ORIGINAL Mohebbi ARTICLE et al
Oral Impacts on Daily Performance in 20- to 50-yearolds Demanding Dental Care in Tehran, Iran: Association with Clinical Findings and Self-reported Health Simin Z. Mohebbia/Sedigheh Sheikhzadehb/Azizollah Batebic/ Seyed Hossein Bassird Purpose: To determine the prevalence and intensity of oral impacts on daily performance in 20- to 50-year-olds attending the dental clinic at Tehran Dental School and to investigate the association between the Oral Impacts on Daily Performance (OIDP) score, self-reported oral and general health and clinical findings of oral health. Materials and Methods: The study population comprised 20- to 50-year-olds attending the dental clinic before receiving any treatments. Data were collected using questionnaire-led interviews and clinical examinations. The questionnaire consisted of a validated questionnaire of the Persian version of the OIDP index, sociodemographic characteristics and self-reported general and oral health of subjects. The number of teeth, prosthetic status and the decayed, missing and filled tooth score (DMFT) were recorded according to WHO criteria. Statistical analyses were performed by Wilcoxon test and linear regression modeling. Results: A total of 499 individuals participated in the study. Among the subjects, 82.6% had experienced one or more oral impacts on their daily activities, and 49.5% of impacts were reported to be of severe or very severe intensity. Eating was the performance most frequently affected (50.1%) followed by smiling (16.2%) and sleeping (11.8%). The OIDP score was higher in the participants with a lower wealth index (P = 0.015) and in those with more decayed teeth (P = 0.013). The association between self-reported oral health and OIDP score was of borderline significance (P = 0.05). Conclusion: Oral health status has an enormous impact on the daily performance of Iranian adults attending the dental care center. More emphasis on oral health care in disadvantaged populations, particularly in countries with a developing oral health system, is required. Key words: OIDP, oral health, oral impacts on daily performance, quality of life, self-assessment Oral Health Prev Dent 2014;1:29-36
Submitted for publication: 18.01.12; accepted for publication: 21.12.12
doi: 10.3290/j.ohpd.a31217
T
he contemporary definition of heath is no longer based on the absence of disease and illness, but psychological and social functioning are also inseparable from the concept of health (World Health Organization, 1946; Wilson and Cleary, 1995). It is well known that several inherent limitaa
Assistant Professor, Department of Community Oral Health, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.
b
Resident, Department of Orthodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.
c
Assistant Professor, Department of Health Promotion, Faculty of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
d
Researcher, Dental Research Center, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.
Correspondence: Dr. Seyed Hossein Bassir, Dental Research Center, School of Dentistry, Tehran University of Medical Sciences, 1439955991, Tehran, Iran. Tel: +1-310-801-4208, Fax: +98-21880-15-961. Email:
[email protected]
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tions are associated with traditional oral health indices. Traditional indices do not evaluate functional and psychosocial dimensions of oral health, neither do they reflect the individual’s perceived health status. In addition, clinical indices cannot depict the satisfaction of subjects or their ability to perform daily activities (Locker, 2004; Sheiham and Tsakos, 2007). In response to these limitations, oral health related quality of life measures have been developed in order to improve oral health evaluation by assessing functional, social and psychological outcomes of oral disorders (Adulyanon and Sheiham, 1997). The Oral Impact on Daily Performance (OIDP) is one of the most widely used oral health related quality of life measures, focusing on measuring oral impacts which seriously affect an individual’s daily performance (Adulyanon et al, 1996). This index is based on the conceptual framework of the
