Introduction: 
Despite technological advances in operative dentistry, dental avulsion in the elderly remains a concern insofar as edentulism can constitute a handicap for these people, due to the deficiencies, incapacity and disadvantage it creates. In Cameroon, the causes of dental extractions in the elderly remain poorly known due to the limited number of studies on the issue. The aim of the study was to identify the reasons and immediate complications of dental avulsion in the elderly in Cameroon.
Methodology: This was a descriptive and prospective cross-sectional study, conducted over 9 months during 2020 in three health facilities in Yaounde. The recruitment of patients was consecutive and exhaustive. All consenting patients aged sixty years and over who underwent dental extraction were included. The data collected were analyzed using SPSS version 23.0 software. 
Results: Out of 307 elderly people who came for consultation, 133 had undergone a dental extraction, i.e. a prevalence of 43.32%. Females were predominantly represented with a frequency of 54.13% and a male/female sex ratio of 0.84. The average age was 65.53 ± 8.38 years with extremes of 60 and 101 years. Caries and its complications was the most common indication for extraction with 68.11%, followed by periodontal disease with 22.34%. Desmodontitis was the most common carious condition with 48.65%, while chronic periodontitis was the most common periodontal disease with 78.82%. Dental fractures and pain were the immediate complications encountered with 61.90% and 38.09% respectively. Edentulism is a consequence of the periodontal disease.
Conclusion: In sum, dental extraction in the elderly is frequent. Dental caries and periodontal disease are the main causes. The resulting edentulism could have a negative impact on the elderly.
Keywords: Dental Extraction; Dental caries; Elderly complications; Periodontal disease.

In gerontology, age-related pathologies are a fundamental concern, as physiological changes in the oral cavity may be accentuated by certain chronic pathologies or by associated medications [1]. Despite advances in periodontology, endodontics and conservative dentistry, and the development of new techniques in the field of oral prevention, tooth extraction is still a common practice among the elderly [2]. A total of 30% of people over 65-74 years of age have no natural teeth [3]. However, toothlessness can be a major handicap for these elderly people, as it leads to difficulties in eating, thus creating under nutrition, which could be the cause of generalized malaise in elderly subjects [1,3]. 
The reasons for dental extractions are multiple and vary very little from one country to another; according to the WHO, dental caries and periodontal disease are the main causes of dental extraction [3]. Indeed, the indigence of patients linked to their advanced age, their deteriorated state of health due to the various pathologies they carry, the duration of care, the cost and even the failures of care can impact on the life span of a tooth. Tooth extraction remains an unavoidable option when all conservative treatment options have been exhausted [3,4]. 
In Africa, epidemiological surveys on oral health report an increased frequency of dental extraction due to the recrudescence of caries and periodontal disease [5-7]. Cameroon is no exception [5]. In recent decades, the causes of dental extraction have been increasing in underdeveloped countries, to the point where we are witnessing an epidemiological transition. This is favored by a change in dietary habits and the non-rigorous application of good oral hygiene [5-8]. In addition, the problem of dependence of the elderly, who are not always well cared for by their relatives, could be added to this. This is why our study proposed to list the reasons for dental extraction and its immediate complications among the elderly in Cameroon.

This was a descriptive and prospective cross-sectional study, which took place over nine months from December to August 2020 in three health facilities in the stomatology and geriatrics departments of the Yaoundé Central Hospital (HCY), the Cardinal Paul Emile LEGER National Rehabilitation Centre (CNRPH) and the Cameroonian Presbyterian Church Dental Office of Djoungolo (CDD-EPC) in Yaoundé.
The recruitment of consenting patients aged 60 years and above, in whom the diagnosis requiring a dental extraction was proven, was spread out from 06 February 2020 to 29 May 2020. Recruitment was consecutive and exhaustive, with a minimum sample size of 120 patients. Data collected using a data sheet included socio-demographic variables, reason for consultation, types of teeth to be extracted, reasons for extractions and its immediate complications. The data collected were analyzed using SPSS version 23.0 software. The results were entered and tabulated using Microsoft Word and Excel 2016.

