Journal of Clinical Gerontology & Geriatrics 5 (2014) 91e95

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Journal of Clinical Gerontology & Geriatrics

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Original article

Relationship between oral health and nutritional status in the elderly:

A pilot study in Lebanon

lou, MSc Human Nutrition a, *, Christa Boulos, MD a, Salim M. Adib, MD, PhD b,
Myrna El He
Nabil Tabbal, MPH c
a
Saint Joseph University Campus of Medical Sciences, Beirut, Lebanon
b
World Health Organization, East Mediterranean Regional Office, Cairo, Egypt
c
INSERM U897, Universit
e Victor Segalen, ISPED, Bordeaux, France

a r t i c l e i n f o a b s t r a c t

Article history: Background/objective: Oral health is an integral part of the general health and well-being of the elderly.
Received 8 October 2013 Compromised oral health can have a negative impact on food intake that leads to a deterioration in
Received in revised form nutritional status. This study aimed to explore, for the first time in Lebanon, the relationship between
23 February 2014
oral health and nutritional status in a population of elderly patients newly admitted to a hospital.
Accepted 6 April 2014
Available online 21 June 2014
Methods: A comprehensive survey was administered to 115 persons aged 70 years and older. They were
admitted during 3 consecutive months to various wards of the Rafic Hariri University Hospital (RHUH;
Beirut, Lebanon), which is the largest public hospital in Lebanon. Medical, socioeconomic, anthropo-
Keywords:
elderly
metric, and dietary data were collected. Nutritional status was assessed by the Mini-Nutritional
Geriatric Oral Health Assessment Index Assessment (MNA) and oral health was assessed by the Geriatric Oral Health Assessment Index
Lebanon (GOHAI), a tool that evaluates an individual's self-perception of oral health status. This was followed by
malnutrition an examination of the oral cavity to count the remaining teeth, to record the presence and status of
Mini-Nutritional Assessment dentures, and to assess xerostomia.
oral health Results: The prevalence of undernutrition was 6.1%, with the additional risk of malnutrition observed in
37.4%. More than 50% of individuals in need of dental care (i.e., a GOHAI score > 14) were at risk of
nutritional deficits. A negative self-perception of oral status was significantly associated with a risk of
nutritional deficit, but the risk disappeared after adjusting for socioeconomic factors, neurosensory
disorders, and chronic diseases.
Conclusion: Our results strongly demonstrate the importance of oral care within the elderly Lebanese
population to reduce the risk of malnutrition and improve oral health-related quality of life.
Copyright © 2014, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan
LLC. Open access under CC BY-NC-ND license.

1. Introduction coming decades. At the same time, nutrition, and more specifically
undernutrition, has become a real concern in the aging population.
The aging of the world's population seems inevitable and is In fact, the prevalence of protein-energy malnutrition (PEM) is
correlated with the decline in fertility rates and longer life expec- becoming alarmingly high in hospital and institutional settings. The
tancy. At the beginning of the 21st century, people aged 60 years adverse outcomes of PEM on general health, quality of life,
and older numbered approximately 600 million around the globe. morbidity, and mortality are now well established.2 Several risk
This is three times as many people as there were 50 years ago. By factors for malnutrition in the elderly have been identified such as
2050, elderly people are expected to represent 20% of the world's age-related changes, high prevalence of chronic diseases, poly-
population, and will be more numerous than the population pharmacy, psychological and social conditions, institutionalization,
younger than 14 years old.1 This global trend in population aging is and poor oral health.3
emerging as the major economic, political, and social issue of the There is much interest in the oral health problems of the elderly
and its influence on nutrition. Poor oral health has a negative
* Corresponding author. Saint Joseph University Campus of Medical Sciences,
impact on dietary intake and nutritional status when the capacity
Damascus Street, B.P. 11-5076, Riad El Solh, Beirut 1107 2180, Lebanon. to chew and eat is diminished.4 In the elderly population, food
E-mail address: [email protected] (M. El He
lou). selection is limited in people with edentulism, the lack of or

http://dx.doi.org/10.1016/j.jcgg.2014.04.002
2210-8335/Copyright © 2014, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. Open access under CC BY-NC-ND license.
92 M. El H
elou et al. / Journal of Clinical Gerontology & Geriatrics 5 (2014) 91e95

