|Year : 2015 | Volume
| Issue : 1 | Page : 19-24
Comparative assessment of oral health related quality-of-life between rural and urban chronic periodontitis patients
Vishakha Grover1, Ranjan Malhotra1, Shivani Dhawan1, Gagandeep Kaur1, Anoop Kapoor2
1 Department of Periodontics and Oral Implantology, National Dental College and Hospital, Gulabgarh, India
2 Department of Periodontics and Oral Implantology, Shri Sukhmani Dental College and Hospital, Dera Bassi, Mohali, Punjab, India
|Date of Web Publication||2-Feb-2015|
3145, Ground Floor, Sector 37-D, Chandigarh
Source of Support: None, Conflict of Interest: None
Purpose: The aim of the present investigation was to assess and compare the oral health-related quality-of-life (OHRQoL) in the rural and urban chronic periodontitis patients of Punjab using short questionnaire of oral health impact profile (OHIP-14).
Materials and Methods: A total of 100 patients suffering from chronic periodontitis with pocket depth ≥4 mm in at least one proximal site and a minimum of 20 teeth were screened and divided into two groups - rural and urban (50 participants in each group). Clinical parameters, that is, plaque index (PI), gingival index (GI), pocket probing depth (PPD), and OHRQoL were assessed in all patients using OHIP-14 questionnaire.
Results: Results showed that mean PI (2.11 ± 0.635), GI (1.61 ± 0.45), PPD (3.12 ± 0.692), and OHIP-14 (11.49 ± 9.733) scores were significantly higher in the rural population as compared to urban population (1.69 ± 0.45, 1.56 ± 0.355, 3.30 ± 0.973, and 5.88 ± 5.588) suffering from chronic periodontitis. Most affected domain in case of the rural population was functional limitation whereas psychological disability was most affected in the urban population. Statistically significant positive correlation was observed between the periodontal parameters and OHIP-14 (P < 0.001) in both the groups.
Conclusion: Within the limitations of the study, periodontal status and OHRQoL are significantly correlated with each other in both rural and urban groups.
Keywords: Chronic periodontitis, quality-of-life, rural, Urban
|How to cite this article:|
Grover V, Malhotra R, Dhawan S, Kaur G, Kapoor A. Comparative assessment of oral health related quality-of-life between rural and urban chronic periodontitis patients. Saudi J Oral Sci 2015;2:19-24
|How to cite this URL:|
Grover V, Malhotra R, Dhawan S, Kaur G, Kapoor A. Comparative assessment of oral health related quality-of-life between rural and urban chronic periodontitis patients. Saudi J Oral Sci [serial online] 2015 [cited 2020 Jan 18];2:19-24. Available from: http://www.saudijos.org/text.asp?2015/2/1/19/150587
| Introduction|| |
Health-related quality-of-life (HRQoL) is an emerging subject of importance during recent years. This is based on the realization that the effects of a disease or condition cannot be fully determined by solely using clinical measures, since these do not take into consideration the subjective experiences that individuals have, concerning their health. , In 1948, the World Health Organization (WHO) defined health as "complete physical, mental, and social well-being, and not merely the absence of disease or illnesses." In consideration of this definition, it became clear that assessing health merely with indicators of physical health would overlook some important aspects of health.  Quality-of-life measures are of importance in order to look beyond than just the presence of health or disease. It should consider the way that the individual perceives his state of health and how this perception impacts on his daily performance. The quality-of-life of a person as well as the factors that contribute to it varies according to differences in age, gender, education, and regional as well as cultural differences that can greatly affect and/or can further reduce the individual's functionality and psychological well-being. Thus, HRQoL is considered as a multidimensional concept, which refers not only to patients' physical well-being but also to their psychological and social well-being. It is widely recognized for the assessment of healthcare outcomes. One of the major factors that has got a significant impact on the overall HRQoL is the oral health of the individual. ,,,
Oral health is an integral part of the overall health of all individuals. It definitely exhibits impact on the daily functions and well-being of an individual, leading even to the possibility of incapacitating them either physically or psychologically and ultimately affecting the whole society. , Periodontal disease is one of the most common diseases which affect the oral health of the individual. It is the most prevalent dental disease affecting people worldwide as well as in Indian community. Because of its high prevalence, chronic nature, and a wide range of effects on the general health of the individual, it is thought to have a significant bearing in affecting the quality-of-life of an individual.
