. One limitation of this study is that the Helkimo indices do not include several important TMD-related factors, such as bruxism evaluation and social and psychological aspects. However, recent attempts to improve quantification of TMD have involved more extensive questionnaires, such as the Research Diagnostic Criteria for Temporo-Mandibular Disorders (RDC/TMD)21. Though more comprehensive, as a rule, the RDC/TMD is too lengthy to be used in large samples. Our study found a lower prevalence of TMD among the institutionalised elderly than in the community-dwelling population. As samples of institutionalised elderly presented, as a rule, less adequate systemic22 and oral health23–26 parameters than community-dwelling ones and that there is an important correlation between TMD symptoms and general health and psychosomatic factors10, we did not expect to find poorer results in the community-dwelling group. Furthermore, not only were the results of anamnestic and clinical dysfunction indices statistically better among the institutionalised elderly in our sample, but also the GOHAI index showed a greater self-perception of oral health in this group than in the community-dwelling one. GOHAI indices showing superior results among institutionalised elderly was also an unexpected finding, as the oral health of institutionalised elderly evaluated previously had revealed many Ó 2008 The Authors Journal compilation Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2009; 26: 34–39 38 M.C. Abud et al. unmet needs, not only in Brazil23 but also in other countries24–26. However, McMillan et al.27 found lower percentages of negative impacts among institutionalised elderly, although this group presented an inferior oral health status in an Oral Health Impact Profile (OHIP) evaluation among institutionalised and non-institutionalised Chinese elderly. These authors hypothesise that other factors, such as social and cultural ones, could influence the perception of oral health of the elderly. Our study also found weak and inverse Pearson’s correlations between TMD and GOHAI indices, which were stronger for subjective symptoms (Ai) than for objective (clinical) symptoms (Di). In fact, only weak Pearson’s correlations were found and hence the second hypothesis was also confirmed. When comparing the anamnestic (subjective) Helkimo index for each GOHAI dimension in the two groups, the institutionalised elderly without subjective symptoms of TMD presented higher GOHAI scores for all dimensions. The same comparison applied to the clinical dysfunction (objective) Helkimo index showed the GOHAI physical dimension as having higher scores among individuals presenting Di0 (absence of clinical symptoms of TMD) classification, in both the institutionalised and community-dwelling groups. These findings corroborate earlier reports that also found oral function11–13and quality of life14 to be negatively affected in TMD patients. The aforementioned hypothesis by McMillan et al.27 that social and cultural factors may influence the perception of oral health of the elderly should help explain why the Pearson’s correlations are weak. Similarly, Mesas et al.28 recently reported no association between negative self-perception (measured by GOHAI index) and poor oral health in an elderly Brazilian population. In their study, other factors such as female gender and the presence of depression were associated with negative self-perception. However, it should be noted that TMD evaluations differ significantly from common oral health evaluations. Therefore, and specifically in terms of clinical (objective) signs of TMD, the physical dimension of GOHAI seems to be very sensitive in our study. This may be because the clinical dysfunction Helkimo index deals basically with masticatory functions and the physical dimension of the GOHAI index also deals with functions relating to the masticatory system (the individual’s chewing, swallowing and vocal abilities). Mesas et al.28 also pointed out that the GOHAI index has, on the whole, proved inadequate to identify poor oral health, but the index correctly identifies individuals who need more comprehensive multi-professional care. These arguments are corroborated by Österberg and Carlsson10, who reported that TMD alterations in a cohort of 70-year-old subjects presented a significant association with several general health and psychosomatic factors. These authors also pointed out that the co-morbidity of TMD symptoms, psychological factors and pain in other parts of the body are therefore presumably part of a multi-symptomatic situation. Furthermore, Lee et al.29 evaluated a sample of 1600 elderly Taiwanese individuals regarding their clinical situations and patients’ subjective perceptions and discussed what impact these items had on the health-related quality of life (HRQoL), using the SF-36 questionnaire. After controlling for socio-demographic variables, they observed that individuals’ subjective perceptions of their oral health status had a greater impact on their HRQoL than the clinical indicator (dentate or edentulous). Our results are consistent with their findings, as we observed a stronger inverse correlation between subjective self-reported items (anamnestic-Ai) and GOHAI than between clinical issues (Di) and GOHAI. These findings emphasise, for the clinician, the fact that subjective symptoms, sometimes associated with a multi-symptomatic situation, probably produce a greater impact on the oral health selfperception of the elderly than objective clinical signs. With this fact in mind, clinicians should evaluate the complaints of elderly patients to take into consideration their frailty which, in a broad sense, involves physical, social, cognitive and psychological dimensions and co-morbidity30. From this standpoint, a multi-professional approach is necessary to form adequate diagnoses and provide relief for the patients’ symptoms. Conclusion The prevalence of TMD symptoms among this sample of elderly individuals was relatively low, self-perception of oral health was reasonable and the institutionalised elderly presented superior results for both parameters than the communitydwelling group. There were weak and inverse correlations between TMD signs and symptoms and the self-perception of oral health. Symptom-free institutionalised elderly presented superior scores in all GOHAI dimensions and elderly subjects without clinical TMD signs (Di0) presented higher GOHAI physical dimension scores in both groups. 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