inadequate prosthetic rehabilitation, dental caries, periodontal drinks and foods, and feeding mode. The total score obtained
diseases, and xerostomia.5 Patients who report the presence of oral allowed participants to be categorized into three groups: (1) pa-
disorders are at high risk of malnutrition. This underlines the tients with good nutritional status (i.e., the MNA score > 23.5), (2)
importance of measuring a patient's self-perception of problems patients at risk of malnutrition (i.e., the MNA score 17e23.5), and
related to the oral cavity and performing a clinical examination.6 (3) undernourished patients (i.e., a MNA score < 17).
In Lebanon, problems related to oral health in the elderly are A concomitant inspection of the oral cavity identified the
poorly understood. This pilot study aims to explore the relationship following: the number of natural remaining teeth (
20 teeth, <20
between oral health and nutritional status in a population of Leb- teeth, or complete edentulism); the wear, type, and status of den-
anese noninstitutionalized elderly patients who were newly tures (i.e., well-fitting or poorly fitting); the presence of dental pain
admitted to hospital for acute medical conditions. when chewing; and the presence of xerostomia.9 Visual inspection
of the oral cavity was followed by the administration of the Arabic
2. Methods version of the GOHAI.10 This 12-item questionnaire measures the
patient's self-perception of oral health problems and the need for
2.1. Design and setting dental care in three dimensions: (1) oral function, (2) pain and
discomfort in the oral cavity, and (3) psychosocial aspects of oral
This cross-sectional study was conducted for 3 consecutive problems. For each item, patients are questioned about the fre-
months and designed to include all eligible persons aged 70 years quency of their experience in the previous 3 months and answered
and older who requested admission to the various wards of Rafic on a 5-level scale: “never”, “rarely”, “sometimes”, “often”, and
Hariri University Hospital (RHUH), which is the largest Lebanese “always”; the answers were coded from 1 to 5, respectively. The
public hospital (544 beds) that is located on the outskirts of total summative score ranges from a minimum of 12 points to a
southern Beirut. Most RHUH patients have a low socioeconomic maximum of 60 points, with a higher score indicating compro-
status with practically no medical coverage. Prior to the study, the mised oral health. Individuals with GOHAI scores >14 were
agreement of the hospital's Medical Research and Ethics Committee considered in need of dental care.11 The Arabic version of GOHAI
was obtained. used in this study is a version previously tested for validity and
reliability in Saudi Arabia.10
2.2. Inclusion and exclusion criteria
2.4. Statistical analysis
To be eligible for the study, patients had to meet the following
inclusion criteria: Lebanese individuals who were 70 years or older Data were collected and analyzed using SPSS version 13.0 for
who did not have a hypercatabolic state (i.e., not on dialysis, no Windows (SPSS Inc., Chicago, IL, USA). Bivariate analyses were used
end-stage kidney disease, not admitted to the intensive care unit, to measure the association of nutritional status (i.e., the dependent
noncancerous), were physically capable of undergoing examination variable) with socioeconomic variables, feeding characteristics, and
(i.e., they did not have significant skin lesions, amputation, or lower oral status. The Chi-square test was used to test the association for
limb edema), had no problems with malabsorption, were not categorical variables, whereas the t test was used for two inde-
receiving artificial feeding, and were able to communicate. Eligible pendent quantitative variables. A p of 0.05 indicated statistical
patients were required to provide a signed voluntary informed significance. A multiple logistic regression model was constructed
consent form prior to being included. Consenting patients were to evaluate the relationship between nutritional status and oral
visited after admission. Their cognitive status was assessed using health while taking into account the confounding variables of so-
the Mini-Mental State Examination (MMSE) in its validated Arabic cioeconomic factors, neurosensory disorders, and chronic diseases
version, which was adapted from the original version.7 Only pa- (p  0.05). The adjusted odds ratio (OR) was calculated to measure
tients with a MMSE score of
24, which indicated an acceptable the strength of the association between different variables and the
cognitive status, remained in the study population. dependent variable (adjustments were performed for age, sex,
educational level, and pre-existing chronic diseases).
2.3. Data collection
3. Results
Socioeconomic data (i.e., age, sex, living conditions, level of
education), medical data, and dietary information (e.g., ability to The present study included 115 elderly patients who were aged
shop and prepare food, meal consumption, and avoidance of certain 70 years or older with a mean age of 76.2 ± 5.6 years. In this sample,
solid foods) of the individuals were collected using a general 48.7% of patients were illiterate and 33.9% of patients had achieved
questionnaire that controlled for possible confounding factors [e.g., an elementary level of education (Table 1). For dietary conditions,
socioeconomic factors, neurosensory disorders diagnosed by a 23.5% of patients were unable to shop and 25% of patients were
medical doctor, and chronic diseases such as cardiac failure, res- unable to prepare their meals. Furthermore, 49.6% of the study
piratory failure, diabetes, rheumatoid arthritis (listed in the pa- population avoided certain solid food items (e.g., steak, lettuce,
tient's medical file)]. Weight (measured by a calibrated mechanical carrot, radish, apple, and nuts). For general health status, 35.7% of
scale) and height were assessed to calculate the body mass index patients had at least three chronic diseases (e.g., hypertension,
(BMI). Anthropometric measurements were complemented by the diabetes, osteoporosis) and approximately one-half (54.8%) of the
circumferences of the arm and calf. The nutritional status of elderly patients took more than three drugs daily (Table 1). The nutritional
individuals was assessed using the Mini-Nutritional Assessment assessment on hospital admission detected an undernutrition
(MNA) questionnaire in its complete validated form.8 It was prevalence of 6% and a 37.4% risk of malnutrition with a mean MNA
administered in two steps: the first step detects a decline in food score of 23.6 ± 4. For oral health status, 69.6% of the population had
intake, weight loss, loss of mobility, acute disease or stress, neu- complete edentulism; of these only 9% of patients were not wearing
ropsychological problems, and a decrease in BMI in the previous 3 a dental prosthesis. Only 5.2% of patients retained
20 their natural
months. The second step assesses the living conditions, the pres- teeth. Among elderly patients wearing a dental prosthesis, 25% of
ence of polypharmacy, the presence of pressure ulcers, the number patients complained of ill-fitting dentures. In addition, 69.6% of
of full meals ingested daily, the number and frequency of intake of patients complained of xerostomia. The mean GOHAI score was
 M. El H
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Table 1
Characteristics of 115 elderly study participants by nutritional status.

