|Year : 2021 | Volume
| Issue : 1 | Page : 60-64
Hyposalivation is the main risk factor for poor oral health status in Indonesian elderly
Dewi Agustina1, Bernadetta Esti Chrismawaty1, Lisdrianto Hanindriyo2
1 Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
2 Department of Preventive and Community Dentistry, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
|Date of Submission||22-Oct-2018|
|Date of Decision||28-Aug-2020|
|Date of Acceptance||31-Aug-2020|
|Date of Web Publication||28-Jan-2021|
Dr. Dewi Agustina
Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, Jalan Denta 1, Sekip Utara, Yogyakarta 55281
Source of Support: None, Conflict of Interest: None
Aim: To analyze the effect of xerostomia and hyposalivation as risk factors for poor oral health status in Indonesian elderly. Materials and Methods: Oral health status of 158 elders in Yogyakarta, Indonesia was determined using Oral Hygiene Index-Simplified, Decayed, Missing, and Filled Teeth (DMFT) index, modified Community Periodontal Index, and number of natural occluding pairs (NOP). Xerostomia was determined by Xerostomia Inventory and hyposalivation was identified by measuring whole unstimulated saliva flow. Bivariate and multivariate analyses were done to analyze the possible correlation between the event of hyposalivation and xerostomia with each of the independent variables (oral health status) and to assess the simultaneous effect of hyposalivation and xerostomia for the event of poor oral hygiene (OH), respectively. Results: Periodontal pocket, high DMFT index, poor OH, ≤5 NOP, xerostomia, and hyposalivation were experienced by 41, 113, 44, 116, 94, and 40 of 158 participants, respectively. Based on the bivariate analysis between the event of xerostomia and oral health status indicators, it was found that there was a significantly different proportion of OH condition between the group of participants with and without xerostomia (P = 0.035). Conversely, the proportions of periodontal pocket and OH condition were significantly different between the group of participants with and without hyposalivation with P values of <0.001. The multivariate analysis demonstrated that the participants with hyposalivation and xerostomia have a 5.68 and 2.49 times higher risk of experiencing poor OH condition, respectively, accounted for 20% of the total model. Conclusion: Hyposalivation is the main risk factor for poor oral health status in Indonesian elderly.
Keywords: Elderly, Hyposalivation, Oral Health Status, Risk Factor
|How to cite this article:|
Agustina D, Chrismawaty BE, Hanindriyo L. Hyposalivation is the main risk factor for poor oral health status in Indonesian elderly. J Int Oral Health 2021;13:60-4
|How to cite this URL:|
Agustina D, Chrismawaty BE, Hanindriyo L. Hyposalivation is the main risk factor for poor oral health status in Indonesian elderly. J Int Oral Health [serial online] 2021 [cited 2021 Dec 3];13:60-4. Available from: https://www.jioh.org/text.asp?2021/13/1/60/308361
| Introduction|| |
The world population is aging quickly. Many factors contribute to this process, such as improvement in public health, and advancements in medicine. Indonesia is heading toward an aging population. By 2050, Indonesia is expected to have 72 million individuals aged 60 years and older and will be one of six countries in the world with more than 10 million individuals aged 80 years and older. One of the provinces in Indonesia with the highest number of elderly is the Province of Daerah Istimewa Yogyakarta. The district of Kota Yogyakarta, as one of the five districts in the Province of Daerah Istimewa Yogyakarta, was enlisted as the district with the highest density of population, which around 12.4% of its total population was comprised by elderly people. Yogyakarta is a city with the longest life expectancy in Indonesia, so many elderly associations grow rapidly here.