In an effort to capture the impact of oral disorders on patient's physical, psychological as well as social well-being and their ability to perform daily activities, there has been development of a large spectrum of HRQoL measures in the field of dentistry. Many dental questionnaires or structured interviews (sometimes referred to as "sociodental indicators") have been developed over the last 20 years, to measure the impact of oral health on quality-of-life experiences either directly or indirectly including Oral Impacts on Daily Performances, Oral Health Quality-of-Life Inventory, Geriatric/General Oral Health Assessment Index and oral health impact profile (OHIP). But the psychometric properties and predictive validity of many of these sociodental indicators were weak. , So to overcome this, the OHIP in its short form (OHIP-14), was developed by Slade and Spencer , for the measurement of disability and discomfort due to oral conditions. It comprises 14 items which were derived from the original 49-items version. These items were subsequently transformed into seven subscales based on a conceptual oral health framework suggested by Locker and Allen  and derived from the WHO (1980) which is widely used now-a-days for the assessment of oral health-related quality-of-life (OHRQoL). Because of its high reliability and validity, OHIP-14 has been utilized in many studies for assessing the impact of oral diseases on quality-of-life of individuals.  Differences in the oral health status can be seen when comparing differing regions within a country (rural and urban) or between countries and geographical locations due to various regional factors including the individual factors (age, gender, congenital genetic endowment), lifestyle (dietary habits, physical activity, consumption of luxury products), living environment, working environment, socioeconomic status, educational status, and healthcare and social factors. ,, There is a paucity of information about the effects of periodontal disease and various regional factors on the quality-of-life of individuals which is essential for the personalized treatment planning, evaluation of public health interventions and for allocation of resources.
Hence, in order to enhance our understanding of the effects of periodontal disease on the quality-of-life of an individual taking into consideration the role of social and regional factors, the present investigation was planned to assess and compare the OHRQoL in rural and urban chronic periodontitis patients of Punjab using short questionnaire of OHIP-14.
| Materials and Methods|| |
Totally, 110 patients suffering from chronic periodontitis referred to the Department of Periodontology and Oral Implantology, National Dental College and Hospital, Derabassi (Punjab) were screened and selected according to the Inclusion and Exclusion criteria. 100 Eligible patients were divided into two groups - rural and urban groups consisting 50 participants in each group.
Inclusion and exclusion criteria
Patients with chronic periodontitis, with pocket depth ≥4 mm in at least one proximal site, and a minimum of 20 teeth were included in the study. Patients were excluded if they were edentulous, below 18 years of age and having any systemic debilitating conditions
All participants received an oral examination by the same examiner for the assessment of plaque index (PI), , gingival index (GI), , and pocket probing depth (PPD). William's periodontal probe was used to measure the PPD from the gingival margin to the bottom of the periodontal sulcus or pocket at two proximal sites of the tooth.
Information regarding the demographic variables (age, gender), educational status (assessed as the highest level of qualification received such as no qualifications, below degree level, and degree level and above) and Oral Hygiene Measures was collected with the help of interviews and questionnaire. Data regarding OHRQoL were collected using OHIP-14 questionnaire which contained 14 questions based on the frequency of adverse impacts caused by oral conditions during last year. For example, subjects were asked, "How often during the past year have you had painful aching in your mouth because of problems with your teeth or mouth?" OHIP-14 items have been grouped into seven dimensions: Functional limitation (trouble pronouncing words and worsened taste), physical pain (aching in mouth and discomfort eating foods), psychological discomfort (feeling self-conscious and feeling tense), physical disability (interrupted meals and unsatisfactory diet), psychological disability (difficulty relaxing and embarrassment), social disability (irritability and difficulty in doing usual jobs), and handicap (life less satisfying and inability to function). Respondents were asked to rate each item on a 5-point Likert scale coded 0 "never," 1 "hardly ever," 2 "occasionally," 3 "fairly often" and 4 "very often." The OHIP-14 score is the sum of responses and ranges from 0 to 56, with higher scores indicating poorer OHQoL. For the rural participants, the OHIP-14 questionnaire was translated for the 1 st time to a vernacular language (Punjabi) for their convenience. For illiterate participants, the questionnaire was explained by local personnel for the collection of data.