n (%) Good nutritional status Nutritional deficit p

(N ¼ 65) (N ¼ 50)

n (%) n (%)

Mean age (SD;y) 76.2 (5.6) 75.7 (4.8) 77.0 (6.4) 0.214
70 10 (8.7) 6 (60.0) 4 (40.0) 0.737
71e75 52 (45.2) 32 (61.5) 20 (38.5)
76e80 31 (27.0) 16 (51.6) 15 (48.4)
>80 22 (19.1) 11 (50.0) 11 (50.0)
Sex
Female 59 (51.3) 35 (59.3) 24 (40.7) 0.534
Male 56 (48.7) 30 (53.6) 26 (46.4)
Living conditions
With spouse 64 (55.6) 37 (57.8) 27 (42.2) 0.754
Without spouse 51 (44.4) 28 (54.9) 23 (45.1)
Level of education
Illiterate 56 (48.7) 24 (42.9) 32 (57.1) 0.014a
Elementary 39 (33.9) 28 (71.8) 11 (28.2)
Secondary or more 20 (17.4) 13 (65.0) 7 (35.0)
Number of pre-existing chronic diseases
0 11 (9.5) 7 (63.6) 4 (36.4) 0.117
1 26 (22.6) 17 (65.4) 9 (34.6)
2 37 (32.2) 24 (64.9) 13 (35.1)

3 41 (35.7) 24 (58.5) 17 (41.5)
Use of more than three drugs/d
Yes 63 (54.8) 27 (42.9) 36 (57.1) 0.001a
No 52 (45.2) 38 (73.1) 14 (26.9)
Physical ability to shop
Yes 70 (60.9) 54 (77.1) 16 (22.9) <0.001a
Sometimes 18 (15.6) 4 (22.2) 14 (77.8)
No 27 (23.5) 7 (25.9) 20 (74.1)
Physical ability to prepare meals
Yes 40 (55.6) 32 (80.0) 8 (20.0) <0.001a
Sometimes 14 (19.4) 5 (35.7) 9 (64.3)
No 18 (25.0) 5 (27.8) 13 (72.2)
Meal consumption
Always/mostly alone 45 (39.1) 27 (60.0) 18 (40.0) 0.546
Always/mostly with family or in institution 70 (60.9) 38 (54.3) 32 (45.7)
Avoidance of certain solid foods
Yes 57 (49.6) 25 (43.9) 32 (56.1) 0.007a
No 58 (50.4) 40 (69.0) 18 (31.0)
Number of remaining natural teeth