It is common for elderly to take several medications at the same time, known as polypharmacy often prescribed by multiple health providers. The high prevalence of polypharmacy with aging may lead to an increased risk of inappropriate drug use most importantly, adverse drug reactions (ADRs). Numerous factors play an essential role in the occurrence of ADRs and age has a very critical impact on the occurrence of ADRs. The adverse reactions are common in an elderly that is in line with one of the geriatric syndromes, i.e., iatrogenic. One of the most common oral adverse effects associated with medications is xerostomia either with or without hyposalivation. Xerostomia is defined as the subjective sensation of dry mouth., The use of medications and age independently increases the likelihood of developing xerostomia. It is known that more than 500 drugs may lead to hyposalivation such as antihypertensives, anticholinergics, antihistamines, benzodiazepines, cytostatics, diuretics, antidepressants, decongestants, and skeletal muscle relaxants. The majority reported culprit drugs were antihypertensive medications followed by cardiovascular drugs. Nevertheless, some systemic diseases such as diabetes mellitus (DM), Sjogren’s syndrome, and thyroid disease and other conditions such as stress, anxiety, radio-chemotherapy complication, and mouth breathing were also related to hyposalivation.
Saliva is essential to maintain the integrity of oral soft and hard tissue. Saliva helps in swallowing, oral hygiene (OH), speech, mastication, and taste. When hyposalivation occurs, it can impact many oral disorders such as dental caries, gingivitis, and mastication problems. In turn, these disorders eventually will decrease oral health-related quality of life (OHRQoL) as shown by the previous study that the more dental caries the lower the OHRQoL. Until now, it is still unknown which one between xerostomia and hyposalivation actually is the risk factor for the poor oral health of the elderly. By knowing the risk factor for poor oral health, the health providers would be able to plan the more adequate oral health management for elderly; expectedly the management will improve the OHRQoL of elderly. The aim of this study was to analyze the effect of xerostomia and hyposalivation as risk factors for poor oral health status in Indonesian elderly.
| Materials and Methods|| |
Setting and design
Three subdistricts representing the District of Kota Yogyakarta were purposively selected due to its ease of accessibility and the availability of prominent community health stations for elderly (Posyandu Lansia) system. The chosen subdistricts were Danurejan, Gedongtengen, and Jetis. Subsequently, five Posyandu Lansia were simple randomly chosen from these subdistricts for the recruitment of participants in this cross-sectional study. The five Posyandu Lansias were Posyandu Lansia Kemetiran, Gowongan, Suryatmajan, Tegalpanggung, and Danurejan.
Due to the availability of resources, letters of invitation to this survey were sent to 200 (40 invitations for each Posyandu Lansia) simple randomly selected members of the Posyandu Lansia aged 60 years and older. All recipients were informed about the purpose and methodology of the study. Appointment for the examination was given for individuals upon the submission of their written informed consent. There were 88% (n = 176) positive responders, after the invitation for this survey (24 participants did not respond). Eighteen persons from a total of 176 positive responders failed to come to the examination venue due to several personal reasons such as urgent family matters and lack of transportation. Therefore, finally, there were 158 elderly people involved in this study as study subjects. None of the participants required special assistance for their daily activities.
Intraoral examination was conducted for the subjects by four trained dentists under sufficient illumination with artificial light. Measurement of OH using Oral Hygiene Index-Simplified (OHI-S; good for 0–3; moderate for 3.1–6; poor for 6.1–12), periodontal tissue condition using modified Community Periodontal Index was classified for with and without periodontal pocket, Decayed, Missing, and Filled Teeth (DMFT) index (with the category for very low: <5.0; low: 5.0–8.9; moderate: 9.0–13.9; high: >13.9), and number of natural occluding pairs (NOP) of teeth. Measurement of dental status (except OHI-S) was examined using the procedures outlined in the WHO Basic Oral Health Survey 2013. Each examination above determined the oral health status of the subjects and was used as an oral health status indicator. The evaluation of xerostomia was conducted using the Xerostomia Inventory (XI) questionnaire which was translated into Indonesian language. The XI is a validated questionnaire that consists of 11 items. For each item, the subject was asked to rate on a 5-point Likert scale from 0 (never), 1 (hardly ever), 2 (occasionally), 3 (fairly often) to 4 (very often) based on the past 3 months experience. If there was answer/s “fairly often” and/or “very often,” it was indicated that subject suffered from xerostomia. Hyposalivation (volume of saliva <0.1 ml/min) was identified by measuring whole unstimulated saliva flow using the spitting method. All data were recorded in Oral Health Status Form.