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WHO international classification of Impairments, Disabilities and Handicaps (ICIDH) (WHO, 1980), which was adapted for dentistry by Locker (1988). The major adaptation is that three levels of measurements are outlined. The first level of impairment refers to the oral status and conditions (immediate biophysical outcomes) evaluated routinely by clinical indicators, the second level (intermediate impacts) includes pain, discomfort, functional limitation or dissatisfaction about appearance, and the third level (ultimate impacts) represents physical, psychological and social difficulties in the individual’s ability to perform activities of daily life (Adulyanon et al, 1996). The OIDP focuses only on the measurement of the ultimate impacts, and it is comprised of 11 elements which assess the impact of oral health on certain activities and behaviours that cover the physical, psychological and social aspects of daily life. The OIDP score reflects the frequency as well as the severity of the oral impacts (Sheiham et al, 2001). OIDP has been used in several studies in different populations. It has been shown that the OIDP has adequate psychometric properties in different cultural settings and has also been verified to be reliable and valid in cross-sectional populationbased studies (Sheiham et al, 2001; Srisilapanan and Sheiham, 2001; Tsakos et al, 2001b; Robinson et al, 2003; Tsakos et al, 2004; Astrøm et al, 2005; Kida et al, 2006; Dorri et al, 2007; Naito et al, 2007; Jung et al, 2008; Montero et al, 2008; Hobdell et al, 2009; Ostberg et al, 2009; Pereira et al, 2009; Erić et al, 2011; Thelen et al, 2011). Furthermore, it is also valid in studies of patients with specific oral conditions, such as prosthetic rehabilitations (Al-Omiri and Karasneh, 2009), orthodontic appliances (Traebert and Peres, 2007), periodontal problems (Costa et al, 2011), traumatic injuries (Cortes et al, 2002) and malocclusion (de Oliveira and Sheiham, 2003). Oral health related quality of life measures could be directly influenced by socioeconomic conditions. Therefore, psychometric properties of OIDP must be re-established when it is used in a new setting (Streiner and Norman, 1995). Dorri et al (2007) adapted the OIDP index into Persian; they showed that it is a valid and reliable measure for use in Iranian adult populations. The authors reported that about two-thirds of adults had suffered from at least one oral impact (Dorri et al, 2007); however, no clinical examination was included in that study. Moreover, there is no available data on the oral health related quality of life in Iranian patients de-
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manding dental care. Therefore, the objectives of the present study were to determine the prevalence and intensity of the oral impacts on daily performance in 20- to 50-year-olds attending the clinic of Tehran Dental School and to investigate the association between OIDP score, self-reported oral and general health and clinical findings of oral health.
MATERIALS AND METHODS The present cross-sectional study was conducted from March 2011 to June 2011 at the School of Dentistry, Tehran University of Medical Sciences. The Tehran School of Dentistry is the largest and oldest dental faculty in the country with the highest patient turnover. The study population comprised all 20- to 50-year-olds attending the dental clinic at the school of dentistry from 10 to 12 a.m. on all days before receiving any treatments. The convenience sample size calculation was based on the results of a pilot study (_ = 0.05 with a 95% CI and SD = 2.14). Each participant was given a brief explanation about the purpose and process of the study. Subjects then signed informed consent forms before being recruited into the study. The study protocol was reviewed and approved by the Clinical Research Ethics Board of Tehran University of Medical Sciences. Data were collected using questionnaire-led interviews and clinical oral examinations. The questionnaire consisted of validated questions on demographic characteristics, socioeconomic (SES) status, OIDP index and the perceived general and oral health conditions of the subjects. Oral examination was performed to assess clinical oral health status by recording the number of teeth and prosthetic status, as well as by using the decayed, missing and filled tooth index (DMFT). The interviews and clinical oral examinations were conducted by two trained and calibrated (minimum kappa = 0.85) senior dental students. Data were collected over the entire 3-month period.
