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Oral health related quality of life of Greek adolescents: a cross-sectional study.

Introduction

Health-related quality of life (HRQoL) is a subject that has gained in importance during recent years. The impact of an individual's health on his/her daily activities can be significant. Quality of life, in general, as well as the factors that contribute to it varies according to differences in age, gender as well as cultural differences [McGrath and Bedi, 2002]. Actions and interactions can be greatly affected which in turn may further reduce the individual's functionality and psychological well being. Thus, HRQoL is considered a multi-dimensional concept, which refers to patients' physical, psychological and social well-being. It is widely recognised for the assessment of healthcare outcomes. A factor that can significantly impact on the HRQoL is the OH (OH) of the individual [McGrath and Bedi 1999; John et al., 2003].

The OH status can in turn be affected by many personal, social and local factors. Differences in the OH status can indeed be seen when comparing differing regions within a country or between countries and geographical locations [Vargas et al., 2003]. Indeed in a recent epidemiological study in Greece, significant differences were found between different regions and between urban and rural (agricultural) areas for the oral status of the inhabitants of these regions [Oulis et al., 2009].

During the last two decades a large spectrum of HRQoL measures have been developed in the field of dentistry, in an effort to capture the impact of oral disorders both on patients' physical and psychological as well as social well-being and their ability to perform daily activities. [Slade, 1997a, Garratt et al., 2002]. This has resulted in the development of the OH-related quality of life (OHRQoL) measurements.

The short form of the OH impact profile (OHIP-14), which was originally developed by Slade and Spencer [1994] for the measurement of disability and discomfort due to oral conditions is one of the most widely known OHRQoL instruments. It consists of 14 items derived from 49-items of the original version [Slade 1997b]. The items of both versions are transformed into seven sub-scales based on a conceptual OH framework suggested by Locker [1988] and derived from the World Health Organisation [1980]. The OHIP-14 is less time-consuming and more practical, thus preferable while a wide range of studies have shown it to have comparable reliability and validity [Slade, 1997b and Locker, 1988] with the long version.

The aim of the present study was to investigate the impact of OH status on the quality of life of a cross-section of adolescents belonging to different population groups in different regions of Greece. This is a part of a larger study investigating the quality of life in different age groups.

Materials and Methods

The study was conducted in different regions of Greece. A random sample consisting of a total of 515 Greek adolescents between the ages of 15-18 years (mean 16.1 [+ or -] 0.9) were selected from different urban and rural areas. The discrimination of the individuals according to the different regions was based on international standards and the last census of 2001 of the Hellenic Statistical Authority. Moreover, in order to be able to make comparisons with the findings of a previous epidemiological study [Oulis et al., 2009], subjects were selected from the following counties. Attica and Thessaloniki, which are the two counties having the major metropolitan centres (where the majority of the Greek population is situated). The three counties with non-metropolitan cities, specifically Achaia (Patras), Ioannina and Kastoria (for simplification these areas will be referred to using the name of their major city). Consequently, from the above mentioned regions of Greece a distinction was made between inhabitants of urban and rural areas.

Stratified cluster sampling was used in order to obtain representation of diverse population groups which may have different quality of life. Given the fact that subjects embraced a number of distinct characteristics sampling frames were used in each region to categorise schools as a first strata and then students 15-18 years of age in each class as second strata. Each stratum was then sampled as an independent sub-population, out of which the schools were selected at first and then the adolescents at each school. This sampling procedure enables inferences to be made about specific subgroups with reference to regions and quality of life parameters for adolescents in the selected schools.

All subjects were acquainted with the purpose of the study, which was approved by the committee for ethics and research of the Athens dental school, all of whom provided informed consent. A self-administrated questionnaire was designed, and face-to-face interviews were conducted by one dentist trained in OHRQoL terms between October 2007 and September 2009. Participants were asked to evaluate on a 5-point Likert scale (0=never, 1=hardly ever, 2=occasionally, 3=fairly often and 4=very often) how frequently during the last year they had experienced any of the problems assessed by the validated 14-item OHIP, while data regarding their socio-demographic profile (e.g. information concerning age, sex, parental education level and occupation) were also recorded.

The short form of the OHIP-14, as mentioned above is one of the most widely known OHRQoL instruments. Apart from the general score, the results can be broken down into the seven subscales which represent the different facets or impacts of OH. These sub-scales are psychological disability, social disability, handicap, physical disability, physical pain, functional limitation and psychological discomfort. The OHIP-14 has been validated for the Greek language for both adolescents [Roumani et al., 2010] and adults.

