Oral Health Status of the Elderly in Residential Homes in Saudi Arabia Essay (Article)

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Introduction

Oral health care for the ever increasing elderly residents living in the nursing and elderly homes have continuously proved challenging for the caregivers who are overly required to offer the necessary support in terms of daily health maintenance. Taking into account their serenity due to old age, the caregivers hence assume the overall responsibility of offering good oral care practices while continuously monitoring their oral health to avoid occurrence of dental diseases (Schou 34). The elderly forms a substantial component of the larger population and the figure is expected to increase exponentially due to the witnessed life expectancy brought about by economic development in many parts of the world. For instance, the number of elderly persons (60 years and above) is expected to increase from about 670 million to almost two billion by the year 2050 representing a threefold increase. About 60 % of the elderly people reside in the developed world where majority of them are housed in nursing an elderly homes. In addition, an increase of the most elderly persons(over 80 years) from about 40 million in 2005 to more than 275 million in 2050. Saudi Arabia has about 730,000 elderly people (65 years and above) in 2010 that represent 2.5 % of the total population (Central Intelligence Agency, 2010).

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Having a population ofabout12 million citizens, Saudi Arabia is quickly developing. In the recent past, the nation has experienced an incredible escalation in the socioeconomic sector which has influenced the people’s way of living to a great deal. The percentage of the population over 60 is rising and expected to more than double by 2020. By 2020 the number of old people is expected to grow from approximately 1 million (4 percent of the population) to roughly 2.5 million (7 percent of the population). (World Health Organization) Although the majority of the elderly live independently in the community in Saudi Arabia, a growing number of older people live in different institutions. According to the latest records from the Ministry of Social Affairs a total of 665 of elderly live in 10 residential homes. Dental Caries is one of the most significant health problems facing the population. Some studies have shown that Saudi Arabian, adolescent and adults have a high caries rate, but there are no studies about the elderly (Al-Shammary 16).

Severe cases of tooth decay, tooth loss and conditions such as periodontitis and edentulism have been witnessed in elderly people who are disadvantaged socially and economically. In Saudi Arabia, provision of dental care services is mainly undertaken by the government thereby ensuring accessibility to all its citizens. Inability and unwillingness on the part of the elderly to seek medication has worsened the health situation in the nursing and elderly homes. More importantly, an increasing trend has shown that the elderly has very low perception of their oral heath as compared to the overall physical health thereby influencing negatively the health seeking behavior (Papas et al 54).

Most importantly, it is very crucial to appreciate the fact that, when they grow to be toothless, people’s oral health needs do not end. For instance, the jaws may persist to resorb with time. On the other hand, prostheses which are not well fitting can negatively impinge on chewing, which would consequently contribute to improper nourishment. This notwithstanding, toothless people are usually predisposed to mucosal ailments, oral cancer as well as shifts in salivary gland performance (Scooper, Solllecito and De Ross 267). Moreover, the increasing population of old people will result in a high demand for dental care services. In contrast, extensive attention at the national level directed at oral health in children has overshadowed the concerns of the old people. The lack of appropriate public health or policy interventions focusing on the plight of old people in Saudi Arabia has resulted in deterioration in their health. In light of this, it is evident that unless a paradigm shift in the dental care occurs, elderly people will continue to suffer while demand for dental care will surge (Saub and Evans 198).

Assessment of the oral health status and needs of the growing number of homebound and institutionalized older people will aid in the organization of a prevention-oriented oral health care program to improve quality for life of the elderly. In addition this survey will provide a good environment to a more extended and accurate nationwide study for the dental health status of the elderly.

Literature Review

Previous studies have depicted that the commonest problems facing the institutionalized people include poor oral hygiene coupled with oral health alignment. The poor oral health status is occasioned by the fact that oral tissues have the propensity to be affected due to changes in body metabolism and functioning brought about by advancing age (Lamy et al 443). Other several studies have indicated poor oral health and limitation in accessing dental care in the elderly mainly residing in the nursing homes (Berg and Morgenstem 652). While majority of the people continually maintain their teeth to old age, the onset of old age ushers the era of dependency and increasing need to seek regular dental care in the elderly home setting (Kiyak 95).

