Does non-institutionalized elders have a better oral health status compared to institutionalized ones? A systematic review and meta-analysis

Farias, Ilky Pollansky Silva e; Sousa, Simone Alves de; Almeida, Leopoldina de Fátima Dantas de; Santiago, Bianca Marques; Pereira, Antonio Carlos; Cavalcanti, Yuri Wanderley

doi:10.1590/1413-81232020256.18252018

Ilky Pollansky Silva e Farias

Departamento de Clínica e Odontologia Social, Centro de Ciências da Saúde, Universidade Federal da Paraíba. yuri@ccs.ufpb.br

https://orcid.org/0000-0002-9171-947X

Simone Alves de Sousa

Departamento de Clínica e Odontologia Social, Centro de Ciências da Saúde, Universidade Federal da Paraíba. yuri@ccs.ufpb.br

https://orcid.org/0000-0002-3254-9036

Leopoldina de Fátima Dantas de Almeida

Departamento de Clínica e Odontologia Social, Centro de Ciências da Saúde, Universidade Federal da Paraíba. yuri@ccs.ufpb.br

https://orcid.org/0000-0001-5997-6612

Bianca Marques Santiago

Departamento de Clínica e Odontologia Social, Centro de Ciências da Saúde, Universidade Federal da Paraíba. yuri@ccs.ufpb.br

https://orcid.org/0000-0001-9559-913X

Antonio Carlos Pereira

Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas. Piracicaba, SP, Brasil.

https://orcid.org/0000-0003-1703-8171

Yuri Wanderley Cavalcanti

Departamento de Clínica e Odontologia Social, Centro de Ciências da Saúde, Universidade Federal da Paraíba. yuri@ccs.ufpb.br

https://orcid.org/0000-0002-3570-9904

Collaborators

IPS Farias, LFD Almeida, BM Santiago and YW Cavalcanti designed the study. IPS Farias and YW Cavalcanti performed electronic database searches, applied appropriate eligibility criteria and performed the quality assessment of included studies. SA Sousa, BM Santiago, AC Pereira and YW Cavalcanti performed and interpreted meta-analysis. IPS Farias, LFD Almeida and SA Sousa drafted the manuscript. BM Santiago, AC Pereira and YW Cavalcanti revised the manuscript for important intellectual content.

