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Oral health related quality of life
Article · March 2013
DOI: 10.4103/2231-0762.115700 · Source: PubMed
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Review Article
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 identified the shift in the perception of health from
merely the absence of disease and infirmity to complete
In the preamble of its constitution, the World Health physical, mental, and social well‑being, the definition of
Organization (WHO) states “Health is a state of the WHO. This shift happened in the second half of the
complete physical, mental, and social well‑being and 20th century and it was the result organization (WHO)
not merely the absence of disease and infirmity.”[1] as the key issue in the conception of health related
Recent developments in the definition of health and quality of life (HRQOL) and subsequently OHRQOL a
measurement of health status have little impact on “silent revolution” in the values of highly industrialized
dentistry. The dental profession has remained narrowly societies from materialistic values that concentrate on
clinical in its approach to oral health equating health with economic stability and security to values focused on
disease. This is the reason why dentistry has remained self‑determination and self‑actualization.[3]
immune to this broadening concept of health. So now it
is important to know that quality of life (QOL) measures It is evident from the literature that the notion of
are not a substitute of measuring outcomes associated OHRQOL appeared only in the early 1980s in contrast
to the general HRQOL notion that started to emerge
with the disease, but are adjunct to them.[2]
in the late 1960s. One explanation for the delay in
the development of OHRQOL could be the poor
Oral health related quality of life (OHRQOL) is a
perception of the impact of oral diseases on QOL.
relatively new, but rapidly growing phenomenon, which
Only 40 years ago, researchers rejected the idea that
has emerged over the past 2 decades. Slade and others
oral diseases could be related to general health. Davis
asserted that apart from pain and life‑threatening
Access this article online cancers, oral disease does not have any impact on
Quick Response Code: social life and it is only linked with cosmetic issues.[4]
Website:
Likewise, others have argued that dental disease was one
www.jispcd.org
of the frequent complaints such as headache, rash, and
burns that were perceived as unimportant problems[5]
DOI: that rarely contributed to the classic “sick role” and
10.4103/2231-0762.115700 therefore should not be an excuse for exemption from
work.[6] Later, in the late 1970s, the OHRQOL concept
1 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
started to evolve as more evidence grew of the impact of
Functions:
oral disease on social roles.[7‑10] - Mastication
Psychologic:
- Appearance
- Speech - Self esteem
Clearly, clinical indicators of oral diseases such as
dental caries or periodontal diseases were not entirely ORAL HEALTH
RELATED QUALITY
suitable to capture the new concept of health declared OF LIFE
by WHO, particularly the aspects of mental and social
well‑being. This has created a demand for new health
Pain / Discomfort:
status measures, in contrast to clinical measures of -
Social:
Intimacy - Acute
disease status. As a result, researchers started to develop - Communication - Chronic
alternative measures that would evaluate the physical,
Figure 1: Factors associated with oral health related quality of life
psychological, and social impact of oral conditions on an
individual. These alternative measures are in the form Uses of quality of life measures in clinical practice
of standardized questionnaires.[11] • Identifying and prioritizing problems
• Facilitating communication
CONCEPT OF OHRQOL • Screening for hidden problems
• Facilitating shared clinical decision making
The concept of “OHRQOL” captures the aim of • Monitoring changes/responses to treatment.[15]
new perspective i.e., the ultimate goal of dental
care mainly good oral health. According to the US Properties needed by measures used in clinical practice
Surgeon General, oral disease and conditions can • Validity
“…undermine self‑image and self‑esteem, discourage • Appropriateness and acceptability
normal social interaction, and cause other health • Reliability
problems and lead to chronic stress and depression • Responsiveness to change
as well as incur great financial cost. They may also • Interpretability.[15]
interfere with vital functions such as breathing, food
selection eating, swallowing and speaking, and with Indices used to measure OHRQOL
activities of daily living such as work, school, and
family interactions”.[12] People assess their HRQOL by For the public health purposes, oral health can be
comparing their expectations and experiences.[13] quantified at the macro level using the societal measures
of oral conditions, which demonstrate that oral disease
QOL is a highly individual concept. Mount and Scott creates a substantial burden of illness, particularly
likened the assessment of it to assessing the beauty among disadvantaged groups. The OHRQOL is a
of rose: No matter how many measurements are multidimensional concept that is capturing people’s