Due to several reasons, a disproportionate effect on the elderly occurs due to the increasingly high number of oral and dental diseases. As a result of exposing the teeth to microbes for a long duration, the oral cavities are likely to wear and tear, a situation which is often aggravated by chewing, talks as well as other caustic oral practices which include bruxism (Ettinger and Miller-Eldride, 91). From a global perspective, high cases of tooth loss, oral precancer/cancer and dental caries have characterized poor oral health in old people. Common autoimmune disorders such as pemphigus and pemphgoid cause considerable suffering to old people (Fillit, Rockwood and Woodhouse 45).

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More often than not, the elderly people call for several medications when they are affected by problems such as reduced production of saliva, a condition that can unfavorably impinge on the efficiency of chewing, affecting their quality of life which could lead to enormous teeth problems as well as their supporting makeup (Fox and Eversole 32). Extensive tooth decay and loss leads to reduction in the chewing performance while affecting the food choice (White, Caplan and Weintraub, 50). For instance, edentulous people have a high tendency to avoid dietary fibers thereby preferring foods rich saturated fats and cholesterols. Physical inactiveness associated with the elderly can also contribute to trouble when dealing with fundamental oral hygiene measures (MacEntee, Thorne & Kazanjian, 168). More importantly, old people may develop social handicaps related to efficiency during the communication process. Poor oral health is closely intertwined with poor general health primarily because of similarity in the risk factors. For example, occurrence of periodontitis is closely associated with development of diabetes mellitus and chronic respiratory disease (Fillit, Rockwood and Woodhouse 45).

A study carried out in Turkey indicated that screening is an effective measure in the identification of the dental needs and the overall oral health status among the elderly. The findings further denoted that oral health conditions were poor, inadequacy in oral self care and oral hygiene-related habits (Ünlüer, Gokalp and Dogan 27). Likewise, Peltola et al found out that oral and denture cleanliness was generally poor among the elderly in the residential homes (94). Another study has indicated the tendency of governments ignoring oral health during the synthesis of policies and implementation of health plans. In addition, failure to prescribe minimum measures with regard to the requirements concerning the management of elderly homes may have led to the surge in dental cases. The failure of authorities to integrate oral health care in the overall management of elderly people has curtailed the achievement of sustainable and better oral care (Carter et al 43).

While most elderly people in developed countries seek dental care regularly, the contrary was observed in elderly homes in Turkey (Muncu et al 90). Reluctance in embracing the dental care has been attributed to negligence and preference to general health compared to oral health (Fillit, Rockwood and Woodhouse 45). About 30 % of dentates in nursing homes in Lithuania, 54% in Denmark and 27.6 % in Turkey brushed their teeth at least two times each day (Christensen 232). Tooth loss was predominantly found to exist in several studies carried out in many areas. Although variations in significant differences were noted, the proportion of edentulousness in Turkey was 67.4 %, 64.4 % in Athens while 43 % in institutionalized people in Spain (Karkazis and Kossini 158; Spanish Geriatric Oral Health Research Group 229).

Treatment needs in the residential homes are not regularly met in the residential homes. According to a study carried out in New Zealand, majority of the residents reported being seen regularly especially by a qualified medical practitioners who could refer them to specialist dentists (Carter et al 43). Treatment of oral diseases in residential homes in Turkey was impossible owing to the high cost and inaccessibility. Factors such as prices, subsidies and availability of dental care services had a strong influence in the overall improvement of oral treatment regardless whether restorative, prosthetic and periodontal in nature (Ünlüer, Gokalp and Dogan 27).

Research Problem

According to the latest survey from the Ministry of Social Affairs in Saudi Arabia, there are 10 institutions for elderly in Saudi Arabia with a total of 665 residents, little is known about their oral health problems.

Research Significance

Dental professionals and oral health policy planners need more up-to-date and accurate information of the patterns of the disease among the elderly population in order to predict possible disease trends and establish plans for future goal achievements.

Research Objectives

To determine the oral health status and treatment needs of elderly residents of the residential homes in Saudi Arabia

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Research Methodology

The total sample size was approximately 665 residents of the elderly institutes in 9 different cities in Saudi Arabia 245 females and 420 males. In-depth interviews and clinical examination was conducted according to the WHO criteria (World Health Organization 8). The statistics on educational and occupational status, weight, gender, age, oral hygiene measures, access to dental care, smoking habits, as well as general diseases and prescription was recorded using structured questionnaires. Assessment of coronal and root caries, periodontal disease, dental status and related treatment needs was carried out through clinical and (if possible) radiographic examination. Voluntary participation was applied during the survey, where consent was acquired from all the participants before the dental examinations were carried out. Recording of the assessment findings of the screening examination was done on a specially prepared sheet based on the WHO health form. Statistical analysis of collected data was conducted using SPSS statistical program in order to evaluate the statistical significance between variables.