Measures Demographic characteristics were assessed in terms of age and gender. Educational level was used as the first indicator of the socioeconomic status (SES) and determined by the highest educational level. It was classified into four categories: primary school or less, secondary or high school,
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university education, and postgraduate studies. The second indicator of SES was the wealth index evaluated based on the family income, house ownership, household size and number of persons in the household. Monthly family income was grouped as: less than US $ 400, US $ 401–700, US $ 701– 1400, US $ 1401–2100 and over US $ 2100 (US $=11000 Rials at the time of study). House ownership was recorded with three response options: owner, free of charge for service, tenant. Household size was classified into 4 levels: less than 50 m2, 50–100 m2, 100–150 m2 and more than 150 m2. The response alternatives for each item were then scored so that higher scores showed greater wealth. The number of persons in the household was categorized into four groups: 1 person, 2 persons, 3 persons and 4 persons or more. A sum variable of the wealth index was then calculated by dividing the sum score by the number of people in the household. Data on the impacts of oral condition on daily living activities were obtained using a Persian version of the OIDP, which had been previously used and validated in Iranian adult population (Dorri et al, 2007). The OIDP documented the presence of problems or difficulties in the following daily activities during the past 6 months: eating, speaking, cleaning teeth/dentures, doing light physical activities, going out, sleeping, relaxing, smiling, emotional stability, enjoying contact with other people and performing one’s main role or work. Two scales were used for assessing the frequency of impacts. The period pattern was used for the case of a frequency of oral impacts lower than once a month, determined by using a 0- to 5-point scale, where 0 = ‘never affected’ and 5 = ‘over three months in total’. The regular pattern was used for the case of frequency greater than once a month, where 0 = ‘never affected’, 1 = ‘less than once a month’, 2 = ‘once or twice a month’, 3 = ‘once or twice a week’, 4 = ‘3–4 times a week’ and 5 = ‘every or nearly every day’. The severity score was also documented using a 0- to 5-point scale, ranging from 0 for ‘no effect’ and 5 for ‘very severe effect’ (Adulyanon and Sheiham, 1997). Finally, subjects were requested to determine the specific oral condition that caused each impact. Each OIDP performance score was calculated by multiplying the corresponding frequency and severity scores. The overall OIDP score was then the sum of all performance scores divided by the maximum possible score and multiplied by 100 to obtain a percentage (Dorri et al, 2007).
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Individuals’ assessments of their general and oral health conditions were documented by asking the single-item rating questions of ‘how would you describe your general health?’ and ‘how would you describe your oral health’ with 5 response options, ranging from 1 for very good to 5 for very poor (Chen et al, 1997). The clinical oral examination was performed in a dental unit according to WHO criteria (WHO, 1997). The examination included recording of the number of teeth as well as the DMFT index. The prosthetic status was assessed for the maxilla and mandible separately as: no prosthesis, one fixed partial denture, more than one fixed partial denture, removable partial denture, a combination of fixed and removable partial dentures and removable complete denture.
Statistical analysis The statistical analyses were performed using a software package (PASW statistics 18, SPSS; Chicago, IL, USA). The Wilcoxon test was used to compare the distributions of participants according to the prosthetic status. The associations between ODIP score, self-reported oral health, clinical findings and backgrounds were examined using linear regression analysis, and the related Beta and Pvalues were reported. A significance level of _ = 0.05 was used for all comparisons.
RESULTS A total of 499 individuals (51.9% females) completed a personal interview followed by a full-mouth clinical examination (response rate = 99.4%). The mean age was 34.8 (± 9.91) years, ranging from 20 to 50 years. The socioeconomic characteristics of the participants are shown in Table 1. The majority of the participants had only completed a middle or high school education (78.0%). 17.4% of the participants had an income of more than US $ 700 per month, and most of them lived in a home that they owned (57.9%). More than half of the subjects lived in a 50–100 m2 home (55.3%) and predominantly, the number of persons in the household was four or more (61.1%). The mean for the wealth index was 2.1 (± 1.2), ranging between 0.75 and 10. Clinical data showed that the mean number of teeth was 26.72 (± 6.76), and participants had a
