Community Dent Oral Epidemiol 2012; 40: 8995 All rights reserved

2011 John Wiley & Sons A/S

Preference for dentists home visits among older people

Komulainen K, Ylo stalo P, Syrja la A-M, Ruoppi P, Knuuttila M, Sulkava R, Hartikainen S. Preference for dentists home visits among older people. Community Dent Oral Epidemiol 2012; 40: 8995. 2011 John Wiley & Sons A S Abstract Objectives: To investigate factors associated with older peoples preference for a dentists home visit. Methods: This is a report on 321 homedwelling participants (mean age 81.6) in the population-based Geriatric Multidisciplinary Strategy for Good Care of the Elderly (GeMS) study, conducted in 20042005 in the city of Kuopio in eastern Finland. The information about sociodemographic and general health-related factors and the use of social and health services was collected by two study nurses using a structured interview. Each study subject was given a clinical oral examination and an interview about oral health and the use of dental health care services by one of two dentists. Logistic regression models were used to estimate odds ratios (OR) and 95% condence intervals (CI). Results: Of the study subjects, 25.9% preferred a dentists home visit. The preference for choosing a dentists home visit was associated with a low score (24) in the Mini-Mental State Examination, OR 6.1 (CI: 2.913.6), and a low score (<8) on the scale of Instrumental Activities of Daily Living, OR 8.0 (CI: 3.618.6). It was also associated with living alone, OR 5.9 (CI: 2.713.0), and high use of home care services, OR 9.3 (CI: 4.619.0). Conclusions: The ndings of this study emphasize the need to organize dentists home visits in order to increase equality in the use of dental health care services among the older people with disabilities.

stalo4, Kaija Komulainen1,2,3, Pekka Ylo 4,5 la , Piia Ruoppi3, Anna-Maija Syrja Matti Knuuttila4,6, Raimo Sulkava7 and Sirpa Hartikainen1,2,8
1 Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland, 2Faculty of Health Sciences, Clinical Pharmacology and Geriatric Pharmacotherapy Unit, School of Pharmacy, University of Eastern Finland, Kuopio, Finland, 3Social and Health Centre of Kuopio, Kuopio, Finland, 4Department of Periodontology, Institute of Dentistry, University of Oulu, Finland, 5Oulu Health Centre, Oulu, Finland, 6Oral and Maxillofacial Department, Oulu University Hospital, Oulu, Finland, 7Faculty of Health Sciences, Division of Geriatrics, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland, 8Leppa virta Health Centre, Leppa virta, Finland

Key words: dental health care services; older people Kaija Komulainen, Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio Campus, P. O. Box 1627, 70211 Kuopio, Finland Tel.: +358403552440 Fax: +35817162424 e-mail: kaija.komulainen@uef. Submitted 2 May 2010; accepted 2 July 2011

Researchers have identied several barriers to the use of dental health care services among older people. These barriers typically include factors such as impaired mobility, illness, inconvenience, high cost, and poor access to dental services (1, 2). The relative importance of these barriers naturally varies from individual to individual and from country to country, depending on circumstances and insurance coverage (3, 4). For some older people, dental health care services can be arranged only through domiciliary oral health care (4, 5). To date, the possibility to receive domiciliary dental visits has been reported in several countries (610), although the proportion of domiciliary visits of all dental visits has been reported to be low (6, 911) and even decreasing (11). At the same time, the demand
doi: 10.1111/j.1600-0528.2011.00631.x

for domiciliary dental care is increasing as a result of the aging population and the increasing number of dentate and functionally dependent elderly people and also as a result of legislative pressure (6, 9, 11). From the egalitarian point of view, oral health care should also be available to all people regardless of their living circumstances or age (4, 12). To our knowledge, the factors that affect older peoples preference for a dentists home visit have not been investigated, and it would be important to better understand and consequently be able to meet the oral health needs of the older population. The aim of this study was to investigate the factors associated with preference for a dentists home visit among home-dwelling older people.