20 6 (5.2) 4 (66.7) 2 (33.3) 0.828
<20 29 (25.2) 17 (58.9) 12 (41.1)
Totally edentulous 80 (69.6) 44 (55.0) 36 (45.0)
Edentulism
Yes 80 (69.6) 44 (55.0) 36 (45.0) 0.619
No 35 (30.4) 21 (60.0) 14 (40.0)
Wears dental prosthesis (partial or total)
Yes, well-fitting 65 (59.6) 41 (63.1) 24 (36.9) 0.129
Yes, ill-fitting 21 (19.2) 11 (52.4) 10 (47.6)
No 23 (21.1) 9 (39.1) 14 (60.9)
Xerostomia
Yes 86 (74.8) 52 (60.5) 34 (39.5) 0.929
No 29 (25.2) 13 (44.8) 16 (55.2)
Mean GOHAI score (SD) 18 (7.1) 16.9 (7.2) 19.3 (6.9) 0.075
GOHAI (categorized)
Need dental care 64 (55.6) 30 (46.9) 34 (53.1) 0.019a
No need for dental care 51 (44.4) 35 (68.6) 16 (31.4)
GOHAI (quartiles)
1st 45 (39.1) 31 (68.9) 14 (31.1) 0.048a
2nd 17 (14.8) 11 (64.7) 6 (35.3)
3rd 26 (22.6) 13 (50.0) 13 (50.0)
4th 27 (23.5) 10 (37.0) 17 (63.0)

GOHAI ¼ Geriatric Oral Health Assessment Index; SD ¼ standard deviation.

a
Items in bold font indicate statistical significance (p < 0.05).

18 ± 7.1. More than one-half (55.6%) of the participants needed who were more malnourished were those who lacked the ability to
dental care (i.e., their GOHAI score was <14; Table 1). shop or to prepare meals. The exclusion of certain foods was also
Because of the low prevalence of malnutrition, “malnutrition” significantly associated with nutritional deficit. By contrast, a
and “risk of malnutrition” were summed together as one category higher level of education seemed to have a protective effect with
referred to as “nutritional deficit” in the rest of the analysis. A regard to nutritional status. There were no associations between
significant association was observed between the risk of nutritional nutritional deficit and age, sex, living, and food conditions, and the
deficit and the use of more than three drugs daily. Elderly patients number of chronic diseases (Table 1).
94 M. El H
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Table 2
Logistic regression of the nutritional status of 115 elderly study participants.

n Good nutritional Nutritional deficit Adjusted OR (95% CI)a

status (N ¼ 65) (N ¼ 50)

% %

Mean age (SD;y) 115 75.7 (4.8) 77.0 (6.4) 1.03 (0.95e1.12)
Sex
Female 59 (51.3) 35 (59.3) 24 (40.7) 1
Male 56 (48.7) 30 (53.6) 26 (46.4) 2.01 (0.79e5.12)
Level of education
Illiterate 56 (48.7) 24 (42.9) 32 (57.1) 1
Elementary 39 (33.9) 28 (71.8) 11 (28.2) 0.26 (0.09e0.70)
Secondary or more 20 (17.4) 13 (65.0) 7 (35.0) 0.63 (0.15e2.71)
Edentulism
Yes 80 (69.6) 44 (55.0) 36 (45.0) 2.57 (0.71e9.33)
No 35 (30.4) 21 (60.0) 14 (40.0) 1
Wears dental prosthesis (partial or total)
Yes, well-fitting 65 (59.6) 41 (63.1) 24 (36.9) 1
Yes, ill-fitting 21 (19.2) 11 (52.4) 10 (47.6) 1.01 (0.30e3.33)
No 23 (21.1) 9 (39.1) 14 (60.9) 2.66 (1.00e7.06)
Xerostomia
Yes 86 (74.7) 52 (60.5) 34 (39.5) 0.82 (0.30e2.25)
No 29 (30.4) 13 (44.8) 16 (55.2) 1
GOHAI (quartiles)
1st 45 (39.1) 31 (68.9) 14 (31.1) 1
2nd 17 (14.8) 11 (64.7) 6 (35.3) 0.85 (0.20e3.61)
3rd 26 (22.6) 13 (50.0) 13 (50.0) 2.22 (0.68e7.26)
th
4 27 (23.5) 10 (37.0) 17 (63.0) 2.84 (0.79e10.24)
Number of pre-existing chronic diseases
0 11 (9.5) 7 (63.6) 4 (36.4) 1
1 26 (22.6) 17 (65.4) 9 (34.6) 1.09 (0.17e7.16)
2 37 (32.2) 24 (64.9) 13 (35.1) 1.16 (0.19e7.29)

3 41 (35.7) 24 (58.5) 17 (41.5) 3.12 (0.49e20.06)

GOHAI ¼ Geriatric Oral Health Assessment Index.

a
The items in bold font indicate statistical significance (p < 0.05).