Besides OHIP-14, the questionnaire also included items for the assessment of different types of construct validity given the absence of a universally accepted "gold standard". More specifically, data regarding self-perceived general and OH status were taken into consideration, as well as participants' satisfaction with their OH status.

The associations between the OHIP-14 score and its seven sub-scales with the self-perceived quality of life were evaluated with Spearman correlations. Comparisons that were made were between metropolitan vs. non-metropolitan, rural vs. urban and the self-perceived health status (both oral and general).

Results

The total number of adolescents interviewed numbered 515. From the two major metropolitan areas the number of subjects were: Athens 112 subjects of whom none were considered to live in rural conditions; Thessaloniki 100 subjects of whom 13 were considered to live in rural conditions on the outskirts of the city. For Patras, there were 102 subjects with 49 rural, for Ioannina there were 100 subjects with 50 rural and for Kastoria there were 101 subjects with 30 rural.

Internal reliability refers to how consistent a study is in measuring what it claims to measure. The internal reliability of self-reported quality of life is often assessed using Cronbach's alpha (a) psychometric measure. In our study the Cronbach alpha test was found to be a=0.86 indicating a high level of internal consistency.

The subjects overall had a relatively low weighted OHIP-14 score of 1.24 (SD 2.04). The metropolitan subjects had a lower score when compared with the non-metropolitan (0.89 vs. 1.48, respectively), however this difference was smaller when the subjects were distinguished as rural or urban (Fig. 1). A score above 1.0 means that there was an impact, albeit small, of OH on the overall quality of life. The same low impact is obvious if the results are shown with the additive method (Fig. 2). The metropolitan subjects especially showed a lower impact of their OH on their quality of life (10.3 mean additive score vs. 14.2 for the non-metropolitan subjects). This score was found to have a significant correlation with both the metropolitan/non-metropolitan (r=0.143, p<0.01) distinction as well as the rural/urban (r=0.09, p<0.05).

For the seven subscales of the OHIP-14 tool (Tables 1 and 2) five were found to have significant correlations for the inhabitants of the different areas. Specifically, important and significant correlations were discovered for functional limitation (p<0.01), handicap (p<0.05) and social disability (p<0.01) both for the metropolitan/non-metropolitan as well as the urban rural distinction. The trend discovered was for a higher impact in inhabitants of the more rural and non-metropolitan regions. Physical pain did not differ between the different regions but physical disability did correlate significantly (at the 0.01 level) for the metropolitan/non-metropolitan distinction.

For the two psychological subscales (psychological discomfort and psychological disability), a relatively high score for discomfort (>2) was reported for the different cities without, however, important differences between cities or the types of regions. Phychological disability however did return a significant correlation (p<0.01) between the type of regions.

Concerning the OHIP-14 score and the gender differences, the scores were found to be at a similar level for the two genders: with male 1.2 (SD=2.0) and female 1.3 (SD=2.0). Only two of the seven subscales were found to be significantly different between genders. The first was the impact of physical pain (p<0.05), with males returning a score of 2.3 (SD [+ or -] 1.7) and female subjects 2.6 (SD [+ or -] 1.6). The same was true concerning the handicap subscale, with males at 1.6 (SD [+ or -] 1.7) and females at 2.0 (SD [+ or -] 1.8) (p<0.01).

No correlations were found between the OHIP-14 scores, or of any of its sub-scales, with the parental education level and occupation.

A majority of 82.4% of the adolescents considered their general health to be good, while only 17.6% as fair. This is mirrored in all the five areas (Figure 3) with the majority having a positive opinion. Nobody considered their general health as being bad. Concerning OH (Figure 4) 60.6% of the adolescents judged this as being good, 37.1% fair and 2.3% bad. When regions were examined, the youths from Ioannina had the lowest percentage (54.5%) for self-perceived OH as being good. Significant correlations were found (at the p [less than or equal to] 0.01 level) for the OHIP-14 score with both self-reported oral and general health. The majority (407 subjects) considered their general health to be good which was reflected in their mean OHIP score of 1.1. For OH the number considering it to be good was greatly lower (296) than for general health. For OH a number of subjects (12) even reported it as being bad, and these individuals had a mean OHIP-14 of 3.3.

For the question 'are you satisfied with your OH?' a significant correlation (p [less than or equal to] 0.01) was determined for the score with OH satisfaction. The majority of the subjects (n=370) were satisfied and thus had a low impact on their quality of life (mean OHIP-14 score of 0.8). Those that were not satisfied with their OH (n=122) had a higher OHIP-14 score of 2.4.