Initially, the characteristics of the participants were described based on their oral health status by each status’ proportion. Subsequently, bivariate analysis was done using a chi-square test to analyze the possible correlation between the event of hyposalivation and xerostomia with each of the independent variables (oral health status). Finally, multivariate analysis by binary logistic regression was done to assess the simultaneous effect of hyposalivation and xerostomia for the event of poor OH. All calculations and statistical analyses were performed using SPSS for Windows software (version 6.0; IBM, Armonk, New York). Statistical significance was set at α = 0.05.
| Results|| |
The subjects consisted of 41 males and 117 females aged 60–92 years. The description of the subjects in accordance with their intraoral examination is presented in [Table 1]. From the intraoral examination, it was clear that the most oral condition encountered in elderly was ≤5 NOP of teeth (73.4%), then followed by high DMFT (71.5%) and xerostomia (59.5%). Majority of elderly (72.2%) had fair up to good OH. Hyposalivation and periodontal pocket occurred in 25.3% and 25.9% of elderly, respectively [Table 1].
Based on the bivariate analysis between the event of xerostomia and oral health status indicators, it was found that there was a significantly different proportion of OH condition between the group of participants with and without xerostomia (P = 0.035) [Table 2]. On the other hand, the data presented in [Table 3] showed that the proportions of periodontal pocket and OH condition were significantly different between the group of participants with and without hyposalivation with P values of <0.001. The binary logistic regression analysis [Table 4] showed that the participants with hyposalivation and xerostomia have a 5.68 and 2.49 times higher risk of experiencing poor OH condition, accounted for 20% of the total model.
|Table 2: Bivariate analysis of oral health status based on xerostomia condition|
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|Table 3: Bivariate analysis of oral health status based on hyposalivation condition|
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|Table 4: Multivariate analysis of xerostomia and hyposalivation toward poor OH condition|
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| Discussion|| |
According to [Table 1], it was clear that ≤5 NOP of teeth, high DMFT, and xerostomia were the three most conditions found in the elderly. Furthermore, the results from the bivariate analysis given in [Tables 2] and  clearly demonstrated that poor OH was the oral health status indicator that showed significant differences among the participants with and without xerostomia and hyposalivation, while the proportion of periodontal pocket event was different among the participants with and without hyposalivation.
Compared to other oral diseases, dental caries and periodontal disease are the two most prevalent of oral diseases that cause tooth loss. Periodontal disease is an oral infectious disease that affects mainly tooth-supporting tissues such as gingiva, alveolar bone, and periodontal ligament. These two are infectious diseases that originated from poor OH. Tooth decay is caused by dental plaque, which carries the Gram-anaerobic bacteria that cause periodontal disease. It is assumed that the development of dental plaque is faster in elderly compared to young people.
The sequence of periodontal disease starts from gingivitis, if this inflammation is untreated, it might develop further to form periodontal pocket and involving the deeper periodontal tissue such as alveolar bone and periodontal ligament. Occurrence of dental caries commences by the attachment of food debris on the tooth surface, then it will be digested by a bacterial enzyme to produce an acidic agent and low oral pH that can demineralize hard tissue of the tooth such as enamel and dentin. The unrestored dental caries will develop progressively to reach tooth pulp. If periodontal disease and dental caries are still untreated, the infection becomes extensive and causes tooth loss., So, to prevent tooth loss, people should increase their OH.
Results of this study suggested that hyposalivation was the main risk factor for poor oral health. Physiologic amounts of salivary secretion are important to maintain oral health. Saliva plays a crucial role in oral health because it can buffer acids, contains antibodies that can prevent oral mucosa and teeth against harmful substances, and aids in tooth remineralization. When someone experiences hyposalivation, there is more risk of developing caries, oral infections, and denture discomfort compared to someone who has normal salivary secretion., Saliva also helps to maintain a neutral oral pH and serves as a reservoir of calcium and phosphate ions to remineralize teeth. Saliva contains enzymes, IgA, lactoferrin, histatins, and defensins to maintain the oral immune system.
