Abstract
This study aimed to determine the prevalence of oral mucosal lesions and risk factors among the institutionalized elderly Lebanese population. A representative sample of 526 individuals (49% males and 61% females) aged 65 years and above was examined. A questionnaire and clinical examination were administered. Bivariate and multivariate regressions were carried out. The frequency of oral mucosal lesions was 22.8% and it was associated to the use, integrity (p < .002), and hygiene level (p < .047) of removable mandibular and maxillary prosthesis. Multiple regression analysis also predicted the relationship between the mandibular prosthesis hygiene level and the occurrence of mucosal lesions. The factors controlling the occurrence of oral mucosal lesion were mainly related to the level of oral care given to the individuals. Therefore, a proper oral health care system should be implemented in the Lebanese residential homes to ensure the well-being of the residing population.
Keywords: denture hygiene, elderly, institutionalized population, oral mucosal lesion
Introduction
The aged population has been increasing in number worldwide (United Nations, 2015). The same trend is observed in Lebanon, where the elderly population has increased from 4.9% in 1970 to 10% in 2007 (El Osta et al., 2015).
Chronic diseases, physical and mental disabilities, and other comorbidities are highly prevalent in the elderly population (Atramont et al., 2017). In this context, the oral health of this population has steered a lot of attention in dentistry (Miyazaki et al., 2017). More specifically, the oral mucosal health is essential for the well-being of the elderly as a poor oral mucosa status increases permeability to chemicals, carcinogens, and pathogens. The oral mucosa becomes vulnerable to lesions with age because of the decrease in collagen synthesis and slow regenerative rate (Abu Eid et al., 2012). In addition, weakening of the immune defense against pathogens with age increases the risk of developing lesions in the oral cavity (Dundar & Ilhan Kal, 2007; Martori et al., 2014). Various factors influence the oral mucosal health such as habits (smoking, alcohol drinking, etc.), prosthesis use, hygiene level, systematic diseases, and medication usage.
According to Wood and Goaz (1997), the normal oral mucosa in Caucasians ranges from dark to pale pink, and changes in color reflects an altered integrity. Mucosal lesions vary between white, red, yellow, brown, blue, and black; each color indicating a condition that could range from an insignificant anomaly to a life-threatening disease. For example, red mucosal lesions may be caused by mechanical, thermal, chemical trauma, infection, or auto-immune diseases. These conditions may cause the thinning of the epithelial and an increased vascularity, resulting in a red mucosal lesion. On the contrary, factors such as caustic chemicals, fungal infections, and malignant transformations may cause white oral lesions, because of accumulation of nonkeratotic material or to the thickening of the keratotic layer. In this context, the classification of the oral mucosal lesions according to the color helps at the first step of diagnosis.
Oral health is imperative to the well-being and the prevention against mucosal lesion can improve the welfare of elderly people. In fact, several studies have reported a poor oral health of elderly living institutions compared with those living with their families (Baumgartner et al., 2015; Kumara Raja et al., 2015). In Lebanon, the prevalence rate of oral mucosal lesion in elderly individuals living in nursing homes is not known, due to limited number of studies. This parameter could be a good indicator of the importance of a proper dental care implementation in these institutions.
The aim of this study was to assess the prevalence of oral mucosal lesions in Lebanese elderly individuals living in residential homes along with the risk factors including age, sex, medical condition, medication, prosthesis wearing, and oral hygiene.
Materials and Methods
Sample
The present cross-sectional study was approved by the ethical committee of our University (ID# 146/242018).
All the participants were informed about the objectives and details of the study. After reading the consent form, they were asked to sign as acceptance of participation. In case of illiteracy, the examiner would read and explain the information to get their approval. As for the individuals with cognitive impairment, the nurses in charge were asked to contact the parents and get their consent, and the nurses would sign the agreement.
Elderly individuals were approached at 23 nursing homes distributed all over the five districts of Lebanon: Beirut, South, North, Mount Lebanon, and Bekaa. One to three institutions were selected in each geographical area following a stratified, proportional, and random sampling technique, as previously described by Adebola and Ajayi (2014). Participants who could not be examined because of a terminal illness or a severe cognitive impairment were excluded. A total of 526 residents were finally selected for the study.
