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J Med Sci, Volume 50, No. 2, 2018 April: 1-6Agustina D et al.

, The correlation between occurrence of dental caries

and oral health-related quality of life on elderly population in Yogyakarta Special Region

The correlation between occurrence of dental

caries and oral health-related quality of life on
elderly population in Yogyakarta Special Region
1* 2 3 4
Agustina D , Hanindriyo L , Widita E , Widyaningrum R
Department of Oral Medicine, 2Department of Dental Public Health, 3Program Study of Dental
Hygiene, 4Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Universitas Gadjah
Mada, Yogyakarta, Indonesia.

DOI: http://dx.doi.org/10.19106/JMedSci005002201808

Dental caries is the most common oral disease affecting humans. Based on Indonesia
Basic Health Research in 2013, dental caries prevalence increased up to 53.2% compared
to 43.4% in 2007. One of the two most increasing prevalence occurred in population of
more than 65 years. This disease might affect oral health-related quality of life (OHRQoL)
since it causes pain, physical and psychological discomfort. The aim of study was to
investigate the correlation between occurrence of dental caries and OHRQoL of elderly
population in Yogyakarta Special Region. Occurrence of dental caries and OHRQoL were
determined using Decay-Missing-Filling Teeth (DMFT) Index and Geriatric Oral Health
Assessment Index (GOHAI), respectively for 118 elderly aged 60-84 years consisting
73 female and 45 male. The data then were classified into very low, low, moderate and
high DMFT and low, moderate and high GOHAI. Spearman’s rank correlation test was
conducted to determine correlation between occurrence of dental caries and OHRQoL.
Mean scores of DMFT Index and GOHAI were 16.61 ± 7.16 and 47.97 ± 9.03,
respectively. Very low, low, moderate, and high DMFT Index were experienced by 4
(3.38%), 13 (11.02%), 25 (21.19%) and 76 (64.41%) of 118 elderly, respectively.
Low, moderate and high GOHAI were experienced by 71 (60.17%), 25 (21.19%) and 22
(18.64%) of 118 elderly, respectively. The significantly correlation between dental caries
and OHRQoL was observed in this study (r = -0,265; p = 0.004). In conclusion, there
is a negative moderate correlation between the occurrence of dental caries and OHRQoL
of elderly population in Yogyakarta Special Region.

Karies gigi merupakan penyakit mulut yang paling umum pada manusia. Berdasarkan
data Riset Kesehatan Dasar Indonesia 2013, prevalensi karies gigi meningkat hingga
53,2% dibandingkan 43,4% pada 2007. Salah satu dari dua peningkatan prevalensi
paling tinggi terjadi pada populasi usia di atas 65 tahun. Penyakit ini dapat mempengaruhi
kualitas hidup terkait kesehatan mulut (oral health-related quality of life = OHRQoL)
karena menyebabkan nyeri, ketidaknyamanan fisik dan psikologi. Tujuan penelitian ini
adalah untuk mengkaji hubungan antara kejadian karies gigi dan OHRQoL pada populasi
usia lanjut di Daerah Istimewa Yogyakarta (DIY). Kejadian karies gigi dan OHRQoL diukur
berturut-turut dengan indeks karies gigi (Decay-Missing-Filling Teeth = DMFT) dan
indeks penilaian kesehatan mulut usia lanjut (Geriatric Oral Health Assessment Index
= GOHAI) terhadap 118 usia lanjut berumur antara 60-84 tahun yang terdiri dari 73
wanita dan 45 laki-laki. Data yang diperoleh dikelompokkan menjadi indeks DMFT sangat

* corresponding author :dewi_agustina_fkg@ugm.ac.id

J Med Sci, Volume 50, No. 2, 2018 April: 1-6

rendah, rendah, sedang dan tinggi dan GOHI rendah, sedang dan tinggi. Uji korelasi rank
Spearman dilakukan untuk menentukan hubungan antara kejadian karies dan OHRQoL.
Rerata skor indeks DMFT dan GOHAI berturut-turut adalah 16,61 ± 7,16 dan 47,97 ±
9,03. Indeks DMFT sangat rendah, rendah, sedang dan tinggi dialami oleh berturut-turut
4 (3,38%), 13 (11.02%), 25 (21,19%) dan 76 (64,41%) dari 118 usia lanjut. GOHAI
rendah, sedang dan tinggi dialami berturut-turut oleh 71 (60,17%), 25 (21,19%) dan 22
(18,64%) dari 118 usia lanjut. Hubungan secara nyata antara karies gigi dan OHRQoL
ditunjukkan dalam penelitian ini ( r = -0,65; p = 0.004). Dapat disimpulkan terdapat
hubungan negatif sedang antara karies gigi dengan kualitas hidup terkait kesehatan mulut
pada populasi usia lanjut DIY.