For preliminary investigation of the validity and reliability of the Punjabi version of the questionnaire forty subjects attending the outpatient department of National Dental College and Hospital, Derabassi from the month of January, 2013 to March, 2013 aged 17-46 years, were subjected to complete the OHIP-14 questionnaire in English along with the Punjabi version. After a follow-up time of 1-month, the subjects completed the second administration of the questionnaire. Correlation coefficients comparing OHIP-14 scores of the two versions ranged from 0.35 to 0.71. The intraclass correlation (0.83) was high, indicating good reliability.
All statistical analyses have been carried out using the SPSS ver. 17 (SPSS Inc. Chicago, USA). Mean and standard deviations were calculated for the variables to be compared. Nonparametric analysis was done using the Mann-Whitney test and the correlations among the variables were calculated using the Pearson's correlation coefficient. Multivariate regression analysis was used to test for significance in relation to continuous and categorical variables, respectively, while controlling for possible confounders.
| Results|| |
A total of 100 participants suffering from chronic periodontitis was categorized according to the region of distribution into rural and urban each having 50 participants with age ranging from 21 to 65 years with the mean age of 43.25 years. Power of the study was calculated on the basis of OHIP-14. Mean OHIP-14 in urban group was 5.88 ± 8.69 and in a rural group was 11.49 ± 8.54. With the sample size of 50 in each group, power of the study was calculated to be 94.2%. The mean PI, gingival index (GI), and PPD in rural participants were found to be 2.11 ± 0.635, 1.61 ± 0.45, and 3.12 ± 0.692, respectively, whereas in the urban participants, it was 1.69 ± 0.45, 1.56 ± 0.355, and 3.30 ± 0.973, respectively. A statistically significant difference in OHIP-14 scores was observed in the two groups with rural participants (11.49 ± 9.733) having higher scores than urban participants (5.88 ± 5.588). In the OHIP-14 variables also, there was a statistically significant difference in the functional limitation, physical disability, and psychological disability categories with mean scores of 1.84 ± 1.84, 1.65 ± 1.87, and 1.63 ± 1.75 for the rural participants and 0.75 ± 1.3, 0.51 ± 1.02, and 0.59 ± 0.96 for the urban participants respectively [Figure 1]. Pearson's correlations among the periodontal parameters and OHIP-14 variables within each group are summarized in [Table 1] and [Figure 2]a-c showing a positive correlation between PI, GI, and PPD with OHIP-14 scores in both rural and urban groups. Multivariate regression analysis of periodontal parameters (PI, GI, PPD), age, gender, area (rural/urban), and educational status with OHIP-14 variables is depicted in [Table 2]. A statistically significant positive relation between physical disability and PPD was observed. Functional limitation and GI scores were also significantly related indicating the influence of periodontal disease on quality-of-life of patients.
|Figure 1: Bar diagram showing comparison of oral health impact profile-14 variables between the two groups|
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|Figure 2: (a) Scatter diagrams showing Pearson's correlation between oral health impact profile (OHIP-14) and plaque index in rural and urban population, (b) scatter diagrams showing Pearson's correlation between OHIP-14 and GI in rural and urban population, (c) scatter diagrams showing Pearson's correlation between OHIP-14 and Pocket probing depth in rural and urban population|
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|Table 1: Pearson's correlation between periodontal parameters and OHIP-14 in rural and urban participants|
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|Table 2: Multivariate regression analysis of PI, GI, PPD with the OHIP-14 variables, age, gender and educational status in rural and urban participants with chronic periodontitis|
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| Discussion|| |
Although recent decades have witnessed a surge in the area of OHRQoL research, relatively little is known about the influence of periodontal disease on the quality-of-life of patients. The current study aims to explore the association between periodontal disease and quality-of-life of subjects suffering from chronic periodontitis residing in rural and urban regions of Punjab.