Out of 307 patients who came for consultation, dental extraction was performed in 133 patients, i.e. a prevalence of dental extractions of 43.32%. The recruitment was done at the CNRPH, 82 patients, at the HCY of which 114 patients were in the Geriatric Department and 73 in Odontostomatology, and finally, 38 at the CDD-EPC. The highest frequency was observed at the CNRPH, with 50.38% [Table 1].

Table 1: Distribution of extraction frequencies by place of recruitment.

A total of 72 female patients were recorded, i.e. 54.13%, with a sex ratio of 0.84. The average age was 65.53 ± 8.38 years with extremes of 60 and 101 years. The most represented age group was 60-70 years, with 113 patients, or 84.96%. In our series, the predominant educational level was secondary school with 64 patients or 48.12%; followed by 28.58% (n=38) of primary school level. 87.97% of our participants were independent. Retired people were predominantly represented with a total of 51 patients, i.e. 38.35% of cases [Table 2].

Table 2: Distribution of the work force by socio-professional category.

Clinically, pain was mentioned as the reason for consultation in 71 patients, i.e. 53.38% of cases. Other reasons for consultation were bad breath, plaque and routine visit in 06 patients (04.6%) [Table 3].

Table 3: Distribution of the number of patients according to the reason for consultation.

Out of a total of 367 teeth extracted in 133 patients, the 1st and 2nd molars were extracted in the majority of cases with 39.23% for a total of 144 teeth, followed by the wisdom teeth with 24.80% for 91 teeth [Table 4].

Table 4: Distribution of extractions by tooth type.

A total of 204 teeth were extracted in the mandible (55.65%) compared to 163 teeth in the maxilla (44.35%). The reasons for tooth extraction were multiple. About 68.11% of the teeth had carious disease followed by 22.34% of teeth avulsed due to periodontal disease, and only 02 teeth were extracted for prosthetic reasons [Table 5]. Out of a total of 261 teeth extracted due to caries and its complications, the most recurrent diagnosis was desmodontitis in 127 teeth or 48.65% [Table 6]. A total of 85 avulsed teeth were due to periodontal disease. Sixty seven teeth had chronic periodontitis or 78.82% [Table 7].

Table 5: Distribution of staff by reason for extraction.

Table 6: Distribution of reasons for caries and its complications by gender.

Table 7: Teeth extracted from periodontal disease causes.

Regarding immediate complications following dental extraction, out of 367 extractions performed, 346 avulsions were performed without any immediate complication, i.e. 94.42%. On the other hand, we had 21 cases of immediate complications, i.e. 5.71% [Table 8]. All participants who underwent an extraction were edentulous.

Table 8: Distribution of immediate complications.

This study was conducted in the city of Yaounde during 2020 in a context of psychosis of the Covid19 pandemic, when elderly people refused to go to the hospital for fear of being infected. The recruitment of patients aged 60 years and above at the HCY was all the more difficult as the care Centre for Covid19 patients to date is not far from the Odontostomatology and Geriatrics departments. The CDD, which is one of the major institutions for the treatment of oral diseases, has seen its daily patient quota fall during this period. It is in this state of affairs that recruitment was made during a health campaign organized from February 21 to May 8, 2020, by the Association of Dental Surgeons of Cameroon (ANCDC), at the CNRPH Cardinal Paul Emile LEGER, which does not house an Odonto-stomatology department.

This study showed that the prevalence of dental extractions among the elderly in Cameroon was 43.32%. The frequency of dental avulsion was higher at the CNRPH with 50.38%, followed by 31.58% at the CDD-EPC and finally 18.04% at the HCY. This could be explained by the fact that the elderly who came to the campaign at the CNRPH had known oral problems and received free care. Whereas at the HCY, those in the geriatric department were not in favor of dental care out of fear, since the Odontostomatology department was located not far from the Centre for the care of Covid patients.

This prevalence is higher than those found in the literature [5,10]. Indeed, the difference in results could be explained by the fact that our study population consisted only of elderly people, whereas the studies cited concerned a large population of all age groups; people aged 60 and over constituted a very small proportion of their samples.

The average age of our participants was 65.53% with extremes of 60 and 101 years. The most represented age group was 60-70 years with 84.96%. This corroborates the results of Tavitian et al. in 2010 in France, who found the same age range with 42.63% [1].

