A survey was carried out in the summer of 1966 of the oral condition of all male patients over 60 years old, at Saint Vincent de Paul Hospital Malta, a government geriatric institution. All the patients were examined with regards to the number and condition of the teeth, the presence of calculus and periodontal disease, and the degree of dental attrition. A questionnaire was completed on the drinking and smoking habits, masticatory ability, dry feeling of oral mucosa and subjective evaluation of dentures, when present. Further related subjects discussed following this survey are leukoplakia, pigmentation and other lesions. The geriatric patient tends to respond to noxious stimuli in an atrophic rather than in a productive manner so that dental and oral symptoms of disease are not prominent. This was evident in this survey and very few of the patients had any specific oral complaints. The dental surgeon has an important role in the health team looking after geriatric patients and should keep his patients under constant surveillance rather than wait for specific complaints.peer-reviewe

Camilleri, George E.

Cuschieri, Carmel L.

English

OAR@UM

tail. Finally, figures are given to show that in the more recent years, the number of perinatal deaths has decreased whereas the number of necropses has increased. Acknowledgement We wish to thank Professor G. P. Xuereb, Head of the Department of Patho-41 logy, for his encouragement and helpful criticism. References BUTLER, N.R. and BO:<1HAM, D.G., Perinatal Mortal-ity, (E. & S. Livingstone, Ltd., 1963). BAIRD, et al. (1953), J. Obstet. Gynaec. Brit. Emp., 8r, 473. U.N. Demographic Year Book 1963. THE ORAL CONDITION OF ELDERLY I NSTITUTIONALlSED MALES GEORGE E. CAMILLERI H.D.D., F.D.S. Dental Surgeon, St. Luke's Hospital Lecturer, Royal University ot Malta and CARMEL L. CUSCHIERI * M.D. St. Vincent de Paul Hospital Medical Officer, A survey was carried out in the sum-mer of 1966 of the oral condition of all male patients over 60 years old, at Saint Vincent de Paul Hospital, a government geriatric institution. All the patients were examined by one of us (GEC) with an anglepoise lamp as a light source, except in bedridden patients who were seen under natural light. Dental mirrors and probes were used initially but the dental probe was soon abandoned as many patients objected to its use and tooth probing was not yielding any more information than plain visual examination. The number and condition of the teeth, the presence of cal-culus and periodontal disease, and the degree of dental attrition were recorded. A questionaire was completed on the drinking and smoking habits, masticatory ability, dry feeling of oral mUcosa and subjective evaluation of dentures, when present. The patients were classified as rron-* Now Med:cal Officer, Depa,tment vf Medi-c:ne, St. Luke's Hosp:tal smokers, moderate smokers or heavy smokers. It was found, however, that usually the degree of. heavy smoking was commensurate with the patient's con-sumption of alcoholic beverages. Accord-ingly, the terms adopted were: (a) non-smokers or drinkers; (b) moderate smokers and/or drinkers and (c) heavy smokers and/or drinkers. A moderate smoker and/or drinker was taken to be one who smoked up to 20 cigarettes daily and who consumed less than 1 litre of locally ma-nufactured wine (ten to twelve per cent ethyl alcohol). The heavy drinker and/or smoker surpassed the 1 litre limit as re-gards wine and smoked more than 20 cigarettes daily. Information about these naons wa:; initially taken from the patient himself, checked with his clinical records and finally corroborated by a clinical examin-ation (CLG). Thus it was found that the number of cases with chronic bronchitis and emphysema rose steadily from the moderate to the severe groups. SimIlarly, signs and symptoms of liver cirrhosis with 42 ascites, peripheral neuritis and obliterative arterial disease, involving mainly the lower limbs, were prevalent in the heavy drinkers/smokers group. The majority of the patients examined (over 90 per cent) had been unskilled workers, mostly farm labourers, dock hands and hawkers. The age distribution of 215 patien~s examined and a further division into den-tulous and edentulous