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Material and methods

Study population and data collection
This study is based on a subpopulation of 321 (229 women and 92 men) home-dwelling old people, mean age of 81.6 (SD 4.6) years, who were participants in the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study aimed at preventing disability and preserving autonomy in older people (13). Initially, a random sample of 1000 persons aged 75 on November 1, 2003, was drawn from the population of the city of Kuopio (88 253 inhabitants, 5615 of whom were aged 75 years) and randomized with the aid of computer-generated numbers into an intervention group (n = 500) and a control group (n = 500). The GeMS studys intervention group underwent a Comprehensive Geriatric Assessment (CGA). The GeMS study intervention was focused on optimizing geriatric treatment, including the adjustment of medication and improvement of functioning and nutrition. Standard medical care was available to the participants in the control group. The CGA was made by a team of two physicians, two study nurses, and two physiotherapists. The participation rate in the original study was 78.1% (n = 781); in the intervention group, 80.8%; and in the control group, 75.4% (not in this study). According to the study protocol, the clinical oral examination was performed for the participants who were randomized into the GeMS study intervention group. An invitation to the clinical oral examination was conducted by telephone (a call to the participant or to a family member in case of cognitive or communication problems) and conrmed with a mailed letter. At the baseline, during the years 20042005, two dentists interviewed the participants on their oral self-care habits and use of dental health care services and performed the clinical oral examinations for 354 participants (27 refused and 23 died before the oral examination). After the sample was restricted to home-dwellers, this study population included 321 participants. The interviews and examinations by the dentists were carried out in the primary care settings of the Social and Health Centre of Kuopio or in the persons home. The clinical oral examinations (extra-oral and intra-oral) were performed in a standard dental unit based on written instructions. The dentists home visits were carried out in similar manner, with the exception that the

dental unit was not available; the source of light was a headlamp for the dentist and a ashlight for the dental nurse when extra light was needed, and moisture was controlled with cotton rolls and gauzes instead of ordinary dental devices. The dentists were calibrated by having them jointly examine the rst seven study participants from the ID number list of the participants. Because of the high age of the participants and the length of the study (one hour), no repeated examinations were performed.

Outcome variable and explanatory variables

The outcome variable was preference for a dentists home visit, which was based on the participants choice of coming to the dental clinic or alternatively receiving a dentists home visit for the clinical oral examination. If the study participant was unable to express his her preference, a family member of the participant chose whether the participant came to the dental clinic or received a dentists home visit. Sociodemographic explanatory variables included age, gender, education (7 versus <7 years), and cohabitation (living alone versus living with another person). Cognitive and functional capacity were assessed using the Mini-Mental State Examination (MMSE) test (14) and the Instrumental Activities of Daily Living (IADL) test (15), respectively. The MMSE test seeks information about six aspects of cognitive function: orientation to time and place, repetition, concentration, short-term memory, language, and visual-motor integrity. The MMSE score was categorized into two groups based on earlier literature (16): impaired cognitive function, MMSE score 24 versus normal cognitive capacity, MMSE score 2530. The functional ability test (IADL) is an eight-item scale including the use of a telephone, shopping for groceries, preparing food, housekeeping, doing laundry, using transportation, managing medication, and handling nances. In this study, the scores of the IADL test were classied into two categories: IADL score 8 (fully independent) versus IADL scores <8 (one or more deciencies in the IADL test). Use of home care services organized by the community was asked and classied into two categories according to whether the participant received home care services. These services included assistance with medication or basic nursing activities but did not include assistance in cleaning, cooking, or shopping.