Database	Strategy
PubMed (Medline)	((((((((((((((Aged[MeSH Terms]) OR Aged[Title/Abstract]) OR Elderly[Title/Abstract]) OR (Aged, 80 and over[MeSH Terms])) OR (Aged, 80 and over[Title/Abstract])) OR Oldest old[Title/Abstract]) OR Nonagenarians[Title/Abstract]) OR Nonagenarian[Title/Abstract]) OR Octogenarians[Title/Abstract]) OR Octogenarian[Title/Abstract]) OR Centenarians[Title/Abstract]) OR Centenarian[Title/Abstract])) AND (((((((((((((Institutionalization[MeSH Terms]) OR Institutionalization[Title/Abstract]) OR Institutionalizations[Title/Abstract]) OR Institutionalized Persons[Title/Abstract]) OR Institutionalized Person[Title/Abstract]) OR Person, Institutionalized[Title/Abstract]) OR Persons, Institutionalized[Title/Abstract]) OR Homes for the aged[MeSH Terms]) OR Homes for the aged[Title/Abstract]) OR Old Age Homes[Title/Abstract]) OR Home, Old Age[Title/Abstract]) OR Homes, Old Age[Title/Abstract]) OR Old Age Home[Title/Abstract])) AND (((((((((((((((((((((((((((((((((((((((((((Dental caries[MeSH Terms]) OR Dental caries[Title/Abstract]) OR Dental Decay[Title/Abstract]) OR Caries, Dental[Title/Abstract]) OR Decay, Dental[Title/Abstract]) OR Carious Dentin[Title/Abstract]) OR Carious Dentins[Title/Abstract]) OR Dentin, Carious[Title/Abstract]) OR Dentins, Carious[Title/Abstract]) OR Dental White Spot[Title/Abstract]) OR White Spots, Dental[Title/Abstract]) OR White Spots[Title/Abstract]) OR Spot, White[Title/Abstract]) OR Spots, White[Title/Abstract]) OR White Spot[Title/Abstract]) OR Dental White Spots[Title/Abstract]) OR White Spot, Dental[Title/Abstract]) OR Tooth loss[MeSH Terms]) OR Tooth loss[Title/Abstract]) OR Loss, tooth[Title/Abstract]) OR Periodontitis[MeSH Terms]) OR Periodontitis[Title/Abstract]) OR Periodontitides[Title/Abstract]) OR Pericementitis[Title/Abstract]) OR Pericementitides[Title/Abstract]) OR Gingivitis[MeSH Terms]) OR Gingivitis[Title/Abstract]) OR Gingivitides[Title/Abstract]) OR Dental plaque[MeSH Terms]) OR Dental plaque[Title/Abstract]) OR Plaque, dental[Title/Abstract]) OR Dental plaque index[MeSH Terms]) OR Dental plaque index[Title/Abstract]) OR Index, Dental Plaque[Title/Abstract]) OR Dental Plaque Indexes[Title/Abstract]) OR Indexes, Dental Plaque[Title/Abstract]) OR Dental Plaque Indices[Title/Abstract]) OR Indices, Dental Plaque[Title/Abstract]) OR Stomatitis, denture[MeSH Terms]) OR Stomatitis, denture[Title/Abstract]) OR Denture Stomatitides[Title/Abstract]) OR Denture Stomatitis[Title/Abstract]) OR Stomatitides, Denture[Title/Abstract])
Web of Science	TS=(Aged OR Elderly OR "Aged, 80 AND over" OR Oldest old OR Nonagenarians OR Nonagenarian OR Octogenarians OR Octogenarian OR Centenarians OR Centenarian) AND TS=(Institutionalization OR Institutionalizations OR Institutionalized Persons OR Institutionalized Person OR Person, Institutionalized OR Persons, Institutionalized OR Homes for the aged OR Old Age Homes OR Home, Old Age OR Homes, Old Age OR Old Age Home) AND TS=(Dental caries OR Dental Decay OR Caries, Dental OR Decay, Dental OR Carious Dentin OR Carious Dentins OR Dentin, Carious OR Dentins, Carious OR Dental White Spot OR White Spots, Dental OR White Spots OR Spot, White OR Spots, White OR White Spot OR Dental White Spots OR White Spot, Dental OR Tooth loss OR Loss, tooth OR Periodontitis OR Periodontitides OR Pericementitis OR Pericementitides OR Gingivitis OR Gingivitides OR Dental plaque OR Plaque, dental OR Dental plaque index OR Index, Dental Plaque OR Dental Plaque Indexes OR Indexes, Dental Plaque OR Dental Plaque Indices OR Indices, Dental Plaque OR Stomatitis, denture OR Denture Stomatitides OR Denture Stomatitis OR Stomatitides, Denture)
