2.oral health and the quality of life i

Behavioral Sciences and
Communication Skills
Oral Health and the Quality of Life I
Dr. Caroline Mohamed
1Dr, Caroline Mohamed

Outline of lecture
Oral health and the quality of life
I and II
•Oral-Health-Related Quality of Life:
Definition and historical reflection.
The significance of oral health in terms of public health.
The interrelation between general well being and oral health
•How do we assess it?
•Its role in research.
•Its role in clinical practice.
•Dental/Dental hygiene education. 2Dr, Caroline Mohamed

Is a healthy smile available for all
the children around the world?
Dr, Caroline Mohamed 3

• Unfortunately no !
• Disparities in oral health have emerged as a major
public health problem because socially
disadvantaged groups and nations experience high
levels of oral diseases.
• Caries is one of the most common preventable
childhood chronic diseases. It affects 60% to 90% of
school-aged children in most industrialized
countries.

• Are oral diseases a threat for
global health?

• Yes, because :
• Oral health is an integral part of general health.
• Most oral diseases share the common environmental
and behavioral risk factors with chronic diseases
( cardio vascular disease, obesity & cancer)

Oral health
• Oral health should be assessed as not only the
absence or presence of disease; but also in terms of
its contribution to physical functioning aspects and
social and psychological well-being.

• Tell me some of the possible negative
health consequences of primarily
dental caries among children and
adolescents….

Dental caries consequences...
• such as:
• low self-esteem,
• reduced quality of life & lost school time.
• functional limitations, and
higher risk for hospitalization,
• nutrition & sleep disruption.

• They can contribute to developmental patterns by
such phenomena as obesity and decreased body
height.
• Dental caries can also have negative impacts on
growth and disability.

• Therefore approaches to promote better oral health
and to reduce the inequalities should take into account
both the interrelation between oral health and general
well-being as well as
• the individual behavioral,
• psychological determinants,
• social determinants and
• the complicated pathways
of interaction between
these factors.

ORAL HEALTH
GENERAL WELL-
BEING
SOCIETY
INDIVIDUAL
BEHAVIOR &
PSYCHOLOGY

Definition
• Oral-health related quality of life (OHRQoL) is defined
as that part of a person's quality of life that is
affected by his person's oral health.
• Specifically, OHRQoL considers how oral health
affects the person's functioning (biting, chewing,
speaking), sensations of pain/discomfort, and
psychological (appearance, self-esteem) as well as
social well-being.

• OHRQoL focuses clinicians' attention on the patient
as a whole, and thus fosters truly patient centered
care.
• It can remind basic and clinical researchers in the oral
health sciences that the ultimate outcome of any
intervention or treatment should be an improvement of
a person's quality of life; and it can support dental
and dental hygiene educators in their efforts to train
patient-centered, culturally sensitive, future health
care providers.

• Communicating OHRQoL concerns to the public can be
a successful way to advocate for patients in need of
dental care and/ or without access to dental care.
• It is a powerful behavioral concept that can unite
clinicians, researchers, and educators in their
ultimate goal of improving patients' lives and public
health in general.

History- the dark ages- 70s
• Lay persons´s perceptions of oral health conditions
should not constitute a justification for exemption from
work at the 70s, oral conditions were not regarded as
illnesses because they do not conform with the “ sick
role “(Gerson, 1972)
• Perceptions of health in UK population headaches,
rashes, burns and troubles with teeth were seen as
“ trivial “ problems - not recognized or accepted as ill
health. ( Dunnel and Cartwright, 1972)

70 s
• 1st International Dental Collaborative Study ( Davis,
1976 ) - aside from pain or rare life – threatining
neoplasms, oral disease was associated only with
aesthetics or perceptions of self- esteem, rather than
effects on social roles.

70 s
•The shift from defining health and disease in a purely
biological manner may have begun when the World
Health Organization offered its programmatic
definition of health as more than just physical health
in the 1940s (World Health Organization, 1948).

WHO Health difinition
• Health is not only the absence or presence of a disease;
but also “the state of complete physical, mental and
social well-being”.
• This definition underlines the fact that health is a
resource for everyday life and a positive concept
emphasizing social and personal resources, as well
as physical capacities.
• Modern concept of health has a number of dimensions
(such as physical, mental, emotional, social).

70 s
In medicine, Engel (1977) introduced his now famous
biopsychosocial model of health. This model stressed a
holistic approach to patient care and reflected on the
value of treating patients instead of "body parts." It
views biological processes, psychological factors, and
social forces as interrelated influences all three forces
affect and are affected by one another.