Data Collection and Intraoral Examination
The medical, demographic, daily habits, and social characteristics including age, gender, district, smoking habits, frequency of family or friends visits, degree of autonomy regarding toilet and nutrition, medical condition, medication consumption, dry mouth sensation, tooth brushing frequency, and denture use (partial/complete removable mandibular/maxillary prosthesis) were collected using a questionnaire administered by one investigator in each district. In addition, participants were asked about their access to oral health in the last 12 months and the reasons of their dental visits. The nurse in charge was present during the exam and confirmed the answers of the respondents, when needed.
The questionnaire was developed by two contributors and five examiners, each in one district, underwent the data collection. The pilot study was undertaken on 10 participants by each one of them. Therefore, the questionnaire was pilot tested on a total of 50 residents, in all five Lebanese districts.
The five examiners were also calibrated according to World Health Organization (WHO) guidelines to ensure that they follow a standardized plan and to minimize the disparities between the different examiners.
After having filled the questionnaire, participants were then subjected to a clinical oral examination respecting the biosafety standards of the WHO using sterilized mirror and probe, gloves, mask, and gauze pads. This visual examination was conducted in the morning (10:00 a.m.–12:30 p.m.) for two reasons: (a) to benefit from better daylight for the visual exam, and (b) to ensure that participants are in good state of mood and energy for an optimal participation.
The hygiene level of removable prosthesis was assessed and coded according to the presence and absence of food deposits: “0” for the absence of food deposits, “1”for recent food deposits, “2”for old food deposits, and “3” for calculus (Cohen et al., 2006).
Statistical Analyses
The statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS®, version 24.0, IMB®) and Stata/SETM 11.1 statistical softwares. Descriptive analysis was performed to detail the distribution of the oral mucosal lesions across the sociodemographic characteristics of participants (origin, age, gender, visitors, and smoking), maxillary and mandibular removable dentures use and condition, oral hygiene practice, autonomy, chronic diseases, and medications.
Bivariate regressions were applied to establish the relationship between the variables and the development of oral mucosal lesion. Multivariate regressions were finally used to estimate regression coefficients, standard errors, 95% confidence intervals (CI) and two-sided p values. Statistical significance was set at .05.
Results
Among the total sample of 526 examined institutionalized geriatric individuals, 156 were 65- to 74-year old and 370 were older. Around 61% were women. The participants were mostly located in Mount Lebanon (286), followed by Beirut (106), Bekaa (57), North (48), and then South (29). In terms of habits, the majority were did not smoke for the last 5 years (84%) and 7.4% reported smoking more than 15 cigarettes per day. They were moderately visited by family members and friends (Table 1).
Table 1.
Bivariate Associations Between Selected Background Characteristics and the Presence of Mucosal Lesions (n = 526).
| Associated background characteristics | No lesions |
Localized lesions |
Generalized lesions |
p value |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Age (years) | ||||
| 65–74 | 128 (82.1) | 20 (12.8) | 8 (5.1) | .207 |
| ≥75 | 278 (75.1) | 68 (18.4) | 24 (6.5) | |
| Sex | ||||
| Males | 157 (77.3) | 36 (17.7) | 10 (4.9) | .623 |
| Females | 249 (77.1) | 52 (16.1) | 22 (6.8) | |
| Districts | ||||
| Beirut | 92 (86.8) | 8 (7.5) | 6 (5.7) | <.001** |
| South | 6 (20.7) | 17 (58.6) | 6 (20.7) | |
| North | 46 (95.8) | 2 (4.2) | 0 (0.0) | |
| Mount Lebanon | 218 (76.2) | 48 (16.8) | 20 (7.0) | |
| Bekaa | 44 (77.2) | 13 (22.8) | 0 (0.0) | |
| Smoking status | ||||
| 0 cigarettes for the last 5 years | 341 (77.0) | 75 (16.9) | 27 (6.1) | .987 |
| <5 cigarettes/day | 13 (76.5) | 3 (17.6) | 1 (5.9) | |
| 5–15 cigarettes/day | 21 (84.0) | 3 (12.0) | 1 (4.0) | |
| >15 cigarettes/day | 29 (74.4) | 7 (17.9) | 3 (7.7) | |
| Main visitor | ||||
| None | .721 | |||
| Family | 303 (76.3) | 66 (16.6) | 28 (7.1) | |
| Neighbor | 19 (76.0) | 5 (20.0) | 1 (4.0) | |
| Caretaker | 4 (100.0) | 0 (0.0) | 0 (0.0) | |
| Other | 17 (77.3) | 4 (18.2) | 1 (4.5) | |
| Frequency of visits | ||||
| <1/week | 152 (79.2) | 30 (15.6) | 10 (5.2) | .159 |
| 1/week | 126 (78.8) | 21 (13.1) | 13 (8.1) | |
| >1/week | 65 (68.4) | 23 (24.2) | 7 (7.4) | |
p < .05. **p < .01.