Results

Socio-demographic characteristics and their respective personal characteristics for all the participants are presented in table 1. Out of the 51 male subjects, 81 % were under the age of 80 years in comparison with 53.1 % of women. On average 75 % of the subjects were below 80 years of age which represented 21 subjects.

Table 1: Percentage distribution of number of remaining teeth by age and gender of institutionalized elderly subjects.

CharacteristicsMale
(n=51)
n (%)
Female
(n=32)
n (%)
Total (n=83)
n (%)
P-value
Age
<7034 (66.7)13 (40.6)47 (56.6)0.004
70-743 (5.9)3 (9.4)6 (7.2)
75-798 (15.7)1 (3.1)9 (10.8)
80-843 (5.9)7 (21.9)10 (12.0)
≥853 (5.9)8 (25.0)11 (13.3)

The number of remaining teeth in the subjects is presented in table 2.The number of remaining teeth in males below 74 years was more than 20 in 18.9 %of the male subjects as compared to 6.3% in female subjects. On average, the number of remaining teeth in subjects more than 75 years was 61%.

Table 2: Distribution of institutionalized elderly subjects by dentition and gender.

Number of remaining teeth____
GenderAge Groups≤45-19≥20Total, n (%)P-value
Male<7451.429.718.936 (72.0)0.065
≥7578.60.021.414 (28.0)
Female<7493.80.06.316 (50.0)0.596
≥7587.56.36.316 (50.0)
Total<7464.220.815.153 (38.97)0.080
≥7583.33.313.383 (61.03)

The dental status of the elderly people in the Riyadh institutions is shown in table 2. The number of sound teeth in males was 419 in males while the females had 136 sound teeth. This translated to a mean of 8.22 ± 9.25 in men subjects while compared to 4.25 ± 6.38 in female subjects. A median o f5 was recorded in the male participants while compared to 1 in females. Overall, the average mean in males was 6.69 ± 8.45 compared to an average median of 3. The minimum and maximum number of sound teeth was 0 and 31 in males, 0 and 23 in female subjects while the average was 0 and 31. The number of decayed teeth was 146 in males while compared to 36 in female subjects with a mean of 2.86 ± 3.83 and 1.13 ± 2.88 in males and females respectively. The median number of decayed teeth was 2 in males as compared to 1 in female subjects, with a minimum maximum of 0-17, 0-12 and 0-17 for the males, females and total respectively. Out of 1336 missed teeth, 605 were recorded in males with a mean of 11.86 ± 12.54, a median of 5 as compared to 22.84 ± 11.18 and 5 in females. The total number of DMFT was 1545 with a mean of 17.78±12.62 in males and median of 31 in females. The male subjects had 3 filled teeth compared to 24 in females with a mean of 0.75 ± 1.78 in females and median of 0 in both sets of subjects.

Table 3: Distribution of institutionalized elderly subjects by dental status and gender.

Dental StatusMaleFemaleTotalP-value
Number of sound teeth (n)4191365550.037
Mean±SD8.22 ± 9.254.25 ± 6.386.69 ± 8.45
Median513
Minimum-Maximum0-310-230-31
Number of decayed teeth (crown) (n)146361820.031
Mean ± SD2.86 ± 3.831.13 ± 2.882.19 ± 3.58
Medan211
Minimum-Maximum0-170-120-17
Number of missed teeth (crown) (n)6057311336<0.0005
Mean ± SD11.86 ± 12.5422.84 ± 11.1816.10 ± 13.12
Median52914
Minimum-Maximum0-320-320-32
Total number of DMFT (n)7547911545<0.0005
Mean ± SD17.78±12.6224.72 ± 9.9818.61 ± 12.58
Median133121
Minimum-Maximum0-320-320-32
Number of decayed root (crown) (n)140201600.006
Mean ± SD2.75 ± 3.950.63 ± 1.9619.3 ± 3.47
Median100
Minimum-Maximum0-180-100-18
Total number of filled (n)324270.008
Mean ± SD0.06 ± 0.310.75 ± 1.780.33 ± 1.17
Median000
Minimum-Maximum0-20-80-8
The assessment of the periodontal status carried out using the CPI scores indicated that only 7 subjects reported six sextants combined with healthy periodontal status. 35 subjects had calculus indicating high tendencies of poor oral hygiene in the elderly people (Table 4).

