Or i gi nal ar t i c l e

Prevalence of oral mucosal lesions in institutionalized elderly

people in Mashhad, Northeast Iran
Pegah M. Mozafari
1
, Zohreh Dalirsani
2
, Zahra Delavarian
1
, Maryam Amirchaghmaghi
1
,
Mohammad T. Shakeri
3
, Abdollah Esfandyari
4
and Farnaz Falaki
1
1
Oral and Maxillofacial Diseases Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran;
2
Dental
Research Center , Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran;
3
Department of Public Health and Community
Medicine, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran;
4
Private Dental Clinic, Kerman, Iran
Gerodontology 2011; doi: 10.1111/j.1741-2358.2011.00588.x
Prevalence of oral mucosal lesions in institutionalized elderly people in Mashhad, Northeast Iran
Objective: The aim of this study was to determine the prevalence of oral mucosal lesions in
institutionalized elderly people in Mashhad, northeast of Iran.
Background: This study was conducted to assess the prevalence of oral lesions in the institutionalized
elderly.
Methods: In this survey, we studied all of the nursing homes in Mashhad; a total of ve encompassing
237 residents. The subjects were examined and lesions recorded in a designed checklist. T-test, chi-square
and Fishers exact tests were used for the analysis.
Results: The mean age of the patients was 79.59 8.88. Ninety-eight per cent of cases had at least one
oral mucosal lesion. The most common lesions were ssured tongue (66.5%), atrophic glossitis (48.8%),
sublingual varicosity (42%) and xerostomia (38%). There was no signicant difference in the prevalence of
denture-related lesions (DRLs) between men and women (p > 0.05). Xerostomia was more prevalent in
7079-year-old than in 6069-year-old subjects. No case of oral malignant lesion was detected.
Discussion: These ndings revealed a higher prevalence of oral mucosal lesions in Mashhad city com-
pared with other studies conducted in other major cities in Iran and abroad. The results emphasise the
necessity of national programmes towards oral health promotion.
Keywords: elderly, institution, oral lesions, Mashhad, Iran.
Accepted 15 August 2011
Introduction
Perhaps the most important change in the distri-
bution of global population has been the growth in
the proportion of elderly people, especially in the
developed countries. In 1950, only 10% of the US
population was aged 65 years or older. It is esti-
mated that this value will reach 20% by the year
2030
1
. In Iran, only about ve million people are
over the age of 60 years (7.3%)
2
.
In Iran, traditionally most elderly have been
homebound, but recently by developing nursing
homes, some of this population is moving towards
being kept in institutions, especially in large
towns
2
.
National oral health data of homebound and
institutionalized elderly people are lacking, but
some investigations have reported the oral health
status of the elderly in different parts of Iran
36
.
In a survey in Kahrizak, Tehran (the capital of
Iran), 84% of geriatrics had at least one oral
lesion
6
. Recently, Rabiei et al.
5
reported a 86.1%
prevalence of oral mucosal lesions in Rasht city
(North of Iran).
There are no data on oral health in institu-
tionalized people in the northeast of Iran. As some
lesions are more prevalent in advanced age, this
study was conducted to assess the oral mucosal
conditions among institutionalized elderly people
over 60 years old in Mashhad, Iran [World Health
2011 The Gerodontology Society and John Wiley & Sons A/S 1
Organisation has classied people aged 60 years
and above as elderly in developing countries]
7
.
Methods
A descriptive analytic study was designed to
determine the frequency of oral mucosal lesions,
from October 2008 to March 2009. All ve nursing
homes either private or public in Mashhad were
enrolled in this survey, with a total 237 residents.
Inclusion criteria were as follows: elderly people
who aged 60 years or older, were cooperable, were
able to withstand a bed-side examination and had
complete medical records. During the study, the
subjects rights were protected and an informed
consent was obtained either from the study
participants or their relatives. Any uncooperative
patient during the study was excluded.
Among 237 elderly people, 202 persons (85.2%)
were eligible and agreed to participate in this study.
Oral mucosa examination was performed by one of
the two specialists in oral medicine (PMM or ZD),
which were calibrated in clinical diagnosis using
previously established diagnosis criteria
1,8
.
