|Year : 2019 | Volume
| Issue : 5 | Page : 280-286
Association between chronic periodontitis and oral health–related quality of life in Indian adults
Tarun Yadav, Priyanka Chopra, Shalini Kapoor
Department of Periodontics, Faculty of Dental Sciences, Shree Guru Gobind Singh Tricentenary University (SGT University), Gurugram, Haryana, India
|Date of Web Publication||24-Sep-2019|
Dr. Shalini Kapoor
Department of Periodontics, Faculty of Dental Sciences, SGT University, Chandu-Budhera, Gurugram–Badli Road, Gurugram 122505, Haryana.
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To assess the marked effect of periodontal conditions on oral health–related quality of life in the population of India. Materials and Methods: This cross-sectional study was carried out among 450 participants, with specific age group 30–60 years, residing in the Gurugram District, Haryana, through various camps conducted by the Faculty of Dental Sciences, SGT University, Gurugram, both in rural and urban areas. The data collection included a combination of clinical examination for the assessment of oral health status and questionnaire administration. Two pretested questionnaires and significant oral findings were the sources of data collection. Age and gender were calculated with correlation quality of life as P > 0.05. Prevalence of oral impacts with severity of periodontitis was analyzed using chi-square test and analysis of variance. Results: The severity of periodontal disease has a direct effect on oral health–related quality of life. Oral impact prevalence was found to be 59% and 81% in participants with moderate periodontitis and/or severe periodontitis, respectively. The extent and severity were also found to be proportional to the severity of periodontitis. Conclusion: Oral health–related quality of life worsens with the extension in severity of chronic periodontitis.
Keywords: Adults, Oral Health, Oral Impacts, Periodontitis, Quality of Life
|How to cite this article:|
Yadav T, Chopra P, Kapoor S. Association between chronic periodontitis and oral health–related quality of life in Indian adults. J Int Oral Health 2019;11:280-6
|How to cite this URL:|
Yadav T, Chopra P, Kapoor S. Association between chronic periodontitis and oral health–related quality of life in Indian adults. J Int Oral Health [serial online] 2019 [cited 2021 Mar 2];11:280-6. Available from: https://www.jioh.org/text.asp?2019/11/5/280/267715
| Introduction|| |
Chronic periodontitis disease is an immune-mediated inflammatory disease, the primary etiology for the disease is specific bacterial complexes in the oral biofilm. The disease may lead to attachment loss and alveolar bone in susceptible patients. Pocket formation and/or gingival recession are major characteristic features clinically. Chronic periodontal disease affects 65% of the Indian population and is considered to be cause of concern for oral health problems in country. The aforementioned global issue of oral health disease relies on the clinical parameters but only few studies have emphasized the importance of social indicators on oral health. Because of this, there was a concept change from managing signs and symptoms to giving patient a voice and also taking in account their subjective experiences and interpretation of their experiences.
Quality of life (QoL) has been defined as “an individual’s perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.” QoL is an overall approach, which not only takes into account an individual’s physical, psychological, and spiritual functioning but also their connections with their environments and opportunities for maintaining and enhancing skills. Evaluation of oral health–related quality of life (OHRQoL) brings together the dimension of social impact and clinical indicators, measures the extent to which health status disrupts normal functionality and social roles, and produces major changes in behavior.
The QoL a person enjoys has a direct effect on his or her daily activity. Good health is reflected in the QoL having a two-way relationship between each other. The poor health affects the routine activities and can decrease the function of an individual and psychological well-being. Evidence from the past reveals that factors such as age/sex, socioeconomic status, and cultural aspects have a strong association with health-related QoL. The concept of OHRQoL has a multidimensional constructs that basically reflects people’s comfort and satisfaction with respect to oral health, that is, while eating, sleeping, mastication, and public interaction.