The majority suffered from at least one chronic disease, including arterial hypertension (HTA) (311), behavioral disorders (150), and diabetes (141) (Table 2) and consumed at least one antihypertensive medication (310) and anticoagulants (246) (Table 2).
Table 2.
Bivariate Associations Between Medical Background and the Presence of Mucosal Lesions (n = 526).
| Associated background characteristics | No lesions |
Localized lesions |
Generalized lesions |
p value |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Diabetes | ||||
| Yes | 112 (79.4) | 21 (14.9) | 8 (5.7) | .749 |
| No | 294 (79.4) | 67 (17.4) | 24 (6.2) | |
| HTA | ||||
| Yes | 241 (77.5) | 52 (16.7) | 18 (5.8) | .943 |
| No | 165 (76.7) | 36 (16.7) | 14 (6.5) | |
| Vasculo cerebral accident | ||||
| Yes | 53 (74.6) | 15 (21.1) | 3 (4.2) | .480 |
| No | 294 (79.4) | 67 (17.4) | 24 (6.2) | |
| Dementia | ||||
| Yes | 89 (77.4) | 20 (17.4) | 6 (5.2) | .893 |
| No | 317 (77.1) | 68 (16.5) | 26 (6.3) | |
| Behavioral disorders | ||||
| Yes | 113 (75.3) | 31 (20.7) | 6 (4.0) | .167 |
| No | 293 (77.9) | 57 (15.2) | 26 (6.9) | |
| Cancer | ||||
| Yes | 13 (81.3) | 1 (6.3) | 2 (12.5) | .315 |
| No | 393 (77.1) | 87 (17.1) | 30 (5.9) | |
| Respiratory failure | ||||
| Yes | 17 (63.0) | 7 (25.9) | 3 (11.1) | .224 |
| No | 389 (78.0) | 81 (16.2) | 29 (5.8) | |
| Parkinson disease | ||||
| Yes | 28 (82.4) | 3 (8.8) | 3 (8.8) | .342 |
| No | 378 (76.8) | 85 (17.3) | 29 (5.9) | |
| Other | ||||
| Yes | 86 (71.7) | 25 (20.8) | 9 (7.5) | .273 |
| No | 320 (78.8) | 63 (15.5) | 23 (5.7) | |
| Antidepressants | ||||
| Yes | 170 (80.2) | 32 (15.1) | 10 (4.7) | .348 |
| No | 236 (75.2) | 56 (17.8) | 22 (7.0) | |
| Corticoids | ||||
| Yes | 15 (93.8) | 1 (6.3) | 0 (0.0) | .138 |
| No | 390 (76.6) | 87 (17.1) | 32 (6.3) | |
| Antibiotics | ||||
| Yes | 8 (88.9) | 0 (0.0) | 1 (11.1) | .174 |
| No | 398 (77.0) | 88 (17.0) | 31 (6.0) | |
| Neuroleptics | ||||
| Yes | 97 (74.6) | 24 (18.5) | 9 (6.9) | .724 |
| No | 309 (78.0) | 64 (16.2) | 23 (5.8) | |
| Anticoagulants | ||||
| Yes | 189 (76.8) | 46 (18.7) | 11 (4.5) | .213 |
| No | 217 (77.5) | 42 (15.0) | 21 (7.5) | |
| Antihypertensives | ||||
| Yes | 238 (76.8) | 54 (17.4) | 18 (5.8) | .849 |
| No | 168 (77.8) | 34 (15.7) | 14 (6.5) | |
| Antiglycemics | ||||
| Yes | 111 (78.7) | 22 (15.6) | 8 (5.7) | .878 |
| No | 295 (76.6) | 66 (17.1) | 24 (6.2) | |
| Other | ||||
| Yes | 76 (71.0) | 23 (21.5) | 8 (7.5) | .248 |
| No | 330 (78.8) | 65 (15.5) | 24 (5.7) | |
| Toilet use autonomy | ||||
| Autonomic | 145 (81.0) | 28 (15.6) | 6 (3.4) | .213 |
| Partially dependent | 86 (78.9) | 17 (15.6) | 6 (5.5) | |
| Totally dependent | 175 (73.5) | 43 (18.1) | 20 (8.4) | |
| Feeding autonomy | ||||
| Autonomic | 294 (77.2) | 62 (16.3) | 25 (6.6) | .863 |
| Partially dependent | 42 (79.2) | 8 (15.1) | 3 (5.7) | |
| Totally dependent | 69 (75.8) | 18 (19.8) | 4 (4.4) | |
HTA = arterial hypertension.
