J Stomatol Oral Maxillofac Surg 120 (2019) 234–239

Available online at

ScienceDirect
www.sciencedirect.com

Review

Quality of life related to oral health and its impact in adults

J.C. Spanemberg a,*, J.A. Cardoso b, E.M.G.B. Slob c, J. López-López d
a
Faculty of Medicine and Health Sciences (School of Dentistry), University of Barcelona, Spain
b
College of Agrarian Sciences and Health, Brazil
c
UNINTER International University Center, Brazil. Nursing Degree Federal University of Parana, Brazil
d
Faculty of Medicine and Health Sciences (School of Dentistry), Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute), IDIBELL,
University of Barcelona, [2_TD$IF]Spain

A R T I C L E I N F O A B S T R A C T

Article history: Oral health is part of general health, and is recognized as an essential component of quality of life (QoL).
Received 13 December 2018 For years, oral health was determined solely by the clinic, which did not allow an evaluation of the true
Accepted 4 February 2019 impact of oral diseases on the patients’ daily lives. The development of instruments for assessing QoL
Available online 11 February 2019
related to oral health has occurred due to the urgency of determining the effects of changes in the oral
cavity of individuals. This study aims, through a bibliographical survey, to describe issues involving the
Keywords: relationship between QoL and oral health focusing on methodological and conceptual aspects as well as
Quality of life
considering how oral health of adult individuals affects their QoL in a general way. Research in this area
Oral health
Adult health
has developed the concept of "quality of life related to oral health", which comprises four categories:
Oral diseases functional factors, psychological factors, social factors and existence of discomfort or pain. The negative
impacts that poor oral health of the population have on their QoL makes this issue a relevant problem for
public health. Although most oral problems do not represent an immediate risk of death, they are
responsible for decreasing the QoL of individuals as they prolong states of pain and suffering, and cause
functional, aesthetic, nutritional and psychological problems. Actions focused on health education with
emphasis on self-perception, self-protection and self-care should be explored. Programs based on equity
seeking to reduce inequalities and their negative effects on people’s QoL should also be explored.
C 2019 Elsevier Masson SAS. All rights reserved.

1. Introduction of changes in the oral cavity of individuals. A growing interest in

dental research has sought to quantify the consequences of a
Several conditions affect quality of life (QoL) related to oral health disease that affects the routine of the patient. Some questionnaires
in the daily lives of many patients. Many people throughout the have been developed to measure the impacts of oral problems on
world, especially the poorest, are still afflicted by oral problems such quality of life.
as caries and periodontal diseases. For many years, oral health was Problems caused by oral diseases on people’s lives include
determined solely by the clinic, which did not allow an evaluation of chewing problems, less food intake with consequent weight loss,
the true impact of oral diseases on the patients’ daily lives. insomnia, irritability, and low self-esteem. As for adolescents and
The World Health Organization (WHO) published, in 1995, a children, there is a decrease in school performance [3]. Several
project to develop an international method for assessing quality of other cases such as malocclusion, tooth eruption disorders, dental
life, the World Health Organization Quality of Life Assessment trauma, mouth soft tissue tumors, clefts in lips and palate, tooth
(WHOQOL) [1]. The aim of the project was to highlight the value of stains, such as dental fluorosis, may also affect some patients with
understanding patients’ perceptions about their QoL for treatment a variable frequency. However, there is little information about its
decisions and the approval of new medicines [2]. possible functional, emotional and social consequences [4].
The development of instruments for assessing QoL related to Does the poor oral health condition of the population exert a
oral health emerged due to the urgency of determining the effects negative impact on their quality of life? Is this a relevant problem
for public health? Due to all problems that individuals may suffer
because of poor oral health or other disorders related to the health
* Corresponding author. [4_TD$IF]Departament of Odontoestomatology, Faculty of
of the stomatognathic system, it is of utmost importance to know
Medicine and Health Sciences, School of Dentistry Campus Bellvitge, University
of Barcelona, Second Floor, Room 2.32, [5_TD$IF]Spain.
the QoL of each patient in relation to its oral health, as well as the
E-mail address: jcs_odontologia@yahoo.com.br (J.C. Spanemberg). factors that contribute to modify it positively or negatively, both in

https://doi.org/10.1016/j.jormas.2019.02.004
2468-7855/ C 2019 Elsevier Masson SAS. All rights reserved.
 J.C. Spanemberg et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 234–239 235