The subjects were examined using a portable
high-intensity light, a dental mirror and a tongue
blade. All parts of the oral cavity were examined.
Sometimes, sterile gauze was used to remove debris
from any white lesion to test whether or not it
could be wiped off. If any further diagnostic pro-
cedure (e.g. biopsy, radiography) was necessary,
the patient was referred to the Oral Medicine
Department of Mashhad Dental School. The teeth
were examined carefully. The type and length of
time of denture-wearing were also recorded. Pre-
vious or current consumption of tobacco and
alcohol was recorded. Duration of institutionalisa-
tion was recorded as well.
Demographic data (age, gender, name, educa-
tional level, etc.) and medical records were
recorded using the attendants les in the institute.
Statistical analysis was performed using SPSS 13.5
(SPSS Inc, Chicago, IL, USA). T-test, chi-square and
Fishers exact tests were used for comparative
analysis. p value of <0.5 was considered to indicate
statistical signicance.
Results
Two hundred and thirty-seven subjects (men= 53;
women= 184) underwent this survey. Thirty-ve
subjects were excluded because of severe dementia
and related uncooperativeness (34) and severe
disability
1
. The patients ranged from 60 to
105 years old and were categorized according to
three age groups: 6069; 7079; and 80 and older.
The mean age of the patients was 79.59 8.88
(women= 80.30 8.29; men=77.15 10.40).
Mean age was higher in females than males
(p = 0.033). Most institutionalized elderly patients
were aged 85 and older. Duration of institution-
alisation was from <189 months (mean =
39.8 months). No signicant relationship was
observed between duration of institutionalisation
and number of lesions (P > 0.05).
The most common systemic disorders were
dementia (38.6%), hypertension (29.7%) and
cardiovascular diseases (28.7%). Table 1 shows the
frequency of systemic diseases in this study. Most
subjects were in a middle socio-economic level
(89%). Other subjects were in high (6%) and low
(5%) socio-economic level. Most patients were in a
middle educational level (75%). Eleven per cent
(n = 23) were not educated at all. Others were in a
high level of education (14%). Because most
people were in a middle educational level and
socio-economic situation, no signicant difference
was found (P > 0.05).
Ninety-eight per cent of cases had at least one
oral mucosal lesion. The most common lesions
were ssured tongue (66.5%), atrophic glossitis
(48.8%), sublingual varicosity (42%) and xerosto-
mia (38%). Table 2 presents the prevalence of oral
mucosal disorders in the study participants,
according to age groups. Table 2 also shows the
different frequency of lesions in the three age
groups. Atrophic glossitis was signicantly lower in
6069 years old than other age groups (p = 0.03).
Xerostomia was signicantly higher in 7079-year-
old group than the 6069-year-old group
(p = 0.013). Candidiasis was signicantly higher in
80 years and older cases than other age groups
(p = 0.01).
Among all subjects, 97.8% of men had at least
one lesion compared with 98% of women
(p > 0.05). Xerostomia was signicantly higher in
women (p = 0.026). Traumatic ulcer, macroglossia,
Table 1 Prevalence of systemic diseases in study partic-
ipants.
Disease Number (percent)
Dementia 78 (38.6%)
Hypertension 60 (29.7%)
Cardiovascular disease
(other than Hypertension)
58 (28.7%)
Diabetes mellitus 50 (24.7%)
CVA 30 (14.8%)
Other diseases 21 (10.3%)
2011 The Gerodontology Society and John Wiley & Sons A/S
2 P. M. Mozafari et al.
papillary palatal hyperplasia, recurrent herpes
labialis and angular cheilitis were found exclusively
in women.
One hundred and nineteen cases were denture
wearers (M = 26/47 (55.3%); F = 93/155 (60%)),
and 109 persons of this group had at least one
denture-related lesion (DRL) (Table 3). There was
no signicant difference in prevalence of DRLs
between men and women (p > 0.05). Denture
stomatitis was signicantly higher than other DRLs
(p = 0.001). Of 83 non-denture wearers, 20 were
dentate, having an average of four teeth, while 63
cases were edentulous. Duration of denture-wear-
ing was from ve to 34 years (mean = 19.7 years).