“Plaque-Host-Substrate” theory
Host
21
D Caroline Mohamed
Socio economic
situation
Family Education

70 s
• Around this same time, a change occurred in the way the
term " quality of life" was used in the social sciences.
• Until the 1970s, quality of life had been largely used to
describe societies. Starting in the 1970s, the term began
to be used when analyzing individuals' well-being.
• In psychology, wellness began to be considered as a
crucial aspect of a person's life, and health
psychology began to develop as an independent area
of research around this time.

70 s
•The research community in the US started focusing on the
concept of quality of life, although patients' interactions
with the health care system were always motivated by
quality of life issues such as suffering from pain or not
being able to function.

70s
Patients encountered new cancer treatments (e.g.,
chemotherapy) that were likely to prolong their lives but
reduced the quality of their lives drastically, which led
them to reflect on the cost and benefit of such treatment
and to consider quality of life as a crucial factor for their
decisions.

70 s
In dentistry, the National Institute of Dental and
Craniofacial Research (NIDCR) played a major role in
introducing the concept of oral-health related quality of
life (OHRQoL) to the scientific community by funding
two major conferences centered on this term and
supporting significant numbers of research studies on
this topic.
The first conference was organized by Slade in 1996 and
focused on the measurement of OHRQoL.

2000
The second conference was organized as as an
interdisciplinary workshop on OHRQoL at the University
of Michigan.
The participants worked together with researchers from
dentistry, medicine, nursing, psychology, and public
health to reflect on the role of OHRQoL for clinicians,
basic, clinical, and behavioral researchers as well as
dental educators in the oral health sciences.

These two meetings have inspired
numerous research studies since then and
made the term "OHRQoL" widely used.

2000
In the year 2000, the first-ever Surgeon General's Report
on Oral Health was published in the United States.In her
foreword to this report, the secretary of the U.S. Department
of Health and Human Services, Donna E. Shalala, wrote,
"oral health problems can lead to needless pain and
suffering, causing devastating complications to an
individual's well-being, with financial and social costs
that significantly diminish quality of life and burden
American society". (US. Department of Health and Human Services, 2000).

There was a focus on the relevance of dental health for a
person's quality of life reflecting programmatic shift away
from viewing oral health and disease merely as the
number of decayed, missing, and filled teeth due to
caries, or in terms of attachment loss or pocket depth
due to periodontal disease to a truly patient centered
perspective of oral health, by directing the attention
from the oral cavity to the person as a whole..

Oral-Health-Related
Quality of Life-How Do We
Assess It?

One major step in establishing a new concept in a scientific
field is to develop measurement instruments. Slade
(2002) provides an excellent overview of the three ways
OHRQoL is assessed, namely with:
a) social indicators,
b) global self-ratings of OHRQoL,
and
c) multiple item surveys of OHRQoL.

a) Social indicators of OHRQoL such as:
• the days of restricted work due to dental visits or
• days of work missed because of dental pain or
• children's restricted activity days due to dental
problems or dental visits
can serve an important function by showing that oral
disease has a clear impact on society as a whole.

b) Global self-ratings of OHRQoL usually ask respondents
in surveys such as the third National Health and Nutrition
Examination Survey (NHANES) of the US adult population
to rate their dental health on a five-point scale ranging
from 1 = poor to 5 = excellent.
Such a global assessment can allow comparisons
between different population groups in one country, or
even between countries.

c) Multiple item surveys of OHRQoL.
One of the most widely used instruments is the Oral Health
Impact Profile (OHIP; Slade & Spencer, 1994). It consists of forty-nine
questions concerned with the respondents' functioning;
pain; physical, psychological, and social disability; and
handicap.
The items are answered on five-point rating scales. A
short version of this scale, the OHIP-14, is available as
well (Slade, 1997b).
In addition to these general OHRQoL scales, condition-
specific scales such as the Xerostomia Related Quality of
Life Scale (Henson et al., 2001) were developed as well.

How can we measure OHRQoL in
children or patients whose
special needs may make it
difficult to communicate, such
as in patients with autism or
dementia?

In this case, proxy measurement, namely asking
a significant other to evaluate the child's or
adult's OHRQoL, may be a solution.
Is proxy measurement a valid
way to determine OHRQoL?