And finally for the question 'how does your OH compare to others?' a significant correlation (p<0.01) of the OHIP-14 score was determined with how each individual perceived their OH to their peers. An almost equal number answered 'better' or the 'same' (221 and 226, respectively) but 37 considered their OH to be worse. The impact score increased quite significantly over the three answers (0.8, 1.2 and 3.5 for better, same, and worse, respectively).

[FIGURE 4 OMITTED]

Discussion

Clinical measures, when looked at separately, do not take into consideration the subjective experiences that individuals have concerning the effects of a disease or condition [Larson 1999]. Quality of life measures are of importance in order to look further than just the presence of health or disease and into the way that the individual perceives his state of health and how this impacts on his daily performance. Moreover, this is of importance when considering health care and how it is provided to different groups and if it is according to the specific needs they may have.

As has been mentioned, OH is an integral part of the overall health of all individuals. It has the power to impact on the daily function and well-being of an individual, leading even to the possibility of incapacitating him/her either physically or psychologically. Indeed, the 18th secretary of the USA Department of Health and Human Services, Dr. Shalala, stated that 'OH problems can lead to needless pain and suffering, causing devastating complications to an individual's well-being, with financial and social cost that significantly diminish quality of life and burden American society' [USA Department of Health and Human Services 2000]. Of course this applies to all societies in general. Thus it is for the overall good of both the individual and society that quality of life is taken into account.

The present study was a population-based study using the short form of the OHIP with 14 standardised questions that had previously been translated into the Greek language and tested for validity. The internal consistency found for the present study with a Cronbach a of 0.86, greatly exceeds the minimum recommended level for this instrument. The sample was chosen to be representative of the Greek population in this specific age group of 15-18 year-olds. This is the first study to examine this section of the Greek population concerning OH quality of life.

Similar to the findings of previous studies in other populations [Soe et al., 2004; Lopez and Baelum, 2006] the impact of OH is limited for youngsters and young adults. Scores above 1.0 mean that there is an impact of OH on the overall quality of life. The present study showed a weighted OHIP-14 score of 1.24 meaning a relatively low effect and confirming the previous studies. Moreover, the sub-scales affected in the present study agree with findings from a similar but larger group of students in Spain, which used the long form [Lopez and Baelum, 2006].

The low impact on quality of life can be attributed to the normally lower severity of oral and dental diseases found in young adults and adolescents. The major impacts on an individual's quality of life are usually seen after severe periodontal disease and tooth loss which severely increases problems in function [Parker and Jamieson, 2010]. Indeed an adult Swedish population the highest OHIP score was associated with severe tooth loss [Einarson et al., 2009] something that was logically very low (or non-existent) in the present group. However, when the self-perceived level of health for the subjects of this study was considered as being bad or worse than their peers the impact also increased significantly reaching to a score of 3.5. A low perception of OH also led to a higher impact on the quality of life of the individual, emphasising the validity of the OHIP-14 questionnaire. This perception can however be affected, apart from the actual oral condition, by the general outlook of a young person which by general admission tends to be less pessimistic than older adults and thus would probably tend to overlook less important problems with their OH.

Similarly, the metropolitan subjects had a lower score when compared with the non-metropolitan (0.89 vs. 1.48, respectively). This can be attributed again to possible differences in OH levels between the two regions. Indeed a recent epidemiological survey of the Greek population [Oulis et al., 2009] did show disparities in OH levels.

OH impacts on the quality of life of the individual, even in adolescence. Though it was of a low impact, it was not completely negligible even in such a general population study. It would be of great interest to further investigate the OH quality of life in individuals focusing on those with significant signs of disease, present or past. These data are important in order to be able to efficiently advocate for resources as well as to allocate public funds and resources in dentistry [Reisine, 1985]. It is important to place dental and OH in the proper context and to show the powers that be that this factor affects the ability to function which in turn has more far reaching economic ramifications.

Conclusions

Functional limitation, handicap, physical pain and psychological discomfort were the primary dimensions affecting the QoL of the subjects. Subjects from metropolitan/urban regions had higher OH related quality of life (OHRQoL) compared to those in non-metropolitan/rural areas. The respondents' self-reported general and dental health correlated significantly with their OHRQoL as measured by the OHIP-14. OH was considered by 44% of adolescents to be better than their peers, reflected in their better OHIP-14 score of 0.8 (SD [+ or -] 1.7)

Acknowledgements

The authors thank all the people from the different regions of Greece, who contributed to the completion of this survey, conducted as part of the National Program 'Assessment and Promotion of the OH of the Hellenic Population' under the auspices of the Hellenic Dental Association in collaboration with the dental schools of Athens and Thessaloniki.

