Oral health related quality of life

Abstract

Diseases and disorders that damage the mouth and face can disturb well-being and his self-esteem. Oral health-related quality of life (OHRQOL) is a relatively new but rapidly growing notion. The concept of OHRQOL can become a tool to understand and shape not only the state of clinical practice, dental research and dental education but also that of community at large. There are different approaches to measure OHRQOL; the most popular one is multiple item questionnaires. OHRQOL should be the basis for any oral health programme development. Moreover, research at the conceptual level is needed in countries where OHRQOL has not been previously assessed, including India.

Full text

1 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1
Oral health related quality of life
Darshana Bennadi, C. V. K. Reddy1
Departments of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, SAHE University,
Tumkur, 1J. S. S Dental College and Hospital, Mysore, Karnataka, India
Corresponding author (email:<darmadhu@yahoo.com>)
Dr. Darshana Bennadi, Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital,
SAHE University, Agalkote, Tumkur ‑ 572 107, Karnataka, India.
Abstract
Diseases and disorders that damage the mouth and face can disturb well‑being and his self‑esteem. Oral health‑related
quality of life (OHRQOL) is a relatively new but rapidly growing notion. The concept of OHRQOL can become a
tool to understand and shape not only the state of clinical practice, dental research and dental education but also that
of community at large. There are different approaches to measure OHRQOL; the most popular one is multiple item
questionnaires. OHRQOL should be the basis for any oral health programme development. Moreover, research at the
conceptual level is needed in countries where OHRQOL has not been previously assessed, including India.
Key words: Health, indices, oral health related quality of life, oral health
BACKGROUND
In the preamble of its constitution, the World Health
Organization (WHO) states “Health is a state of
complete physical, mental, and social well‑being and
not merely the absence of disease and infirmity.”[1]
Recent developments in the definition of health and
measurement of health status have little impact on
dentistry. The dental profession has remained narrowly
clinical in its approach to oral health equating health with
disease. This is the reason why dentistry has remained
immune to this broadening concept of health. So now it
is important to know that quality of life (QOL) measures
are not a substitute of measuring outcomes associated
with the disease, but are adjunct to them.[2]
Oral health related quality of life (OHRQOL) is a
relatively new, but rapidly growing phenomenon, which
has emerged over the past 2 decades. Slade and others
identified the shift in the perception of health from
merely the absence of disease and infirmity to complete
physical, mental, and social well‑being, the definition of
the WHO. This shift happened in the second half of the
20th century and it was the result organization (WHO)
as the key issue in the conception of health related
quality of life (HRQOL) and subsequently OHRQOL a
“silent revolution” in the values of highly industrialized
societies from materialistic values that concentrate on
economic stability and security to values focused on
self‑determination and self‑actualization.[3]
It is evident from the literature that the notion of
OHRQOL appeared only in the early 1980s in contrast
to the general HRQOL notion that started to emerge
in the late 1960s. One explanation for the delay in
the development of OHRQOL could be the poor
perception of the impact of oral diseases on QOL.
Only 40 years ago, researchers rejected the idea that
oral diseases could be related to general health. Davis
asserted that apart from pain and life‑threatening
cancers, oral disease does not have any impact on
social life and it is only linked with cosmetic issues.[4]
Likewise, others have argued that dental disease was one
of the frequent complaints such as headache, rash, and
burns that were perceived as unimportant problems[5]
that rarely contributed to the classic “sick role” and
therefore should not be an excuse for exemption from
work.[6] Later, in the late 1970s, the OHRQOL concept
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Journal of International Society of Preventive and Community Dentistry 2January-June 2013, Vol. 3, No. 1
Bennadi and Reddy: Oral health related quality of life
started to evolve as more evidence grew of the impact of
oral disease on social roles.[7‑10]
Clearly, clinical indicators of oral diseases such as
dental caries or periodontal diseases were not entirely
suitable to capture the new concept of health declared
by WHO, particularly the aspects of mental and social
well‑being. This has created a demand for new health
status measures, in contrast to clinical measures of
disease status. As a result, researchers started to develop
alternative measures that would evaluate the physical,
psychological, and social impact of oral conditions on an
individual. These alternative measures are in the form
of standardized questionnaires.[11]
CONCEPT OF OHRQOL
The concept of “OHRQOL” captures the aim of
new perspective i.e., the ultimate goal of dental
care mainly good oral health. According to the US
Surgeon General, oral disease and conditions can
“…undermine self‑image and self‑esteem, discourage
normal social interaction, and cause other health
problems and lead to chronic stress and depression
as well as incur great financial cost. They may also
interfere with vital functions such as breathing, food
selection eating, swallowing and speaking, and with
activities of daily living such as work, school, and
family interactions”.[12] People assess their HRQOL by
comparing their expectations and experiences.[13]
QOL is a highly individual concept. Mount and Scott
likened the assessment of it to assessing the beauty
of rose: No matter how many measurements are
made (Ex‑color, Smell, Height, etc.) the entire beauty of
the rose is never captured. QOL that are important to
an individual, although systems in which patient specify
at least some of the qualities are likely to come closest.
Florence Nightingale was one of the first clinician to
insist on measures the outcome of care to evaluate
treatment.[2]
Definition
OHRQOL as “a multidimensional construct that
reflects (among other things) people’s comfort when
eating, sleeping, and engaging in social interaction; their
self‑esteem; and their satisfaction with respect to their
oral health.”[14]
OHRQOL is associated with:[15] Functional factors,
Psychological factors, Social factors, and Experience of
pain or discomfort [Figure 1].
Uses of quality of life measures in clinical practice
• Identifyingandprioritizingproblems
• Facilitatingcommunication
• Screeningforhiddenproblems
• Facilitatingsharedclinicaldecisionmaking
• Monitoringchanges/responsestotreatment.[15]
Properties needed by measures used in clinical practice
• Validity
• Appropriatenessandacceptability
• Reliability
• Responsivenesstochange
• Interpretability.[15]
Indices used to measure OHRQOL
For the public health purposes, oral health can be
quantified at the macro level using the societal measures
of oral conditions, which demonstrate that oral disease
creates a substantial burden of illness, particularly
among disadvantaged groups. The OHRQOL is a
multidimensional concept that is capturing people’s
perception about factors that are important in their day
today life. The need to develop patient centered measures
of oral health status was first recognized by Cohen and
Jago.[7] Fundamentally, there are three categories of
OHRQOL measure as indicated by Slade.[16] These are
social indicators, global self‑ratings of OHRQOL and
multiple items questionnaires of OHRQOL. Briefly, social
indicators are used to assess the effect of oral conditions at
the community level. Typically, large population surveys
are carried out to express the burden of oral diseases
on the whole population by means of social indicators
such as days of restricted activities, work loss, and school
absence due to oral conditions. While social indicators
are meaningful to policy‑makers, they have limitations
in assessing OHRQOL. For example, using work loss to
measure the impact of oral diseases is not an appropriate
indicator for those who are not working.
Global self‑ratings of OHRQOL, also known as
Functions:
- Mastication
- Speech
ORAL HEALTH
RELATED QUALITY
OF LIFE
Pain / Discomfort:
- Acute
- Chronic
Social:
- Intimacy
- Communication
Psychologic:
- Appearance
- Self esteem
Figure 1: Factors associated with oral health related quality of life