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The study participants were also asked about visits to primary health care. Visits to a primary care physician consisted of visits to a physician in public and or private health care and home visits by a physician (classied as yes versus no) during the past year. Also, the mean number of visits to a physician during the past year was asked and recorded. Visits to dental health care included visits to a dental technician, a dental hygienist, and or a dentist in public and or private dental care. The interval since the last dental visit was asked and the variable was classied into three categories: <1, 13, and over 3 years. In addition, the pattern of dental checkups was asked. This variable was used as a dichotomous variable: a visit to dental care at regular, scheduled intervals (varying between 4 months and 2 years) or being in a dental recall system versus irregular use of dental health care services. In the clinical oral examination, the subject was dened as dentate if he she had at least one clinically visible tooth or dental radix. The number of teeth was classied into three categories: 19, 10 19, and 20 teeth. The presence of dental caries was assessed by means of visual and tactile examinations after slight drying of the teeth. Dental caries was examined on each surface of every tooth and recorded as crown caries (caries had reached the dentin layer of the clinical crown), root caries (softened root surface), crown and root caries, or carious dental radix. In this study, dental caries was recorded at tooth level; a tooth was dened as carious if any of the above-mentioned criteria was fullled on any surface of the tooth. Periodontal pocket depth was measured by probing (WHO periodontal probe) at two sites: the mesiobuccal and distopalatal distolingual surfaces of each tooth. Periodontal condition was measured by the presence of teeth with a deepened periodontal pocket (4 mm). Supra- and subgingival calculus were recorded during the probing of periodontal pockets. The use, type, and condition of the denture were recorded. Presence of denture stomatitis was recorded if there was smooth or nodular redness in the oral mucosa. Toothbrushing frequency was categorized as at least twice a day versus less. Denture cleaning was categorized as at least twice a day versus less. Unstimulated saliva was collected before the clinical oral examination with the participant sitting in a relaxed position, leaning slightly forward. After swallowing, saliva was passively drained for 5 mins into a cup graded in 1.0-ml

increments to 30 ml. The classication of a low ow rate, <0.1 versus 0.1 ml min, was based on literature (17, 18). The descriptive characteristics of the study population are shown in Table 1.

Statistical methods
Odds ratios (OR) with 95% condence intervals (CI) were estimated using logistic regression models. When analyzing the role of functional ability and cognitive function as determinants of the participants preference, we used as confounders variables that, according to current knowledge, were associated with the participants preference for a home visit (Table 2). In order to quantify the effect of factors which are of interest but cannot be considered causally associated with preference for a dentists home visit, we adjusted only for age, gender, and education (Tables 3 and 4). The statistical analyses were performed using SPSS 14.0 for Windows (SPSS, Chicago, IL, USA).

Ethical considerations
Written informed consent was obtained from the study participants or their relatives. The study protocol was approved by the Research Ethics Committee of the Hospital District of Northern Savo, as required by Finnish legislation. In case of problems with communication or the memory of the participant, the appointment for the examination visit was made with a family member. The relative or the person responsible for providing home care services was present during the dentists home visit in these cases. Written information about the key ndings of the clinical oral examination was given to each study participant.

Results
Twenty-six percent (n = 83) of the participants expressed preference for a dentists home visit. Preference for a dentists home visit was associated with an MMSE score 24, OR 6.1 (CI: 2.913.6), and a low IADL score (<8), OR 8.0 (CI: 3.618.6) (Table 2). In addition, preference for a dentists home visit was associated with high use of home care services and less use of primary health care services, such as visits to a physician and dental health care services (Table 3). The associations between oral health and preference for a dentists home visit are shown in Table 4. Those who preferred a home visit more likely had a