Females represented about 54.13%, and the gender ratio male/female was 0.84. This result is not always in line with the literature, as tooth extraction is not related to gender [8,9,11].

In terms of socio-professional status, retired people were the most affected with 38.35%. This could be justified by the fact that these people were financially limited, dependent on their relatives, and their oral health was relegated to the background.

Our sample consisted of 87.97% independent patients and 12.03% dependent patients. These results could be explained by the fact that our participants were mostly young seniors [12].

Clinically, pain was the main reason for 71 patients (53.38%). This result is in line with the literature [1,5,8,11]. Indeed, pain is the most frequent manifestation of oral diseases. It is therefore the intolerance of pain that most often leads patients to seek medical attention.

The types of teeth extracted were 1st and 2nd molars with 39.23%. Several African authors found the same teeth [5,9,13]. However, in some studies in Italy and Canada, wisdom teeth were extracted more [4,15]. Anatomical and physiological particularities may explain this difference. Wisdom teeth not only have a difficult access position, but also often grow in a malposition. Consequently their brushing is sometimes approximate [2]. As our study population was an old one, a large proportion of these patients no longer had wisdom teeth. This could justify the fact that the 1st and 2nd molars were the most extracted teeth.

We obtained an average of 2.75 extracted teeth per patient. This was higher than the literature finding of 1.06 to 2.37 teeth extracted per patient [16]. The difference could be explained by the fact that our study population was an old population likely to have more oral pathologies and very limited financially than a mixed population that includes young and working adults.

The reasons for tooth extraction were multiple. Extractions due to caries were the most common, at 68.11%. This confirms the data of several authors [5,8,9,11,13]. Several reasons could explain this reason for avulsion: the quality of oral hygiene which decreases with age, ignorance, and the distance from dental care center’s for certain patients who have retired to rural areas, the socio-economic level and the attitude of patients who generally only come for consultation at the terminal stage of the carious process [17]. Furthermore, periodontal disease was the second most common reason for extraction with 22.34%. This is in line with the literature, which tells us that dental caries and periodontal disease are the most frequent causes of dental extractions [3]. Of the 261 teeth extracted for carious causes, desmodontitis dominated with 48.65%. In contrast, a study in Cameroon in 2020 [5] found pulp gangrene in 70.5% of patients. In the elderly, desmodontitis on decaying teeth was not very painful and was discovered incidentally during a consultation. Pulpal necrosis came second with 21.07% of cases. During our study we did not encounter any cases of osteitis compared to Nokam Abena et al. in 2020 who had 1.7% [5].

 Periodontal disease accounted for 22.34% of cases in our sample. While a study in Cameroon in 2020 found 5% [5]. This low rate could be explained by the low representativeness of elderly subjects in their sample whereas ours was made up of elderly people only. Chronic periodontitis was the most represented periodontal disease with 78.82%, which could be due to the fact that our study population was ageing and therefore at risk of developing periodontitis [14]. This strong dominance can also be explained by the fact that this pathology often evolves quietly and leads to mobilities that would prevent them from eating. This was also the reason for consultation for some. These periodontal diseases were mostly present in the 60 to 70 year old age group. We can justify this by the predominance of this age group in our sample.

Figure 1: A 60 year old female patient with decayed teeth in pulp necrosis; B 62 year old male patient with decayed teeth in pulp necrosis; C 69 year old male patient with tartar periodontitis.

Tooth extraction in the elderly was frequent. Caries followed by periodontal disease were the recurrent indications for tooth extraction. Molars were the most extracted teeth. The immediate complications encountered were dental fractures and pain.

We would like to thank the people in charge of the three health facilities at the Yaounde Central Hospital (HCY), the Cardinal Paul Emile LEGER National Rehabilitation Centre (CNRPH) and the Cameroonian Presbyterian Church Dental Office in Djoungolo (CDD-EPC) in Yaounde.

We also thank the heads of the Odontostomatology and Geriatrics departments of the Yaounde Central Hospital (HCY), the medical staff of the Cardinal Paul Emile LEGER National Rehabilitation Centre for the Disabled (CNRPH) and the Dental Office of the Cameroonian Presbyterian Church of Djoungolo (CDD-EPC) in Yaounde, for their collaboration. We are very grateful for the patience of the elderly, the target population without whom this study could not have been carried out.

