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The impact of periodontitis on oral health-related quality of life: a review of the evidence from observational studies

LS Al-Harthi,* MP Cullinan,* JW Leichter,* WM Thomson**Department of Oral Sciences, School of Dentistry, University of Otago, New Zealand.

ABSTRACT

Modern population based oral health management requires a complete understanding of the impact of disease in orderto provide efcient and effective oral health care and guidance. Periodontitis is an important cause of tooth loss and hasbeen shown to be associated with a number of systemic conditions. The impact of oral conditions and disorders on qual-ity of life has been extensively studied. However, the impact of periodontitis on quality of life has received less attention.This review summarizes the literature on the impact of periodontitis on oral health-related quality of life (OHRQoL).Relevant publications were identied after searching the MEDLINE and EMBASE electronic databases. Screening of titles and abstracts and data extraction was conducted. Only observational studies were included in this review. Most of the reviewed studies reported a negative impact of periodontitis on OHRQoL. However, the reporting standards variedacross studies. Moreover, most of the studies were conducted in developed countries.

Keywords: Periodontitis, oral health-related quality of life, oral health impact prole, review.

Abbreviations and acronyms: OHIP = oral health impact prole; OHRQoL = oral health-related quality of life.(Accepted for publication 27 February 2013.)

INTRODUCTION

Periodontitis is an inammatory disease caused byspecic bacterial complexes in the dental plaque bio-lm. In susceptible individuals, this disease may leadto loss of the periodontal ligament and alveolar bone.Clinically, it is characterized by pocket formationand/or gingival recession. The mild to moderate formof chronic periodontitis is the most common, withprevalence estimates ranging from 13% to 57%,depending on the sample characteristics and the case

denition used.1 3

Severe periodontitis affects 5% to15% of the general population 4 and is considered tobe a major oral health problem. 5

Decades ago, studies investigating the burden of periodontitis and other oral diseases and conditionswere characterized by the use of clinical parametersalone. No studies had incorporated social indicatorsto account for the consequences of oral diseases. Thisled Cohen and Jago to propose the use of socio-dentalindicators, which incorporated the functional, psycho-logical and social consequences of oral conditions forthe individual, not merely the signs and symptoms of various diseases. 6 As a result, this change of concept

moved management from treating the signs and symp-toms to giving patients a voice, and to consideringtheir subjective experiences and interpretations of their conditions.

To date, there is no universal agreement on the de-nition of oral health-related quality of life (OHR-QoL); however, consensus maintains that OHRQoL isa subjective construct and best reported from thepatients perspective. It is also multidimensional, witha number of domains. Recent years have seen thedevelopment and validation of OHRQoL instruments

to capture the non-clinical aspects of oral diseases.These multidimensional instruments which measurethe impact of diseases on well-being and quality of lifecomprise various physical, social and psychologicaldomains. 7 They are comparable in that they rely onself-reports; however, they differ in their number of items, response format, and in their item content. 8

The impact of periodontitis on quality of life hasreceived relatively little attention. This may be due tothe few symptoms experienced by periodontal patientsin the early stages of the disease, in contrast to otheroral diseases and conditions. 9 There have been severalreports from clinical studies on the impact of

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periodontitis on OHRQoL. Comparing and synthesiz-ing their ndings is difcult because of their use of arange of approaches to dening periodontal statusand measuring OHRQoL. 10 17 Most of the observa-tional studies which have reported on the impact of periodontitis on OHRQoL 18 24 have shown an associ-ation. However, it is possible that the observed associ-ation was due to the concurrent effect of other oraldiseases on OHRQoL. Therefore, it is desirable thatthe literature on periodontitis and OHRQoL be care-fully scrutinized to determine whether the apparentimpact was indeed due to the periodontitis and not toassociated conditions such as caries or the incrementalloss of teeth.

