throughout   the world , the proportion of older people in the general population has increased in recent years . in   addition to other general health issues
there is a high level of tooth loss , dental caries , periodontal disease , xerostomia and cancer [ 1 , 2 ] .
there are several studies on the dental status of institutionalized older people throughout the world .
for example , studies have been reported from the united states ,   australia [ 4 , 5 ] , canada ,   india , italy [ 8 , 9 ] ,   greece ,   croatia ,   the fiji islands ,   hong kong   and singapore ,   indicating that the dental status of institutionalized older people is generally poor , with a high decayed , missing , or filled teeth ( dmft ) index .   in brazil ,
the demographic transition has been particularly accelerated , which has been associated with a higher demand for long care facilities for older people . despite this , data on institutionalized older people from brazil are scarce .
some reports from south brazil suggest that the oral health of institutionalized older people is poor [ 15 , 17 ] .  
data on the dental status of institutionalized older people from the northeast of the country , which has different socioeconomic and cultural characteristics from the south and is considered the poorest region of the country , are virtually nonexistent .
in particular , there is no data on the factors that contribute to poor oral health status in these special populations and the state of oral hygiene practices . to assist in filling this gap ,
a cross - sectional study was performed assessing oral status and hygiene practices of residents in a nursing home in fortaleza , a capital city in northeast brazil .
this cross - sectional study was performed in the institution  lar torres de melo  , a nursing home in fortaleza , capital of cear state in northeast brazil .
lar torres de melo  is the largest institution for older people in the state and typically would have about 220 residents .
all individuals residing in the institution and who matched the who definition for older people were eligible for the study .
of the 220 residents , 167 ( 75.9% ) met this inclusion criterion of 65 years of age .  
the study consisted of a clinical oral examination ; a structured interview using a pretested questionnaire to assess oral hygiene practices , such as frequency of oral hygiene , type of hygiene , and visits to dentists ; the analysis of the patients ' records to obtain data on age , marital status , time in the institution , general literacy level ( years of schooling ) , and retirement status .
professional carers were interviewed in some cases , particularly when the older people were not in the physical or mental condition to answer questions . the clinical oral examination consisted of assessment of the dmft using brazilian standard procedures , which were similar to who standards .   to reduce interobserver bias ,
detailed clinical data , including periodontal diseases and   the use and need of prosthesis of the study population , are published elsewhere .
data were double entered into a database using the epi info software package ( version 6.04d , centers for disease control and prevention , atlanta , usa ) and checked for entry errors .
after bivariate analysis using t test and kruksal wallis test ,   appropriate multiple linear regression , using the dmft as the dependent variable , was performed .
all variables with a significance level of p < .25 were included in the regression analysis .
regression analysis was done with stata   software ( version 8 ; stata corporation , college station , tex , usa ) .
the study was approved by the ethical review board of the federal university of cear , brazil . informed written consent
one hundred and sixty individuals were included in the study ( 95.8% of the target population ) .
the mean age was 76.6 years ( standard deviation = 8.6 years ) , with a maximum age of 100 years .
the mean time of living in the institution was 8.2 years ( range :   1 month50 years ) .
ninety - three ( 58.1% ) were edentulous , and the mean number of teeth missing was 28.4 .
the mean dmft of all study participants was 29.7 ( sd = 4.4 ; edentulous participants were allocated a dmft of 32 ) .
the mean dmft for the 67 dentate individuals was 26.6 ( sd = 5.3 ) ; 16 ( 23.9% ) of these presented a dmft of 32 .
of all participants , 109 ( 68.1% ) had a dmft of 32 , which meant that they did not have a single healthy tooth .  
almost 90% practiced oral hygiene , and more than three - quarters of these did not need the help of a professional carer .
a minority had visited a dentist in the preceding three months , most commonly for dental extraction .
only 58 participants perceived a need for treatment ; however , clinical examination revealed the need for at least some dental treatment in all 160 cases . in the bivariate analysis ,
only sex , age , and general literacy level were significantly associated with the dmft ( table 3 ) .