Keywords: dental caries - DMFT index – oral health – elderly – quality life

INTRODUCTION the tooth, tooth loss, and infection or abscess

Despite advancements in oral disease formation.3 The earliest sign of a new carious
science, dental caries continues to be a lesion is the appearance of a chalky white spot
worldwide health concern, affecting humans on the surface of the tooth, indicating an area
of all ages. Approximately 2.3 billion people of demineralization of enamel. Visible pits or
(32% of the population) have dental caries holes in the teeth are strong positive indicator
in their permanent teeth worldwide.1 Dental of tooth decay.2
caries is one of the most common oral diseases Recently, health is defined by a complete
and it is linked to bacteria in the dental plaque physical, mental and social well-being, not
overlying the dental hard tissue. Although merely the absence of disease. Thereby the
acid generating bacteria are the etiologic quality of life of a patient is taken into account.
agents, dental caries has been thought of as Oral health-related quality of life (OHRQoL)
multifactorial since it is influenced by dietary is defined as a multidimensional construct
and host factors as well. In addition, the role of that reflects people’s comfort when eating,
saliva as a defense system against dental caries sleeping, and engaging in social interaction;
is well documented. These defense systems their self-esteem; and their satisfaction with
include clearance, buffering, antimicrobial respect to their oral health.5 The OHRQoL is
agents, and calcium and phosphate delivery usually assessed by studying how factors such
for remineralization.2 as function, pain, psychological, and social
The first and most common symptom of aspects affect the well-being of an individual.6
dental caries is toothache. This is typically an Oral health-related quality of life is a more
infection or irritation of the tooth pulp usually holistic approach in health care, in order
causes the pain. Tooth pain or achy feeling, to improve the oral related satisfaction and
particularly after sweet, hot, or cold foods quality of life of patients, and not merely the
and drinks are first indicator. If dental caries eradication of disease.7
is more severe, it can cause eating difficulty.3 The elderly population have significantly
Dental caries can also cause bad breath and increased in recent years. About 80% of the
foul tastes.4 In highly progressed cases, an world elderly population is found in developing
infection can spread from the tooth to the countries.8 World Health Organization (WHO)
surrounding soft tissues. Complications may predicted that the population of elderly in
include inflammation of the tissue around Indonesia will reach 11.34% or 28.8 million

Agustina D et al., The correlation between occurrence of dental caries
and oral health-related quality of life on elderly population in Yogyakarta Special Region

people in 2010.9 It is also predicted that the daily life of elderly that results in decreasing
population of elderly in Indonesia will be up of oral function, self confidence and social life
to 25% in 2050.10 Amongst 33 provinces in that eventually affect OHRQoL. According to
Indonesia, Yogyakarta Special Region is a report of Indonesia Basic Health Research in
province with the highest number of elderly 2013, prevalence of dental caries in Indonesia
that reaches up to 14.02% in 2010. Moreover, in 2013 increased up to 53.2% compared to
Yogyakarta Special Regions is a province 43.4% in 2007. One of the two most increasing
with the longest life expectancy as well i.e. prevalence occurred in population of more
up to 74.2 years in 2010 and in 2035 will than 65 years.17 The aim of this research was
be predicted up to 75.5 years.11 The longer to evaluate the correlation between occurrence
life expectancy of population in Yogyakarta of dental caries and OHRQoL of elderly
Special Region is contributed by following population in Yogyakarta Special Region.
factors : (i) comfortable environment; (ii)
very good social support for elderly activities;
(iii) very good community care; (iv) a relative
cheap of life expenditure; (v) adequate health Subjects
care facilities for elderly; (iv) accessible This was an observational community-
health care facilities.12 based cross-sectional study. A total of 118
Health problem of elderly varies as elderly (60-84 years) consist of 45 males
consequences of physiologic or pathologic and 73 females from six representative urban
processes. Elderly people prone to chronic and rural areas of Yogyakarta Special Region
diseases and acute infections. This condition participated in this study. Three community
is deteriorated by decreasing immune system health station for elderly (Posyandu Lansia)
in elderly. Elderly at least have one chronic representing urban area i.e. Wirobrajan,
medical disturbance, so increasing elderly Sewon and Minomartani and rural area
population might increase percentage of i.e. Pundong, Moyudan and Berbah were
chronic diseases as well.13 It is common that randomly chosen for this study participants
polymedication is experienced by elderly. recruitment. Fifty nine subjects were recruited
Majority of elderly at least is taking one from eh area. Rural-urban characteristic
prescribed medication.14 Polypathology and was based on the criterions published by the
polymedication result from aging and disease Indonesian National Board of Statistics in
processes. Medication for systemic diseases 2010. A scoring technique which corresponds
and systemic disease itself in elderly might with the population density, proportion
cause hyposalivation either with or without of agricultural-related profession, and the
xerostomia. It has been reported that 80% of existence of public-leisure facilities was used
prescribed medication cause xerostomia.15 to establish the criterion.11 The protocol of
On the other hand, oral health and the study was approved by the Medical and
function deteriorate as long as getting older.16 Health Research Ethics Committee (MHREC)
Poor oral health in elders is caused by of Faculty of Medicine, Universitas Gadjah
edentulism, dental caries, periodontal disease, Mada and Dr. Sardjito General Hospital,
xerostomia, dysfunction of salivary gland and Yogyakarta (Approval number : KE/FK/441/
oral mucosal lesion including oral precancer.8 EC/2016).
All these findings may give badly impact for