Table 4: Distribution of institutionalized elderly subjects by periodontal status and gender (CPI scores).

Permanent status (CPI scores)Male n (%)Female n (%)Total n (%)p-value
Sound4 (7.8)3 (9.4)7 (8.4)0.807
Bleeding on probing7 (13.7)8 (25)15 (18.1)0.194
Calculus26 (51.0)9 (28.1)35 (42.2)0.040
Shallow pockets10 (19.6)5 (15.6)15 (18.1)0.646
Deep pockets1 (2.0)0 (0.0)1 (1.2)0.425

There were 33.7% who needed one more surface lining while a further 28.9 required two or more surface fillings. 48.2 % of the subjects required to undergo tooth extraction with 68 % of dentate male subjects. 35.5% of the dentate male subjects required two or more surface linings.

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Table 5: Distribution of treatment needs of institutionalized elderly subjects by gender.
Treatment needsMale (n=51 dentate subjects) n (%)Female (n=32 dentate subjects)
n (%)
Total (n=83 dentate subjects) n (%)p-value
One surface fillings21 (41.2)7 (21.9)28 (33.7)0.070
Two or more surface fillings18 (35.3)6 (18.8)24 (28.9)0.106
Extraction35 (68.6)5 (15.6)40 (48.2)<0.0005

88.2 % of the male subjects had no prosthetic status-upper as compared to 84.4 % in the male subjects. In male subjects, 3.9 % had full removable dentures while compared to 9.4 % of the women subjects. There were 2.0 % of male had more than one bridge while the female subjects had 2.4 %.

Table 6: Distribution of prosthetic status-upper of institutionalized elderly subjects by gender

prosthetic status – upperTotal
no prostheticbridgemore than one bridgefull removable denture
sexmaleCount4531251
% within sex88.2%5.9%2.0%3.9%100.0%
femaleCount2711332
% within sex84.4%3.1%3.1%9.4%100.0%
TotalCount7242583
% within sex86.7%4.8%2.4%6.0%100.0%
Table 7: Chi square tests. Chi-Square Tests.
ValuedfAsymp. Sig. (2-sided)
Pearson Chi-Square1.425a3.700
Likelihood Ratio1.4083.704
Linear-by-Linear Association.9371.333
N of Valid Cases83
a. 6 cells (75.0%) have expected count less than 5. The minimum expected count is.77.

There were 96.1 % of males reporting having no prosthetic with 2.0% having full removable denture. There were 9.4 % of the women subjects who reported bridge while 87.5 % of women had no prosthetic cover.

Table 8: Distribution of prosthetic status-upper of institutionalized elderly subjects by Gender.

prosthetic status – lowerTotal
no prostheticbridgefull removable denture
sexmaleCount491151
% within sex96.1%2.0%2.0%100.0%
femaleCount283132
% within sex87.5%9.4%3.1%100.0%
TotalCount774283
% within sex92.8%4.8%2.4%100.0%
Table 9: Chi-Square Tests.
ValuedfAsymp. Sig. (2-sided)
Pearson Chi-Square2.509a2.285
Likelihood Ratio2.4592.292
Linear-by-Linear Association.5471.460
N of Valid Cases83
a. 4 cells (66.7%) have expected count less than 5. The minimum expected count is.77.
The distribution of prosthetic need in upper jaw is shown in table 10. About 42% of the male subjects required multipurpose prosthesis, 10% of one-unit prosthesis as compared to 6.2% who required no prosthesis and 31.2 % in need of multiunit prosthesis in women subjects.
Table 10: Distribution of prosthetic need-upper of institutionalized elderly subjects by Gender.
prosthetic need – upperTotal
no prosthesis needone unit prosthesismulti-unit prosthesiscombination one + multifull prosthesis
sexmaleCount512151850
% within sex10.0%2.0%42.0%10.0%36.0%100.0%
femaleCount221001832
% within sex6.2%6.2%31.2%.0%56.2%100.0%
TotalCount733153682
% within sex8.5%3.7%37.8%6.1%43.9%100.0%

Table 11: Chi-Square Tests.