1. Tavitian P, Tosello A, Videau J, et al. 2010. État Bucco-Dentaire Et Statut Nutritionnel: Étude Anthropo-Épidémiologique Chez Les Personnes Âgées. Antropo, 22, 19-28.

2. Boutonnet PH, Bequain JF. Morphologie Des Dents Humaines. EMC Stomatol. 10;1991:3-4.

3. Organisation Mondiale De La Santé. Formulation D’une Politique De Santé Bucco-Dentaire: Manuel a Usage Des Responsables De Programmes De Santé Bucco-Dentaire Dans La Région Africaines De L’oms. Genève 2006.

4. 30. Italio F, Angelillo, Carmelo G, et al. Surver Of Reasons For Extraction Of Permanent Teeth In Italy. Community Dent Oral Epidemiol. 1996;5:336-340

5. Nokam Abena ME, Gamgne Guiadem C, Mengong H, et al. Raisons d’Avulsion Dentaire En Stomatologie En Milieu Camerounais. Health Sci. Dis. 2020;8: 80-83.

6. Aliou T. Extractions Dentaires : Étiologies Et Dents Concernées Au Service D’odontostomatologie Chirurgicale Du CHUOS De Bamako. Thèse 2007-2008 N°386.

7. Mangaga P. Les Raisons D’extractions D’extraction Dentaire Au Gabon [Thèse]: Médecine Dentaire Dakar: Université Cheikh Anta Diop Dakar; 2003.

8. Mahamadou S. Aspects Épidemio-Clinique Des Extractions Dentaires Au CHU-OS De Bamako: 306 Cas. [Thèse] De Chirurgie Dentaire : Faculté De Médecine De L’Université De Bamako; 2013.

9. Marikamosse. Enquête Sur L’extraction Dentaire Au Niveau Du Cabinet Dentaire Privé Du Dr. Ly O.Sangaré. [Thèse] De Chirurgie Dentaire: Faculté De Médecine De L’Université De Bamako; 2010.

10. Agoda P. L’extraction Dentaire Au CHU De Lomé À Propos De 981 Malades De 1996 À 2001[Thèse]: Chirurgie Buccale: Lomé ; 2005:178.

11. Soumare I. Motifs D’extraction De Dents Permanentes En Mauritanie. [Thèse]: Chirurgie Dentaire. Dakar: Université Cheikh Anta Diop De Dakar; 2009:85.

12. Père C. La Réhospitalisassion Précoce Des Personnes Âgées De 75 Ans Et Plus Après Un Passage En Unité D’hospitalisation De Très Courte Durée (UHTCD): Cas De L’uhtcd Du Centre Hospitalier De Bourges. [Thèse]: Doctorat En Médecine, Faculté De Médecine De L’Université De Tours ; 2018.

13. Agoda P, Boko, Tchamdjo P, et al. Extraction Dentaire Au CHU-Campus De Lomé: À Propos De 981 Malades ,De 1996 À 2001. Développ Et Santé. 2005;169:62-69.

14. Jean-Marc B, Martin P, Mike B, et al. Maladies Parodontales Chez Les Adultes De 35 À 44 Ans Du Québec ; Journal De l’Association Dentaire Canadienne, 2001;67:1.

15. Murry H, Clarke M, Locker D, et al. Reasons For Tooth Extractions In Dental Practices In Ontario, Canada Accordind To Tooth Type. Int Dent J. 1997;1:3-8.

16. Chrysanthakapoul NA. Reasons For Extraction Of Permanent Teeth In Greece: A Five Years Follow-Up Study 2011;1:19-24 .

17. Ngapeth M, Itoua E, Obounou A, et al. Etude Clinique Des Complications Infectieuses Dentaires Et Péri Dentaires Observes À l’Hôpital Central De Yaoundé : À Propos Of 161 Cas. Odontostomatol Trop. 2001;1:5-10.

Corresponding author: Nokam Abena Marie Elvire, Head of the Odontostomatology, Department at the District Hospital of green city Yaounde, Cameroon. E-mail: nokamabena@yahoo.fr

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