however , this variable was confounded by age ( i.e. , the mean age of females was higher than that of males ) . in the multiple regression analysis , age (
 = 0.11 ;   p = .005 ) , general literacy level (  =   0.79 for each additional year of schooling ; p = .003 ) , and practice of any type of oral hygiene (  = 2.5 ;   p = .02 ) were independently significantly associated with the dmft .
however , only 13% of the variance of the dmft could be accounted for by these three independent variables ( r = 0.13 ) .
a lower dmft was observed among individuals who performed their own oral hygiene and used a toothbrush .
however , these and other variables regarding oral hygiene habits ( such as practicing any type of oral hygiene , frequency of oral hygiene , cleaning the tongue , and regular tooth brushing after meals ) did not show any significant association with the dmft .
our study shows that the experience of dental caries ( as represented by the dmft index ) in institutionalized older people in northeast brazil is extremely high .
the data also found that there were insufficient oral hygiene practices in this special population .
similar to most studies on institutionalized older people throughout the world [ 314 ] , a high proportion of the population was edentulous .
the oral health status in the general older people population has been addressed increasingly in the past years , but the oral health of institutionalized older people and underprivileged populations continues to be a neglected issue [ 1 , 2023 ] .  
the dmft varies considerably not only between different socioeconomic groups , but also between different countries and cultures , and it is consistently higher in institutionalized people than among community - dwelling populations [ 415 , 17 , 24 ] .  
for example , in hong kong , the mean dmft index was 21.4 in institutionalized as compared to 17.7 in noninstitutionalized older people .  
a small number of other studies from southern brazil indicate that the oral health status of institutionalized as well as noninstitutionalized older people was also very poor [ 15 , 17 , 25 ] .   in southern brazil ,
the dmft in institutionalized was as high as 30.8 , which was similar to our study population from the northeast ( dmft = 29.7 ) .
a representative national survey made in 2002/2003 on oral health conditions in the brazilian population revealed a mean dmft of 27.8 in community - dwelling older people .
oral hygiene practices in the study population were inadequate , and this group of older people had poor access to dental health care . in all residents , a need for treatment by a dentist was detected by the clinical assessment , but only 44% had perceived that need . in brazil , residents in these institutions tended to have very poor socioeconomic conditions , and the findings of the present study indicate that dental health care for the poorest and oldest in society needs more attention .
initially , these issues were discussed with the director of the institution , and a dentist now regularly performs preventive and curative oral health care activities .
an integrated approach is needed , and oral health education should include all stakeholders .   additionally , it is necessary to implement curative and rehabilitation measures in these populations to reduce the need for future dental treatment .   due to the cross - sectional design
, causal and temporal relationships between independent variables and dmft could not be clearly established .
in addition , a possible limitation of the study was that it was conducted in a single institution , although this was the largest nursing home in the state of cear .   in conclusion
, this study shows that the dental status of institutionalized older people in the state of cear is very poor .
there is a lack of perceived need for dental services and of adequate oral self - care .
dental health education is also needed focusing on the special needs of this neglected and socioeconomically deprived population to improve their quality of life .
 in this study we describe the dental status and oral hygiene practices in institutionalized older people and identify factors associated with poor dental status . 
 a cross - sectional study was performed in a nursing home in fortaleza , the capital of cear state ( northeast brazil ) . 
 the number of decayed , missing , and filled teeth ( dmft ) was assessed in the residents of the nursing home ( n = 167 ; mean age = 76.6 years ) . 
 the mean dmft value was 29.7 ; the mean number of missing teeth was 28.4 . 
 ninety - three ( 58.1% ) were edentulous . 
 almost 90% practiced oral hygiene , but only about half used a toothbrush . 
 only 8% had visited a dentist in the preceding three months . 
 most of the variables regarding oral hygiene habits ( such as the use of toothbrush , frequency of oral hygiene per day , regular tooth brushing after meals ) did not show any significant association with the dmft . in multivariate regression analysis , age , general literacy level , and practice of oral hygiene 
 were independently associated with the dmft ( r2 = 0.13 ) . institutionalized 
 older people in northeast brazil have poor dental status , and oral hygiene practices are insufficient . 
 dental health education is needed focusing on the special needs of this neglected and socioeconomically deprived population to improve their quality of life . 
1. Introduction
2. Methods
3. Results
4. Discussion