Around half (47%) of the examined subjects experienced a dry mouth sensation and 22.8% presented with oral mucosal lesions visible to the naked eye. The majority of these lesions were localized (74.2%) and were red in color (16%) (Table 3).
Table 3.
Percent Distribution of Institutionalized Geriatric Persons by Selected Oral Health Signs and Symptoms (n = 526).
| Variable | n | % |
|---|---|---|
| Dry mouth sensation | ||
| Yes | 247 | 47.0 |
| No | 258 | 49.0 |
| Not indicated | 21 | 4.0 |
| Mucosal lesions visible to the naked eye | ||
| Yes | 120 | 22.8 |
| No | 406 | 77.2 |
| Localized mucosal lesionsa,b | ||
| Yes | 89 | 74.2 |
| No | 31 | 25.8 |
| Generalized mucosal lesionsa,b | ||
| Yes | 32 | 26.7 |
| No | 88 | 73.3 |
| Color | ||
| Red | 84 | 16.0 |
| White | 15 | 2.9 |
| Yellow | 1 | 0.2 |
| Black | 5 | 1.0 |
| Blue | 19 | 3.6 |
| Rose | 1 | 0.2 |
Note. Four Individuals exhibited combination of two lesions (red and white, red and black, red and blue, black and blue).
Total sample is 120—only those with mucosal lesions visible. bOne subject exhibited both localized and generalized mucosal lesions and is counted in both.
At the bivariate level, the presence of mucosal lesions was related to 10 major factors including district, number of teeth remaining, tooth brushing autonomy, brushing at least once per day, mandibular prosthesis worn during the exam, maxillary and mandibular prosthesis hygiene level, owns a maxillary or a mandibular removable prosthesis, and unmet need for prosthesis (Tables 1, 4, and 5). Factors such as age, sex, medical condition, and consumed medicines could not be associated with the presence of mucosal lesions (Tables 1 and 3).
Table 4.
Bivariate Associations Between Oral Hygiene Factors and the Presence of Mucosal Lesions (n = 526).