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‘good’ or ‘very good’, while only 31% of the participants perceived their oral health condition as such. Moreover, 42.5% (95% CI, 38%–47%) of the subjects described their oral health condition as ‘poor’
mean DMFT index of 11.74 (± 6.78) (4.38 [± 3.67] decayed, 4.29 [± 6.41] missing and 3.07 [± 3.23] filled teeth). The majority of the subjects did not have any fixed or removable prostheses in the maxilla or mandible (77.3% and 83.8%, respectively, P < 0.001) and a small number of the participants had a maxillary or mandibular removable complete denture (both 1.8%) (Table 2). The prevalence of the oral impacts was very high. 82.6% (95% CI, 79%–86%) of the subjects had experienced one or more oral impacts on their daily activities in the last 6 months (Table 3) and 49.5% (95% CI, 45%–54%) of impacts were reported to be of severe or very severe intensity. The mean overall OIDP score was 5.63 (± 5.56) ranging from 0 to 36.4. The most prevalent affected performance was eating (50.1%). Among the subjects whose eating was affected, 50.8% reported it to be severe or very severe and 19.2% ranked it as a moderate impact. Smiling was the second most prevalent affected performance (16.2%), followed by sleeping (11.8%), cleaning teeth (10.6%) and emotional stability (10.0%). Impacts on doing light physical activities and going out were the least prevalent (6.6% and 5.2%, respectively). Among the impacts, speaking was the most severely affected impact; 70% of participants with impacts on speaking reported it to be severe or very severe. Although performing one’s main role or work and doing light physical activities were less affected, the impacts were mostly very severe when they were affected. The most frequently perceived oral problem was toothache (25.1%). Tooth decay and tooth fracture were the second and third most frequently reported cause of oral impacts (13.8% and 9.2%, respectively). Among the study population, 73.7% (95% CI, 69%–80%) rated their general health condition as
Table 1 Socioeconomic characteristics of 20- to 50-yearolds (N=499) attending patients’ clinic at Tehran dental school
Educational level
Family income (per month)
Variables
n
%
Primary school or less
37
7.4
389
78.0
University education
57
11.4
Postgraduate studies
16
3.2
≤ US $ 400
89
17.8
US $ 401–700
323
64.7
US $ 701–1400
69
13.8
8
1.6
Middle or high school
US $ 1401–2100 >US $ 2100
10
Owner House ownership
Free of charge for service Tenant < 50 m2
Household size
50–100 m2
289
57.9
39
7.8
171
34.3
99
19.8
276
55.3
84
16.8
2
40
8.0
1 person
22
4.4
2 persons
71
14.2
3 persons
101
20.2
4 persons or more
305
61.1
100–150 m >150 m
Number of persons in household
2
2
Table 2 Percentage distribution of prosthetic status in the study population (N=499) Prosthetic status
Maxilla
Mandible
n
%
n
%
386
77.3
418
83.8
One fixed partial denture
56
11.2
33
6.6
More than one fixed partial denture
30
6.0
21
4.2
Removable partial denture
9
1.8
6
1.2
Combination of fixed and removable partial dentures
9
1.8
12
2.4
Removable complete denture
9
1.8
9
1.8
No prosthesis
Statistical significance by Wilcoxon test, P-value< 0.001.
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participants with a lower wealth index (Beta = -0.479, P = 0.015) and also in those with more decayed teeth (Beta = 0.322, P = 0.013). The association between self-reported oral health
or ‘very poor’. The corresponding figure for the perceived general health was 3.4%. Table 4 shows the factors associated with higher OIDP score. The OIDP score was higher in the
Table 3 Prevalence and intensity of impacts in the study population (N=499) Performance Eating Smiling Sleeping
Clean- Emotion ing teeth
Relaxing
Social Speakcontact ing
Work
Light activities
Going out
Overall impact
Prevalence of impacts n
250
81
59
53
50
46
44
40
37
33
26
412
%
50.1
16.2
11.8
10.6
10.0
9.2
8.8
8.0
7.4
6.6
5.2
82.6 Total impactsb (N=719)
Intensity of impactsa Very little
12.8 (32)
13.6 (11)
6.8 (4)
18.9 (10)
8.0 (4)
6.5 (3)
15.9 (7)
10 (4)
16.2 (6)
12.1 (4)
23.1 (6)
12.7 (91)
Little
17.2 (43)
22.2 (18)
11.9 (7)
24.5 (13)
6.0 (3)
21.7 (10)
43.2 (19)
10 (4)
24.3 (9)
18.2 (6)
26.9 (7)
19.3 (139)
Moderate
19.2 (48)
27.2 (22)
15.2 (9)
20.7 (11)
18.0 (9)
19.6 (9)
4.5 (2)
10 (4)
16.2 (6)
24.2 (8)
19.2 (5)
18.5 (133)
Severe
32.0 (80)
18.5 (15)
37.3 (22)
28.3 (15)
42.0 (21)
37.0 (17)
20.5 (9)
42.5 (17)
13.5 (5)
18.2 (6)
19.2 (5)
29.5 (212)
Very severe
18.8 (47)
18.5 (15)
28.8 (17)
7.5 (4)
26.0 (13)
15.2 (7)
15.9 (7)
27.5 (11)
29.8 (11)
27.3 (9)
11.5 (3)
20.0 (144)
a
Impact intensity: % (number) of adults with impact at each intensity level. b Total impacts: % (number) of impacts at each intensity level
Table 4 Factors related to OIDP score in 20- to 50-year-olds (N = 499) referring to Tehran Dental School as revealed by a linear regression modeling 95 % CI Factors
Beta
Lower limit
Upper limit
Std. Error
Sig.