A decrease in salivary secretion is common in elderly. Salivary function decreases with age, however, now it is accepted that the production of saliva and its composition are associated with age in healthy people.,, Salivary dysfunction in old people is mainly a consequence of systemic diseases, medications, and head and neck radiotherapy. According to the explanation above, there are many medications that might cause hyposalivation. On the other hand, some diseases such as Sjogren’s syndrome, uncontrolled DM, salivary gland diseases, thyroid disease, renal and liver disease, hepatitis C virus, and human immunodeficiency virus infection are closely related with hyposalivation as well. Other conditions such as radio-chemotherapy complication, dehydration, psychological conditions (stress, anxiety), complication of chronic graft-versus-host disease, malnutrition, and mouth breathing were also attributed to hyposalivation. In this study, 45 subjects had hypertension, among them, most consumed antihypertensive medications such as captopril, irtan, valsartan, and noperten. It is generally known that captopril is an antihypertensive drug of the angiotensin-converting enzyme inhibitor (ACEI) group. This drug will inhibit ACE in rennin–angiotensin–aldosterone system that causes dry mouth. On the other hand, valsartan is included in angiotensin receptor blocker as another alternative of ACEI medication (because of cough effect) that has less xerogenic effect. According to the results of the interview with subjects, some subjects also frequently consumed other medications such as cold cures, analgetics, nonsteroidal anti-inflammatory drugs, antireflux agent for gastritis, cardiovascular, and antiasthmatic drugs. Those consumed medications might be included in xerogenic medications as explained above.
In this study, DM was also detected in 18 subjects. According to a previous study, about 92.5% of 120 diabetic subjects presented a decrease in salivary flow while 49.2% reported moderate to severe xerostomia/dry mouth. There was a significant relationship between DM and xerostomia. Therefore, in this study, it is clear that the prevalence of xerostomia in elderly is partly contributed by DM.
The oral health status may be jeopardized by frailty, disability, and/or care dependency, by its consequences, such as medication, challenging behavior, and dietary requirements, and by limited access to professional oral health care. Most of the epidemiological studies on oral health care of older people conclude that adequate professional oral health care is needed in response to the large unmet treatment needs. It was identified that poor oral health has the potential to become a new geriatric syndrome.
The limitation of this study is that it is a cross-sectional one, so it could not explain the causal relationship between hyposalivation and suspected attributed factors such as medication. For future studies, a different design such as case-control or longitudinal study should be carried out to explain the relationship among hyposalivation, xerostomia, oral health, general health, and quality of life comprehensively in elderly.
| Conclusion|| |
From the above discussion, it is clear that xerostomia and hyposalivation contributed to the poor oral health status in this study. It is shown that Indonesian elderly with hyposalivation has a 5.68-fold risk of having poor OH when compared to the elderly without hyposalivation, while the elderly with xerostomia has 2.49 times higher risk of experiencing poor OH compared to the elderly without xerostomia. It is concluded that hyposalivation is the main risk factor for poor oral health status in Indonesian elderly.
Improving oral health status of elderly by minimizing the occurrence of xerostomia and hyposalivation. This effort needs interprofessional collaboration with other health personnel.
The authors gratefully acknowledge the funding provided by Dana Masyarakat, Faculty of Dentistry, Universitas Gadjah Mada which makes this research possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
DA conceptualized the study and developed the first draft of the manuscript. DA and BEC collected the data. LH developed the data analysis plan for the study. All authors were involved with the review of the manuscript, finalization of the manuscript, and approved the manuscript for submission.
Ethical policy and institutional review board statement
The study protocol was approved by the Ethics Committee of the Faculty of Dentistry, Universitas Gadjah Mada, Indonesia (Approval number: 683/KKEP/FKG-UGM/EC/2014).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
The data that support the findings of this study are available from the corresponding author (DA) upon reasonable request.
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[Table 1], [Table 2], [Table 3], [Table 4]