persons are given in Table I. 60-64 years 65-69 years 70-74 years 75-79 years 80-84 years 85-89 years 90-94 years Total TABLE I Age Distribution Ed.mt'JZouS Dentulous 12 18 13 19 25 29 24 25 19 14 6 10 1 99 116 Dentition Total 30 32 54 49 33 16 1 215 Teeth were recorded as Missing; Pre-sent; Decayed or Roots. Teeth with an intact crown, including those with early interstitial or fissural caries, severe perio-dontal disease or gross calculus accretions were classified as PRESENT. Teeth with an obvious large carious cavity were listed as DECAYED; however, since these teeth were usually useful members of the den-tition, they have been grouped together with teeth present in the statistical results. A tooth with complete destruction of the crown and with little or no dental struc-tures above the gingiva was considered as a ROOT. From the total tooth expectancy of 6880 (215 patients x 32 teeth) there were 1007 (14%) teeth and 284 (4%) roots pre-sent. There were 116 (54%) patients with at least on3 tooth present (Dentulous Group) and the distributicn of teeth and roots in this group is given in Table lI. The highest l1l:mber of teeth r;resent was in the 60-64 year group (37%) and the lowest in the 80-84 year group (15%). In the maxilla there were 22 % teeth present (ranging from 28% in the 60-64 year group, to 12% in the 80-84 year group) and in the mandible there were 32% teeth present (ranging from 46% in the 60-64 year group to 18% in the 80-84 year group). The division into a dentulous and an edentulous group tends to give a false picture as several of the patients classified as dentulous had only a few teeth or roots and would in fact have been better off edentulous. Sheldon (1948) adopted the standard of six teeth or more present to consider the natural dentition as adequate. According to this criterion, there were 62 patients with an adequate dentition and 54 with an inadequate natural dentition. Corridan (1965) recently examined a com-parable hospitalised group in Cork, Ire-land, and his results together with those of a survey carried out in Wolverhampton, England, before the start of the National TABLE H Distribution of Teeth and Roots in Dentulous Group Age Tooth Maxilla and Mandible Maxilla Mandible Group Expec- Teeth Raf'ts Teeth Roots Teeth Roots Years tancy 60-64 ;76 212 (37%) 28 (5%) 79 (28%) 17 (6%) 133 (46%) 11 (4%) 65-69 608 182 (28%) 48 (7%) 80 (26%) 15 (4%) I02 (30%) 33 (10%) 70-74 928 267 (28%) 80 (9%) ro4 (22%) 37 (8%) 163 (34%) 43 (ro%) 75-79 300 210 (25%) 55 (7%) 84 (20%) 25 (6%) 126 (30%) 30 (8%) 80-84 448 67 (15%) 45 (Jo%) 27 (12%) 22 (10%) 40 (18%) 23 (ro%) 85-90 320 68 (20%) 27 (8%) 34 (20%) 13 (8%) 34 (20%) 14 (8%) 90-95 32 ----- ---TOTAL 3712 1007 (27%) 284 (7%) 408 (22%) 129 (6%) 599 (3 2%) 155 (8%) ----- ---- ----Health Service (She Id on, 1948) on old patients living at home are compared in Table Ill. The smaller number of eden-tulous patients in the Maltese group and the larger number of English elderly per-sons supplied with dentmes are the main differences. Periodontal disease and attrition An attempt to use a Periodontal Disease Index (Russel 1956) was soon given up. The severe periodontal disease and gross calculus generally present to-gether with the few instances of a good dental arch made indexing superfluous. James's (196::1) objective classification of the periodontal status into Good, Moder-ate and Poor was followed. Such a small number had a moderate ginginval condi-tion (none had a good condition) that the periodontal condition of the group is best considered as poor. The evaluation of the degree of attri-tion also proved fruitless. Although one did meet the rare individual with even attrition in an adequate dental arch, the majority of dentulous persons had only a few teeth present which occluded irregu-larly and an evaluation of the degree of attrition was meaningless. Periodontal disease is the major cause of tooth loss in Malta, in persons over 30 years, (Camilleri, 1966) and it increases in importance in old age. Attention to oral hygiene and treatment of periodontal dis-ease is undoubtedly the chief requirement of the dentulous group. Mastication The estimation of masticatory ability was based on the reply given by the pa-tient