Age
0.058
− 0.043
0.159
0.051
0.257
− 0.665
− 2.471
1.141
0.915
0.468
0.369
− 0.832
1.569
0.608
0.545
0.172
− 0.425
0.768
0.302
0.571
− 0.479
− 0.866
− 0.093
0.196
0.015*
Self-reported oral health
0.502
− 0.351
1.355
0.432
0.050*
Filled teeth
0.214
− 0.102
0.530
0.160
0.183
Missing teeth
0.168
− 0.153
0.489
0.163
0.304
0.322
0.068
0.577
0.129
0.013*
− 0.154
− 1.808
1.499
0.838
0.854
− 2.861
0.691
0.900
0.229
Gender
1
Self-reported general health Educational level Wealth index 1
Decayed teeth Maxillary prosthesis
3
Mandibular prosthesis 1
2
3
2
− 1.085 3
male = 1, female = 2; very good = 1, very poor = 5; No prosthesis, one fixed partial denture, more than one fixed partial denture, removable partial denture, a combination of fixed and removable partial dentures and removable complete dentures. * P ≤ 0.05. Variables were used in their continuous form (R2 = 0.156).
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and OIDP score was of borderline significance (P = 0.05). The overall OIDP score was lower in the subjects who reported their oral health to be better. The regression model fitted well (R2 = 0.156).
DISCUSSION The present study assessed the prevalence and intensity of oral health related impacts and the effects they had on the quality of daily life of individuals attending the clinic and also explored the association between OIDP scores, self-reported oral and general health condition and clinical findings of oral health. The results revealed the mean OIDP score to be 5.6 in this population. In addition, the prevalence of impacts on 11 aspects of daily performance was found to very high; 82.6% of the study population reported having experienced one or more impacts affecting their daily life during the past six months. Taking into account that OIDP impacts are ‘ultimate impacts’, the effect of oral health condition on the quality of life of this population is estimated to be enormous, particularly in low SES individuals. The prevalence of impacts reported in the present study (82.6%) is higher than that reported by Dorri and colleagues who assessed the prevalence of oral impacts in an adult working Iranian population, using similar methodology and the same index, but reporting a prevalence rate of 64.9%. They also reported a lower mean OIDP score (4.15) than did the present study (Dorri et al, 2007). These differences can be explained by the fact that the present study was performed on a population attending the dental clinic, which sees more dental problems compared to the general population. This notion is supported by a previously published study by Montero et al (2011), who reported a higher prevalence of impacts in Spanish dental patients than in the general Spanish population. Nevertheless, they reported a lower OIDP score (5.2) and impact prevalence for dental patients (68.5%) than did the present study. This might be associated with differences in oral health conditions between the two populations; the sample population in the present study had a higher DMFT score compared to Spanish dental patients (11.74 vs 9.8). Moreover, socioeconomic and cultural discrepancies could be other underlying factors responsible for the differences in the prevalence of oral impacts between the populations.