| Associated background characteristics | No lesions |
Localized lesions |
Generalized lesions |
p value |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Dry mouth sensation | ||||
| No | 69 (75.8) | 18 (19.8) | 4 (4.4) | .512 |
| Yes | ||||
| No. of teeth remaining | ||||
| Edentulous | 206 (70.0) | 64 (21.8) | 24 (8.2) | <.001** |
| ≤20 | 158 (84.0) | 22 (11.7) | 8 (4.3) | |
| >20 | 42 (95.5) | 2 (4.5) | 0 (0.0) | |
| Tooth brushing autonomy | ||||
| Independent | 42 (87.5) | 4 (8.3) | 2 (4.2) | .004** |
| Partially dependent | 6 (100.0) | 0 (0.0) | 0 (0.0) | |
| Totally dependent | 2 (100.0) | 0 (0.0) | 0 (0.0) | |
| Not performed | 149 (85.2) | 20 (11.4) | 6 (3.4) | |
| N/A (edentulous) | 207 (70.2) | 64 (21.7) | 24 (8.1) | |
| Brushing at least 1/day | ||||
| Yes | 29 (87.9) | 2 (6.1) | 2 (6.1) | <.001** |
| No | 170 (85.9) | 22 (11.1) | 6 (3.0) | |
| N/A (edentulous) | 207 (70.2) | 64 (21.7) | 24 (8.1) | |
| Maxillary prosthesis worn during exam | ||||
| Yes | 129 (62.9) | 53 (25.9) | 23 (11.2) | .201 |
| No | 9 (81.8) | 2 (18.2) | 0 (0.0) | |
| Mandibular prosthesis worn during exam | ||||
| Yes | 98 (60.5) | 43 (26.5) | 21 (13) | .031* |
| No | 16 (84.2) | 3 (15.8) | 0 (0.0) | |
| Maxillary prosthesis hygiene level | ||||
| No deposits | 25 (73.5) | 4 (11.8) | 5 (14.7) | .047* |
| Recent deposits | 29 (65.9) | 13 (29.5) | 2 (4.5) | |
| Old deposits | 46 (67.6) | 16 (23.5) | 6 (8.8) | |
| Calculus | 28 (48.3) | 20 (34.5) | 10 (17.2) | |
| Mandibular prosthesis hygiene level | ||||
| No deposits | 22 (75.9) | 3 (10.3) | 4 (13.8) | .007** |
| Recent deposits | 24 (66.7) | 11 (30.6) | 1 (2.8) | |
| Old deposits | 26 (63.4) | 12 (29.3) | 3 (7.3) | |
| Calculus | 25 (44.6) | 18 (32.1) | 13 (23.2) | |
p < .05. **p < .01.
Table 5.
Bivariate Associations Between Oral Health Care Accessibility Factors and the Presence of Mucosal Lesions (n = 526).
| Associated background characteristics | No lesions |
Localized lesions |
Generalized lesions |
p value |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Owns a removable maxillary prosthesis | ||||
| Complete | 120 (61.5) | 53 (27.2) | 22 (11.3) | <.001** |
| Partial | 17 (85.0) | 2 (10.0) | 1 (5.0) | |
| None | 269 (86.5) | 33 (10.6) | 9 (2.9) | |
| Owns a removable mandibular prosthesis | ||||
| Complete | 97 (59.9) | 46 (28.4) | 19 (11.7) | <.002** |
| Partial | 17 (89.5) | 0 (0.0) | 2 (10.5) | |
| None | 292 (84.6) | 42 (12.2) | 11 (3.2) | |
| Unmet need for prosthesis | ||||
| Yes | 355 (78.4) | 70 (15.5) | 28 (6.2) | .002** |
| No | 27 (73.0) | 7 (18.9) | 3 (8.1) | |
p < .01.
The south governorate showed the highest percentage of mucosal lesion (79.3%) and the north governorate (4.2%) the lowest rate (Table 1).
Of the entire examined geriatric sample, 294 subjects were edentulous (55.6%) and only around 10% had 21 or more teeth (Table 4). As for the removable prosthesis use, 195 participants had a complete removable one (20 maxillary and 162 mandibular) and 19 presented with a partial removable mandibular prosthesis. However, 453 had an unmet need for prosthesis (Table 5). Only a minority maintained a good hygiene of their prosthesis, with 84.2% of maxillary and 82.1% of mandibular dentures having deposits (recent, old, or calculus).
Among the edentulous (295) population, 30% presented with either a generalized or a localized mucosal lesion (Table 4). Individuals with greater number of teeth presented mucosal lesions to a lesser extent (p < .001; Table 4). However, an enormous neglect was noticed for people with remaining teeth as the majority did not perform the tooth brushing activity, leaving only 33 participants with regular tooth brushing activity, among which the majority were independent in performing the activity. These individuals showed a lower percentage of mucosal lesion occurrence compared with those who did not brush their teeth on daily basis (p < .001; Table 4).
