Health Services Victoria; DMFT = decayed, missing and filled permanent teeth ..... Victorian Health Promotion Foundation (Australia). The authors would like to ...
SCIENTIFIC ARTICLE
Australian Dental Journal 2007;52:(3):198-204
Profile of the oral health among ambulant older Greek and Italian migrants living in Melbourne R Mariño,* H Calache,† C Wright,‡ M Morgan,§ M Schofield,얍 V Minichiello¶
Abstract Background: Over the last 50 years an increasing number of migrants have settled in Australia. These immigrants now constitute a large proportion of the Australian population, and some research suggests that they may be at high-risk for oral diseases. Methods: This paper presents data on the oral health status of a convenience sample of 721 ambulant Greek- (n=367) and Italian-born (n=354) adults aged 55 years or older. The volunteer participants were recruited through ethnic social clubs located in Melbourne, Australia. Results: The sample was largely a dentate one (83.6 per cent); with a mean DMFS score of 67.5 (s.d. 37.4). Dentate participants had 13 per cent of their restorative care unmet, and 57.3 per cent needed oral hygiene instruction plus removal of stain and hard deposits on their teeth. Almost 8 per cent required complex periodontal therapy and 30 per cent of those fully edentulous were in need of full dentures. Conclusions: Comparing these findings with existing data on oral health of older adults in Australia, the participants in this study appear to have lower DMFS scores and a higher prevalence of gingivitis, but less need for complex periodontal treatment. Inequalities were apparent in the proportion of unmet restorative and prosthetics needs. Key words: Older adults, migrants, oral health status, treatment needs. Abbreviations and acronyms: ANOVA = analysis of variance; CALD = culturally and linguistically diverse; CPI = Community Periodontal Index; DHSV = Dental Health Services Victoria; DMFT = decayed, missing and filled permanent teeth; NHANES = National Health and Nutrition Examination Survey; NOHSA = National Oral Health Survey of Australia. (Accepted for publication 26 October 2006.) *Cooperative Research Centre for Oral Health Science, The University of Melbourne, Victoria. †Dental Heath Services Victoria, Melbourne. ‡Centre for Oral Health Strategy, NSW Health, New South Wales. §School of Dental Science, The University of Melbourne, Victoria. 얍Psychotherapy and Counselling Federation of Australia, Melbourne, Victoria. ¶School of Health, The University of New England, Armidale, New South Wales. 198
INTRODUCTION In 2001, 13.1 per cent of the Victorian population was 65 years old or over,1 with a significant proportion (27 per cent) of them born overseas.2 In Victoria, Italian-born people are the largest culturally and linguistically diverse (CALD) community of older people.1 Italians represent almost 25 per cent of all senior CALD people and are more than twice as large as the next highest CALD community, the Greeks.1 The Australian National Oral Health Survey (NOHSA) in 1987–19883 provided a first national and state representative sample of the oral health status of Australians. This survey used clinical examinations and interviews to explore oral health behaviour. However, although participants born in places other than Australia were considered, limitations in the sample size preclude any conclusions on the oral health status of ethnic senior citizens. The Victorian section of the NOHSA survey noted that, regardless of place of birth, about 58 per cent of participants 70 years or older were edentulous. These data contrast with the South Australian finding of only 41 per cent of Adelaide residents having no teeth.4 Bergman et al.,5 in their study of senior Victorians, found significant associations between birthplace and oral health status. The analysis revealed that adults who were older, female, Australian-born, or holders of pensioner health benefits had higher rates of edentulism. In addition, European-born dentate senior citizens (other than the United Kingdom) were more likely to have fewer decayed teeth than Australian-born senior citizens. A study of older persons living independently in Adelaide and Mt Gambier4 revealed an overall DMFT (decay, missing and filled permanent teeth) index of 23.3 teeth per person—14.7 missing teeth and a further 0.2 retained as roots, 8.3 filled teeth and 0.3 decayed teeth. These results are similar to studies conducted in Melbourne, which reported a DMFT of 22.1 for people aged more than 55 years6 or for dentate 60 years or older Victorians, who had a mean DMFT of 25 teeth, with the greatest component of the index being missing teeth.4 The epidemiology of root caries in older people Australian Dental Journal 2007;52:3.