YES!
Research showed that parents' assessment of their
child's OHRQoL correlated significantly with objective
oral health indicators such as decayed, missing, and
filled teeth due to caries and decayed, missing, and filled
surfaces due to caries scores (see Filstrup et al., 2003), as
well as with their children's self-assessments.

An additional benefit of asking parents or care givers about
another person's OHRQoL may be that it could engage the
patient in reflecting on the importance of oral health for
his or her quality of life.

Oral-Health-Related Quality of Life-Its Role
in Research
Research concerning oral health issues ranges from:
• basic science research,
• to clinical research,
• behavioral research, and
• public health-related studies,
and it addresses quite diverse topics
ranging from tissue regeneration to access to care issues.
•OHRQoL can play an important role in all these different
types of research.

•In order to develop therapies that have more predictable
outcomes and truly enhance patients' oral health and
quality of life, many factors such as the pain involved for
the patient and esthetic concerns need to be addressed.
•Sommerman ( 2002) arguments focused on breaking basic
science research out of its relative isolation, by demonstrating
that the ultimate goal of enhancing oral health and quality
of life can only be reached in an interconnected effort
with other researchers, clinicians, and educators.

•Concerning basic science research, Somerman (2002)
made a powerful argument when she pointed to the fact that
the outcome of all research endeavors is the
improvement of orocraniofacial health and ultimately
quality of life, and that basic science research cannot
reach this outcome in isolation.
BASIC SCIENCE RESEARCH
OHRQoL

•She described how basic science research has to
become part of an interwoven cycle of activity, where it
connects with translational, clinical, behavioral, and
health services research as well as with clinical practice
and education to ultimately reach the goal of improving
oral health.
•She illustrated this vision of the interconnectedness of
basic science research by using one specific area of
research in the oral health sciences, namely the
regeneration of orocraniofacial tissues as an example.
•.

Her analysis of this research field led her to argue that while
considerable progress has been made in the areas of
biomimetics, biomaterials, and tissue engineering, the
existing therapies based on this research have
limitations.
SCIENCE RESEARCH
THERAPIES BASED ON THIS
RESEARCH

•OHRQoL in her argument is not merely the ultimate
outcome of basic research, but guides it by providing
additional factors that need to be considered on the way
to new therapies.
•Clinical research quite obviously needs to consider
OHRQoL as one important short- and long-term
outcome of certain treatments.

•In addition, OHRQoL can make an important argument
for or against adopting a treatment approach.
•Henson et al. (2001) showed, for example, how
preserving salivary output in head and neck cancer
patients by using parotid-sparing radiotherapy
affected these patients' quality of life quite
significantly.
•Patients who had been treated with the traditional
radiotherapy had significantly worse quality of life
scores than patients treated with the new approach.

In other instances, quality of life concerns can provide an
argument against using a new treatment approach-
despite its clinical effectiveness.
Flamenbaum et al. (2003) showed, for example, that
chemomechanical caries removal in children may not be
preferable compared to the traditional technique.
These authors used a randomized controlled clinical trial to
compare the clinical efficacy, operator perspective, and
patient perspective of chemomechanical and traditional
caries removal of twenty-two first and second occlusally
cavitated deciduous molars respectively.

They found that the new technique took significantly
more time than the older method. This fact may explain
why the operators reported significantly worse ratings of
the children's behavior in the chemomechanical condition
than in the traditional condition, and why the children did
not respond positively to the new treatment.
If effectiveness alone would have been the criteria to
evaluate this new technique, it would have resulted in a
quite favorable evaluation.
However, the consideration of how the new technique
affected the pediatric patients' quality of life can be a
powerful consideration for clinicians who consider the
adoption of such a new technique.

Clinical research also needs to carefully assess long-term
outcomes of certain treatments. One example for OHRQoL
research with this objective in mind is research on the
quality of life of denture patients.
Gray, Inglehart, & Sarment (2002) showed for example that
quite a considerable percentage of the 120 research
respondents with conventional dentures who had
received their dentures between five months and nine
years before they participated in the study reported either
discomfort (20%) or strong discomfort (20%) caused by
their dentures.

Understanding what may affect whether denture patients
have a positive or poor OHRQoL is therefore a crucial
question.

Public health researchers studying oral health issues can also
see the benefit of considering OHRQoL indicators (Eklund
& Burt, 2002). Understanding how oral health disparities
and lack of access to care affect the quality of life of
millions of citizens.
Needs should be carefully documented to inform
politicians and the public in general about the status quo.
It also can be potentially a powerful tool for advocates who
want to reduce these disparities and bring more social
justice to the health care system.