Wearing a removable prosthesis during the exam and its hygiene level affected significantly the status of the mucosa (Tables 4 and 5). Mucosal lesions were less prevalent in individuals with high maxillary (p = .047) and mandibular (p = .007) prosthesis hygiene level (Table 4). Furthermore, the presence of mandibular prosthesis increased the prevalence of oral lesions (p = .031). A statistically significant association was also noted between owning a mandibular prosthesis and the development of dry mouth sensation (data not shown). However, the prosthodontic neglect was noted again as the majority of the population presented an unmet need for prosthesis (Table 5). Independent individuals and those who brushed their teeth more frequently showed the lowest percentage of unmet need for prosthesis. This unmet need also increased the occurrence of localized and generalized mucosal lesions (p < .001; Table 6).
Table 6.
Bivariate Associations Between Oral Hygiene Factors and the Presence of an Unmet Prosthodontic Need (n = 487).
| Associated background characteristics | No unmet need |
Unmet need |
p value |
|---|---|---|---|
| n (%) | n (%) | ||
| Tooth brushing autonomy | |||
| Independent | 27 (61.4) | 17 (38.6) | <.001** |
| Partially dependent | 2 (40.0) | 3 (60.0) | |
| Totally dependent | 0 (0.0) | 2 (100.0) | |
| Not performed | 44 (27.2) | 118 (72.8) | |
| N/A (edentulous) | 154 (56.2) | 120 (43.8) | |
| Brushing at least 1/day | |||
| Yes | 20 (66.7) | 10 (33.3) | <.001** |
| No | 53 (29.0) | 130 (71.0) | |
| N/A (edentulous) | 154 (56.2) | 120 (43.8) | |
| Presence of mucosal lesions | |||
| None | 157 (41.8) | 219 (58.2) | <.001** |
| Localized | 49 (60.5) | 32 (39.5) | |
| Generalized | 21 (70.0) | 9 (30.0) | |
p < .01.
Four variables were incorporated into the final model predicting the presence of mucosal lesions, χ2(10) = 32.26; p =.004; pseudo-R2 = 12.33% (Table 7). Age group and sex were not associated with the presence of mucosal lesions, when controlling for all remaining variables, but were intentionally maintained in the model. Frequency of visits and mandibular prosthesis hygiene level were the only statistically significant predictors of mucosal lesions occurrence. Mandibular prosthesis hygiene level predicted only the presence of localized lesions whereas frequency of visits predicted only the presence of generalized lesions.
Table 7.
Logistic Multivariate Analysis Showing Associations Between Selected Variables and the Presence of Mucosal Lesions (n = 524).
| Associated variables | Adjusted OR |
SE
|
95% CI |
Adjusted OR |
SE
|
95% CI |
||
|---|---|---|---|---|---|---|---|---|
| Mucosal lesions (localized vs. none) | p value | Mucosal lesions (generalized vs. none) | p value | |||||
| Constant | −2.39 | 1.27 | [−4.88, 0.10] | .060 | −2.51 | 1.22 | [−4.92, -0.11] | .041* |
| Age (65–74) | ||||||||
| ≥75 | 0.36 | 0.56 | [−0.74, 1.45] | .524 | −0.53 | 0.72 | [−1.94, 0.88] | .461 |
| Sex (Male) | ||||||||
| Female | −0.36 | 0.45 | [−1.24, 0.52] | .418 | 0.33 | 0.59 | [−0.82, 1.49] | .573 |
| Frequency of visits (<1/week) | ||||||||
| 1/week | −0.97 | 0.52 | [−1.98, 0.04] | .060 | 1.37 | 0.69 | [0.02, 2.72] | .047** |
| >1/week | −0.14 | 0.53 | [−1.18, 0.90] | .786 | 1.08 | 0.78 | [−0.44, 2.60] | .163 |
| Mandibular prosthesis hygiene level (no deposits) | ||||||||
| Recent deposits | 2.74 | 1.13 | [0.53, 4.94] | .015* | −1.64 | 1.19 | [−3.97, 0.69] | .168 |
| Old deposits | 2.34 | 1.11 | [0.17, 4.51] | .034* | −0.51 | 0.85 | [−2.19, 1.16] | .548 |
| Calculus | 2.76 | 1.09 | [0.62, 4.90] | .012** | 0.98 | 0.70 | [−0.39, 2.35] | .161 |
| LR χ2(10) | 32.26 | |||||||
| Prob > χ2 | 0.004 | |||||||
| Pseudo R2 | .1233 | |||||||
Note. OR = odds ratio; CI = confidence interval; LR χ2(x) refers to the likelihood ratio χ2 statistic.
p ≤ .05. **p < .01.