made (Ex‑color, Smell, Height, etc.) the entire beauty of perception about factors that are important in their day
the rose is never captured. QOL that are important to today life. The need to develop patient centered measures
an individual, although systems in which patient specify of oral health status was first recognized by Cohen and
at least some of the qualities are likely to come closest. Jago.[7] Fundamentally, there are three categories of
Florence Nightingale was one of the first clinician to OHRQOL measure as indicated by Slade.[16] These are
insist on measures the outcome of care to evaluate social indicators, global self‑ratings of OHRQOL and
treatment.[2] multiple items questionnaires of OHRQOL. Briefly, social
indicators are used to assess the effect of oral conditions at
Definition the community level. Typically, large population surveys
are carried out to express the burden of oral diseases
OHRQOL as “a multidimensional construct that on the whole population by means of social indicators
reflects (among other things) people’s comfort when such as days of restricted activities, work loss, and school
eating, sleeping, and engaging in social interaction; their absence due to oral conditions. While social indicators
self‑esteem; and their satisfaction with respect to their are meaningful to policy‑makers, they have limitations
oral health.”[14] in assessing OHRQOL. For example, using work loss to
measure the impact of oral diseases is not an appropriate
OHRQOL is associated with:[15] Functional factors, indicator for those who are not working.
Psychological factors, Social factors, and Experience of
pain or discomfort [Figure 1]. Global self‑ratings of OHRQOL, also known as
January-June 2013, Vol. 3, No. 1 Journal of International Society of Preventive and Community Dentistry 2
Bennadi and Reddy: Oral health related quality of life
single‑item ratings, refer to asking individuals a general addition, these measures can be classified into generic
question about their oral health. Response options to instruments that measure oral health overall versus
this global question can be in a categorical or visual specific instruments. The latter can be specialized
analog scale (VAS) format. For example, a global question to measure specific oral health dimensions such as
asking: “How do you rate your oral health today?” can dental anxiety[17] or conditions such as head and neck
have categorical responses ranging from “Excellent” to cancer[18] or dentofacial deformity[19] or to assess specific
“Poor” or VAS responses on a 100 mm scale. populations such as denture impact on nutritional status
of aged population[20] or children.[21]
Multiple items questionnaires are the most widely
used method to assess OHRQOL. Researchers have Furthermore, OHRQOL instruments vary widely
developed QOL instruments specific to oral health in terms of the number of questions (items), and
and the number continues to grow rapidly to comply format of questions and responses. Ten OHRQOL
with the demand of more specific measures. In instruments that have been thoroughly tested to
assess their psychometric properties such as reliability,
Table 1: Name of measures with their authors validity, and responsiveness were presented at the
name and year First International Conference on measuring oral
Authors Name of measure health.[22] Different measures of OHRQOL with their
Cushing et al., 1986 Social impacts of dental disease author name and year[23] is shown in Table 1 whereas
Atchison and Dolan, 1990 Geriatric oral health assessment Table 2 shows different Oral health related quality of life
index
questionnaires.[11]
Strauss and Hunt, 1993 Dental impact profile
Slade and Spencer, 1994 Oral health impact profile
Locker and Miller, 1994 Subjective oral health status Importance of QOL measurement
indicators
Most studies that evaluate changes in the oral health
Leao and Sheiham, 1996 Dental impact on daily living
Adulyanon and Sheiham, 1997 Oral impacts on daily performances status of individual subjects and populations have
McGrath and Bedi, 2000 OH‑quality of life UK been based on the clinical indicators of disease; there
OH = Oral health are relatively few evaluation studies on health and
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 14 Yes/no
appearances
RAND dental health index Pain, worry, conversation 3 4 categories; “not at all” to “a great deal”
General oral health Chewing, eating, social contacts, 12 6 categories; “always‑never”
assessment index appearance, pain, worry, self‑consciousness
Dental impact profile Appearance, eating, speech, confidence, 25 3 categories; good effect, bad effect, no
happiness, social life, relationships effect
Oral health impact profile Function, pain, physical disability, social 49 5 categories; “very often‑never”
disability, handicap
Subjective oral health status Chewing, speaking, symptoms, eating, 42 Various depending on question format
indicators communication, social relations
Oral‑health quality of life Oral health, nutrition, self‑related oral 56 Part A: 4 categories “not at all” to “a
inventory health, overall quality of life great deal”
Part B: 4 categories “unhappy‑happy”
Dental impact on daily living Comfort, appearance, pain, daily activities, 36 Various depending on question format
eating
Oral health related quality Daily activities, social activities, 3 6 categories; “all of time” to “none of