Oral diseases can be categorized using objective and quantitative indicators. To measure oral health, a disease-based model is formulated. Numerous studies have investigated the prevalence of oral diseases in the adults of India but insufficient data are available regarding the effect of oral health diseases that affect an adult’s daily routine and QoL. This study has used Oral Health Impact Profile (OHIP-14) developed by Slade for measuring the disability, functional limitation, and discomfort due to oral conditions. This is one of the most widely used instruments to measure OHRQoL. The original OHIP consisted of 49 items. The major concern was that it is time-consuming and there were few questions, which did not provide any significant information. To overcome this challenge, OHIP-14 was developed by Slade. This questionnaire was highly specific, reliable, less time-consuming, and more practical when compared to OHIP-49.
The concern for using OHIP-14 was to understand the aftermath on QoL due to periodontitis, which has been substantially less entertained in the past. Several reports from clinical studies have been investigated regarding this association but conclusion could not be withdrawn as approaches to define periodontal disease differ in each study.
In India, there is a high prevalence of periodontal disease but the effect of this immune-mediated inflammatory disease on QoL is yet to be established. Henceforth, this study was undertaken with the aim to evaluate the effect of severity of periodontitis on OHRQoL in adults living in Gurugram District of Haryana, India.
The primary outcomes were to determine the prevalence, extent, and severity of oral impacts in relation to periodontal status of Indian adult population.
| Materials and Methods|| |
The data for this cross-sectional survey study were collected from the local population of Gurgaon District (age range: 30–60 years) through various camps conducted by the Faculty of Dental Sciences (FDS), SGT University, Gurugram. Ethical clearance was obtained from FDS, SGT University (Letter dated, November 21, 2016), and written consents were obtained from all the participants. A total of 450 participants with age range of 30–60 years were recruited for the study. Participants were divided into three groups:
- Group 1, severe periodontitis
- Group 2, moderate periodontitis
- Group 3, no disease (gingivitis)/mild periodontitis
Groups were divided using the case definitions presented by the Centre for Disease Control and Prevention for use in studies of periodontitis, which are population based. Individuals with less than 20 teeth were excluded as it is considered that 20 or more teeth are necessary for satisfactory oral function. Pregnant women and people with learning difficulties and disabled people were excluded from this study. An oral examination and two pretested questionnaires were used to collect the data. The validated Hindi translation of OHIP-14 was used for the study. The OHIP-14 scale consists of 14 impact items:
- Trouble in pronouncing words
- Worsening of taste
- Pain in oral cavity
- Uncomfortable to have food
- Feeling tense and stressed
- Feeling of self-conscious
- Unsatisfactory incomplete diet
- Having to interrupt meals
- Difficult to relax
- Feeling embarrassed
- Feeling irritable
- Difficulty in doing usual work
- Life less satisfying
- Totally unable to function
The frequency of experiencing each impact over past 12 months was reported by subjects on a five-point scale:
- Never (Score: 0)
- Hardly ever (Score: 1)
- Occasionally (Score: 2)
- Fairly often (Score: 3)
- Very often (Score: 4)
The oral examination included the assessment of bleeding on probing, measurement of probing pocket depth (PPD), and clinical attachment loss (CAL) on four surfaces (mesiobuccal, buccal/labial, distobuccal, and lingual/palatal) of all teeth present in the mouth, excluding the third molars. The University of North Carolina-15 probe was used to record periodontal parameters. The OHIP-14 questionnaire was filled after the oral examination. The OHIP-14 scores collected from questionnaire were calculated according to the following:
- Prevalence: The percentage of individuals that is reported one or more than one items fairly often or very often.
- Extent: The number of items that is reported fairly often or often.
- Severity: The total OHIP-14 score that is obtained by summing scores for responses for all 14 items, possibly ranges from 0 to 56. Higher the score, more poorer was the OHRQoL.
The statistical data obtained from the study were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 21 (IBM, Armonk, New York). The demographic profile of study population shows normal distribution and homogenous sample. Age and gender were calculated with correlation QoL as P > 0.05. Prevalence of oral impacts with severity of periodontitis was calculated using chi-square test. Analysis of variance (ANOVA) was also applied.
| Results|| |
There were a total of 450 subjects, among which 53.3% were males and 46.7% were females. Of the 450 total subjects, 163 were in the age category of 30–40 years, 219 were in the age category of 41–50 years, and 68 were in the age category of 51–60 years. The demographic profile of study population shows normal distribution and homogenous sample. Age and gender showed no correlation with QoL as P > 0.05. OHRQoL was significantly better with respect to females but the difference was not statistically significant.