J Med Sci, Volume 50, No. 2, 2018 April: 1-6

Protocol of study Data analysis

Subjects were gathered and explained Data were presented as mean ± standar
concerning the goal, the significance and the deviation (SD) or percentage. Spearman’s rank
course of the study. Subjects who willing to correlation test was conducted to determine
participate in the study were given written the correlation between occurrence of dental
informed consent to be signed. The subjects caries and OHRQoL using software of SPSS
were then conducted clinical intraoral of 16.0 version by computer. A p value < 0.05
examination to determine DMFT index (the was considered as signicant.
total number of decayed/D, missing/M and
filled/F permanent teeth in an individual)
using dental diagnostic instrument. Intraoral
examination was carried out by four trained Clinical intraoral examination to
dentists under sufficient illumination with determine DMFT index was conducted to all
artificial light. Dentition status to measure the subjects using dental diagnostic instrument.
DMFT was examined using the procedures The DMFT index value are presented in
guided by the WHO Basic Oral Health TABLE 1. Mean of DMFT index for all
Survey 2013 method. The examiners were subjects was16.61 ± 7.16 with the range
calibrated before and during the survey, between 2 up to 32.
and inter-examiner reliability was assessed.
TABLE 1. Result of DMFT index (n=118)
According to replicated examinations of 10
patients, the Kappa value ranged from 0.75 Number of
to 0.9 which corresponds with substantial to DMFT index Classification subjects
almost perfect agreement according to the n %
WHO Basic Oral Health Survey Method.18 < 5.0 Very low 4 3.38
The classification of DMFT index was very 5.0 – 8.9 Low 13 11.02
low (<5.0), low (5.0-8.9), moderate (9.0- 9.0 – 13.9 Moderate 25 21.19
13.9), and high (>13.9). The maximum score > 13.9 High 76 64.41
of DMFT index is 32 whereby a higher score
indicates a more prevalence of dental caries Oral health-related quality of life
(WHO, 2013).18 Oral health-related quality of determined based on GOHAI score is
life was determined using GOHAI.19 The 12- presented TABLE 2. Mean of GOHAI score
item questionnaire of GOHAI was developed for all subjects was 47.97 ± 9.03 with the
to assess three dimensions of OHRQoL range between 5 up to 60.
i.e. physical function, pain or discomfort
TABLE 2. Result of OHRQoL based on GOHAI
and psychosocial function. It consists of a measurement (n=118)
six point Likert scale from never, seldom,
Number of
sometimes, often, very often and always with subjects
GOHAI score Classification
the score ranging from 0 to 5. The final score n %
ranges from 0 to 60 whereby a higher score ≤50 Low 71 60.17
indicates a better OHRQoL. The classification 51 - 56 Moderate 25 21.19
of GOHAI score was high (57-60), moderate 57 - 60 High 22 18.64
(51-56) and low (≤50).