This Program was sponsored by a Colgate-Palmolive grant.

References

Einarson S, Warnberg Gerdin E, Hugoson A; OH impact on quality of life in an adult Swedish population. Acta Odont Scand 2009, 67;85-93.

Garratt A, Schmidt L, Mackintosh A et al. Quality of Life Measurement: Bibliographic Study of Patients Assessed Health Outcome Measures. British Medical Journal 2002, 324;1-5.

John MT, Le Resche L, Koepsell T et al. DL OH-related quality of life in Germany. European Journal of Oral Sciences 2003, 111;483-491.

Larson JS. The conceptualisation of health. Med Care Res Rev 1999, 56;123-136.

Locker D: Measuring OH. a conceptual framework. Community Dental Health 1988, 5:3-18.

Lopez R, Baelum V. Spanish version of the OH Impact Profile (OHIP-Sp). BMC OH 2006, 6;11-18.

McGrath C, Bedi R. The importance of OH to older people's quality of life. Gerondology 1999, 16-59.

McGrath C, Bedi R. Measuring the impact of OH in life quality in two national surveys--functionalist versus hermeneutic approaches. Community Dentistry and Oral Epidemiology 2002, 30;254-259.

Oulis C, Theodorou M, Mastrogiannakis T et al. OH status and treatment needs of the Hellenic population-a pathfinder survey-proposals for improvement. Hellenic Stomatological Review 2009, 53; 97-120.

Parker EJ, Jamieson LM. Associations between indigenous Australian OH literacy and self-reported OH outcomes. BMC OH 2010, 10;3.

Reisine S. Dental health and public policy: the social impact of dental disease. Am J Public Health 1985, 75;27-30.

Roumani T, Oulis CJ, Papagianopoulou V et al. Validation of a Greek version of the OH impact profile (OHIP-14) in adolescents. European Archives of Paediatric Dentistry 2010, 11;247-252.

Slade GD, Spencer AJ. Development and evaluation of the OH Impact Profile. Community Dental Health 1994, 11;3-11.

Slade GD. Measuring OH and Quality of Life. Chapel Hill, University of North Carolina, Dental Ecology, 1997a.

Slade GD. Derivation and validation of a short-form OH impact profile. Community Dentistry and Oral Epidemiology 1997b, 25;284-290.

Soe KK, Gelbier S, Robinson PG. Reliability and validity of two OH related quality of life measures in Myanmar adolescents. Community Dent Health 2004, 21;306-311.

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W. Papaioannou *, C.J. Oulis **, D. Latsou ***, J. Yfantopoulos ***

* Department of Preventive and Community Dentistry, School of Dentistry, University of Athens, Greece, ** Department of Paediatric Dentistry, School of Dentistry, University of Athens, Greece, *** School of Law, Economic and Political Sciences, University of Athens, Greece

Postal address: Dr. C.J. Oulis, Dept of Paediatric Dentistry, Dental School, University of Athens, Greece.

Email: cjoulis@dent.uoa.gr
Table 1. Mean Oral Health Impact Profile-short form (OHIP-14) for
the sub-scales and total scores according to city of residence in
Greek adolescents

City               Functional          Physical
                   limitation            pain

Athens          1.5 [+ or -] 1.6   2.2 [+ or -] 1.5
Thessaloniki    2.2 [+ or -] 1.6   2.4 [+ or -] 1.7
Patras          2.8 [+ or -] 1.8   2.7 [+ or -] 1.9
Ioannina        2.5 [+ or -] 1.6   2.6 [+ or -] 1.7
Kastoria        2.1 [+ or -] 1.6   2.4 [+ or -] 1.6

City             Psychological         Physical
                   discomfort         disability

Athens          2.1 [+ or -] 1.6   1.2 [+ or -] 1.3
Thessaloniki    2.5 [+ or -] 1.6   1.3 [+ or -] 1.6
Patras          2.6 [+ or -] 2.1   2.0 [+ or -] 1.8
Ioannina        2.5 [+ or -] 1.7   2.0 [+ or -] 1.9
Kastoria        2.5 [+ or -] 1.8   1.9 [+ or -] 1.7

City             Psychological          Social
                   disability         disability