ValuedfAsymp. Sig. (2-sided)
Pearson Chi-Square6.904a4.141
Likelihood Ratio8.6064.072
Linear-by-Linear Association1.3231.250
N of Valid Cases82
  1. 6 cells (60.0%) have expected count less than 5. The minimum expected count is 1.17.

The prosthetic need for lower jaw was 54.0% for multiunit prosthesis in male subjects as compared to 38.7% in female subjects. In addition, 6.0% and 3.2% had no need for prosthesis in their lower jaw in male and female subjects respectively

Table 12: Distribution of prosthetic need-lower jaw of institutionalized elderly subjects by gender.

prosthetic need – lowerTotal
no prosthesis needone unit prosthesismulti-unit prosthesiscombinationone + multifull prosthesis
sexmaleCount302741650
% within sex6.0%.0%54.0%8.0%32.0%100.0%
femaleCount121201631
% within sex3.2%6.5%38.7%.0%51.6%100.0%
TotalCount423943281
% within sex4.9%2.5%48.1%4.9%39.5%100.0%
Table 12: Chi-Square Tests.
ValuedfAsymp. Sig. (2-sided)
Pearson Chi-Square8.796a4.066
Likelihood Ratio10.7864.029
Linear-by-Linear Association1.2981.255
N of Valid Cases81
a. 6 cells (60.0%) have expected count less than 5. The minimum expected count is.77.

Discussion

Despite the fact that the study encountered various limitations in the methodology, screening has proved imperative in effective particularly in identification and assessment of the dental needs coupled with oral health status of the elderly people in the residential homes. More importantly, the inclusion of residential homes in several cities in Saudi Arabia is crucial in bringing out a reliable and holistic picture of the oral health status in the country. The data collected showed that most of the elderly people in the residential homes were below 70 years mainly due to the moderate life expectancy and the social norm where the majority of the elderly people are taken care at the community.

The mean number of sound teeth present in the elderly dentate was 6.69 in this particular study compared to 13.8 in Australia and 3.7 in turkey (Saub & Evans 200; Unluer et al 27). Some similarities were observed in the average number of decayed teeth with 2.19 in this study in comparison to 2.2 in turkey. However, great variations were observed in the number of missed teeth with the study having a mean number of 28.2 in contrast with 16.12 in Turkey. The discrepancies were due to the ease in accessibility and availability of dental care services in Saudi Arabia.

The mean number of caries expressed in terms of DMFT was reported to be 18.61 out of which the missing component comprised 16.10. In contrast, a Turkish, Australia and Spanish study noted had values of 29.3, 24.7 and 25.1 respectively (Unluer et al 27; Stubbs and Riordan 323; Spanish Geriatric Oral Health Research Group 231). However, the figures in the study were slightly higher when compared to studies carried out in non-institutionalized elderly people. For instance, DFMT levels were found to be 13.5 in India and about 12.5 in china (Thomas et al 620; Wang et al 288). Owing to the decrease in remaining teeth with age, the cases of filled and decaying teeth is reduced as age progresses in the elderly people. It is therefore worth noting that as more adults retain their teeth into advanced old age, the higher the risk of contacting dental diseases and therefore need for dental care services (Peltola 98; Reinhardt and Douglass 118). More importantly, the dentate participants having experienced filling of one or less teeth was considerably higher at 2.4 compared to 0.6 in turkey and in other studies. Women were more susceptible to caries hence requiring more filling with 3.1 compared to 1.9 % in men. Shallow pocketing was slightly higher at 18.2 % compared to Ulner et al study in turkey at 10.2 %. Slight difference was also observed in the CPI scores on bleeding on probing with the study reporting 18.1 %compared to 22.4 %.

The prevalence of calculus was found to be almost 50% in the elderly people with 51% in males and 28.1 in females. The prevalence of calculus is an indication of the level of oral hygiene and the frequency of continuous regular care in the dental especially in a particular population. The study figures were substantially lower compared to a Frenkel et al study conducted in the UK that reported 82 % (36).