is not as widely described, although the South Australian study found an average of 3.5 decayed or filled root surfaces.4 Data on the prevalence of periodontal disease suggest that older adults have high periodontal involvement (89 per cent of the South Australian sample had, on average, loss of periodontal attachment of 4mm or more).4 In another study on periodontal health in Melbourne, Spencer et al.6 found that older people and, particularly those born outside Australia, were at higher risk of periodontal diseases. Oral cancer ranked ninth for new cancers in males and 15th for cancer death in Victoria.7 For women, oral cancer ranked 16th for new cancers, and 20th for cancer death. Being one of the most preventable forms of cancer, the mortality rate for men was 2.1 per 100 000 and 0.7 per 100 000 for females.8 However, data for oral lesions are not available for older Australians from CALD background. Despite this growing body of data on the prevalence of oral diseases and conditions in the Australian population, little has been done to determine the oral health status of particular CALD groups in the Australian community, nor cogently identified factors associated with their oral health status. Existing data suggest, however, that oral health problems are likely to be prevalent among CALD groups, and that CALD groups may have more difficulty in accessing appropriate and affordable services.9,10 The characteristics of overseas-born groups are so diverse that assumptions derived from existing data may not be applicable or reliably extrapolated to migrant communities as a whole. Furthermore, as culturally mediated factors are associated with health disadvantage, there is a great need for data to inform the development of appropriate oral health policy and services for older ethnic people.10 The purpose of this paper is to describe the prevalence and severity of dental caries, periodontal diseases, oral mucosal pathology, and wearing of, need for and condition of dental protheses in a southernEuropean background population, 55 years and older, living in Melbourne, and to provide descriptive crosssectional information on its distribution by selected socio-demographic characteristics (such as age, gender, education, living arrangement) and immigration characteristics (proportion of life in Australia). The paper also provides estimates of restorative, periodontal, and prosthetic treatment needs in this population. METHODS Sample The sample comprised men and women aged 55 years or older from Greek and Italian backgrounds, who were members of senior citizens ethnic social clubs in Melbourne, Australia. Lists of Greek (n=59) and Italian (n=90) older citizens clubs were obtained through the Greek and Italian welfare associations in Victoria (Commitato di Assistenza Italiana and the Australian-Greek Welfare Society). Information from Australian Dental Journal 2007;52:3.
these organizations indicates that these older citizens clubs provided a venue for meetings and social activities for about 16 000 Greek and about 26 000 Italian older adults. Fifty-eight southern European elderly ethnic clubs were approached (28 Greek and 30 Italian) with a total membership of 11 206 (5616 and 5590, respectively). Weekly attendance was reported to be about 20 per cent of the total membership. Procedure Trained bicultural and fully bilingual Greek/Italian–English research assistants contacted each club coordinator and arranged a meeting to discuss the project. Once individual written consent was obtained, volunteers were asked to undergo a structured interview and a clinical examination. Participants were not paid for their participation in this study. However, several programmes were initiated for all participants. These included: on-site oral health advice and education, as well as referral to general dental practitioners, dental specialists, and dental emergencies when needed. Data collection extended from October 2000 to mid-June 2001. The study received ethics approvals from The University of New England (Armidale, NSW) and Dental Health Services Victoria (DHSV) Ethics Committees. The interview schedule contained 107 questions covering a variety of topics including: sociodemographic and immigration characteristics; use of oral health care services; perception of oral health status and oral health needs; and oral hygiene habits. The instrument also included questions about attitudes to oral health, and knowledge of causes and risk factors for dental caries, periodontal disease and oral cancer. Questions were developed in English and translated into the target languages (Greek and Italian) following Brislin’s methodology.12 Dental examinations were conducted at the clubs’ facilities using overhead light, dental mirrors and Community Periodontal Index probes.13 Clinical data were recorded using tooth surface level following criteria and recommendations from well-established methods for oral health data collection.13,14 Participants with specific medical conditions such as heart disease, bleeding disorders and anticoagulant therapy were excluded from the periodontal examination. Radiographic examinations were not performed and teeth were not dried before scoring. A team of three examiners received training and calibration in making clinical measurements. Intra- and inter-examiner reliability was checked using Cohen’s kappa statistics. Inter-examiner reproducibility achieved in the duplicate examinations of 20–23 individuals were higher than 0.83 for dental examinations, which indicates substantial to almost perfect agreement.15 Intra-examiner reliability was assessed by the repetition of exams in 20–23 individuals by each examiner; kappa statistics were higher than 0.90, which indicates an almost perfect level of 199
