Evaluation of Oral Health Status Using the Geriatric Oral Health Assessment Index Among the Geriatric Population in India: A Pilot Study

Introduction and aim Clinical indicators alone are insufficient for evaluating oral health. In addition to health and disease, oral health includes socio-dental indicators of physical, psychological, and social aspects of well-being. The adaptive capacity of an individual influences the perception of oral health-related quality of life (OHRQoL). Indices such as the Oral Health Impact Profile, Oral Impacts on Daily Performances, and the Geriatric Oral Health Assessment Index (GOHAI) have been used to measure OHRQoL. This study was designed to assess OHRQoL in older individuals using the GOHAI. Methods Subjects aged older than 65 years who visited our institution from January to March 2016 were included. Subjects with cognitive behavior disorders were excluded. Subjects were assigned into three groups based on age: 65-69 years, 70-74 years, and 75 years or older. The participants were asked 12 questions, and their responses were assessed by age group. Our Institutional Ethics Committee approved the study protocol. Results The 219 subjects recruited included 126 (57.5%) patients aged 65-69 years, 57 (26.0%) patients aged 70-74 years, and 36 (16.4%) patients aged 75 years or older. Several physical, physiological, and psychological aspects of the GOHAI differed significantly among these three groups, with overall OHRQoL decreasing with age. Conclusion Although oral healthcare problems were widespread in the geriatric population, they were not a primary concern. Attitudes toward dentistry require improvement. However, further studies in larger populations are required to assess geriatric oral health.


Introduction
Estimates indicate that, by 2050, 17% of the Indian population will be aged 65 years or older, compared with 7.4% in that age range in 2001 [1]. The number of older adults needing dental care is increasing, as is the need to provide these subjects with optimum dental care. Agerelated deterioration in oral health adversely affects the physical and psychological health of individuals, decreasing their overall quality of life (QoL) [2]. Providing optimum dental care requires the assessment of oral health and its impact on QoL. One of the most specific methods of evaluating oral health in older subjects and its impact on their QoL is the Geriatric Oral Health Assessment Index (GOHAI), which was developed to assess oral health status in geriatric subjects [3][4]. This index has shown satisfactory internal consistency, and its validity has been confirmed in many international studies [5]. The GOHAI has been used to evaluate the physical, physiological, and psychological aspects of oral health, thus aiding routine clinical assessment. The objective of the study was to evaluate the oral-health related QoL in geriatric patients using the GOHAI.

Geriatric oral health assessment index
The GOHAI consists of 12 closed-ended questions (presented in Appendix I) evaluating selfperceived oral health, including pain, discomfort, and psychosocial impact [6]. The response to each question was assessed using a four-point scale, where 1 = never, 2 = sometimes, 3 = frequently, or 4 = always [7]. Responses scored as 1 and 2 were indicative of better oral health with no or few problems and good oral condition, whereas responses scored as 3 and 4 were indicative of poor oral health with multiple problems and bad oral condition. The study was conducted for a period of 2 months. The recruited subjects were divided into three age groups, those aged 65-69 years, those aged 70-74 years, and those aged 75 years or older.
The study was conducted in three stages. The first stage consisted of translating the questions on the GOHAI into Tamil, the local language, and the second stage consisted of its back translation into English. The third stage consisted of administering the GOHAI questionnaire to the study subjects. It was necessary to rephrase and shorten the questions on the GOHAI for more natural understanding. The administered form of the GOHAI questionnaire, modified to suit the target population, is shown in Appendix I.

Translation
Before administering the GOHAI to subjects with cultural and linguistic differences, it had to be translated and validated. Such translations pose two problems: 1) it may not be possible to translate some phrases or words directly and 2) languages exist within unique cultural and social frameworks, changing the meaning of some questions or making them meaningless. The GOHAI questionnaire was translated from English into Tamil by two dental students, who were fluent in both languages [8]. The Tamil version of the GOHAI questionnaire was then translated back into English by another dentist. The back-translated version and the original version were compared to determine if the questions had been adequately translated.

Participants
Subjects who visited the geriatric clinic of the Sri Ramachandra Institute of Higher Education and Research for three months were recruited. Subjects with cognitive and behavioral disorders and in-patients were excluded. The age, gender, and medical history of each participant were recorded, including whether subjects had diabetes mellitus or hypertension, whether they were smokers, and medicines taken. Dental histories were also recorded, such as denture usage, denture stomatitis, pigmentation of the tongue, and smokers' palate.

