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Oral Health Impact of Periodontal Diseases in Adolescents
R. López* and
V. Baelum
Royal Dental College, Faculty of Health Sciences, University of Aarhus, Vennelyst Boulevard 9, DK-8000 Aarhus C, Denmark
Correspondence: * corresponding author, rlopez{at}odont.au.dk
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ABSTRACT
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The need for treatment of destructive periodontal diseases is based on observations made by oral health professionals, who, prompted by clinical findings, recommend treatment. We hypothesized that clinical signs of periodontal destruction have an impact on the oral-health-related quality of life of adolescents. We conducted a cross-sectional study among 9203 Chilean high school students sampled by a multistage random cluster procedure. We recorded clinical attachment levels and the presence of necrotizing ulcerative gingivitis. The students answered the Spanish version of the Oral Health Impact Profile and provided information on several socio-economic indicators. The results of multivariable logistic regression analyses (adjusted for age, gender, and tooth loss) showed that both attachment loss [OR = 2.0] and necrotizing ulcerative gingivitis [OR = 1.6] were significantly associated with higher impact on the Oral Health Related Quality of Life of adolescents. Individuals in lower socioeconomic positions systematically reported a higher impact on their oral-health-related quality of life.
Key Words: adolescence • periodontitis • periodontal disease • quality of life • socioeconomic factors
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INTRODUCTION
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The need for treatment of destructive periodontal diseases is typically based on observations made by dental professionals, who, prompted by findings of clinical attachment loss or increased probing pocket depth, recommend treatment. Less often does periodontal treatment result from individuals demanding treatment owing to self-perceived periodontal problems. Even so, it remains unclear whether, or to what extent, these professional observations of signs of periodontal destruction do represent an impact for the individual.
Patient-centered outcomes research has developed considerably in dentistry during the last two decades (Buck and Newton, 2001), but little attention has been devoted to the impact of periodontal conditions on people’s Oral Health Related Quality of Life (OHRQoL). The results of the few studies that have addressed periodontal conditions as a source of reduced quality of life suggeset either modest (Slade et al., 1996; Jones et al., 2004) or significant (Ng and Leung, 2006) associations between periodontal disease and the quality of life. Unfortunately, those studies have considered only adult populations, and the resilient confounding effects of factors such as age, gender, and socio-economic position have only occasionally been addressed (Ng and Leung, 2006). When socio-economic factors have been considered, adjustment has been by education level only, and influential indicators of socio-economic position, such as income and wealth, have been omitted (Ng and Leung, 2006). However, these factors are closely related to periodontal health (Lopez et al., 2006), and to the way people perceive the impact of health on their quality of life (von Rueden et al., 2006). The aim of this study was to assess the impact of clinical signs of periodontal destruction on the oral-heath-related quality of life of adolescents, taking into account the possible confounding effects of age, gender, and factors representing the most influential dimensions of socioeconomic position.
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MATERIALS & METHODS
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Study Population
The data originated from a population-based study of periodontal diseases conducted among Chilean adolescents (Lopez et al., 2001, 2002). Briefly, the target population was sampled by means of a multistage random cluster procedure, resulting in a study population of 9203 students distributed among 98 high schools of the Province of Santiago. The prevalence estimates are representative of the high school population of the Province of Santiago, which is 85% of the adolescent population of the Province. Details on the sampling methods have been described previously (Lopez et al., 2001; Lopez, 2003). The study protocol was approved by the local ethical committee of the University of Chile, and the headmasters of the selected high schools approved the participation of the institutions and obtained informed consent from the parents of the students. The participants were informed about their right to abandon the study at any time.
Clinical Examinations
In total, 9163 students from the study population accepted the invitation to participate in the clinical examinations, which consisted of: direct recordings of clinical attachment loss (CAL), in mm, at 6 sites on first and second molars and incisors; the recording of the presence or absence of necrotizing ulcerative gingival lesions (NUG); and the recording of tooth loss. Additional details on the recording methods and the reliability of the recordings have been published elsewhere (Lopez et al., 2001, 2002, 2003, 2006; Lopez and Baelum, 2004, 2006a).