Some subjects did not remember the exact duration
of denture-wearing (n = 28). There was a direct
relationship between duration of denture-wearing
and number of DRLs and oral mucosal lesions
(p = 0.04). Other uncommon lesions are listed in
Table 4. No case of oral leukoplakia or oral squa-
mous cell carcinoma was detected.
Nine patients were referred to Oral Medicine
Department to establish clinical diagnosis of their
lesions, and the diagnosis of broma, neuro-
bromatosis, mucocele and oral lichen planus were
conrmed by histopathologic examination. In this
survey, only four cases had no oral lesions. One
case had 10 oral lesions. Most cases had four oral
lesions (mode = 4 lesions).
Alcohol and tobacco habits are listed in Table 5,
but because of the small sample size, no analysis
could be performed.
Discussion
In this study, the prevalence of oral mucosal lesions
was higher compared with previous studies in
other regions of Iran (86.1%, 84%)
5,6
and abroad
such as Venezuela, Turkey, Malaysia, Brazil and
China
912
. Cultural differences, oral habits, educa-
tional level and even genetic difference can be
responsible for this difference.
Because of the cultural beliefs towards respecting
older people, in Iran, most elderly are kept at home
with their relatives and only extremely disabled or
Table 2 Prevalence of oral lesions in the three age groups.
6069 7079 80105
1 Fissured tongue 72.4% Fissured tongue 61.5% Fissured tongue 65.7%
2 Varicosity 37.9% Atrophic glossitis 49.2% Atrophic glossitis 49%
3 Atrophic glossitis 27.5% Xerostomia 44.6% Varicosity 43.5%
4 Gingival recession 24.1% Varicosity 40% Candidiasis 38.8%
5 Xerostomia 20.6% Alveolar ridge recession 27.6% Xerostomia 37%
6 Epulis ssuratum 20.6% Candidiasis 26.1% Alveolar ridge recession 26.8%
7 Candidiasis 17.2% Physiologic pigmentation 23% Epulis ssuratum 21.2%
8 Varix 17.2% Fordyce Granule 21.5% Varix 19.4%
9 Alveolar ridge recession 17.2% Periodontitis 18.4% Physiologic pigmentation 14.8%
10 Fordyce granule 10.3 Varix 16.9% Fordyce Granule 12%
Table 3 Prevalence of denture related lesions (DRLs) in
the study participants.
DRLs Number (%)
Denture stomatitis 65 (54.6%)
Epulis ssuratum 36 (30.2%)
Papillary hyperplasia 5 (4.2%)
Angular cheilitis 3 (2.5%)
None 10 (8.4%)
Total 119 (100%)
Table 4 Prevalence of uncommon lesions in the study
participants.
Uncommon oral lesions Number (%)
Traumatic ulcer 11 (5.4%)
Frictional keratosis 6 (2.9%)
Fibroma 5 (2.4%)
Oral melanotic macule 5 (2.4%)
Toros palatinus 5 (2.4%)
Macroglossia 5 (2.4%)
Echymosis 4 (1.9%)
Gingival recession 4 (1.9%)
Leukoedema 3 (1.4%)
Clicking 3 (1.4%)
Smokers melanosis 2 (0.9%)
Oral lichen planus 2 (0.9%)
Recurrent herpes labialis 2 (0.9%)
Geographic tongue 2 (0.9%)
Neurobromatosis 1 (0.4%)
Recurrent aphthous stomatitis 1 (0.4%)
Mucocele 1 (0.4%)
2011 The Gerodontology Society and John Wiley & Sons A/S
Oral lesions in Iranian elderly people 3
very old persons are passed to institutes. In our
study, most cases were over 80 years old which
could be a reason for a higher prevalence of oral
lesions. The results show the most prevalent oral
lesions being ssured tongue (66.5%) followed by
atrophic glossitis (46.8%) and sublingual varicosity
(42%), which contradicts other studies in Iran. For
example, Rabie reported dry mouth as the most
frequent oral lesion (42.1%)
5
followed by ssured
tongue (29.9%), atrophic glossitis (25.9%) and
sublingual varicosity (22.7%), respectively
5
. Dry
mouth is a subjective complaint, and careful
attention and accepted criteria must be employed
when reporting of this disorder is considered.