Controlling for all other variables in the model, individuals with all types of deposits on their mandibular prosthesis were more likely to present with localized mucosal lesions (recent deposit: odds ratio (OR) = 2.74, p = .015; old deposits: OR = 2.34, p = .034; calculus: OR = 2.76, p = .012). On the contrary, individuals receiving one visit per week were less likely to present with generalized lesions (OR = 0.69, p = .047) (Table 7).
Discussion
Oral mucosal lesions are related to the patient oral habits such as hygiene (Ercalik-Yalcinkaya & Özcan, 2015), smoking, chewing tobacco (Bozdemir et al., 2019; Campisi & Margiotta, 2001), and alcohol drinking (Campisi & Margiotta, 2001), in addition to the quality and integrity of prosthesis (Freitas et al., 2008). Other factors such as age (Bozdemir et al., 2019), sex (Al-Maweri et al., 2015), medical conditions (Bozdemir et al., 2019), and trauma (Campisi & Margiotta, 2001) were also found to affect the integrity of the oral mucosa.
In our study, the prevalence of oral mucosal lesions among institutionalized elderly Lebanese was 22.8%. This percentage is relatively low compared with other developing countries, such as Brazil (79.9%) (Ferreira et al., 2010), Thailand (61.6%) (Wongviriya et al., 2018), and Yemen (77.1%) (Al-Maweri et al., 2015).
The lesions were identified in terms of color (red, white, blue, yellow, black, and rose), the red mucosal lesion being the most common type (16%) and only four people exhibited a combination of two lesions (Table 1). However, each color has a broad prognostic spectrum and may be a sign of reactive, infectious, autoimmune, benign, or malignant condition (Gómez et al., 2007; Gondak et al., 2012; Jessri et al., 2017; Mortazavi et al., 2019). A red lesion, for instance, may include epithelial atrophy, inflammation, or erosion, while a white lesion could include epithelial edema or abnormal keratinization of the mucosa (Jessri et al., 2017). On the contrary, hypercarotenemia, lipoid proteinosis, lymphoepithelial cysts, in addition to various other clinical conditions are associated with yellow lesions (Gómez et al., 2007). An increased production of melanin lead to the formation of brown, black, or blue mucosa (Gondak et al., 2012). This could be caused by different factors including vesicular and melanocytic lesions (Gondak et al., 2012). Therefore, further investigation should be performed to reach a definitive diagnosis.
In the present study, we could not find an association between the development of oral mucosal lesion and age, similarly to what was reported by Wongviriya et al. (2018) and in contrast to the findings of Bozdemir et al. (2019) and Al Maweri et al. (2015). The absence of association with age might be due to the fact that habits, such as smoking and alcohol drinking, usually decrease with the individual getting older, which decreases the risk of oral mucosal development.
In accordance to the findings reported by Patil et al. (2013), our results contradicted the relationship between sex and oral mucosa alteration (Al-Maweri et al., 2015; Bozdemir et al., 2019; Wongviriya et al., 2018). In these studies, authors attributed the difference between genders to the social values of the country that expose men to more risk habits than women, including smoking and drinking, which is not applicable in Lebanon where men and woman are equally exposed to such habits. Nevertheless, the prevalence of oral mucosal lesion was affected by the individual’s geographic background. Indeed, this factor may be controlled by the socioeconomic status of the population in each district, as low socio-economic status and socioeconomic deprivation could lead to a poor oral health (Vieira-Andrade et al., 2011).
Systemic diseases and medication use may lead to the dry mouth sensation, which was reported by 49% of our population. This could eventually lead to oral mucosal alteration. However, similar to previous studies (Al-Maweri et al., 2015; Wongviriya et al., 2018), our results did not associate the medical condition of the patient to the development of oral mucosal lesion.