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The present data revealed ‘eating’ to be the most prevalent daily activity affected by oral problems (50.1%), which is in line with the results of several studies in different populations (Sheiham et al, 2001; Tsakos et al, 2001b; Robinson et al, 2003; Astrøm et al, 2005; Kida et al, 2006; Dorri et al, 2007; Naito et al, 2007; Jung et al, 2008; Montero et al, 2008; Al-Omiri and Karasneh, 2009; Hobdell et al, 2009). Moreover, performances such as ‘smiling’, ‘sleeping’ and ‘cleaning teeth’ were also quite prevalent in the study population (16.2%, 11.8% and 10.6%, respectively). This prevalence pattern is generally consistent with those reported in the previous studies (Astrøm et al, 2005; Montero et al, 2008; Hobdell et al, 2009; Montero et al, 2011). Furthermore, the present findings showed that the least affected performances were ‘going out’ and ‘doing light activities’ (5.2% and 6.6%, respectively), which are comparable with those observed in an adult Iranian population (Dorri et al, 2007). In addition to the high prevalence of impacts, the intensity of impacts was severe to very severe in almost half of them, indicating that the quality of life was seriously compromised by oral health problems. Regarding the major cause of OIDP impacts, it was found that ‘toothache’ was the most frequently reported perceived oral problem; this finding is in accordance with those reported in the studies performed in the Spanish population (Montero et al, 2008), a population of older Tanzanians (Kida et al, 2006) and also patients demanding dental care in England (Robinson et al, 2003). From a sociodemographic view, according to the present data, there are no significant relationships between OIDP score and age or gender of the subjects, which is in line with some of the previous studies (Kida et al, 2006; Bernabé et al, 2007). The present data also revealed that participants with a higher level of wealth had lower OIDP scores than the less well-off. This finding is in accordance with other studies using the OIDP index (Srisilapanan and Sheiham, 2001; Kida et al, 2006) and also with studies using other indicators (Atchison and Dolan, 1990; Locker and Slade, 1993), indicating that reduced oral health related quality of life is mostly observed in socially and economically disadvantaged groups. Nevertheless, in the present study, no relationship was found between educational level and OIDP score, in accordance with the study of Srisilapanan and Sheiham performed in a Thai population (Srisilapanan and Sheiham, 2001). These findings suggest that factors related to
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wealth may be more influential than educational level in determining responses to the oral health condition. The present results showed that 73.7% of the subjects reported their perceived general health status as ‘good’ or ‘very good’. This value is very similar to the 73% reported in an adult working Iranian population (Dorri et al, 2007). However, in the present study, 42.5% of subjects rated their oral health status as ‘poor’ or ‘very poor’, which is much higher than the 26.7% observed in the working Iranian population (Dorri et al, 2007). This could be attributed to the fact that, unlike the aforementioned study, the sample population in the present study comprised subjects who were demanding dental treatment. A significant association between the subjective oral health status and the OIDP score was also revealed in the present study, which suggests that subjects who perceived better oral health condition were more likely to have a lower OIDP score. A similar relationship has been found in other studies in a variety of age groups and populations (Astrøm et al, 2005; Kida et al, 2006; Dorri et al, 2007; Jung et al, 2008). This may have implications for the usefulness of single-item selfrated oral health; however, the strength of the association between the subjective oral health status and the OIDP score should be further investigated. From the clinical perspective, consistent with results reported in previous studies (Kida et al, 2006; Montero et al, 2008; Montero et al, 2011), the presence of decayed teeth demonstrated a significant association with the OIDP score. However, it was found that the prosthetic status of the patients had no relationship with the OIDP score. This could be explained by the study of Montero et al (2008), who found that prosthodontic factors mostly affect oral satisfaction rather than the impact level. Since satisfaction could be influenced by values, beliefs, expectations and self-comparisons with previous status (Montero et al, 2008), less satisfaction with oral health status is not always in line with the quality of life. This study was performed to assess the magnitude of oral impacts on daily life in a population with higher dental needs. Whereas the previous study in an Iranian population had not included any clinical data, the present dental setting facilitated oral examinations. A possible limitation of the present study could be the fact that the participants were recruited from a dental care centre. Therefore, further investigations are recommended to collect data from different locations and also el-
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derly and adolescent populations to confirm or refute the findings reported here. Moreover, interventional studies are recommended to evaluate whether dental care reduces the impacts and improves the quality of life.
CONCLUSION Although dental diseases are not life threatening, the oral health status had a great impact on the daily performance of Iranian adults attending the dental care center. More emphasis on oral health care and oral disease prevention in disadvantaged populations, particularly in countries with a developing oral health system, is required.
ACKNOWLEDGEMENTS This project was supported by grant No. 90-02-09-13753 the from Research Deputy of Tehran University of Medical Sciences. We would like to thank Dr. M. Dorri for providing us with the Persian version of the OIDP questionnaire.
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Oral Health & Preventive Dentistry