of life conversation the time”
Oral impacts on daily Performance in eating, speaking, oral 9 Various depending on question format
performances hygiene, sleeping, appearance emotion
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
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
welfare from the subject’s perception.[24] Over the on providing truly patient centered care, culturally
last 30 years, the use of socio‑dental indicators in oral competent and able to work from an interdisciplinary
epidemiology has been widely advocated, because perspective. It can contribute to prioritizing the work
single measures of clinical disease do not document of administrators and it can motivate dental educators
the full impact of oral disorders.[25,26] These indicators by showing them the tremendous difference that their
were constructed and tested in epidemiological studies students can make in the lives of patients.[15,26]
on different populations to build a more concrete
relationship between subjective and objective oral Research on OHRQOL: Current status and future
health measures, which would help to estimate the real directions
population needs.[26]
Research on QOL has gained interest and visibility
Several methods have been developed to minimize in recent decades internationally. “How” we live and
the complexity and social and cultural relative aspects not just “how long” we live has increasingly become
of QOL as well as to provide indexes capable to recognized as a central issue in health‑care and health
capture data beyond the biological and pathological research. QOL assessment received heightened visibility
disease process. In general, health‑related QOL can with the release of the healthy people 2010 health
be determined by two approaches: The first includes promotion and disease prevention initiative. The first
an interpretative and qualitative explanatory method healthy people initiative was started in 1979 and focused
and the second, which is the most common approach mainly on changes in disease measures.
is usually based on the questionnaires that emphasize
the subject’s perception on physical and psychological Current objectives of this initiative are to increase
health and functional capacity.[27] quality and years of healthy life and to eliminate health
disparities.[15]
The results obtained by using these instruments are
usually reported as a score system, which indicates the Workshops on QOL outcomes assessment are;
severity of the outcome measures or oral diseases.[28]
Information on QOL allows the evaluation of feelings Major research recommendations that arose from the
and perceptions in the individual level, increasing workshop were,
the possibility of effective communication between • Oral health needs to be defined and conceptualized
professionals and patients, better understanding of the and appropriate operational measures need to be
impact of oral health on the lives of the subject and family, brought into systematic use
and measuring the clinical results of services provided.[26] • More research needs to be conducted to
conceptualized and measure oral health as a system
In public health, QOL measurement is a useful tool to contributing to total health
plan welfare policies because it is possible to determine • Mediating and independent variable influencing oral
the population needs, priority of care, and evaluation health outcomes need to be thoughtfully considered
of adopted treatment strategies; thus helping in the • An assessment of “Outcomes for whom” needs
decision making process.[29] Regarding research, these to be made to determine the nature and extent of
measurement tools help to assess the outcomes of indicators
treatments or actions and further develop guidelines for • Methodological issues such as following need to be
evidence‑based clinical practice.[27] addressed, development of outcome measure for
longitudinal studies; appropriateness of measures
OHRQOL to refocus dental education as influenced by the passage of time, sensitivity,
specificity, reliability, and validity.[15]
Educating patient about good oral health promotion and
preventive care will therefore be crucial. OHRQOL Specific research recommendations that focus on social,
considerations can serve as a tool for bringing about psychological, and economic impacts of oral conditions
these changes in the perspective of future clinician. and treatment,
Dental education aims at training future clinician, • Testing the sensitivity of generic health status
researchers, and administrators as well as future dental indicators for persons with oral conditions and
educators. OHRQOL is a crucial concept in professional disorders
lives of all these groups. It provides researchers with a • Exploring whether generic instruments such as
chance to consider the larger perspective of how their sickness illness profile could be modified for use in
research will ultimately serve point. It focuses clinician patients with oral conditions
January-June 2013, Vol. 3, No. 1 Journal of International Society of Preventive and Community Dentistry 4
Bennadi and Reddy: Oral health related quality of life
• A ddressing methodological problems as well as dental problems. J Can Dent Assoc (Tor) 1972;38:370‑2.
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