Another study in Tehran city reported varicosity
(44.7%), denture stomatitis (18.2%), varix
(17.8%) and papillary hyperplasia of palate
(15.3%) as the most common oral lesions
6
. In an
another survey among private and governmental
institutes of Tehran, ssured tongue (50.7%),
candidiasis (18.4%) and atrophic glossitis (17.5%)
were most prevalent lesions
4
.
Generally, the prevalence of oral lesions is higher
than other studies in Iran; for example, ssured
tongue is about twofold higher in our region.
(66.5% vs. 25.9%, 50.7%, 2.9%)
36
. It can be due
to a nutritional deciency or allergy which is
more common in northeast of Iran
13
. In our study,
there was no gender difference in the overall
prevalence of oral lesions, similar to Corbets
11
ndings. Van wyk, Lin and Motaleb Nejad reported
a male predominance for some oral lesions
6,14,15
,
but in Mosquedas
16
research women had more
oral lesions. In our survey, xerostomia was more
prevalent in women (p = 0.013) and some lesions
(traumatic ulcer, macroglossia, papillary palatal
hyperplasia, recurrent herpes labialis and angular
cheilitis) were found exclusively in women. This
could be due to larger sample size of women versus
men (184 vs. 53). Motaleb Nejad found that men
had more varicositis and women had more denture
stomatitis, papillary hyperplasia, epulis ssuratum
and traumatic ulcer
6
.
Dementia was the most prevalent systemic disease
followed by hypertension and cardiovascular dis-
eases, while in other similar studies cardiovascular
diseases and hypertension were the most frequent
systemic diseases. The higher frequency of dementia
could be explained by the fact that most people keep
their elderly relatives at home unless they have some
kind of severe disabilities (e.g. denemsia, cere-
brovascular accident) or when they are very old (80
andolder), therefore a higher frequency of dementia
is anticipated. No correlationwas found betweenthe
kind of systemic diseases and the frequency of oral
lesions.
Most denture wearers (91.5%) had at least one
DRL. Denture stomatitis and epulis ssuratum were
the most frequent DRLs. Other researchers reported
a frequency of 1833% for DRLs
6,9,1719
. A higher
prevalence of DRLs can be due to old unstable
dentures, poor oral health status and lack of regular
oral examinations
6,11
. The result revealed that there
was a direct relationship between duration of den-
ture-wearing and number of DRLs and oral mucosal
lesions. In our study, 79.7% of subjects had more
than two lesions where other reports showed less
number of oral lesions
911
.
Although the number of oral mucosal lesions can
be related to age, gender, education, socio-economic
status, smoking, dentures and systemic diseases
9,16
,
in our study, educational level, socio-economic sta-
tus and duration of institutionalisation had no im-
pact on frequency of oral lesions. This study has as-
sessed some possible risk factors for oral lesions such
as smoking and alcohol habits, but no analysis could
be performed because of the small size.
Conclusions
Expansion of the elderly population is the most
important change in the global population. A high
frequency of some lesions in this population
necessitates national programmes towards oral
health promotion that has been neglected in the
Iranian population. Therefore, regular oral exami-
nation by dentists and oral medicine specialists
must be part of geriatric medicine services.
Acknowledgement
The authors would like to extend their appreciation
to the vice chancellor for the research, MUMS
(Mashhad University of Medical Sciences), for the
nancial support. The results described in this paper
were part of a (D.D.S) students thesis proposal.
References
1. Ship J. Oral health in geriatric patients. Hamilton: BC
Decker Inc, 2006.
Table 5 Prevalence of alcohol and tobacco habits in the
study participants.
Previous Current Total
Tobacco 11 4 15
Qelyan 9 9
Alcohol 2 2
2011 The Gerodontology Society and John Wiley & Sons A/S
4 P. M. Mozafari et al.
2. Mirzaei M, Shams Ghahfarokhi M. Demography
of elderlies in Iran according to national statistics
between 1976 to 2006. Salmand 2007; 2: 326331.