3 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1
Bennadi and Reddy: Oral health related quality of life
addition, these measures can be classified into generic
instruments that measure oral health overall versus
specific instruments. The latter can be specialized
to measure specific oral health dimensions such as
dental anxiety[17] or conditions such as head and neck
cancer[18] or dentofacial deformity[19] or to assess specific
populations such as denture impact on nutritional status
of aged population[20] or children.[21]
Furthermore, OHRQOL instruments vary widely
in terms of the number of questions (items), and
format of questions and responses. Ten OHRQOL
instruments that have been thoroughly tested to
assess their psychometric properties such as reliability,
validity, and responsiveness were presented at the
First International Conference on measuring oral
health.[22] Different measures of OHRQOL with their
author name and year[23] is shown in Table 1 whereas
Table 2 shows different Oral health related quality of life
questionnaires.[11]
Importance of QOL measurement
Most studies that evaluate changes in the oral health
status of individual subjects and populations have
been based on the clinical indicators of disease; there
are relatively few evaluation studies on health and
Table 1: Name of measures with their authors
name and year
Authors Name of measure
Cushing et al., 1986 Social impacts of dental disease
Atchison and Dolan, 1990 Geriatric oral health assessment
index
Strauss and Hunt, 1993 Dental impact profile
Slade and Spencer, 1994 Oral health impact profile
Locker and Miller, 1994 Subjective oral health status
indicators
Leao and Sheiham, 1996 Dental impact on daily living
Adulyanon and Sheiham, 1997 Oral impacts on daily performances
McGrath and Bedi, 2000 OH‑quality of life UK
OH = Oral health
single‑item ratings, refer to asking individuals a general
question about their oral health. Response options to
this global question can be in a categorical or visual
analogscale(VAS)format.Forexample,aglobalquestion
asking: “How do you rate your oral health today?” can
have categorical responses ranging from “Excellent” to
“Poor”orVASresponsesona100mmscale.
Multiple items questionnaires are the most widely
used method to assess OHRQOL. Researchers have
developed QOL instruments specific to oral health
and the number continues to grow rapidly to comply
with the demand of more specific measures. In
Table 2: Oral health related quality of life questionnaires
Instrument Dimensions measured No. of question Response format
Social dental scale Chewing, talking, smiling, laughing, pain
appearances
14 Yes/no
RAND dental health index Pain, worry, conversation 3 4 categories; “not at all” to “a great deal”
General oral health
assessment index
Chewing, eating, social contacts,
appearance, pain, worry, self‑consciousness
12 6 categories; “always‑never”
Dental impact profile Appearance, eating, speech, confidence,
happiness, social life, relationships
25 3 categories; good effect, bad effect, no
effect
Oral health impact profile Function, pain, physical disability, social
disability, handicap
49 5 categories; “very often‑never”
Subjective oral health status
indicators
Chewing, speaking, symptoms, eating,
communication, social relations
42 Various depending on question format
Oral‑health quality of life
inventory
Oral health, nutrition, self‑related oral
health, overall quality of life
56 Part A: 4 categories “not at all” to “a
great deal”
Part B: 4 categories “unhappy‑happy”
Dental impact on daily living Comfort, appearance, pain, daily activities,
eating
36 Various depending on question format
Oral health related quality
of life
Daily activities, social activities,
conversation
3 6 categories; “all of time” to “none of
the time”
Oral impacts on daily
performances
Performance in eating, speaking, oral
hygiene, sleeping, appearance emotion
9 Various depending on question format
RAND = The short form (36) Health survey is a survey of patient health, The SF‑36 is a measure of health status and is commonly used in health economics as
a variable in the quality‑adjusted life year calculation to determine the cost‑effectiveness of a health treatment, The original SF‑36 came out from the Medical
outcome study, MOS, done by the RAND Corporation. Since then a group of researchers from the original study released a commercial version of SF‑36 while the
original SF‑36 is available in public domain license free from RAND. The SF‑36 and RAND‑36 include the same set of items that were developed in the Medical
Outcomes Study. Scoring of the general health and pain scales is different, however, The differences in scoring are summarized by Hays, Sherbourne, and Mazel
(Health Economics, 2: 217‑227, 1993). RAND name originated as a contraction of research and development