Agustina D et al., The correlation between occurrence of dental caries
and oral health-related quality of life on elderly population in Yogyakarta Special Region

Spearman’s rank correlation test showed percentage of older people performing regular
a negative moderate significant correlation oral hygiene.23
between the occurrence of dental caries and Aging is a natural and progressive process
OHROoL of elderly population in Yogyakarta capable of producing limitations and changes
Special Region (r = -0.265; p = 0.004). in the functioning of the body making the
individual more vulnerable and susceptible
to chronic diseases such as osteoarthritis,
osteoporosis or Parkinson’s disease.24
Majority of subjects (64.41%) had high Severity of osteoarthritis in the hands is
DMFT index (≥13.9) with the mean value of correlated with impaired functional ability
16.61 ± 7.16. This DMFT index was higher resulting in unable to maintain proper oral
than that in New Delhi’s elderly (13.8) that hygiene that leads to plaque accumulation
obtained from total of 452 participants.20 which increases the likehood of dental
Other DMFT index of New Delhi’s elderly that caries.25,26 Parkinson’s disease is characterized
obtained from 448 people aged ≥60 years was by dementia and loss of cognitive abilities
14.4.21 According to Indonesia Basic Health cause patients having difficulties to memorize
Research the prevalence of dental caries oral hygiene practice.27 In addition, in the
in Indonesia in 2013 increased up to 53.2% early stages patients may present the inability
compared to 43.4% in 2007. The two most to perform functions and their motor skills
increasing prevalence occurred in population that makes patients have difficulty to maintain
of more than 65 years (14.3%) and in children the oral health care.28
of 12 years (13.7%). Other commonly oral problem experienced
Oral and dental disease is the most disease byelderlyisxerostomia.Xerostomiaissubjective
suffered by people with the prevalence up to feeling of dry mouth either accompanied with
61%. Dental caries and periodontal (tooth hyposalivation (saliva secretion per minute
supporting tissue) disease were the two most <0.1 mL) or not.29 It is estimated that about
oral and dental diseases experienced by 30% of the population older than 65 suffer
Indonesian population.17 These diseases are from xerostomia.30 Medications and systemic
caused by dental plaque (biofilm) as a result disease are aggravating factors that contribute
of poor oral hygiene which leads to bacteria to xerostomia in the elderly.31 Xerostomia has
spreading across the tooth’s surface. Biofilm a variety of possible causes. In recent years,
accumulates in the oral cavity causes dental the most common cause of xerostomia is
caries and periodontitis.22 medications. Xerostomia has been associated
Only a few countries have national data with more than 500 medications. Xerostomia
on oral hygiene habits among older people. can be caused by many factors such as diseases,
Tooth brushing remains the most popular medications, complications of radiation-
oral hygiene practice worldwide. However, therapy or chemotherapy, dehydration,
according to the country reports this practice psychological conditions such as anxiety and
is less frequent in developing countries than in stress, complication of chronic graft-versus
developed countries. Meanwhile, traditional host disease (cGVHD), malnutrition and mouth
oral self-care by use of chew sticks or powder breathing.32,33 Xerostomia-associated diseases
is common in developing countries. Within could be Sjogren syndrome, sarcoidosis,
regions, substantial variation is reported in the diabetes mellitus, primary biliary cirrhosis,

J Med Sci, Volume 50, No. 2, 2018 April: 1-6

rheumatoid arthritis, stroke, Alzheimer’s, this condition was probably influenced also by
depression, and chronic anxiety. Some ageism concept that was believed by almost
medication that can cause xerogenic effects all elderly.37 In this concept, elderly believes
such as analgesics, antianxiety/ sedative/ that deterioration of oral condition was natural
hypnotics, anticonvulsants, antidepressants, process and occurs for all elderly, so it makes
antihypertensives, antihistamines, elderly having less effort to improve their oral
bronchodilators, diuretics, gastrointestinal condition.
drugs, antispasmodics, cytotoxic drugs, skeletal To assess OHRQoL in this study was
muscle relaxants.34-35 Patient with hyposalivation something so difficult since concept of quality
or xerostomia also are susceptible to oral of life is elusive and abstract. Quality of life
infection including candidiasis, dental caries, can be intuitively understood however, it
periodontal disease and tooth loss.36 Without is very difficult to be defined. Perception of
enough saliva, oral environment cannot be quality of life is influenced by many factors
maintained in optimal pH, so the mouth is such as socio-economic condition, level of
colonized rapidly with cariogenic bacteria and education, cultural, political, practical contexts
oral self-cleansing cannot be implemented that in where the quality of life is implemented
causes bad oral hygiene,32 in turn, someone will and measured. Talking about quality of life,
be more susceptible having dental caries. So, someone should think with multidimensional
the high prevalence of dental caries in this study and complex orientation since quality of
might be contributed as well by medications life does not have a clear border and is very
consumed and diseases experienced by the subjective. Quality of life assessment is full of
subjects. In this study 19 subjects consumed life values.38
antihypertensives, eight subjects consumed A negative moderate significant
analgesics/anti-inflammatory medications. correlation between the occurrence of dental
Six subjects consumed antihistamines and caries and OHRQoL of elderly population in
five subjects consumed gastrointestinal drugs. Yogyakarta Special Region was observed in
Besides that, it was detected that eight subjects this sudy. It indicates that an increase score
suffered from diabetes mellitus. Osteoarthritis, of DMFT index declines in the OHRQoL.
rheumatoid arthritis and stroke, each was also The negative moderate significant correlation
experienced by one subject. Another cause meant the more dental caries the more impact
of dental caries is poor oral hygiene since the on GOHAI score by decreasing the OHRQoL.
biofilm will more accumulated in oral cavity. Or it can be concluded that the higher score of
In this study, 51 of 118 subjects (43.22%) DMFT, the lower the OHRQoL of the elderly
had poor oral hygiene that made them prone population in Yogyakarta Special Region.
experiencing dental caries. Person with dental caries will have a
The majority of elderly (60.17%) had symptom of pain. The pain is getting severe
low OHRQoL that might be caused by poor along with the more progressive caries process.
oral health condition in this study (TABLE When the enamel and dentin are destroyed,
2). This findings supported the statements the cavity becomes more noticeable. Once
that deterioration of oral health and function the decay passes through enamel, the dentinal
go along with the increasing age of people.16 tubules, which have passages to the nerve of
From this result it seemed that the care towards the tooth, become exposed, resulting in pain
oral health was still low in elderly in which that can be transient, temporarily worsening