general health and oral health. Taking into account, the problem of abstracts to exclude publications that presented less information
oral health and the quality of life directly related to it, this study regarding the subject proposed for this study. Articles that referred
aims, through a bibliographical survey, to describe issues involving only to QoL in general, without addressing issues related to oral
the relationship between QoL and oral health, focusing on health or QoLROH, were also excluded.
methodological and conceptual aspects as well as analyzing After an initial search that resulted in 5030 papers, this
how oral health of adult individuals affects their QoL in general. number was reduced to 1,465 by using the inclusion criteria
"English and free full text". Then, we selected the last ten years,
2. Methodology which resulted in 660 papers. After reading the abstracts, we
reduced this number to 41 articles selecting articles that showed
2.1. Literature search strategy and data extraction some clinic evidence. All 41 papers were read in their entirety by
all authors, who came to a consensus about their level of
A bibliographic survey was carried out in online publications evidence. Those that were not considered relevant to this review
databases. The search was performed through an analysis of articles by two or more authors were excluded. The Scottish Intercolle-
published in national and international journals between 2007 and giate Guidelines Network (SIGN) criteria were used for meth-
2017. The search was conducted in the databases PubMed/Medline/ odological validation [5].
Lilacs/Bireme/BVS and SciELO using terms such as: "oral health-related
quality life, oral health impact profile (English); qualidade de vida e 3. Results
saúde bucal, saúde bucal em adultos, qualidade de vida relacionada à
saúde bucal (Portuguese); salud bucal y calidad de vida em adultos, Only 28 of the 41 articles showed evidence level of 1+, 2+, 3 or 4,
impacto en la calidad de [10_TD$IF]vida y salud bucal de adultos (Spanish)". as well as a recommendation level of A, B, C or D (Fig. 1).

2.2. Selection, inclusion criteria and assessment of quality 4. Literature review

We decided to address different topics: concept of QoL, quality 4.1. Quality of life: concepts
of life and its association with oral health, instruments for
measuring QoLROH in adults, and clinical indicators of oral health. In 1948, the World Health Organization (WHO) defined "health
One of the first criteria adopted was a selective reading of article not only as the absence of diseases, but as the condition of perfect
[(Fig._1)TD$IG]

Fig. 1. Flow diagram of the systematic review.