Oral Health Related Quality of Life Instrument
All 9163 persons who participated in the clinical examinations were invited to answer the Spanish version of the Oral Health Impact Profile (OHIP-Sp). The instrument was developed from the original Oral Health Impact Profile (OHIP) questionnaire (Slade and Spencer, 1994), which is a comprehensive and widely used instrument for assessing the impact of oral health on the quality of life. An extensive body of literature documents its validity and reliability among adults (Slade, 1997, 1998; Allen et al., 2001; Soe et al., 2004; Locker et al., 2004), as well as among adolescents (Broder et al., 2000; Soe et al., 2004). The internal consistency and the convergent and discriminative validity of the Spanish version of the OHIP have been previously reported for adolescents (Lopez and Baelum, 2006b). In addition, the OHIP has been shown to be reliable (Slade, 1997; Soe et al., 2004) and sensitive to changes (Slade, 1998; Allen et al., 2001), and to exhibit suitable cross-cultural consistency (Allison et al., 1999). These qualities make it an excellent tool for the purpose of the present study, which places strong demands on the test chosen, due to periodontal destruction being considerably milder among adolescents than among adults (Lopez, 2003). This calls for an instrument with high reliability and appropriate sensitivity, to capture the possibly lesser oral health impact (for review, see Lopez and Baelum, 2006b). Finally, while alternative questionnaires have been developed for children, these have not been validated in adolescent populations (Jokovic et al., 2002; Foster Page et al., 2005).
A few modifications were introduced in the use of the OHIP-Sp for adolescent populations. We decided to use ’lifetime’ as the recall period, and dichotomized the answers categories to ’yes’ or ’no’, rather than using the original Likert-like ordinal scale. This decision was based on the recognized disadvantages of using ordinal scales for questionnaire responses (Massof, 2004). The decision was also influenced by the results of a previous investigation, where the OHIP was used among adults, which suggested that the differences between and among groups may be consistent, independent of the use of dichotomous or ordinal scaling systems (Slade, 1998). The fact that an impact on the oral-health-related quality of life is likely to be less among adolescents than among adults further supported the use of a lifetime recall period among adolescents. While it may be argued that periodontal destruction around permanent teeth cannot have an impact before eruption of these teeth, it must be taken into consideration that the disease process is chronic in nature, and that a great loss of sensitivity would be expected if the recall period was restricted to a shorter period of time. The implications of these amendments have been thoroughly discussed in a previous report (Lopez and Baelum, 2006b).
Socio-demographic Correlates
The students who participated in the clinical examination also provided information on 8 indicators of socio-economic position. For the present analyses, we considered only 6 indicators that were statistically significantly associated with CAL and NUG in multivariable analyses (Lopez et al., 2006): household size, housing status, number of cars owned by the family, monthly paternal income, and the level of parental education achieved (Table 1 ).
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Table 1. Distribution of Periodontal Conditions According to the Socio-demographic Characteristics of the Study Population (n = 9133)
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Missing Values
The number of missing answers for the OHIP-Sp was calculated, and questionnaires with more than 5 missing answers were excluded from the analyses.
Logistic Regression Analyses
The total OHIP-Sp score (possible values = 0–49) was calculated for each person (Fig.), and this variable was dichotomized with the median score of 8, such that persons with scores in the range from 0 to 7 (46.9%) were considered to represent low OHRQoL impact, and persons with scores of 8 and above were considered to represent high OHRQoL impact. Univariable logistic regression analyses were carried out for the socio-economic indicators and either of the clinical outcomes (clinical attachment loss  3 mm and the presence of necrotizing ulcerative gingival lesions). Variables with a p-value < 0.25 in the univariable analyses (Hosmer and Lemeshow, 2000) were selected to be included as covariates in age, gender, and tooth-loss-adjusted multivariable logistic regression analyses. Tooth loss was included in the models with a view to adjustment for caries as a cause of impact, since caries is the main cause of tooth loss in this young population. We used the option ’robust cluster’ for the procedure ’logit’ (StataCorp., Release 9, College Station, TX, USA) to account for the fact that the students were clustered in classes, which were the final sampling unit. The regression models were built by the consecutive exclusion of single variables from the full model, with the likelihood ratio test used to determine the importance of the variable, as previously described (Hosmer and Lemeshow, 2000). Following exclusion of a variable, the model was refitted, and the stability of the estimates was checked. The interactions checked for included those between the periodontal disease variables, NUG and CAL, and the indicator variables for socioeconomic position. Non-significant variables were retained in the model as confounders if their removal would result in a change of the estimates by more than 15%.