The aim of this literature review was to determinewhether periodontitis did indeed impact negatively onOHRQoL in the various general populations whichhave been studied. The studies included in this review

were observational epidemiological studies, whethercross-sectional or prospective. Reports had to includeinformation on: (1) how periodontal attachment losswas measured; (2) the clinical periodontal parametersmeasured (i.e. pocket depth and/or clinical attachmentloss/level); and (3) how cases of periodontitis weredened. They also had to have used a validated,multi-item OHRQoL instrument. From a total of 446screened abstracts from 1947 to December 2011,seven papers met the inclusion criteria. Those sevenstudies each used a representative sample (Table 1).There were two Australian studies 22,23 and one eachfrom Hong Kong, 18 Chile, 19 New Zealand 20 and theUnited Kingdom. 25 One study analysed data fromthree cross-sectional studies. 24

Impact of periodontitis on OHRQoL

Six of the seven studies reported a negative impactof periodontitis on OHRQoL. 18 21,23,24 These stud-ies had different ways of reporting their ndings,with some reporting the prevalence of impacts, andothers reporting differences by the severity of impacts. The strength of the association wasreported in ve of the seven studies reviewed (with

an OR of only 1.5 (95% CI = 1.02 2.19) to 2.0(95% CI = 1.5 2.5), or RR = 1.3 (95% CI = 1.2 1.4)). However, due to the diversity in thresholdsused to dene levels of periodontitis or compro-mised OHRQoL, these estimates may simply be anartefact of the thresholds used by different investiga-tors. This, though, does not suggest that thereported association does not exist. The study byMari ~no et al . was the only one that showed nodirect association between periodontal status andmean OHIP score. 23 In assessing the OHRQoLdomains most affected, it is apparent from Table 1that the nature of the association between

periodontitis and OHRQoL is mainly physical (func-tional) and psychological. This was a consistent pat-tern across the different OHRQoL instruments.

Four of the seven studies controlled for covariatesin reporting the impact of periodontitis onOHRQoL. 19 21,24 A study by Slade et al . showed thatmissing teeth and number of decayed root surfaceshad higher impact on OHRQoL than maximumpocket depth. 24 Similarly, in the Dunedin study therewas an association between periodontitis and OHR-QoL (with an OR of 1.5 (95% CI = 1.02 2.19)),however, that for decayed surfaces was higher withan OR of 1.95 (95% CI = 1.35 2.81). 20 This showsthat, although both oral diseases impacted OHRQoLnegatively, they did so to a different extent. Other fac-tors have also been reported to affect OHRQoL; theseinclude tooth loss and age. 19,21

There were a number of limitations in the studies

presented and, accordingly, in our ability to reviewthem critically. Reporting OHRQoL data only asmean scores does not adequately represent differencesin impact between groups. Investigating and reportingdifferences in impact prevalence, extent and severitywould strengthen the validity of ndings. The preva-lence is reported as the percentage of people reportingone or more items fairly often or very often, andthe extent is reported as the number of items reportedfairly often or very often; the severity is reported asthe mean OHIP-14 score. The only study whichreported the prevalence, extent and severity of OHR-QoL impact was that by Lawrence et al .20 Theyfound that there was a signicant impact of periodon-titis on OHRQoL prevalence and severity, but not itsextent.

Moreover, it is important to clearly and validlyidentify cases of periodontitis in such studies; forexample, a case denition of 3 + mm CAL may notrepresent true periodontitis cases because it mayincorporate individuals who may have only gingivitisor recession with a healthy periodontium. Thus, a keyprinciple when investigating the periodontitis OHR-QoL relationship is to use a range of measures andcase denitions in order to examine the robustness of

the association. Brennan et al . reported the prevalenceof impact of different domains of the Euro-QoL usingdifferent case denitions. 22 They found that there wasa low prevalence of impact with gingivitis and gingi-val recession, and a high impact prevalence withpocket depth and loss of attachment. The studiesreviewed here used different methods of collectingdata and different case denitions, and they used arange of OHRQoL instruments. Moreover, differentreporting criteria were used for describing the associa-tion of periodontitis and OHRQoL. All of these fac-tors impeded any attempts to systematically comparethe ndings of these studies.

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CONCLUSIONS

The heterogeneity of methods and reporting in the

studies made it difcult to draw denite conclusionson the strength of association between periodontitisand OHRQoL. Most studies have shown a negativeimpact of periodontitis on OHRQoL, but some didnot control for confounding by other oral conditions,and others did not report why they had chosen only afew variables to control for in their multivariate anal-yses. Because OHRQoL is a subjective phenomenonand many factors may affect it, it is important toadjust for known confounding factors (particularlyother clinical conditions which impact on peoplesday-to-day lives) in order to avoid misinterpreting thedata and the apparent strength of association.