on whether he was able to eat the crust of Maltese bread or discarded it to 43 eat the softer central portions only. They were then graded as eating a Hard or Soft diet. In the dentulous patients the Hard/ Soft ratio was [j'j /59 whilst in the cden-tulousgroup it was 49/50. There is not much discrepancy between the two groups and probably the r:resence or otherwise of teeth (as found in our study) does not make much difference to the ability to eat a hard type of diet. It is interesting, however, to note that in the edentulous group who succ~eded in wearing their dentures the Hard/Soft ratio was 19/6, suggesting that the persons who persisted in wearing dentures had a better masti-catory ability. Of the triad of complaints of poor aesthetics, local discomfort and limited masticatory function, the latter is the most common and pressing. The possession of a few roots, a mutilated dentition with advanced periodontal disease or a com-pletely edentulous m01;,th make a major contribution to malnutrition in the elderly (Kemp, 1965). Prosthetics There were 99 (46%) totally edfn-tulous patients, of whom 42 had never been fitted with dentures and 57 had been given one or more sets of full upper and full lower dentures. There were also 5 patients who had been supplied with par-tial dentures and one with a full upper denture. An analysis of the 57 patients who had been supplied with full upper and full lower dentures showed that 25 still wore the dentures whilst 32 had dis-carded them completely. Of the patients who had been given but did not wear the dentures, 6 appliances had been supplied privately and 26 from the Government Dental Clinic. The successful dentures had been supplied by private practitioners in TABLE HI Own teeth adequate Own teeth inadequate Edentulous (Full upper and lower dentures) (No natural teeth or denture~) jvlalta 28.9% 25.1% 46.0% 26.6% 20.4% Corh 5.1% 19.0% 70.0% 24.5% 45.5% Wolverhampton 8.5% 18.1% 690.% 59.8% 9.6% 44 16 cases and by the Government Dental Clinic in 9 instances. Examination of some of the discarded dentures showed that in many instances the articulation and fit appeared satisfactory. The discrepancy between dentures supplied privately and those supplied by the Government Dental Clinic is best explained by the fact that the former group had been supplied with dentures before they were admitted to the hospital when they were younger and therefore physiologically and psychologic-ally more adaptable to dentures. The den-turesfitted in the Government Clinic were often supplied to inmate~ poorly receptive to dentures. The inability of the aged per-son to adapt to wearing dentures lies mainly in the neuromuscular mechanism to learn new habits. This has been stressed by dental surgeons (Storer, 1965) and geriatric physicians (Kemp, 1965) alike. In the elderly, a complete dental clearance can seldom be recommended except in cases of gross sepsis (Agate, 1963). Oral mucosa The characteristic features of sene-scent and atrophic oral mucosa such as a glazed red sheen, a diminished elasticity of the cheeks and an indistinct muco-cutaneous junction in the lips were com-monly seen in our patients. These changes are so subtle and gradual that one can only apply non-specific criteria and record gross alterations only. In our patients, the condition of the oral mucosa was general-ly good and surprisingly pliant with no overt signs of nutritional deficiencies . The data on t.he smoking and drink-ing habits show that 59 did not smoke or drink alcoholic beverages, 57 were mo-derate smokers and/or drinkers and 98 heavy smokers and/or drinkers. No data were available on 7 patients. 