The item-wise prevalence of oral impacts according to the severity of periodontitis was determined. Prevalence of oral impacts showed an upward trend with the increase in the severity of periodontitis. In all the three groups, the most experienced impacts were in relation to painful aching in mouth, which comes under the domain of physical pain in relation to moderate periodontitis (n = 115; 76.67%) and in relation to severe periodontitis (n = 120; 80%). It was found that physical pain was maximum in cases of severe periodontitis (P < 0.001). Least experienced impacts were in the domain of psychological discomfort and psychological disability in all the three groups. Significant differences were found among the groups when psychological discomfort and disability were compared (as P < 0.05). But the results were highly significant when satisfaction level for life was compared among mild/no periodontitis (36%), moderate periodontitis (39.3%), and severe periodontitis (46.6%). The severe the periodontitis, the poorer the health-related QoL. This confirms the hypothesis that OHRQoL declines with increase in the severity of periodontitis.
[Table 1] shows that overall prevalence of oral impacts increases with increase in severity of periodontitis using chi-square test. Maximum prevalence was observed with severe periodontitis group (n = 122; 81.33%). The difference among the three groups was found to be statistically significant.
|Table 1: Overall prevalence of oral impacts according to severity of periodontitis|
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[Table 2] shows the extent of oral impacts according to the severity of periodontitis using ANOVA followed by Tukey’s test. When mild periodontitis was compared to moderate periodontitis, the result was not significant, but significant results were obtained when mild periodontitis and moderate periodontitis groups were compared to severe periodontitis, that is, the number of items that responded often and very often are maximum in severe periodontitis group followed by moderate periodontitis.
[Table 3] and [Graph 1] show groupwise distribution of the study population based on mean OHIP scores. Mean OHIP scores were found to be maximum among subjects with severe periodontitis followed by subjects with moderate periodontitis and mild periodontitis. When this difference in mean OHIP scores was compared using ANOVA, it was found that OHRQoL was significantly affected more among subjects with severe periodontitis when compared with those with mild or moderate periodontitis.,
[Table 4] showed the prevalence that is, percentage of subjects reporting often and very often scores were major in no. with severe periodontitis using chi-square test. Extent, that is, the number of items reported fairly often or very often showed that the number was higher as the severity increases but the difference showed mild significance (P < 0.05). Severity, that is, the total OHIP-14 score obtained by summing scores for responses for all 14 items was directly proportional to the severity of disease, that is, the primary end points were positively associated with the severity of periodontitis.
|Table 4: Prevalence, extent, and severity of oral impacts according to severity of periodontitis|
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[Table 5] and [Graph 2] show relationship between the mean added (ADD)-OHIP-14 and mean PPD, CAL, and gingival bleeding scores. Positive correlations were observed among all the three groups, that is, mean OHIP scores were directly proportional to mean PPD, CAL, and gingival bleeding but this association was found to be significant among moderate and severe periodontitis subjects only. This clearly states that clinical findings were strongly associated with moderate and severe periodontitis. No significant association of clinical findings was observed in mild/no periodontitis group.
|Table 5: Relationship between the mean ADD-Oral Health Impact Profile-14 and mean probing pocket depth (PPD), clinical attachment loss (CAL), and gingival bleeding scores|
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|Graph 2: Relationship between the mean ADD-Oral Health Impact Profile-14 and mean probing pocket depth (PPD), clinical attachment loss (CAL), and gingival bleeding scores|
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| Discussion|| |
The concept of health has gone through a paradigm shift in the recent years. The medical health model is greatly expanded by the addition of the psychosocial aspects of health. Instead of interpreting health as a state of absence of organic disease or pathological processes in the past, health is now interpreted as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. This emerged out of a growing recognition that traditional clinical measures of health need to be supplemented by data obtained from patients and/or persons that capture their experiences and concerns. This is accurate for dentistry too, where there has been a mushrooming of instruments and scales to evaluate what has come to be known as OHRQoL and/or the QoL of patients with various oral conditions.