236 J.C. Spanemberg et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 234–239

physical, mental and social well-being." Such a definition generated Quality of life instruments are commonly presented with
many criticisms because it does not allow an objective understand- closed and open questions. Outcome measurements range from
ing of what "complete well-being" is. This is a biological concept objective ones, easily measured, such as death; others are based
belonging to the medical paradigm focusing on etiological agents on clinical or laboratory parameters (e.g., organ failure) including
and clinical outcomes. Its model’s philosophical roots are anchored those based on subjective assessments [14]. They can be divided
in the idea of duality between body and mind, in which mind and into domains: psychological, physical, material, social, among
body are separate entities, and health and disease are seen as others. The basic purpose is to discover the individual’s self-
strictly biological phenomena [6]. perception of his or her oral health and, above all, how it interferes
In 1995, the Quality of Life Group of the WHO Mental Health with their daily life and, consequently, their well-being and
Division defined quality of life as "the individual’s perception of his quality of life [3].
position in life in the context of the culture and values system in It is important that the application of the questionnaire to the
which he lives and in relation to his goals, expectations, standards individual be easy and, if possible, quick. Several instruments are
and concerns" (1). According to this concept, it is inferred that QoL developed in other countries (USA, England, France, Spain, among
is a subjective and broad concept, since it depends on the patient’s others). Therefore, it is mandatory for the application of such
perception. It is multidimensional and composed of different questionnaires in Brazil to be translated and validated for the
dimensions, positive or negative (7). These concepts demonstrate sociocultural characteristics of the population to be investigated
that quality of life can not be interpreted from a narrow [3].
perspective; on the contrary, it must take into account the The instruments that aim to measure the impacts of oral
particularities of each group to be investigated. problems presented by patients on QoL are generally termed socio-
Oral health is part of general health, and is recognized as an essential dental indicators and are fundamental for the construction of
component for quality of life. Research in this area has developed the educational, preventive and curative programs by health pro-
concept of "quality of life related to oral health" (QoLROH), which fessionals. Its applications are broad and include public health
includes four categories: functional factors, psychological factors, social policy actions, clinics and research [3,15].
factors and existence of discomfort or pain [7].
In a more holistic perspective, there has been an increase in [1_TD$IF]4.3. Oral health indicators
studies focusing on the individual not as a body but as a person,
with an increasing importance to subjective experiences and The oral health of the population, throughout history, has
individuals’ interpretations of health and illness [8]. This change of always been evaluated by clinical indicators sensitive to the
model has also provoked transformations in the dental area, with individual’s physical condition (caries, periodontal disease,
an increase in researches seeking to relate the state of oral health of tumors, etc.). With this, dentition is measured by the number of
the population to other diseases and, consequently, its relation decayed, missing and filled teeth, the DMFT index. Other indexes
with quality of life (3). are used to describe the prevalence of diseases, reflecting only the
final stage of the disease. They are very limited when the
4.2. Instruments to measure quality of life related to oral health professional intends to verify pathological effects.
Usually, the evaluation of population needs ignores cultural and
If quality of life is accepted as an entity, it must be recognized socio-behavioral aspects, performing the program of oral health
that there are ways to quantify it. In the last decades, the services considering only normative needs, since it fits a
development of instruments that assess well-being and quality of biomedical model based on the identification of diseases without
life has been increasingly emphasized, and new mechanisms of taking into account the subjective perception of the individual
assessment of QoLROH have been disseminated [9]. [3,16].
There are many tools to assess the dimensions that measure oral Based on this biomedical model, dental care focused on the
health and the quality of life of patients. To measure the impacts of rehabilitation of oral cavity functionality, leaving aside the
oral injuries on the individuals’ quality of life, epidemiological satisfaction and self-perception of the oral health of each patient.
studies have used clinical measurements and measurements based Therefore, it cannot be translated into a model of integral care [13].
on the patients’ self-perception of the impacts that oral problems The indicators that relate oral problems to quality of life were
cause on their daily lives and on their health [10]. developed due to the need to evaluate the oral health condition as
The most applied are the OHIP (The Oral Health Impact Profile) subjectively perceived by patients or to determine the extent of
and its abbreviated version (OHIP-14), the GOHAI (Geriatric Oral oral affections on quality of life [17].
Health Assessment Index), the DIDL (Dental Impacts on Daily Subjective indicators in oral health are a tool to better
Living), and the OIDP (Oral Impacts on Daily Performances) understand the patients’ demands, since they can measure the
[3,7,11]. These instruments were designed to be used for the adult needs reported by them (8) and complete the information provided
population. However, the OHIP and OIDP have also been applied in by clinical indexes, which are not sensitive to the perception of
research with adolescents [3,12]. pain and aesthetics, for example.
The formulation of two of these instruments (OHIP and OIDP) is Such indicators should be used as a complement to clinical
based theoretically on the interpretation that Locker adapted from diagnosis to determine treatments, the possibility of improvement,
ICD-WHO. He established three hierarchical levels of impact and the QoLROH of patients [8,18]. Therefore, the measurement of
according to the degree of affectation of the individual. At the first quality of life is fundamental since it allows us to study the effects
level are oral deficiencies: any functional and anatomical alteration of a treatment or disease, the expectations of the patient, and how
of the stomatognathic apparatus. At the second level are it perceives it according to its environment [13].
intermediate impacts, which are caused by deterioration of the
oral state, pain, discomfort, functional limitations and dissatisfac-
tion with appearance. The third level, or final impact, is represented [12_TD$IF]5. Perception of quality of life of adult individuals and its
by the usual physical, psychological and social activities that a association with oral health
subject may have due to the deterioration of their oral health. This
level is equivalent to that of disability according to the WHO Research has been published proving the association of quality
classification [13]. of life with oral health conditions in individuals of different age
 J.C. Spanemberg et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 234–239 237