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Komulainen et al. Table 1. Characteristics of the study population by place of clinical oral examination All, n = 321 Sociodemographic factors Age, mean (SD) 7579 years, % (n) Gender, females, % (n) Education 7 years, % (n) Living alone, % (n) General health-related factors MMSEa, mean (SD) High, score 2530, % (n) IADLb, mean (SD) High, score 8, % (n) Number of regular drugs, mean (SD) Use of services Use of home care services, % (n) Visit to a primary care physician <1 year, % (n) Number of visits in a year, mean (SD) Time since last dental visit <1 year, % (n) 13 years, % (n) >3 years, % (n) Regular dental checkup, % (n) Oral-health-related factors Unstimulated saliva ow rate <0.1 ml min, % (n) Dentate persons, % (n) Number of teeth, mean (SD) Number of teeth 20, % (n) 1019, % (n) <10, % (n) Presence of dental cariesc, % (n) Presence of calculus teethc >20% of all teeth, % (n) Presence of deepened periodontal pocketsc, % (n) Toothbrushing frequencyc at least twice a day, % (n) Removable dentured, % (n) Denture stomatitisd, % (n) Denture cleaningd at least twice a day, % (n) SD, standard deviation. a Mini-Mental State Examination. b Instrumental Activities of Daily Living. c Among dentate persons. d Among removable denture users. 34.7 (106) 52.3 (168) 14.4 (8.1) 35.7 25.0 39.3 46.4 73.7 58.8 69.0 76.9 20.2 70.0 (60) (42) (66) (78) (123) (97) (116) (247) (50) (173) 30.9 (72) 57.1 (136) 15.5 (7.9) 39.7 27.2 33.1 46.4 75.6 62.7 73.5 74.4 20.9 72.9 (54) (37) (45) (63) (102) (84) (100) (177) (37) (129) 46.6 (34) 38.6 (32) 10.0 (7.6) 18.8 15.6 65.6 46.9 65.6 41.9 50.0 84.3 18.6 62.7 (6) (5) (21) (15) (21) (13) (16) (70) (13) (44) 81.6 46.1 71.3 44.2 54.3 26.2 78.2 6.7 46.7 4.8 (4.6) (148) (229) (137) (172) (4.6) (251) (1.9) (149) (3.0) Dental clinic visit, n = 238 80.7 53.4 68.9 50.0 47.9 27.2 87.8 7.2 57.8 4.4 (3.6) (127) (164) (116) (113) (3.7) (209) (1.3) (137) (2.9) Home visit, n = 83 84.3 25.3 78.3 26.9 72.8 23.6 50.6 5.1 14.8 5.9 (5.6) (21) (65) (21) (59) (5.6) (42) (2.3) (12) (3.2)

18.8 (60) 89.6 (285) 3.7 (3.9) 39.7 18.6 41.7 32.0 (124) (58) (130) (101)

7.2 (17) 93.2 (221) 4.1 (4.2) 45.5 20.0 34.5 37.3 (107) (47) (81) (88)

52.4 (43) 79.0 (64) 2.0 (2.4) 22.1 14.3 63.6 17.1 (17) (11) (49) (13)

reduced unstimulated salivary ow rate, fewer teeth, and brushed their teeth only once a day or less, compared with those who preferred to come to the dental clinic. No essential association was observed between preference for a dentists home visit and the

presence of dental caries or denture stomatitis, but among those who preferred a home visit, there was a tendency toward fewer persons with teeth with deepened periodontal pockets than there were among participants who preferred to come to the dental clinic.

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Preference for dentists home visits Table 2. Sociodemographic factors and general health related to preference for a dentists home visit Unadjusted Adjusteda OR (95% CI) OR (95% CI) Age 80 7579 Gender Females Males Education <7 years 7 years 3.4 (1.95.9) 1.6 (0.83.2) 1.0 1.0 1.6 (0.92.9) 1.4 (0.63.0) 1.0 1.0 2.7 (1.54.8) 1.8 (0.93.8) 1.0 1.0 Table 3. Use of services associated with preference for a dentists home visit Unadjusted OR (95% CI)a Adjusteda OR (95% CI)

Use of home care services Yes 14.5 (7.427.5) 9.3 (4.619.0) No 1.0 1.0 Visit to a physician during No Yes Number of visits in the past year (continuous) the last year 3.6 (1.77.5) 1.0 0.8 (0.70.9) 3.2 (1.47.2) 1.0 0.8 (0.70.9)

Cohabitation Living alone 2.9 (1.75.1) 5.9 (2.713.0) Living with another person 1.0 1.0 MMSE Score 024 7.0 (3.912.6) 6.1 (2.913.6) Score 2530 1.0 1.0 Instrumental Activities of Daily Living Score 17 7.8 (4.115.3) 8.0 (3.618.6) Score 8 1.0 1.0 OR, odds ratios; 95% CI, 95% condence interval. a Adjusted for all explanatory variables presented in the table.