Cochrane Library	#1Aged #2Elderly #3aged, 80 and over #4Oldest old #5Nonagenarians #6Octogenarians #7Centenarians #8#1 or #2 or #3 or #4 or #5 or #6 or #7 #9Institutionalization #10Institutionalizations #11Institutionalized Persons #12Institutionalized Person #13Homes for the aged #14old age homes #15old age home #16#9 or #10 or #11 or #12 or #13 or #14 or #15 #17dental caries #18dental decay #19carious dentin #20dental white spots #21white spots, dental #22white spot #23spot, white #24tooth loss #25loss, tooth #26periodontitis #27pericementitis #28pericementitides #29periodontitides #30gingivitis #31gingivitides #32dental plaque #33plaque, dental #34dental plaque index #35index, dental plaque #36dental plaque indexes #37indexes, dental plaque #38dental plaque indices #39indices, dental plaque #40stomatitis, denture #41denture stomatitides #42denture stomatitis #43stomatitides, denture #44#17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 o r #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 #45#8 and #16 and #44
Scopus	(TITLE-ABS-KEY(Aged) OR TITLE-ABS-KEY(Elderly) OR TITLE-ABS-KEY(Aged, 80 AND over) OR TITLE-ABS-KEY(Oldest old) OR TITLE-ABS-KEY(Nonagenarians) OR TITLE-ABSKEY( Nonagenarian) OR TITLE-ABS-KEY(Octogenarians) OR TITLE-ABS-KEY(Octogenarian) OR TITLE-ABS-KEY(Centenarians) OR TITLE-ABS-KEY(Centenarian)) AND (TITLEABS- KEY(Institutionalization) OR TITLE-ABS-KEY(Institutionalizations) OR TITLE-ABSKEY( Institutionalized Persons) OR TITLE-ABS-KEY(Institutionalized Person) OR TITLE-ABSKEY( Person, Institutionalized) OR TITLE-ABS-KEY(Persons, Institutionalized) OR TITLE-ABSKEY( Homes for the aged) OR TITLE-ABS-KEY(Old Age Homes) OR TITLE-ABS-KEY(Home, Old Age) OR TITLE-ABS-KEY(Homes, Old Age) OR TITLE-ABS-KEY(Old Age Home)) AND (TITLE-ABS-KEY(Dental caries) OR TITLE-ABS-KEY(Dental Decay) OR TITLE-ABS-KEY(Caries, Dental) OR TITLE-ABS-KEY(Decay, Dental) OR TITLE-ABS-KEY(Carious Dentin) OR TITLEABS- KEY(Carious Dentins) OR TITLE-ABS-KEY(Dentin, Carious) OR TITLE-ABS-KEY(Dentins, Carious) OR TITLE-ABS-KEY(Dental White Spot) OR TITLE-ABS-KEY(White Spots, Dental) OR TITLE-ABS-KEY(White Spots) OR TITLE-ABS-KEY(Spot, White) OR TITLE-ABS-KEY(Spots, White) OR TITLE-ABS-KEY(White Spot) OR TITLE-ABS-KEY(Dental White Spots) OR TITLEABS- KEY(White Spot, Dental) OR TITLE-ABS-KEY(Tooth loss) OR TITLE-ABS-KEY(Loss, tooth) OR TITLE-ABS-KEY(Periodontitis) OR TITLE-ABS-KEY(Periodontitides) OR TITLE-ABSKEY( Pericementitis) OR TITLE-ABS-KEY(Pericementitides) OR TITLE-ABS-KEY(Gingivitis) OR TITLE-ABS-KEY(Gingivitides) OR TITLE-ABS-KEY(Dental plaque) OR TITLE-ABS-KEY(Plaque, dental) OR TITLE-ABS-KEY(Dental plaque index) OR TITLE-ABS-KEY(Index, Dental Plaque) OR TITLE-ABS-KEY(Dental Plaque Indexes) OR TITLE-ABS-KEY(Indexes, Dental Plaque) OR TITLE-ABS-KEY(Dental Plaque Indices) OR TITLE-ABS-KEY(Indices, Dental Plaque) OR TITLEABS- KEY(Stomatitis, denture) OR TITLE-ABS-KEY(Denture Stomatitides) OR TITLE-ABSKEY( Denture Stomatitis) OR TITLE-ABS-KEY(Stomatitides, Denture))
Lilacs	((TW:(Aged)) OR (TW:(Elderly)) OR (TW:(Aged, 80 AND over)) OR (TW:(Oldest old)) OR (TW:(Nonagenarians)) OR (TW:(Nonagenarian)) OR (TW:(Octogenarians)) OR (TW:(Octogenarian)) OR (TW:(Centenarians)) OR (TW:(Centenarian))) AND ((TW:(Institutionalization)) OR (TW:(Institutionalizations)) OR (TW:(Institutionalized Persons)) OR (TW:(Institutionalized Person)) OR (TW:(Person, Institutionalized)) OR (TW:(Persons, Institutionalized)) OR (TW:(Homes for the aged)) OR (TW:(Old Age Homes)) OR (TW:(Home, Old Age)) OR (TW:(Homes, Old Age)) OR (TW:(Old Age Home))) AND ((TW:(Dental caries)) OR (TW:(Dental Decay)) OR (TW:(Caries, Dental)) OR (TW:(Decay, Dental)) OR (TW:(Carious Dentin)) OR (TW:(Carious Dentins)) OR (TW:(Dentin, Carious)) OR (TW:(Dentins, Carious)) OR (TW:(Dental White Spot)) OR (TW:(White Spots, Dental)) OR (TW:(White Spots)) OR (TW:(Spot, White)) OR (TW:(Spots, White)) OR (TW:(White Spot)) OR (TW:(Dental White Spots)) OR (TW:(White Spot, Dental)) OR (TW:(Tooth loss)) OR (TW:(Loss, tooth)) OR (TW:(Periodontitis)) OR (TW:(Periodontitides)) OR (TW:(Pericementitis)) OR (TW:(Pericementitides)) OR (TW:(Gingivitis)) OR (TW:(Gingivitides)) OR (TW:(Dental plaque)) OR (TW:(Plaque, dental)) OR (TW:(Dental plaque index)) OR (TW:(Index, Dental Plaque)) OR (TW:(Dental Plaque Indexes)) OR (TW:(Indexes, Dental Plaque)) OR (TW:(Dental Plaque Indices)) OR (TW:(Indices, Dental Plaque)) OR (TW:(Stomatitis, denture)) OR (TW:(Denture Stomatitides)) OR (TW:(Denture Stomatitis)) OR (TW:(Stomatitides, Denture)))