groups. In the literature, there are studies evaluating the impacts of care presented an eightfold higher chance of impacts on QoLROH.
dental problems on QoLROH. The influence of carious lesions on As for the physical disability dimension, the variable total
the individuals’ quality of life was investigated in 2005 and 2013, prosthesis requirement presented a greater explanatory power,
respectively, by Oliveira and Nadanovsky [19] and Ulinski et al. a nine-fold higher chance of negative impacts for individuals who
[20]. The need for extractions and the low quality of life was also declared this need [8].
evaluated by Montero-Martı́n et al. (2009) [21]. The use of In a study carried out with Brazilian pregnant women, the OHIP
prosthesis and problems of temporomandibular dysfunction were was low. In this study, the last visit to the dental surgeon happened
addressed by the studies of Dahlstrom and Carlsson (2010) [22], more than 8 years in the past, and the DMFT index was greater than
Miotto et al. (2012) [8] and Gómez-Pino et al. (2017) [23]. Ng and 13. The most affected dimensions were the psychological
Leung (2006) [24] and O’dowd et al. (2010) [25] investigated the dimensions of OHIP, as well as physical pain (26).
relationship between quality of life and periodontal diseases.
Rosell et al. (2013) [26] evaluated pregnant women.
Silva and Fernandes (2001) [15] state that the self-perception of [13_TD$IF]5. Discussing quality of life and oral health
oral condition and the importance dedicated to it condition the
patients’ behavior. Countless times, they do not seek a dental The concept of quality of life related to oral health requires
surgeon because they do not perceive their real needs. The patient consideration not only of factors such as malaise, pain or functional
gives more importance to the symptoms and functional and social changes, but should also include emotional aspects and social
problems caused by the presence of a disease, while the functions associated with oral health [33].
professional evaluates the condition based on the absence or Oral health is a significant component in the general quality
presence of diseases. of life of people, with important implications for their health
The presence or absence of some condition in adulthood, such status [7]. There are patients who, due to a loss of a tooth, fall
as periodontal disease, dental caries, lost and restored teeth, into depression; however, for others, usually of low socioeco-
generate pain, inability to smile, swallow, chew, taste and kiss, nomic level, tooth loss is an unavoidable reality attributable to
which may compromise the psychosocial well-being and influence natural causes such as pregnancy. This is not to say that
self-expression, communication and facial aesthetics, hindering patients of low socioeconomic status are not ashamed of being
even the professional life and causing absenteeism and, therefore, edentulous, especially when the lost tooth compromises
low economic production, as verified by Bennadi & Reddy’s study aesthetics [34].
in 2013 [27]. These conditions may also have a negative impact on Currently, oral diseases are an important public health problem
health, such as increased risk of decompensated diabetes, arthritis, at global and national levels. They contribute to a high rate of
thrombotic events, preterm births and other diseases [28] that illness and have a significant weight on the QoL of individuals
could lead to complications in adulthood. [35]. They are prevalent diseases that produce complications in all
A systematic review was conducted in 2006 by Naito et al. [29] age groups, with gradients differentiated mainly by age and
to evaluate QoLROH and its association with oral conditions of the socioeconomic status. In adults, it has a great relevance because
population. The selected studies did not provide enough informa- oral conditions are characterized by chronic pathologies with a
tion for a quantitative analysis of the problem, but the researchers slow progression [7,36].
observed a real association between poor oral condition and low The most prevalent oral health problems are dental caries and
quality of life [29]. periodontal disease. They do not only develop physical, but also
Montero-Martı́n et al. (2009) [21] found that the presence of economic, social and psychological consequences, that is, they
decayed teeth, with need for extraction or endodontic treatment, affect the patients’ quality of life [29]. Pain, discomfort,
were the main factors affecting the oral quality of life in Spanish limitations, and other conditions arising from aesthetic factors
adults, since these conditions are usually associated with the affecting social life, eating, exercising daily activities and the well-
presence of pain. In addition, decayed teeth in visible areas, such as being of individuals are often caused by oral problems. There is a
premolars, canines and incisors, were of extreme importance due significant impact on people’s quality of life, which makes it
to their impacts on the social and psychological dimensions of the relevant to understand how the individual perceives his or her
individual. However, the presence of a periodontal disease has not own oral condition, since their behavior is conditioned by this
been correlated with a decrease in the impacts on the QoL of the perception [3].
mouth, unless the periodontal disease is very advanced and Under the standpoint of health promotion, the interrelation-
accompanied by dental mobility [21]. Although other studies in ship between oral health and quality of life has been a source of
Jordan have shown that severe chronic periodontitis does have a caution for professionals in the dental area due to the
significant association with the individual’s quality of life, the most importance of oral problems and the physical and psychosocial
affected domains are those that assessed the presence of pain and impacts it may have on individuals’ lives. Many countries have
physical disability [30]. begun to experience preventive oral health programs in
In a cross-sectional study with a cohort of elderly, Andrade schoolchildren, showing positive results in participants who
et al. (2012) [31] demonstrated that patients with a worse were induced to small changes in their clinical state of oral
quality of life rated their oral condition as poor and were more health and in their psychological state. Due to these results, it
likely to develop depression. Ulinski et al. (2013) [20] evaluated can be concluded that clinical indexes do not adequately reflect
an elderly population in Londrina, Brazil, and observed that the state of oral health since they are not able to capture the
educational level and low monthly income associated with functionality nor the psychological state of the patient [7,37].
higher rates of DMFT were associated with a poorer QoL, which Another fact that has been occurring is that studies carried out
was also found in the study by Fontanive et al. (2013) [32], who verifying the evaluation of quality of life related to oral health
observed individuals aged 50–74 years in the city of Porto Alegre, detect a low impact on individuals, which is inconsistent with the
Brazil. prevalence of oral problems in our society. However, what is it to
In adult patients with reported need for prosthesis (total or be healthy? Alternatively, what is it to feel sick? This subjective
partial), Miotto et al. (2012) [8] found a decrease in quality of life. question takes into account the psychological and sociocultural
The reason for the visit to the dental service was the variable factors of the patient without necessarily having any relation with
related to physical pain. Individuals who sought emergency dental the actual clinical situation of the patient. Thus, many individuals
238 J.C. Spanemberg et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 234–239

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