With regard to oral health status, Table 1 shows a higher mean Approximately 70% of the sample had complete edentulism.
GOHAI score in patients with nutritional deficit, compared to pa- This prevalence is significantly higher than the 20% reported in
tients with good nutritional status. The difference was marginally 2003 by the World Health Organization (WHO) in Lebanese elderly
significant (p ¼ 0.075). The risk of nutritional deficit was signifi- individuals aged between 65 years and 75 years.13 This report did
cantly higher in patients who needed dental care (i.e., a GOHAI not present the methodology used by WHO, which limits the ability
score > 14): >50% of elderly patients requiring dental care were at to compare results. However, it is notable that our study population
risk of nutritional deficit (p ¼ 0.019). A significant association was was older (mean age of 76 years), was hospitalized, and came from
also observed after categorizing the GOHAI score into quartiles. The more disadvantaged backgrounds.
fourth quartile, which indicated a negative perception of oral In our population, 21% of the elderly patients who needed a
health, had a higher risk of nutritional deficit, compared to the first dental prosthesis (partial or total) did not wear any; whereas 25% of
quartile (p ¼ 0.048). This association was not significant after patients of those wearing dentures complained of its poor fit. This
adjusting for confounding variables (adjusted OR, 2.84; 95% confi- could be explained partly by the lack of interest in oral health by the
dence interval, 0.79e10.24; Table 2). In our study, the number of elderly and their companions, and partly by difficulties encoun-
remaining teeth, tooth loss, and the presence and status of dental tered in paying for dental care.
prosthesis and xerostomia were not associated with the risk of A prevalence of 6.1% and 37.4% for malnutrition and the risk of
nutritional deficit. malnutrition respectively, were observed within the population.
These results differ from those published by Guigoz14 in 2006 in a
4. Discussion systematic review of studies that included 30,000 elderly patients
from different countries worldwide, especially in Europe and the
This pilot study is the first of its kind in Lebanon to explore the United States, in which the proportion of malnutrition and risk of
relationship between oral health and nutritional status in elderly malnutrition were 23% and 46%, respectively, in hospitalized
patients. The strength of this study was affected by the small elderly individuals. This lower prevalence could be explained by the
sample size assembled during the study period, which is affected diversity and the high nutritional density of the basic Lebanese diet
by the actual low proportion (<3%) of elderly in Lebanon.12 Patients which includes more nutritious foods with semisolid or liquid
admitted to governmental hospitals in Lebanon are individuals textures, compared to the mostly “meat-based” diet in European
with rather low economic resources, and therefore are not repre- countries. The discrepancy in results could also be explained by a
sentative of the elderly population in Lebanon. The general health difference in the patients' dependency level, health status, and
status of the recruited patients may have contributed to an over- especially by the exclusion of patients with cognitive impairment.
estimation of their oral health problems. However, the patients The bivariate analysis revealed that lack of education, use of
were neither institutionalized nor bedridden, and presented to the more than three drugs daily, physical inability to shop and prepare
hospital for acute conditions, which would limit an additional se- meals, and the exclusion of certain solid foods from the diet are
lection bias. This study is nevertheless a pilot study designed to significantly associated with a nutritional deficit. These results are
establish an appropriate protocol for a national survey. consistent with the results reported in the literature.15,16 With
 M. El H
elou et al. / Journal of Clinical Gerontology & Geriatrics 5 (2014) 91e95 95

regard to the association between oral health and nutritional status, Acknowledgments
>50% of patients needed dental care. The need for dental care was
associated with the risk of nutritional deficit. Similar results were The authors express their gratitude to Rafic Hariri University
observed elsewhere in which the GOHAI, which is a categorical Hospital (Beirut, Lebanon), and especially to its dietary department,
variable (i.e., the need or lack of need for dental care), showed a for facilitating the recruitment of the sampling unit within the
significant association with the MNA results.6 In addition, when the hospital setting.
GOHAI was categorized into quartiles, it showed a significant as-
sociation with the risk of nutritional deficit. The nutritional deficit References
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