Author	Geographic Location	Study Design	Number of elderly	Age	Exclusion criteria	Outcomes included	Statistical analysis	Main Results	Conclusion
Pajukoski et al. (1999)	Finland	Cross sectional	435 elderly (181 institutionalized and 254 non-institutionalized)	70 years and over	Elderly < 70 years old and those that didn't sign the term or didn't had verbal permission	Number of dentate patients and edentulous Number of teeth and decayed teeth Periodontal status (CPI scores)	Chi-square test t test (when applicable).	Edentulous: IP: 66.3% (n=120) / NIP: 42.1% (n=107) (p < 0.001) Mean number of teeth: IP (11.3 ± 7.6) / NIP (16.3 ± 7.4) (p < 0.001) Mean number of decayed teeth: IP (1.3 ± 2.2) / NIP (0.6 ± 0.9) (p < 0.01) CPI score: IP: 0-1 (5.2%) / 2 (35.1%) / 3 (33.3%) / 4 (26.3%) NIP: 0-1 (1.4%) / 2 (44.6%) / 3 (27.7%) / 4 (26.4%) (p > 0.05)	The results of this study confirmed the hypothesis that Institutionalized elderly patients who had many concomitant diseases and used many drugs daily had worse dental health than Non-Institutionalized people
McMillan et al. (2003)	Hong Kong	Cross sectional	586 elderly (268 institutionalized and 318 non-institutionalized)	60 to 80 years old	Elderly people with communication difficulties or suffering from any psychiatric disease including dementia	Edentulous people Caries Experience (DMFT) Periodontal status (CPI scores)	Chi-square and independent t tests	Edentulous: IP: 19% (n=51) / NIP: 10% (n=32) (p<0.05) DMFT: IP: (D: 2.05 ± 0.20 / M: 19.04 ± 0.59 / F: 0.25 ± 0.05) – Total: 21.35 ± 0.56 NIP: (D: 1.13 ± 0.09 / M: 15.70 ± 0.51 / F: 0.84 ± 0.09) – Total: 17.67 ± 0.49 (p<0.001) CPI score: IP: 0-1 (0.5%) / 2 (40.1%) / 3 (39.6%) / 4 (19.8%) NIP: 0-1 (3.4%) / 2 (23.4%) / 3 (54.0%) / 4 (19.2%) (p<0.001)	The institutionalized group had experienced more dental disease in the past and consequently had more missing teeth than the non-institutionalized elderly. Untreated dental conditions were more common in the institutionalized elderly.
Bitetti et al. (2004)	Italy	Cross sectional	364 elderly (258 institutionalized and 106 non-institutionalized)	65 years and over	Elderly < 65 years old	Mean number of permanent teeth Caries Experience (DMFT) Periodontal status (CPI scores)	Chi-square test	Edentulous: IP: 49.6% (n=128) / NIP: 28.3% (n=30) (p<0.001) DMFT: IP: (D: 1.03 / M: 23.84 / F: 0.12) – Total: 24.99 NIP: (D: 1.07 / M: 18.17 / F: 0.51) – Total: 19.75 CPI score: IP: 0-1 (51.92%) / 2 (23.25%) / 3 (8.52%) / 4 (0.38%) NIP: 0-1 (42.44%) / 2 (33.96%) / 3 (16.98%) / 4 (4.71%)	The value of the DMFT in Non-Institutionalized people (NIP) is less than in hospitalized patients, therefore, decay presents a greater prevalence in institutionalized (IP).
Triantos (2005)	Greece	Cross sectional	316 elderly (166 institutionalized and 150 non-institutionalized)	65 years and over	Elderly ≤ 65 years old and those that didn't want to participate	Number of Edentulous Oral lesions Denture-induced stomatitis	Fisher's exact two-sided test	Edentulous: IP: 88.5% (n=145) / NIP: 68% (n=102) (p<0.001) Oral Lesions: IP: 46.2% (n=77) / NIP: 47.2% (n=71) (p>0.05) Denture-induced stomatitis: IP: 9.64% (n=16) / NIP: 11.33% (n=17) (p>0.05)	The present study demonstrated that among elderly people, either living in long-term care facilities or independently in the society, general health problems and oral health issues are common, variable and coexistent, necessitating the daily administration of multiple medications. Prevalence of oral health disorders does not vary significantly between institutionalized and non-institutionalized people
Niestem et al. (2016)	Netherlands	Cross sectional	235 elderly (126 institutionalized and109 non-institutionalized)	65 years and over	Cognitively depressed individuals	Number of dentate patients and edentulous Number of missed teeth (among dentate) Number of individuals with one or more carious teeth (among dentate)	t-test and multiple linear regression	Edentulous: IP: 46% (n=58) / NIP: 39% (n=43) (p>0.05) Mean number of missed teeth: IP: 16.8 ± 8.2 / NIP: 10.7 ± 5.1 (p<0.001) Subjects with one or more carious teeth IP: 57% (n=39) / NIP: 7% (n=11) (p<0.001)	Clinical oral health outcomes of care-dependent participants were significantly worse than those of care-independent participants