The impact of periodontal disease on quality-of-life has received much attention recently in various studies conducted by Saletu et al.,  Patel et al.,  Ng and Leung,  Aslund et al.  which suggested a negative impact of periodontal disease on quality-of-life in adults. A correlation between extent and/or severity of periodontal disease and OHRQoL has been demonstrated by studies conducted by Needleman et al.,  Ng and Leung,  Cunha-Cruz etal.,  Bernabé and Marcenes  which also suggested a significant effect of periodontal disease on quality-of-life. 
Traditionally, periodontal disease has been defined and measured using surrogate markers, most commonly - PPD and clinical attachment loss (CAL). In order to capture patients' perspectives of disease, patient-based outcomes (PBOs) or "true endpoints" are utilized to complement the conventional clinical (surrogate) measures. These subjective measures have been reported to be more relevant to patient's daily lives than objective changes in PPD and CAL. OHRQoL is one PBO and is recognized as an integral part of general health and well-being. , A range of measures has been developed and validated to evaluate OHRQoL. OHIP-14 is one of the most reliable measure for this purpose which have been validated and is utilized in many clinical studies. ,,,,,,,,
Upon analysis of results, it was observed that in both the groups there was a statistically significant relation between the OHIP-14 and the periodontal parameters, that is, PI, GI and PPD indicating that increase in the PI, gingival index, and the PPD worsened the quality-of-life of the patients. On intergroup comparison, it was observed that the mean PI and OHIP-14 scores were greater in the rural than in the urban group indicating that the quality-of-life in urban group was better than in the rural group. In addition, the mean values of various OHIP-14 variables were also higher in the rural than in the urban group with statistically significant differences seen in the functional limitation (P = 0.001), physical disability (P = 0.001), psychological disability (P = 0.002), and handicap (P = 0.038) variables.
Similar findings have been reported by Nagarajan and Chandra et al.  and Ingle et al.  suggesting a significant negative impact of periodontal disease on OHRQoL in the region of Andhra Pradesh and Chennai. Papaioannou et al.  and Al-Harthi  also provided similar insights into the complex association between periodontal disease and quality-of-life and concluded that dental and oral health conditions are factors that do impact on the quality-of-life of individuals residing in Greece and Oman.
In both the groups, the periodontal parameters were significantly correlated with the OHIP-14 scores with PI being most strongly related in rural participants (r = 0.376) and PPD in urban participants (r = 0.378). Another significant observation was the impact of educational status on the quality-of-life of patients. It has been seen that the OHIP-14 scores decreased as the level of education increased. This could possibly be explained by the differences in degree of awareness and psychology of the individual due to changes in the educational status which can influence the perception of quality-of-life of an individual. On the analysis of data using multivariate regression analysis, gingival inflammation has got a significant impact on functional limitation variable of OHIP-14 indicating a negative influence of inflammation of gingiva on quality-of-life. Out of all the OHIP-14 variables, physical limitation was most significantly related to the PPDs indicating that the severity of periodontal disease bears a negative impact on quality-of-life in terms of increased physical disability and discomfort.
All these findings demonstrated that a periodontal disease has got a negative impact on the OHRQoL in both rural and urban participants with the impact being more pronounced in the rural as compared to urban. Since, OHRQoL represents people's subjective assessment of their sense of well-being and ability to perform physical, psychological, and social functions, various sociodemographic factors including socioeconomic status, educational status, and cultural factors play a pivotal role in perception of quality-of-life by an individual. The worsened quality-of-life in the rural region could possibly be attributed to poor oral hygiene, low educational status, and awareness in rural participants. A better understanding of the effects of periodontal disease from individuals' point of view is needed for the planning and evaluation of public health interventions and allocation of resources. Furthermore, this information can be used to demonstrate the burden of periodontal disease on the well-being of population and to advocate resources to improve access to oral health care services.
| Conclusion|| |
Taken together, our findings suggest that a periodontal disease has got a significant negative impact on the quality-of-life of both rural and urban patients residing in Punjab with the rural being affected more than urban. In addition, out of all the OHIP-14 variables, physical disability, and psychological discomfort variables were most significantly affected in rural and urban patients respectively. Further studies are warranted so that best patient-centered treatment options can be utilized to minimize the negative effects of periodontal disease on quality-of-life of patients perceived under different social and cultural environments.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]