3. Ebrahimi Mamaghani M, Vaziri Y, Mahdavi R.
Dental Health and Its Relation to Macronutrient In-
take and Anthropometric Indices in Khuban Pri-
vate Nursing Home. Res Tabriz Med J Tabriz Univ Med
Sci 2007; 29: 21.
4. Maleki Z, Ghaem Maghami A, Lesan S. Compar-
ison of soft tissue lesions (OSTLS) prevalence in
elderly institutionalized population who are resident
in private and govermental institutes In Tehran Iran.
J Dent Sch 2006; 4: 663669.
5. Rabiei KE, Masoudi rad H, Shakiba M, Pourkay
H. Prevalence of oral and dental disorders in institu-
tionalized elderly people in Rasht, Iran. Gerodontology
2010; 27: 174177.
6. Motalebnezhad M, Shirvani M. Oral mucosal
lesions in elderly poulation (Tehran Kahrizak geriatric
institute; 2000). J Babol Uni Med Sci 2002; 4: 2833.
7. Corre a L, Frigerio M, Sousa S, Novelli M. Oral
lesions in elderly population: a biopsy survey using
2250 histopathological records. Gerodontology 2006;
23: 4854.
8. Greenberg MS, Glick M. Burkets oral medicine.
Diagnostic and treatment. Spain: BC decker Inc, 2003:
605619.
9. Mujica V, Rivera H, Carrero M. Prevalence of oral
soft tissue lesions in an elderly venezuelan popula-
tion. Medicina Oral 2008; 13: 270.
10. Junior J, Almeida O, Bozzo L, Scully C, Graner
E. Oral mucosal health and disease in institutional-
ized elderly in Brazil. Commun Dent Oral Epidemiol
1991; 19: 173175.
11. Corbet E, Holmgren C, Philipsen H. Oral mucosal
lesions in 6574 year old Hong Kong Chinese. Com-
mun Dent Oral Epidemiol 1994; 22: 392395.
12. Avcu N, Ozbek M, Kurtoglu D, Kurtoglu E,
Kansu O, Kansu H. Oral ndings and health status
among hospitalized patients with physical disabilities,
aged 60 or above. Arch Gerontol Geriatr 2005; 41: 69
79.
13. Varasteh A, Fereidouni M, Shakeri M et al.
Prevalence of allergic disorders among the population
in the city of Mashhad, Northeast Iran. J Pub Health
2009; 17: 107112.
14. Lin HC, Corbet EF, Lo ECM. Oral mucosal lesions
in adult Chinese. J Dent Res 2001; 80: 14861490.
15. Van Wyk CW, Farman AG, Staz J. Oral health
status of institutionalized elderly Cape Coloreds from
the Cape Peninsula of South Africa. Commun Dent Oral
Epidemiol 1977; 5: 179184.
16. Mosqueda ADM, Velasquez M, Irigoyen M,
Caballero S, Side E. Prevalencia de alteraciones de
la mucosa bucal en el adulto mayor. Estudio en dos
grupos del sur de la ciudad de Mexico. Temas Selectos
de Investigacion clinica 1998; 43950.
17. Kuc I, Samaranayake L, Van Heyst E. Oral health
and microora in an institutionalized elderly popu-
lation in Canada. Int Dent J 1999; 49: 33.
18. Avcu N, Kanli A. The prevalence of tongue lesions
in 5150 Turkish dental outpatients. Oral Dis 2003; 9:
188195.
19. Reichart P. Oral mucosal lesions in a representative
cross-sectional study of aging Germans. Commun Dent
Oral Epidemiol 2000; 28: 390398.
Correspondence to:
Dr. Zohreh Dalirsani, Oral and maxillofacial
diseases research center, Faculty of Dentistry,
Mashhad University of Medical Sciences, Vakilabad
Blvd, 91735 Mashhad, Iran.
Tel.: +989155002857
Fax: +985118829500
E-mail: zdalirsani@gmail.com
2011 The Gerodontology Society and John Wiley & Sons A/S
Oral lesions in Iranian elderly people 5