Oral Health-Related Quality of Life and
Clinical Practice
OHRQoL can affirm a clinician's patient-centered
approach to providing care, and thus ultimately improve
patient-provider interactions.
Clinicians should reflect on the meaning of the term "quality
care" and the role QHRQoL issues could play when
providing quality care for all patients.
From the moment patients schedule appointments to the
time when they leave the dental office and return to their
regimen of oral health promotion at home, OHRQoL can
be of considerable importance.

•Providing quality care may begin with taking a medical and
dental history that includes questions concerning how oral
health affects the patient‘s quality of life thus showing
genuine interest in the patient.
•Understanding the relevance of a patient's chief complaint
for this patient's quality of life can be crucial in getting a
clear sense of the patient's expectations concerning the
treatment outcome.

•Assuring that treatment is provided in a way that pain is
avoided to the degree possible, and providing pain
medication in such a way that pain is managed well are
just two instances that show that a clinician considers the
patient's quality of life issues.
•Ultimately, such a consideration will not merely benefit the
patient, but will be positive for all persons involved in
the clinical interaction.

A recent study with adolescent orthodontic patients showed,
for example, that the best predictor of the number of
missed appointments (as determined in a clinical chart
review) was the pain these patients reported to have
experienced during their orthodontic appointments
(Khan et al., 2004).
The more pain they reported to have suffered, the more
missed appointments they had.

This finding is just one of many research results that shows
that patients' quality of life concerns can shape their
seeking or avoiding dental care, and can affect their
cooperation with treatment recommendations.
Even when providing oral hygiene instructions and
health education in general, a consideration of the
patient's quality of life may be one crucial factor that
will ultimately determine if the patient will engage in the
recommended course of action or not.

Oral-Health-Related Quality of Life and
Dental/Dental Hygiene Education
The Institute of Medicine, 1995 published a report on the
future of dental education, which included some clear
recommendations.
Some of them were concerned with educating future
health care providers in such a way that they will provide
truly patient-centered care, will be culturally literate and
sensitive to diversity issues, and will be able to work
with an interdisciplinary perspective that sees oral
health in the context of a patient's overall health. (Institute of
Medicine, 1995).

Inglehart, Tedesco, and Valacovic (2002) took these
recommendations as a starting point to reflect which role
OHRQoL issues could play in this situation.
They started with an analysis of survey data from 1,864
respondents consisting of dental school faculty as well as
directors in hospital programs, dental hygiene and dental
assistant programs, who had rated the importance of
these recommendations.
Their results provided insight into whether there is a
willingness in the educational community to base its
educational efforts on these recommendations.

Their findings showed that the respondents rated the
importance of offering patient-centered education rather
highly.
Given this finding/ the next question is how dental/dental
hygiene educators can translate this objective into their
classroom and clinic activities.

Inglehart et al. (2002) argued that OHRQoL could serve as a
portal to patient-centered education by shaping the
content and thus the focus of educational efforts in
classrooms/ clinics/ and community settings.
Explicitly encouraging students to reflect on how health
and disease affect patients' quality of life, and which role
quality of life concerns can play for their patient's
utilization versus avoidance of health care services may
be a valuable way to educate patient-centered future
providers.

Thank you!!

Activities
• Make a resume of the most
important points of this lecture and
bring to the next class.

• References
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century-the approach of the WHO Global Oral Health Programme. Geneva: WHO; 2003; [cited
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2 Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007; 369: 51–9.
3 Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral
diseases and risks to oral health. Bull World Health 2005; 83: 661-9.
4 Petersen PE, Estupinan-Day S, Ndiaye C. WHO’s action for continuous improvement in oral
health. Bull World Health 2005; 83: 641-720.
5 Watt RG, Sheiham A. Inequalities in oral health: a review of the evidence and recommendations
for action. BDJ 1999; 187: 6-12.
6 WHO. Constitution. New York: WHO; 1946. In Downie RS, Tannahill C, Tannahill A. Health
Promotion: Models and Values. Oxford: Oxford University Press; 1996. p.9.
7. WHO. Ottawa Charter for Health Promotion [Internet]. First International Conference on Health
Promotion; 21 November 1986; Ottawa, Canada – WHO/HPR/HEP/95.1; [cited 26.03.2008].
Available online: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
8. Daly B, Watt RG, Batchelor P,Treasure ET. Essential Dental Public Health. Oxford: Oxford
University Press; 2002.

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