Journal of International Society of Preventive and Community Dentistry 4January-June 2013, Vol. 3, No. 1
Bennadi and Reddy: Oral health related quality of life
welfare from the subject’s perception.[24] Over the
last 30 years, the use of socio‑dental indicators in oral
epidemiology has been widely advocated, because
single measures of clinical disease do not document
the full impact of oral disorders.[25,26] These indicators
were constructed and tested in epidemiological studies
on different populations to build a more concrete
relationship between subjective and objective oral
health measures, which would help to estimate the real
population needs.[26]
Several methods have been developed to minimize
the complexity and social and cultural relative aspects
of QOL as well as to provide indexes capable to
capture data beyond the biological and pathological
disease process. In general, health‑related QOL can
be determined by two approaches: The first includes
an interpretative and qualitative explanatory method
and the second, which is the most common approach
is usually based on the questionnaires that emphasize
the subject’s perception on physical and psychological
health and functional capacity.[27]
The results obtained by using these instruments are
usually reported as a score system, which indicates the
severity of the outcome measures or oral diseases.[28]
Information on QOL allows the evaluation of feelings
and perceptions in the individual level, increasing
the possibility of effective communication between
professionals and patients, better understanding of the
impact of oral health on the lives of the subject and family,
and measuring the clinical results of services provided.[26]
In public health, QOL measurement is a useful tool to
plan welfare policies because it is possible to determine
the population needs, priority of care, and evaluation
of adopted treatment strategies; thus helping in the
decision making process.[29] Regarding research, these
measurement tools help to assess the outcomes of
treatments or actions and further develop guidelines for
evidence‑based clinical practice.[27]
OHRQOL to refocus dental education
Educating patient about good oral health promotion and
preventive care will therefore be crucial. OHRQOL
considerations can serve as a tool for bringing about
these changes in the perspective of future clinician.
Dental education aims at training future clinician,
researchers, and administrators as well as future dental
educators. OHRQOL is a crucial concept in professional
lives of all these groups. It provides researchers with a
chance to consider the larger perspective of how their
research will ultimately serve point. It focuses clinician
on providing truly patient centered care, culturally
competent and able to work from an interdisciplinary
perspective. It can contribute to prioritizing the work
of administrators and it can motivate dental educators
by showing them the tremendous difference that their
students can make in the lives of patients.[15,26]
Research on OHRQOL: Current status and future
directions
Research on QOL has gained interest and visibility
in recent decades internationally. “How” we live and
not just “how long” we live has increasingly become
recognized as a central issue in health‑care and health
research. QOL assessment received heightened visibility
with the release of the healthy people 2010 health
promotion and disease prevention initiative. The first
healthy people initiative was started in 1979 and focused
mainly on changes in disease measures.
Current objectives of this initiative are to increase
quality and years of healthy life and to eliminate health
disparities.[15]
Workshops on QOL outcomes assessment are;
Major research recommendations that arose from the
workshop were,
• Oralhealth needs to bedefinedandconceptualized
and appropriate operational measures need to be
brought into systematic use
• More research needs to be conducted to
conceptualized and measure oral health as a system
contributing to total health
• Mediatingandindependentvariableinfluencingoral
health outcomes need to be thoughtfully considered
• An assessment of “Outcomes for whom” needs
to be made to determine the nature and extent of
indicators
• Methodologicalissuessuchasfollowingneedtobe
addressed, development of outcome measure for
longitudinal studies; appropriateness of measures
as influenced by the passage of time, sensitivity,
specificity, reliability, and validity.[15]
Specific research recommendations that focus on social,
psychological, and economic impacts of oral conditions
and treatment,
• Testing the sensitivity of generic health status
indicators for persons with oral conditions and
disorders
• Exploring whether generic instruments such as
sickness illness profile could be modified for use in
patients with oral conditions