1. Leukoplakia A clinical diagnosis of leukoplakia was made when there was a distinct white patch clearly distinguishable from the ad-joining normal or atrophic mucosa. Many of the patches, but not all, were slightly raised and involved the cheeks or lips. There were 16 patients with definite white patches of which 2 suggested the possi-bilty of a premalignant condition. One had a distinct erythematous border and centre (erythroplakia) and the other was a large verrucous lesion lining the whole of both cheeks. Of the 16 patients with leukoplakic patches, 2 were non-smokers/drinkers, one was moderate smoker-drinker, and 13 heavy smokers/drinkers. The accepted relationship between the irritational effect of heavy smoking or drinking and leuko-plakia is amply borne out. 2. Pigmentation Together with the change in the oral mucosa from a bright pink to a more vio-laceous dull colour seen in nearly all the patients and probably associated with vascular changes, there was in 21 (9.7%) of the patients a distinct dusky brown pigmentation, localised to the cheeks or even affecting the whole of the oral cavity. This was indistinguishable from the pig-mentation associated with Addison's dis-ease. Oral pigmentation is often considered a sign of systematic disease, but in fact, it is freqquently found in healthy persons and is a common characteristic of the darker races including Caucasian bru-nettes. Becker (1927) had demonstrated the presence of melanocytes in oral mu-cosa that showed no clinical evidence of pigmentation. There is a reduction in the number of melanocytes in the skin during senescence (Fitzpatrick et aI., 1965) yet Walsh (1964) found that pigmentation in-creased with age in the skin exposed to the sun. Garn and French (1963) noted that there was no increase in colour depth in the skin which is normally unexposed. The relationship of oral mucosal pigmen-tation and aging does not seem to have been studied but it is possibly related to local irritation. In the 21 patients with oral pigmentation, 5 were '11oderate and 16 heavy smokers/drinkers. 3. Other lesions Other unusual oral lesions encoun-tered were a nodular hyperplasia of the hard palate and a large haemangioma of the cheek. Four patients had large nodu-lar varicose enlargements of the :mper-ficial collecting veins located in the lips and prominent veins in the ventral surface of the tongue were very common. Comment The geriatric patient tends to respond to noxious stimuli in an atrophic rather than in a productive manner (Massler, 1956) so that dental and oral symptoms of disease are not prominent. This was so in our survey and very few of the patients had any specific oral complaints. Subject-ive responses and complaints are gene-rally unreliable so that periodic and sys-tematic examination is essentia,t to reco-gnise early oral disease (Allen, 1963). Re-cent research in geriatric dentistry has revealed that timely initiation of hormo-nal, nutritional and vitamin therapy is effective in mitigating or even reversing some of the deteriorative changes occur-ring in the oral cavity (Muller, 1959). The dental surgeon has an important role in the health team looking after geriatric patients and should keep his patients under constant surveillance rather than wait for specific complaints. 45 Acknowledgements We thank the Chief Government Me-cal Officer, the Senior Medical Officer, Ministry of Health and the Medical Su-perintendent, St. Vincent de Paul Hospital for permission to carry out the survey. We also gratefully acknowledge the assis-tance of the nursing sisters and staff. References AGATE, J. (1963), The Practice of Geriatrics, p. 1I3. Heinemann, London. ALLEN, E.F. in E.V. COWDRY (1963), The Care of the Geriatric Pati0nt. 2nd. ed. Chap. 13. C.V. Mosby. BECKER, S.W. (1927), Arch. Dermatol. Syphilol., 16, 259. CAM1LLER1, G.E. (1960), St. Luke's Hosp. Gaz. T, 12. CORRIDAN, J.P. (1965)]. Irish dent. Ass. 1I, 132. FITZPATRICK, T.R., SZABO, G. and MITCHELL, R.E. in MONTAGNA, W. (1965), Aging. Chap. VII., Per-gamon. GAR:--1, S.M. and FRENcH, N.Y. (1963), Am. J. obst. Gynec. 85, 873. JAMES, P.M.C., JACKSON, D., SLACK, G.L. and LAWTON, F.E. (1960), Arch. oral. BioI., 3, 57. GEMP, R. (1965), A new look at Geriatrics, p. 87, Pitman. MAssLER, M. (1956), N.Y. J. Dent. 26, 54. MULLER, W. (1959) Zahnaerztl Welt. 60, 72. RUSSEL, A.L. (1965) J. dent. Res. 35, 350. SHELDON, J .H. (1948), The social medicine of old age. Oxford Univ. Press WALSH, R.J. (J964), J. Invest Dermatol., -12, 261. 

A new look at Geriatrics,

Irish dent.

The Practice of Geriatrics,

The social medicine of old age.

The oral condition of elderly institutionalized males

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The oral condition of elderly institutionalized males

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