OHRQoL has implications for dental practice and research in spite of its recent emergence. The World Health Organization recognizes OHRQoL as an integral section of global health program. According to the previous researches, there existed a strong association between chronic periodontitis and OHRQoL. The influence of periodontal disease on the QoL has received mindfulness recently in various studies carried out by Ferreira et al., Ng and Leung, and Patel et al., which suggested a negative impact of periodontal disease on QoL in adults. A correlation between extent and/or severity of periodontal disease and OHRQoL has been shown by studies conducted by Needleman et al., Cunha-Cruz et al., and Bernabé and Marcenes, which also suggested a significant effect of periodontal disease on QoL. To date, however, the impact of mild, moderate, and severe periodontitis on OHRQoL in Indian population has not yet been investigated. Hence, the study was aimed to determine OHRQoL in Indian adults with the use of an assessing tool, that is, OHIP-14.
The OHIP-14 was developed as a shorter version of the OHIP-49. This instrument is one of the most widely used OHRQoL indicators internationally, is available in several languages (including Portuguese, Chinese, French, German, Japanese, Malaysian, Spanish, and Somalian), and has been shown to have face and content validity for different populations.
In this study, we used OHIP-14 as it is a widely used index for the measurement of oral health related with oral diseases. A study, which used OHIP-49, concluded that only 14 items from OHIP-49 identified statistically significant differences in the mean scores between patients with periodontitis and those without. Hence, it suggested that OHIP-49 may not be the most appropriate instrument to assess OHRQoL. Therefore, in this study to understand the association of oral impact with oral health, OHIP-14 was taken into consideration.
The case definition for severe periodontitis was two or more interproximal sites with CAL of ≥6mm (not on same tooth) and one or more interproximal sites with PPD ≥5mm. For moderate periodontitis, it was two or more interproximal sites with CAL of ≥4mm (not on same tooth) or two or more interproximal sites with PPD of ≥5mm (not on same tooth). Those with absence of disease and with mild periodontitis were categorized together as a single group. Similar case definitions were used in studies conducted by Wellapuli and Ekanayake and He et al.
The demographic profile of study population shows normal distribution and homogenous sample. Age-wise group distribution showed QoL did not differ significantly among three age groups when compared using one-way ANOVA test. This clearly stated that age has no correlation with QoL. The results were in accordance with the study carried out by Palma et al. QoL did not differ significantly among males and females. In this study, mean OHIP score was more in females but the difference was statistically insignificant (P > 0.05). The results obtained were contradictory to the result obtained by Lacerda et al. and Silva and Fernandes et al. This variation of result may be attributed to the fact that previous stated studies have more number of females participating in study than males.
In this study, the ubiquity of oral effects showed an upward trend with the severity of periodontitis. OHRQoL declines with the severity of Periodontitis. The most knowledgeable impact in this study was painful aching, which falls under the domain of physical pain (60.6% in mild periodontitis, 76.6% in moderate periodontitis, and 80% in severe periodontitis). Our study is in accordance with the study conducted by Habashneh et al. at University Dental Centre in Jordan, which reported that the prevalence of oral impacts in patients with moderate and severe periodontitis was 54% and 64%, respectively, thus supporting our result that periodontitis has negative impact on OHRQoL. As the prevalence depends on how it is defined, the difference may be attributed to the different case definitions. Costa et al. showed that prevalence rates varied from 14% to 65% when different case definitions were used to define periodontitis. Also difference in the instrument needed to access OHRQoL may contribute to the differences obtained. This could be explained as there are social, cultural, and ethnic dimensions to the perception of oral impacts according to the population studied, so the difference is accepted.