5 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1
Bennadi and Reddy: Oral health related quality of life
• Addressing methodological problems as well as
comparing responses to various subjective oral health
indicators in the same population or patient groups
• Investigatingrelationshipsbetweenclinicalindicators
of disease and subjective indicators measuring disease
impact
• Assessingthevalueofsubjectiveindicatorsinclinical
trialsofexisting/newintervention/technologies
• Testing measures and indicators in populations of
all ages.[15]
CONCLUSION
The OHRQOL can provide the basis for any oral
health‑care program and it has to be considered one
of the important element of the Global oral health
program.[30] Research on trends in dentistry and dental
education shows that in future, fewer dentists will take
care of the increasing number of patients. Therefore,
educating these patients about promoting good oral
health and preventive care will be crucial. Research also
shows that certain population segments are drastically
underserved. Dental education has to make a contribution
if this situation is to change. Finally, with rapidly changing
knowledge base and technology in all health‑care fields,
interdisciplinary considerations and collaborations
become increasingly important. QOL measures are
not only being used in population surveys, but also in
randomized clinical trials, technology assessment in
health‑care and evaluation of health‑care delivery systems.
The perception of QOL has a subjective component and
therefore varies from one culture to another. Therefore,
research at the conceptual level is needed in countries
where the OHRQOL has not been described, like
India. This is a necessary step because adapting models
developed and validated in other cultures could lead to
inaccurate measurement of OHRQOL and may not
address the important issues pertaining to Indian culture.
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Source of Support: Nil, Conict of Interest: None declared.
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