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RESULTS
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In total, 9155 students completed the OHIP-Sp questionnaire. The distribution of the number of missing items revealed no differences by age, gender, or socioeconomic position. The participation rate and the questionnaire completeness were high, with OHIP-Sp total scores being computed for 9133 persons (Lopez and Baelum, 2006b) (Fig. ). The distribution of clinical attachment loss 3 mm and the presence of necrotizing ulcerative gingival lesions, according to the socio-demographic characteristics of the study population, are presented in Table 1.
The logistic regression models demonstrated that clinical attachment loss 3 mm [OR = 2.0] or the presence of necrotizing ulcerative gingival lesions [OR = 1.6] was significantly more likely to have a higher impact on individuals’ OHRQoL than in persons without these periodontal outcomes, even after adjustment for age, gender, tooth loss, and several dimensions of socio-economic position (Table 2). The multivariable logistic regression analyses also revealed that students who reported a relatively lower socio-economic position were more likely to report a higher impact on their OHRQoL, and this finding was independent of the socioeconomic indicator used (Table 2).
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Table 2. Age, Gender, and Tooth Loss Adjusted Logistic Regression Models of Socio-demographic and Periodontal Disease Determinants for Oral-health-related Quality of Life.
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The presence of tooth loss, higher age, and female gender were found to be statistically significantly associated with a higher OHRQoL impact, whether NUG or CAL was considered. The OR estimates were 2.2 for tooth loss, 1.2 for ages 15–17, 1.4 for ages 18–21, and 1.5 for female gender, whether NUG or CAL was considered the periodontal determinant.
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DISCUSSION
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Few data are available suggesting that periodontal conditions are a source of reduced quality of life in adult populations (Ng and Leung, 2006), and the impact of periodontal destruction on OHRQoL has not been investigated among adolescents. The results of a single study conducted among young people in Myanmar demonstrated no association between marked gingivitis and OHRQoL (Soe et al., 2004). The findings of the present study revealed a significant association between the professionally determined presence of signs of clinical attachment loss and necrotizing ulcerative gingivitis and the quality of life of adolescents. Since the present study was carried out adjusted for known demographic and socioeconomic confounders for the associations between periodontal diseases and OHRQoL (Slade et al., 1996; Lopez et al., 2001, 2006; Schwarz and Hinz, 2001; John et al., 2004; Jones et al., 2004; Bisegger et al., 2005; von Rueden et al., 2006), the demonstration of this association suggests that the professionally determined need for periodontal treatment may indeed reflect patient perceptions, although these have not (yet) resulted in a demand for treatment.
The finding that several dimensions of socio-economic position and gender were systematically related to OHIP-Sp scores has not been reported before and substantiates previous reports in the medical field in which adolescents from different social strata and genders tended to perceive their health-related quality of life differently (Schwarz and Hinz, 2001; Bisegger et al., 2005; von Rueden et al., 2006). These findings indicate that better adjustment for gender and socio-economic differences in studies on oral-health-related quality of life are warranted.
A potential limitation of this study is the lack of data on caries, which could be used to adjust for the impact of caries on the OHRQoL of adolescents (Broder et al., 2000). While attempts were made to circumvent this problem by adjustment of the multivariable logistic regression analyses with tooth loss as a proxy variable for caries-related impacts, this may not fully have compensated for the potential impacts of pain and other discomforts due to caries. Another potential limitation is the fact that the OHIP measure was developed for use among adults, rather than among adolescents. It is therefore possible that certain concerns specific to adolescence may have been overlooked. Even so, the OHIP remains the only OHRQoL instrument available that has been validated for use among adolescents (Broder et al., 2000; Soe et al., 2004; Lopez and Baelum, 2006b).
The results of the study demonstrate the existence of tacit self-perceived impact on the OHRQoL of this group of adolescents, which seems to be reflected in the clinical observations made by dental professionals.
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ACKNOWLEDGMENTS
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The study was supported by a grant from the Danish Medical Research Council, by the Department of Oral Health from the Ministry of Health of Chile, and by the Department of Community Oral Health and Pediatric Dentistry from the Faculty of Health Sciences of the University of Aarhus. The authors are grateful to Colgate-Palmolive Chile for the generous donation of 10,000 toothbrushes to be given to the participating students.
Received for publication October 16, 2006.
Revision received May 10, 2007.
Accepted for publication June 1, 2007.
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Journal of Dental Research, Vol. 86, No. 11,
1105-1109 (2007)
DOI: 10.1177/154405910708601116
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ABSTRACT
INTRODUCTION