The study ndings underline the need for morestandardization of investigations of the effects of periodontitis on OHRQoL. Standard periodontalepidemiological terms and concepts (such asprevalence, extent and severity) need to be used,along with clear and accepted case denitions andsystematic approaches to data analyses. Futurestudies should take into consideration these criticalissues in reporting the impact of periodontitis onOHRQoL.

REFERENCES1. Sheiham A, Netuveli GS. Periodontal diseases in Europe. Peri-

odontol 2000 2002;29:104 121.

Table 1. Summary of studies included in the review

Study Assessedsample details

Periodontitisvariables used

OHRQoLinstrument

Dependentvariable(s) used

Impact of periodontitison OHRQoL

Domainsassociated

withperiodontitis

Slade et al. 1996Australia

949 participants a 65years old

Maximum PD OHIP-49 Extent of OHIP scores

Beta = 0.2,SE = 0.1 d(P value = 0.01)

Not reported

Ng andLeung 2006Hong Kong

727 participantsAge 2564 years

Healthy: 2 mm CALSevere attachmentloss:> 3 mm CAL

OHIP-14S Mean OHIP scores Mean totalOHIP-14S of cases 8 times higher

Functionallimitation,physical pain,psychologicaldiscomfort,physicaldisability,psychologicaldisability

Lopez andBaelum 2007Chile

9163 participantsAge 1221 years

CAL 3 mm OHIP-Sp Prevalenceof OHIPscore of 8or more

OR = 2.0, 95%CI = 1.5-2.5 d

Not reported

Brennan

et al. 2007Australia

709 participants

Age 4554 years

GR 6 + mmb

PD 6+

mmLOA 6 + mm c

Euro-QoL Prevalence of

dimensionsof Euro-QoLPercentageof timesdimension isexperienced

Low disability

weights with GR:0.004 (SE = 0.004)High disabilityweights withPD: 0.018(SE = 0.007) &LOA:0.012(SE = 0 .004)

Pain and

discomfortAnxietyanddepression

Lawrenceet al. 2008New Zealand

924 participants32 years

2+ sites with4+ mm CAL

OHIP-14 Mean OHIP scoresPrevalence of 1 +OHIP impactsExtent of OHIP impact

OR = 1.5, 95%CI = 1.02-2.19 d

Psychologicaldiscomfort,physicaldisability,physical pain

Mari ~noet al. 2008Australia

603 Greekand Italianbackground 55years old

CPIPD > 5 mm

OHIP-14SF-12

MeanOHIP scores

No direct associationbetween PD > 5 mmand mean OHIP scoresDirect associationbetween PD > 5 mmand physical healthcomponent of theSF-12 score

Not reported

Bernabe andMarcenes 2010UK

3122participants 16 years(mean = 41.16)

2+ proximalsites with CAL4+ mm and1+ proximalsites with PD4 + mm

OHIP-14 MeanOHIP scores

RR = 1.3, 95%CI = 1.2-1.4 d

Not reported

aIncluded participants from three studies, 26 28 b gingival recession, closs of attachment, d adjusted for covariates.

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19. Lopez R, Baelum V. Oral health impact of periodontal diseasesin adolescents. J Dent Res 2007;86:1105 1109.

20. Lawrence HP, Thomson WM, Broadbent JM, Poulton R. Oralhealth-related quality of life in a birth cohort of 32-year olds.Community Dent Oral Epidemiol 2008;36:305 316.

21. Bernabe E, Marcenes W. Periodontal disease and quality of lifein British adults. J Clin Periodontol 2010;37:968 972.

22. Brennan DS, Spencer AJ, Roberts-Thomson KF. Quality of lifeand disability weights associated with periodontal disease. J Dent Res 2007;86:713 717.

23. Mari ~no R, Schoeld M, Wright C, Calache H, Minichiello V.Self-reported and clinically determined oral health status predic-tors for quality of life in dentate older migrant adults. Commu-nity Dent Oral Epidemiol 2008;36:85 94.

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Address for correspondence:W Murray Thomson

Professor of Dental Epidemiology and Public HealthEditor, New Zealand Dental Journal

Head, WHO Collaborating Centre for Dental Epidemiology and Public HealthDepartment of Oral Sciences, Sir John Walsh

Research InstituteSchool of Dentistry, The University of Otago

PO Box 647 Dunedin

New Zealand Phone: +64 3 479 7116

Mobile: +64 21 279 7116Fax: +64 3 479 7113

Email: murray.thomson@otago.ac.nz

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