agreement on diagnosis of dental caries, according to Landis and Koch’s criteria.15 Measures Clinical data used in this analysis included: decayed surfaces (DS), filled surfaces (FS) and number of teeth present. Number of natural teeth was divided into four groups: “No teeth”; “1 to 10 teeth”; “11-20 teeth”; and “More than 20 teeth”. To further explore dental health status, the dental caries assessment included the proportion of unmet restorative needs. An index was computed to measure restorative needs by dividing the sum of carious surfaces by the sum of carious and filled surfaces – the restorative unmet normative needs index (DS/(DS + FS)).17,18 The prosthetic assessment included determination of the normative need for, and use of, dental prostheses, and the condition of the appliances used by individuals. Denture possession was recorded for each participant by arch. If the participant presented a denture at the time of the clinical examination, the appliance was assessed for defects, stability, retention, and integrity, based on the criteria used in the National Health and Nutrition Examination Survey (NHANES).14 To collect data on the periodontal status, the Community Periodontal Index (CPI) was used, as described in the WHO guide.13 This index was selected to allow comparisons with other surveys done in Australia using the WHO methodology, such as the Socio-Dental Study of Adult Periodontal Health (SAM) Part I6 and Part II19 and the NOHSA.3 To assess soft tissue conditions, participants received a visual examination of the perioral area and a systematic examination of the oral mucosa, as described in the WHO guidelines to epidemiology and diagnosis of oral mucosal diseases and conditions.13,20 No attempt was made to arrive at a definitive diagnosis. This assessment identified presence or absence of any oral mucosal lesions and makes an assessment as to whether a referral to the Oral Medicine Clinic (Royal Dental Hospital of Melbourne) was “not required”, “required immediately” or “required in the near future”. In addition to age and gender, the following sociodemographic information was collected—living arrangement was classified into four groups: “living alone”; “living with spouse”; “living with spouse and daughter/son”; and “living with daughter/son only and living with others”. Participants were classified according to their educational level using three categories: “no formal education or incomplete primary education”; “complete primary education or incomplete secondary education”; and “complete secondary or postsecondary education”. Participants were also asked whether they had a health care card (coded “Yes/No”). Additionally, one immigration variable was included in the analysis: proportion of life in Australia. Because most migrants have lived in their countries of origin before migration, the actual length of residence will 200
vary according to the participant’s age and age of arrival. Length of residence was considered a poor indicator of the effect of contact with the mainstream society. An index [(Current year – year of arrival)/age] made up of the respondent’s length of residence and actual age was computed.21 Analysis The analysis provides basic descriptive information on selected socio-demographic factors, and on the distribution of oral diseases in the population, as well as information on dental status, unmet restorative needs, and aspects of periodontal status. Results were analysed using one-way analysis of variance (ANOVA). A significant ANOVA was followed by post hoc comparisons using Tukey’s Honestly Significant Differences tests. Pearson’s correlations were performed for univariate associations between continuous variables. For variables that were nominal or ordinal, differences between groups were subjected to chi square analysis. When a probability value was smaller than 0.05, the difference was considered to be statistically significant. Data manipulation and analyses were done using SPSS PC (Version 13.0).22 RESULTS A total of 1834 (958 Greek and 876 Italian) older adults volunteered to participate in the study. A total of 751 older adults were examined and interviewed. They were members of 16 Greek and 22 Italian senior clubs. However, 14 participants were younger than the selected age criteria and 16 had incomplete information on dental status. Of the remaining 721 respondents, 367 were from Greek background and 354 from Italian background, with about 63 per cent being female. Mean age was 69.4 years (s.d. 6.7). The largest proportion of participants had no formal education or incomplete primary education (47.1 per cent), with 37.7 per cent having completed primary education, and the remaining 15 per cent had higher levels of education. The majority of the participants lived with their spouses (56.6 per cent), another 15.2 per cent lived alone, 19.1 per cent lived with their children, and 9.1 per cent were in other living arrangements. A health care card was held by 96 per cent of the participants. In assessing immigration history, the average proportion of life lived in Australia was 0.40 (s.d. 0.11). The majority (61.8 per cent) of the participants had lived less than two-fifths (0.40) of their lives in Australia. Another 24.9 per cent had lived between 0.41 and 0.50 of their lives in Australia and the remaining 13.3 per cent a larger proportion. Dental caries experience The mean value of the DMFS index was 67.5 (s.d. 37.4) and ranged from 0 to 128. The distribution of participants by DMFS score showed that three individuals (0.4 per cent) had no history of caries experience (DMFS=0) and 118 participants (16.4 per Australian Dental Journal 2007;52:3.
Table 1. Dental and periodontal status in older migrants living in Melbourne Dental caries history
Mean (s.d.)
DMFS Decayed surfaces Filled surfaces Decayed/filled roots surfaces Missing teeth
67.5 0.6 8.8 1.7 12.3
Number of teeth No natural teeth 1 to 10 teeth 11 to 20 teeth More than 20 teeth Community periodontal index (CPI) Healthy Bleeding on probing Calculus Shallow pockets (4mm or less) Deep pockets (greater than 4mm) Excluded
(37.4) (1.4) (10.2) (3.2) (9.1)1
% (n = 721) 16.4 12.2 32.0 39.4 % (n = 603) 13.8 7.0 48.2 20.1 7.3 3.6
Loss of attachment
% (n = 603)
0 to 3mm 4 to 5mm 6 to 8mm 9 to 11mm More than 11mm Excluded
36.7 30.0 19.9 5.8 3.6 4.0
cent) were fully edentulous. By DMFS components, participants had a mean of 8.8 (s.d. 10.2) filled surfaces and a mean of 0.6 (s.d. 1.4) decayed surfaces. The overall mean DMFT score was 17.0 (s.d. 7.6). Table 1 summarizes dental caries findings for the sample. As expected, age was significantly positively associated with DMFS score and negatively associated with number of filled surfaces (p