The treatment needs were generally higher in men were substantially higher in males as compared with females but were similar regardless of gender. A statistically significant difference with regard to gender was found in this study as observed in Peltola et al study (96). Extraction of teeth was found to be very high in the study with almost half of the subjects as witnessed in previous studies carried out in Athens (Karkazis & Kossini 163). The study has higher percentages of teeth extraction when compared to findings of Saubs and Evans study that recorded a 20% of the dentate subjects due to factors such as dental caries and periodontal disease. While fewer extractions were caused by dental caries in that study, this study recorded even distribution of causes among periodontal and dental caries. Saubs and Evans also found similar characteristics in populations with 46 % of their study sample requiring one restoration and another 30% requiring one root to restore tooth damaged by root caries.

The number of people with no prosthesis in the upper jaw was 86.7 % for males compared to 6.0% of full removable denture. Lack of prosthetic status in the lower jaw was found to be widely prevalent in the subjects at 92.8 % with 2.4 % having full removing removable dentures. In comparison with other studies, there were high levels of operative therapy in the elderly subjects. About 100% of the utilization of operative therapy such as prosthetics and dentures has been recorded in institutionalized elderly particularly in studies carried out in Finland (Pajukoski et al 97; Ekelund 43). The study finding on the absence of prosthetic equipment at 92 % was higher when compared to the 50% recorded in Saubs and Evans study in Australia. 16% of the subjects in an Australian study wore full lower dentures compared to 6% recorded in this study.

The number of remaining teeth in the elderly people can be utilized to serve as a measurement of oral health. It is useful since it offers reasonable assessment that is easily definable and which is not subject to judgments at the personal level. The functionality of the subject dentition depicted by the number of retained teeth at the age of 75 years and above was reported at a low value (13.3) among the subjects. In contrast, Germany and Denmark had 29% and 40 % of their elderly people retaining more than 20 teeth particularly in the ages of 75 and above. This improvement was occasioned by the continuous and regular utilization of dental care services especially preventive therapy and specialized treatment (Mack et al 775; Christensen et al 231).

Further research is needed in this field to help in producing precise data and information vital in directing the policy changes in the public institutions in Saudi Arabia. Of particular importance, are its implications on the provision of affordable preventive therapy and treatment methods aimed at improving the overall quality of the oral health and life of the elderly residents. The study findings provide a general overview on the oral health status and the management of the dental diseases in Saudi Arabia. It therefore provides vital information to the dental profession, researchers and patients since it provides divergent approaches to oral management while providing the required guidance.

Conclusion

The oral health of the elderly population in Saudi Arabia is generally poor taking into account the high cases of decaying and missing teeth, and the need for medical intervention. There is urgent need to continually persuade people to embrace preventive therapy while also seeking medical interventions to enhance the retention of natural teeth into advanced age. Policy changes are required to entrench the development of oral health care services into the overall health plan of institutions hosting elderly people. The ministry of health in Saudi Arabia should make the oral health care services more accessible and affordable to the elderly people by introducing flexible programmes that will allow geriatric specialists to visit the residential homes. Provision of oral health care to the elderly people will not only lead to economic savings but will reduce the work burden of the care givers.

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IvyPanda. (2022, March 16). Oral Health Status of the Elderly in Residential Homes in Saudi Arabia. https://ivypanda.com/essays/oral-health-status-of-the-elderly-in-residential-homes-in-saudi-arabia/

Work Cited

"Oral Health Status of the Elderly in Residential Homes in Saudi Arabia." IvyPanda, 16 Mar. 2022, ivypanda.com/essays/oral-health-status-of-the-elderly-in-residential-homes-in-saudi-arabia/.

References

IvyPanda. (2022) 'Oral Health Status of the Elderly in Residential Homes in Saudi Arabia'. 16 March.

References

IvyPanda. 2022. "Oral Health Status of the Elderly in Residential Homes in Saudi Arabia." March 16, 2022. https://ivypanda.com/essays/oral-health-status-of-the-elderly-in-residential-homes-in-saudi-arabia/.

1. IvyPanda. "Oral Health Status of the Elderly in Residential Homes in Saudi Arabia." March 16, 2022. https://ivypanda.com/essays/oral-health-status-of-the-elderly-in-residential-homes-in-saudi-arabia/.


Bibliography


IvyPanda. "Oral Health Status of the Elderly in Residential Homes in Saudi Arabia." March 16, 2022. https://ivypanda.com/essays/oral-health-status-of-the-elderly-in-residential-homes-in-saudi-arabia/.

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