Athens          0.6 [+ or -] 1.3   0.4 [+ or -] 1.1
Thessaloniki    1.0 [+ or -] 1.5   0.5 [+ or -] 1.0
Patras          1.6 [+ or -] 1.8   1.0 [+ or -] 1.4
Ioannina        1.5 [+ or -] 1.6   1.0 [+ or -] 1.2
Kastoria        1.4 [+ or -] 1.7   0.8 [+ or -] 1.0

City                Handicap             OHIP
                                        SCORE

Athens          1.3 [+ or -] 1.4   0.8 [+ or -] 1.6
Thessaloniki    1.6 [+ or -] 1.6   1.0 [+ or -] 1.2
Patras          2.1 [+ or -] 2.0   1.8 [+ or -] 2.6
Ioannina        2.0 [+ or -] 2.0   1.3 [+ or -] 2.3
Kastoria        2.0 [+ or -] 1.8   1.2 [+ or -] 2.0

City                   OHIP
                       ADD

Athens           9.5 [+ or -] 7.0
Thessaloniki    11.5 [+ or -] 6.2
Patras          15.1 [+ or -] 10.0
Ioannina        14.4 [+ or -] 9.1
Kastoria        13.4 [+ or -] 8.2

Table 2. Mean Oral Health Impact Profile-short form (OHIP-14) for
the sub-scales and total scores according to region.

Region          Functional          Physical        Psychological
                limitation            pain            discomfort

Urban        2.0 [+ or -] 1.7   2.4 [+ or -] 1.7   2.4 [+ or -] 1.7
Rural        2.6 [+ or -] 1.7   2.6 [+ or -] 1.7   2.6 [+ or -] 1.9
Metro        1.8 [+ or -] 1.6   2.3 [+ or -] 1.6   2.3 [+ or -] 1.6
Non-metro    2.5 [+ or -] 1.7   2.5 [+ or -] 1.7   2.5 [+ or -] 1.8

Region           Physical        Psychological          Social
                disability         disability         disability

Urban        1.6 [+ or -] 1.7   1.1 [+ or -] 1.6   0.6 [+ or -] 1.1
Rural        1.9 [+ or -] 1.8   1.6 [+ or -] 1.7   1.0 [+ or -] 1.3
Metro        1.2 [+ or -] 1.4   0.8 [+ or -] 1.4   0.5 [+ or -] 1.0
Non-metro    1.9 [+ or -] 1.8   1.5 [+ or -] 1.7   0.9 [+ or -] 1.2

Region           Handicap             OHIP               OHIP
                                     SCORE                ADD

Urban        1.7 [+ or -] 1.7   1.2 [+ or -] 1.2   12.0 [+ or -] 8.1
Rural        2.1 [+ or -] 2.0   1.5 [+ or -] 1.3   14.5 [+ or -] 9.1
Metro        1.4 [+ or -] 1.4   0.9 [+ or -] 1.4   10.3 [+ or -] 6.6
Non-metro    2.1 [+ or -] 2.0   1.5 [+ or -] 1.5   14.2 [+ or -] 9.3

Table 3. Significance of the Oral Health Impact Profile-short form
(OHIP-14) sub-scales according to city and regions.

                            City        Region

Functional limitation       0.134 **    0.156 **
Physical pain               0.040       0.034
Psychological discomfort    0.073       0.049
Physical disability         0.175 **    0.079
Psychological disability    0.184 **    0.121 **
Social disability           0.143 **    0.117 **
Handicap                    0.150 **    0.109 *

** Significance of relationship at ps 0.01

Figure 1. The mean Oral Health Impact Profile-short form (OHIP-14)
score (SD) according to region. Correlations and significances
are shown.

Metropolitan         0.89 (S.D. 1.42)
Non-metropolitan     1.48 (S.D. 1.48)
Rural                1.53 (S.D. 1.53)
Urban                1.24 (S.D. 1.24)

Note: Table made from bar graph.

Figure 2. The mean additive Oral Health Impact Profile-short
form (OHIP-14) score (SD) according to region.

Metropolitan         10.3 (S.D. 6.6)
Non-metropolitan     14.2 (S.D. 9.3)
Rural                14.5 (S.D. 9.1)
Urban                12 (S.D. 8.1)

Note: Table made from bar graph.

Figure 3. Proportion of responses to the question
'How would you judge your general health?'

                Fair   Good

Athens           13     87
Thessaloniki     23     77
Patras           22     78
Ioannina         18     82
Kastoria         13     87
Urban            22     78
Rural            16     84

Note: Table made from bar graph.
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Author:Papaioannou, W.; Oulis, C.J.; Latsou, D.; Yfantopoulos, J.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:4EUGR
Date:Jun 1, 2011
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