Guideline	Checklist	Pajukoski et al. (1999)	McMillan et al. (2003)	Bitteti et al. (2004)	Triantos (2005)	Niestem et al. (2016)
Study design appropriate?	Cross-sectional (prevalence)	Yes	Yes	Yes	Yes	Yes
	Cohort (prognosis)	NA	NA	NA	NA	NA
	Controlled Trial (treatment)	NA	NA	NA	NA	NA
	Case-control, cross-sectional (cause)	NA	NA	NA	NA	NA
Study sample representative?	Source of sample	+	0	+	+	+
	Sampling method	0	0	0	0	0
	Sample size	0	0	0	0	0
	Entry criteria and exclusions	0	0	0	0	0
Control group acceptable?	Definition of control	0	0	0	0	0
	Source of control	0	0	0	0	0
	Matching/randomization	NA	NA	NA	NA	NA
	Comparable characteristics	0	0	0	0	0
Quality of measurements and outcomes?	Validity	0	0	0	0	0
	Reproducibility	0	0	0	0	0
	Blindness	NA	NA	NA	NA	NA
	Quality control	0	0	0	0	0
Completeness?	Compliance	0	0	0	0	0
	Drop out	NA	NA	NA	NA	NA
	Death	NA	NA	NA	NA	NA
	Missing data	0	0	0	0	0
Distorting influence?	Extraneous treatments	NA	NA	NA	NA	NA
	Contamination	NA	NA	NA	NA	NA
	Changes over time	NA	NA	NA	NA	NA
	Confounding factors	0	0	0	0	0
	Distortion reduced by analysis	0	0	0	0	0
Summary questions	Bias - Are the results erroneously biased in a certain direction?	No	No	No	No	No
	Confounding - Are there any serious confounding or other distorting influences?	No	No	No	No	No
	Chance - Is it likely that the results occurred by chance?	No	No	No	No	No

[1] Collaborators

IPS Farias, LFD Almeida, BM Santiago and YW Cavalcanti designed the study. IPS Farias and YW Cavalcanti performed electronic database searches, applied appropriate eligibility criteria and performed the quality assessment of included studies. SA Sousa, BM Santiago, AC Pereira and YW Cavalcanti performed and interpreted meta-analysis. IPS Farias, LFD Almeida and SA Sousa drafted the manuscript. BM Santiago, AC Pereira and YW Cavalcanti revised the manuscript for important intellectual content.

Brasil

Brasil

Does non-institutionalized elders have a better oral health status compared to institutionalized ones? A systematic review and meta-analysis

Idosos não-institucionalizados apresentam melhor saúde bucal comparado aos idosos institucionalizados? Uma revisão sistemática e meta-análise

Abstract