Statistical analysis
All data were statistically analyzed using IBM SPSS Statistics for Windows, Version 24.0 (Armonk, NY: IBM Corp.). Chi-square test was performed for finding the significant differences between age groups.
The University Ethics Committee approved the protocol of this study (Ref: CSP/17MAY/58/159), and all enrolled subjects provided written informed consent before participating.

Results
A total of 219 subjects aged 65 years or older were recruited. These included 126 (57.5%) subjects aged 65-69 years, 57 (26.0%) aged 70-74 years, and 36 (16.4%) aged 75 years or older. Table 1 shows their responses to the items on the GOHAI questionnaire, subdivided by subject age.

ALWAYS (4)
Limitation of foods?  Discomfort during swallowing was never experienced by 78.6% of subjects aged 65-69 years, compared with 47.2% of those aged ≥75 years. Only 4% of subjects aged 65-69 years always experienced problems with speech, compared with 25% of subjects aged ≥75 years. The percentage limiting contact with other people due to problems with teeth or dentures was significantly lower in subjects aged 65-69 years than those aged ≥75 years (3.2% vs. 22.2%, P = 0.006). The percentages reporting that they never worried about problems with teeth or dentures was higher in subjects aged 65-69 years than those aged ≥75 years (27% vs. 63.9%), whereas the proportion reporting that they always felt uncomfortable eating in front of others was significantly lower in those aged 65-69 years than ≥75 years (6.35% vs. 22.2%, P = 0.024).
Responses to other questions on the GOHAI did not differ significantly among the three age groups.

Discussion
The results of this cross-sectional study showed that older geriatric subjects aged 75 years or older perceived physical problems associated with dentition more acutely than psychological problems. The higher percentages of subjects aged ≥75 years than those in the other age groups experiencing food limitations and having trouble biting firm foods may have been due to differences in the percentages who wore dentures. Although the oldest age group had the highest percentage of edentulous subjects, it had the lowest percentage of denture wearers, 11.1%, compared with the groups aged 65-69 years (12.7%) and 70-74 (26.3%) years. Edentulous subjects have greater difficulty eating foods like raw carrots, apples, and nuts. [9]. Older age has been associated with a higher prevalence of edentulousness, which may correlate with the higher percentages of this group having food limitations and trouble biting [10].
Discomfort during swallowing was significantly more prevalent in subjects aged ≥75 years than in the other two groups. The prevalence of diabetes was higher in this group (30.6%) than in subjects aged 65-69 (29.4%) and 70-74 (28.1%) years. Diabetes has been associated with xerostomia, and xerostomia has been associated with swallowing difficulties [11][12].
Despite the age-associated increase in problems with dentition, the percentage of subjects who never worried about problems associated with teeth or dentures was higher in those aged 75 years or older (63.9%) than in those aged 65-69 years (27.0%) and 70-74 years (31.6%). The use of dental services is a consequence of the patient-perceived need for treatment [13]. Although two-thirds of elderly subjects have poor oral health, only one-third report concerns [14]. Subjects aged 60-64 years and 65-74 years were found to have a more favorable attitude towards dentistry than subjects aged 75 years or older [15]. Thus, despite having more dental problems, subjects in the oldest age group had fewer worries about problems related to teeth or dentures.
Speech problems due to problems with dentition were more acutely perceived by subjects aged 75 years or older than those aged 65-69 and 70-74 years. This difference may be due to the higher prevalence of edentulousness in the oldest age group [10]. Because the quality of speech production is significantly reduced after the loss of teeth, speech problems were perceived more by the oldest age group [16].
The percentages of subjects experiencing discomfort while eating were similar in the three age groups. More than 50% of subjects in each of these groups report always experiencing discomfort while swallowing, suggesting that this may be a common geriatric complaint, not specific to any particular age group. The percentage of subjects always limiting contact with others was higher in those aged 75 years or older than those aged 65-69 and 70-74 years. Edentate non-denture wearing subjects aged 75 years or older experience more trouble with speech formation than dentate individuals [16]. This difficulty with speech results in limiting contact with other people.
Responses to the other questions on the GOHAI did not differ significantly among the three age groups, suggesting that these problems may be perceived similarly across all geriatric age groups.

Limitations
The sample consisted mainly of women, preventing comparisons between men and women.