When the groupwise distribution of study population was compared, it showed that the prevalence of oral impacts increased significantly with the increase in the severity of periodontitis [Table 1]. The prevalence of oral impacts in patients with moderate periodontitis was found to be 59.33%, which is closely similar to the study conducted by Habashneh et al. The results were exactly similar to the results obtained when the prevalence of individual impacts was compared. The result of groupwise distribution was exactly similar to the item-wise distribution. This study showed significant upward monotonic trends for the extent of oral impacts across ordered disease severity groups [Table 2]. When mild periodontitis was compared to moderate periodontitis, the result was not significant, but significant results were obtained when mild periodontitis and moderate periodontitis groups were compared to severe periodontitis, that is, the number of items responded often and very often are maximum in severe periodontitis group followed by moderate periodontitis. The results in this study are in accordance with the study conducted by Wellapuli and Ekanayake where maximum extent of oral impacts was found among severe periodontitis group.
The mean ADD-OHIP score for no disease/mild periodontitis group was 18.35, for moderate periodontitis group was 26.67, and for severe periodontitis group was 37.37 [Table 3], that is, with the increase in severity of periodontitis mean ADD-OHIP score increases. The results from this study are in agreement with the findings of previous researches conducted by Brennan and Spencer, Wellapuli and Ekanayake, and Meusel et al. In contrast, a study by Biazevic et al. found no association between periodontal condition and OHRQoL, though this difference in association could be attributed to different study populations among both the studies.
When clinical parameters were compared to the OHRQoL, this study showed that PPD, CAL, and gingival bleeding had no significant relation with OHRQoL in a disease/mild periodontitis group; however, significant relationship was found between PPD, CAL, and gingival bleeding in moderate and severe periodontitis groups [Table 5], [Graph 2]. In spite of thorough literature search, so far no study could be found, which could establish the relationship of CAL, PPD, and gingival bleeding with OHRQoL among subjects with different severity of periodontitis.
Despite the importance of the results of this study, its cross-sectional design, which does not allow the identification of causal associations, limits the investigation. The limitations of the study were shorter time span and small sample size. For the determination of casual associations, evidence of longitudinal studies is needed. Future scope includes longitudinal studies with more sample size to broaden our current understanding of transitions in oral health outcomes over time and across various geographical locations and to conduct population-based awareness programs regarding OHRQoL.
This study concluded that OHRQoL is strongly influenced by the severity of periodontitis. With the increase in severity of periodontitis, the health-related QoL deteriorates.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL Microbial complexes in subgingival plaque. J Clinical Periodontol 1998;25:134-44.
Yoneyama T, Okamoto H, Lindhe J, Socransky SS, Haffajee AD Probing depth, attachment loss and gingival recession. J ClinPeriodontol 1988;9:581-91.
Handa S, Prasad S, Rajashekharappa CB, Garg A, Ryana HK, Khurana C Oral health status of rural and urban population of Gurgaon block, Gurgaon district using WHO assessment form through multistage sampling technique. J Clin Diagn Res 2016;5:43-51.
Koller M, Lorenz W Quality of life: A deconstruction for clinicians. J R Soc Med 2002;95:481-8.
Allen PF Assessment of oral health related quality of life. Health Qual Life Outcomes 2003;1:40.
Papaioannou W, Oulis CJ, Latsou D, Fantopoulos YJ Oral health-related quality of life of Greek adults: A cross-sectional study. Int J Dent 2011;10:1-7.
Hajian TK, Heidari B, Hajian TA Health related quality of life and its socio-demographic determinants among Iranian elderly people: A population based cross-sectional study. J Caring Sci 2017;6:39-47.
Sirisha NR, Srinivas P, Suresh S, Devaki T, Srinivas R, Simha BM Oral health related quality of life among special community adult population with low socioeconomic status residing in Guntur city, Andhra Pradesh: A cross-sectional study. J Indian Assoc Public Health Dent 2014;12:302-5.
Sischo L, Broder HL Oral health-related quality of life: What, why, how, and future implications. J Dent Res 2011;90:1264-70.
Slade GD Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284-90.
Hongxing L, List T, Astrøm AN Validity and reliability of OIDP and OHIP-14: A survey of Chinese high school students. BMC Oral Health 2014;14:158-68.
Al-Harthi LS, Cullinan MP, Leichter JW, Thomson WM The impact of periodontitis on oral health‐related quality of life: A review of the evidence from observational studies. Aus Dent J 2013;58:274-7.