Previous studies have reported a higher prevalence of oral mucosal lesions in elderly wearing removable dentures compared with nonwearers (Bozdemir et al., 2019; Ferreira et al., 2010). In this study, full denture wearers showed a higher prevalence compared with partial denture wearers (Table 5). Our results are in agreement with Bozdemir et al. (2019) and contradict the results reported by Kovacevic (2017). In fact, complete dentures are mainly made of acrylic resin in which micropores may develop over time, allowing microorganisms to inhabit the prosthesis whereas partial prostheses are primarily made of metal, which does not allow the colonization of microorganisms. Previous studies have also noted a higher prevalence of oral mucosal lesions due to maxillary dentures compared with the mandibular ones (Canger et al., 2009). This was attributed to the smaller surface of mucosa under the latter, which would increase the possibility of mucosal lesion occurrence. However, no significant difference was noted between the two types of prosthesis in our study.
The prevalence of oral mucosal lesion has also been linked to the hygiene level of dental prosthesis. In accordance with previous studies (Ferreira et al., 2010; Freitas et al., 2008), a poor hygiene level of mandibular and maxillary prosthesis resulted in a higher prevalence of oral mucosal lesions (Table 4). Also, an altered integrity of the prosthesis plays a role in the occurrence of oral mucosal lesion.
In this study, participants with unmet need for prosthesis exhibited more oral mucosal lesions than those where the need was met (Table 5). In fact, different studies reported a higher oral mucosal lesion rate in patients individuals with old prosthesis compared with those with newer prosthesis one (Bozdemir et al., 2019; Ferreira et al., 2010; Kovacevic, 2017). The stability and integrity of the prosthesis are altered with time, resulting in traumatic lesions to the oral mucosa. Although prosthesis use pattern may also influence the prevalence of oral mucosal lesions, this variable was not investigated in our study. Indeed, constant use of the prosthesis leads to the development of mucosal lesion due to mechanical irritation and infection (Bozdemir et al., 2019; Ferreira et al., 2010; Kovacevic, 2017).
The multivatiate regression analysis showed that the occurrence of oral mucosal lesion is associated to the frequency of visits and mandibular denture hygiene level when other factors are controlled (Table 7). A statistically significant relation was found between owning a removable mandibular denture and the sensation of a dry mouth. In fact, the combination of dry mouth with mechanical and/or chemical irritations could lead to the development of oral mucosal lesions (Gorsky et al., 2004).
In this study, the relationship between frequency of visits and oral health was also investigated, since it could be related to the fact that an isolated individual might not be interested to maintain a good hygiene and personal appearance because of psychological problems. Unfortunately, in Lebanon, there is a lack of scheduled dental visits for elderly in residential homes. Even the health care staff and nurses are not trained nor informed about oral hygiene importance and techniques.
Our study target was the institutionalized elderly population in Lebanon. Further studies are required to investigate the same variables in the noninstitutionalized Lebanese elderly population to have a more representative sample of the Lebanese geriatric population.
Conclusion
The association between oral mucosal lesion occurrence in the geriatric population living in nursing homes across Lebanon and different risk factors was investigated in this study. Variables such as age, sex, systemic disease, and medication did not favor the development of oral mucosal lesions whereas the use of dentures along with their condition and hygiene level were associated with their prevalence. In addition, the prosthodontic neglect was noted among the studied population. Therefore, the implementation of a solid oral health program in Lebanese nursing homes is crucial to ensure the well-being of the institutionalized elderly population.
Clinical Significance
The global geriatric population is expanding, especially in developing countries. Consequently, the oral health of this population has become a point of focus in dentistry. In Lebanon, a major prosthodontic neglect has been noticed in nursing homes. The prevalence of oral mucosal lesions is an indicator of the oral health condition of elderly individuals. Therefore, this study aimed to shed the light on the importance of implementing an appropriate oral health program in Lebanese nursing homes. For this purpose, factors affecting the prevalence of oral mucosal lesion among an institutionalized elderly Lebanese population have been determined.
Acknowledgments
We would like to thank Mrs. Nadine Saliba who performed the statistical analyses.
Footnotes
Authors’ Note: The views expressed in the submitted article are our own and not an official position of the institution or funder. Sahar Rammal is no longer affiliated to the Lebanese University.
Ethical Approval and Consent to Participate: The protocol of the study was approved by the Committee of Ethics at Lebanese University, (Code: 146/242018). Written and verbal informed consent was obtained from the participants.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Antoine Choufani 
https://orcid.org/0000-0002-7516-9527
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