Time since last dental visit >3 years 3.8 (2.07.1) 13 years 1.5 (0.63.4) <1 year 1.0 Regular dental checkup No Yes 2.9 (1.55.5) 1.0

2.7 (1.35.4) 1.1 (0.52.7) 1.0 2.3 (1.14.8) 1.0

OR, odds ratios; 95% CI, 95% condence interval. a Adjusted for age (continuous), gender, and education (continuous).

Discussion
The number of participants who preferred a dentists home visit was unexpectedly high; about one of four participants chose a dentists home visit. The most important factors associated with a dentists home visit were functional disabilities and cognitive impairment, which earlier have been associated with the risk of becoming a nonuser of dental health care services (1921). The observation that preference for a dentists home visit was also associated with high use of home care services and low use of dental and primary health care services suggests that older people may not have enough resources to use health care services. This is also in accordance with earlier ndings by Brothwell et al. (22), who reported an association between the visitation rate of dental services and the visitation rate of other health services among independently dwelling older people. It can be hypothesized that the underlying cause for this may be the level of functional ability and cognitive function. Oral health was not essentially poorer among the participants who preferred a dentists home visit than it was among those who preferred to

come to the dental clinic. This nding suggests that oral health is not an important factor in choosing between a dentists home visit and a visit to the dental clinic. However, the tendency toward better periodontal health among those who preferred a dentists home visit can be partly explained by the fact that they had a lower number of teeth than did those who preferred the dental clinic, possibly related to previous extraction-oriented treatment modalities owing to high age and poor physical and cognitive abilities. Despite the small between-group differences in oral health, overall oral health among the study participants was not good. This means there was a need for both preventive and other treatments among all these older people. Because these persons have many barriers to attending regular dental health care services, home visit services would be important. The results also indicate that dentists home visits should be put into practice more, as presented by Petersen and Yamamoto (23). The British guidelines for the delivery of domiciliary oral health care services may be useful when organizing these services (24). Dental home visits have been shown to improve oral-health-related quality of life (25, 26), but organization of domiciliary dental services for older people with disabilities is not unproblematic. The problems include limitations in performing dental treatment, high economic costs, time-consuming

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Komulainen et al. Table 4. Oral health and oral health behavior associated with preference for a dentists home visit Unadjusted OR (95% CI) Adjusteda OR (95% CI) (0.62.2) (1.39.9) (0.34.1) (0.42.1) (0.21.3) (0.94.7)

Presence of natural teeth Edentate 2.1 (1.33.5) 1.2 Dentate 1.0 1.0 Number of teethb <10 4.2 (1.611.3) 3.5 1019 1.2 (0.34.3) 1.2 20 1.0 1.0 Presence of dental cariesb Yes 1.0 (0.42.2) 1.1 No 1.0 1.0 Presence of calculus teethb >20% Yes 0.6 (0.71.4) 0.7 No 1.0 1.0 Presence of deepened periodontal pocketsb Yes 0.4 (0.21.0) 0.5 No 1.0 1.0 Toothbrushing frequencyb <Twice a day 2.8 (1.36.1) 3.4 At least twice a day 1.0 1.0 Removable denture Yes No Denture stomatitisc Yes No Denture cleaningc <Twice a day At least twice a day 1.9 (1.03.6) 1.0 0.9 (0.41.7) 1.0 1.5 (0.82.7) 1.0

just started when the material for this study was collected. For the aforementioned reasons (random sample and random allocation), we consider that the results are also fairly well generalizable to the home-dwelling elderly population. In conclusion, the results showed that about onefourth of the participating home-dwelling older people chose a dentists home visit, and preference for a dentists home visit was associated with poor functional ability and impaired cognitive function. Our results suggest that it is important to organize dentists home visits in order to increase equality in the use of dental health care services among the older people with disabilities.

Acknowledgements
(1.48.0) The GeMS study was nancially supported by the Social Insurance Institute of Finland and the City of Kuopio. We thank Piia Lavikainen for statistical guidance.

1.1 (0.52.0) 1.0 1.0 (0.52.1) 1.0 1.6 (0.83.1) 1.0 2.0 (1.13.6) 1.0

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