Page RC, Eke PI Case definitions for use in population-based surveillance of periodontitis. J Periodontol 2007;78:1387-99.
Deshpande NC, Nawathe AA Translation and validation of Hindi version of oral health impact profile-14. J Indian Soc Periodontol 2015;19:208-10.
Ainamo J, Bay I Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.
Wade DT, Halligan PW Do biomedical models of illness make for good healthcare systems? BMJ: Br Med J 2004;329:1398-401.
Shamrany AM Oral health-related quality of life: A broader perspective. East Mediterr Health J 2006;12:894-901.
Sayed NE, Baeumer A, Sayed SE, Wieland L, Weber D, Eickholz P, et al
. Twenty years later: Oral health related quality of life and standard of treatment in chronic periodontitis patients. J Periodontol 2018;9:1-8.
Ferreira MC, Dias-Pereira AC, Branco-de-Almeida LS, Martins CC, Paiva SM Impact of periodontal disease on quality of life: A systematic review. J Periodontal Res 2017;52:651-65.
Ng SK, Leung WK Oral health-related quality of life and periodontal status. Community Dent Oral Epidemiol 2006;34:114-22.
Patel RR, Richards PS, Inglehart MR Periodontal health, quality of life, and smiling patterns—An exploration. J Periodontol 2008;79:224-31.
Needleman I, McGrath C, Floyd P, Biddle A Impact of oral health on the life quality of periodontal patients. J Clin Periodontol 2004;31:454-7.
Cunha-Cruz J, Hujoel PP, Kressin NR Oral health-related quality of life of periodontal patients. J Periodontal Res 2007;42: 169-76.
Bernabé E, Marcenes W Periodontal disease and quality of life in British adults. J Clin Periodontol 2010;37:968-72.
Santos CM, Oliveira BH, Nadanovsky P, Hilgert JB, Celeste RK, Hugo FN The Oral Health Impact Profile-14: A unidimensional scale? Cad Saude Publica 2013;29:749-57.
Durham J, Fraser HM, McCracken GI, Stone KM, John MT, Preshaw PM Impact of periodontitis on oral health-related quality of life. J Dent 2013;41:370-6.
Wellapuli N, Ekanayake L Association between chronic periodontitis and oral health-related quality of life in Sri Lankan adults. Int Dent J 2016;12:31-8.
He S, Wei S, Wang J, Ji P Chronic periodontitis and oral health-related quality of life in Chinese adults: A population-based, cross-sectional study. J Periodontol 2018;89:275-84.
Palma PV, Caetano PL, Leite IC Impact of periodontal diseases on health-related quality of life of users of the Brazilian unified health system. Int J Dent 2013:2013:150357.
Lacerda JTD, Castilho EAD, Calvo MCM, Freitas SFTD Oral health and daily performance in adults in Chapeco, Santa Catarina State, Brazil. Cadernos de Saude Publica 2008;24:1846-58.
Silva SRC, Fernandes RAC Self-perception of oral health status by the elderly. Revista Saude Publica 2001;35:349-55.
Al Habashneh R, Khader YS, Salameh S Use of the Arabic version of Oral Health Impact Profile-14 to evaluate the impact of periodontal disease on oral health-related quality of life among Jordanian adults. J Oral Sci 2012;54:113-20.
Costa FO, Guimarães AN, Cota LO, Pataro AL, Segundo TK, Cortelli SC, et al
. Impact of different periodontitis case definitions on periodontal research. J Oral Sci 2009;51:199-206.
Brennan DS, Spencer AJ Life events and oral-health-related quality of life among young adults. Qual Life Res 2009;18:557-65.
Meusel DRDZ, Ramacciato JC, Motta RHL, Junior RBB, Florio FM Impact of the severity of chronic periodontal disease on quality of life. J Oral Sci 2015;57:87-94.
Biazevic MG, Rissotto RR, Michel-Crosato E, Mendes LA, Mendes MO Relationship between oral health and its impact on quality of life among adolescents. Braz Oral Res 2008;22: 36-42.
[Graph 1], [Graph 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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