Agustina D et al., The correlation between occurrence of dental caries
and oral health-related quality of life on elderly population in Yogyakarta Special Region

with exposure to heat, cold, or sweet foods esteem caused by difficulties in speech and
and drinks. A tooth weakened by extensive mastication.39 All of those impacts of dental
internal decay can sometimes suddenly caries in turn affect OHRQoL negatively.
fracture under normal chewing forces. When This is the first study conducted in
the decay has progressed enough to allow the Yogyakarta Special Region to correlate the
bacteria to overwhelm the pulp tissue in the occurrence of dental caries and OHRQoL in
center of the tooth, a toothache can result and elderly population. The results of this study
the pain will become more constant. Death might be considered by Indonesian government
of the pulp tissue and infection are common especially in Yogyakarta Special Region to
consequences. The tooth will no longer be plan the better oral health management for
sensitive to hot or cold, but can be very tender elderly, in turn, it can increase OHRQoL.
to pressure. Dental caries can also cause bad To improve the oral health or to reduce the
breath and foul tastes. In highly progressed occurrence of dental caries in elderly requires
cases, an infection can spread from the tooth inter-professional collaboration of health
to the surrounding soft tissues.3 personnel since dental caries is a multi-
By understanding the chronological factorial disease modulated by many aspects
process of tooth decay, it was clear that of health and behavior not only oral ecology.
dental caries will cause pain and the pain will Finally, the limitations of our study
influence the GOHAI assessment. There was should be taken into consideration. The exact
three dimensions of OHRQoL i.e. physical mechanism of this relationship was not clarified
function, pain or discomfort and psychosocial in this study and it needs to be further explored
function that was assessed in GOHAI. If the in longitudinal studies. Since this study was
dental caries was still untreated, the dental a cross sectional, which was conducted on
pulp will be non vital, and then the infection modest sample size of 118 subjects, study with
will spread to the periodontal tissue causing larger sample sizes needs to be carried out in
of tender to pressure. The latter will result in the future to endorse the results observed in our
eating difficulty that was associated with the study. Future work with larger, more diverse
oral dysfunction. Dental caries becomes area populations and more complete information
of focal infection if still untreated. And it has would be essential to complete our findings.
to be extracted to prevent the spreading of the Furthermore, as the nature of the sample size
infection. Dental caries and periodontal disease used in this study, the result generalisability
is the two most oral disease that cause tooth might not be completely dependable.
loss. Tooth loss will impair mastication function
of oral tissue. Unrehabilitated tooth loss may
influence psychological condition of someone.
Psychosocial aspect includes a lower self In conclusion, there is a negative
esteem, restrictions to daily life and worrisome moderate significant correlation between the
towards oral problems. In the psychosocial occurrence of dental caries and OHRQoL
aspect, speech and eating difficulties can impair of elderly population in Yogyakarta Special
social interactions which may cause some Region. The higher score of DMFT index, the
patients to avoid social engagements where lower the OHRQoL of the elderly population
it affects the OHRQoL.30 Social interactions in Yogyakarta Special Region.
may also be affected due to a decreased self-

J Med Sci, Volume 50, No. 2, 2018 April: 1-6

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