ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al
Association of oral health related quality of life with dental anxiety and depression along with general health among people of Bhopal district, Madhya Pradesh RGK Shet1, Gaurvi Jain2, Sohani Maroli3, Kirti Jajoo Srivastava4, Sitaram Prasad Kasina5, GS Shwetha6 1Professor,
Department of Prosthodontics, Manasarovar Dental College, Bhopal, Madhya Pradesh, India; 2Reader, Department of Prosthodontics,
Rishiraj College of Dental Sciences, Bhopal, Madhya Pradesh, India; 3Professor & Head, Department of Conservative Dentistry & Endodontics, St. Joseph Dental College, Eluru, Andhra Pradesh, India; 4Senior Lecturer, Department of Prosthodontics, Peoples Dental Academy, Bhopal, Madhya Pradesh, India; 5Senior Lecturer, Department of Prosthodontics, St. Joseph Dental College, Eluru, Andhra Pradesh, India; 6Reader, Department of Orthodontics & Dento-facial Orthopaedics, KLE Society’s Institute of Dental Sciences, Bangalore, Karnataka, India.
ABSTRACT Background: To associate oral health related quality of life with dental anxiety and depression along with general health among people of Bhopal district, Madhya Pradesh. Materials & Methods: A cross sectional questionnaires based survey was conducted among the subjects of Bhopal district, Madhya Pradesh. The survey was carried among 101 subjects aging from 20-40 years. Subjects under investigation were belonging to various occupations. They were assigned a questionnaire. Questionnaire consisted of four parts, first part consists of socio-demographic data along with dental visiting habits, second part has OHqOL-questionnaire, third part has general health (sf-12) and fourth part has hospital anxiety and depression questionnaire. Questionnaire was used for assessment of OHqOL. It consists of 16 questions which takes into account both effect and impact of oral health on quality of life. Dental anxiety and depression was measured by Hospital Anxiety and Depression Scale. Each question was provided with four options and numbering ranging from 0-3. For general health consideration sf-12 v2 was being used, which calculates two values PCS and MCS giving result in percentage. Results: A large proportion of respondent perceived oral health as having an enhanced effect on their quality of life in all three aspects that is general health, social and psychological. This is in stark contrast to other studies, where only physical aspects of oral health were more frequently considered to have the greatest overall impact of life quality compared with items relating to social, psychological and general health aspects. Conclusion: Gender variations were not apparent in the study. Both genders were likely to perceive oral health as it is impacting strongly on their quality of life. No significant gender variations are seen. But both have specific oral health needs and are most likely to utilize dental services which may be the key in understanding oral health behavior, including dental attendance patterns. Key Words: Dental anxiety and depression, general health, hospital anxiety and depression scale, OHqOL. How to cite this article: Shet RG, Jain G, Maroli S, Srivastava KJ, Kasina SP, Shwetha GS. Association of oral health related quality of life with dental anxiety and depression along with general health among people of Bhopal district, Madhya Pradesh. J Int Oral Health 2013; 5(6):1-8. Source of Support: Nil
Conflict of Interest: None Declared
Received: 11th August 2013
Reviewed: 15th September 2013
Accepted: 15th October 2013
Address for Correspondence: Dr. RGK Shet. Department of Prosthodontics, Manasarovar Dental College, Bhopal, Madhya Pradesh, India. Email: [email protected]
[1]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al Introduction
general health, as various studies are done by using HADS to measure out anxiety level and its direct and
In 1948, the World Health Organization (WHO)
indirect consequences on general health. To date most
defined health as being "complete physical, mental and
anxiety scales have received limited attention to their
social well-being, and not merely the absence of
theoretical underpinnings. Dental anxiety is not
diseases or illnesses".
unitary and has been typically conceived under three
Measures of oral health-related quality of life (OHqOL)
connected approaches: behavioral, cognitive, and
are increasingly being used in descriptive population-
physiological. Self report methods primarily assess the
based research as a means of capturing nonclinical
cognitive component which can be split into at least 2
aspects of oral health that patients deem most relevant
valid constructs.
to their overall health and well-being.1 When OHqOL
So present study was conducted to associate oral
measures are used alongside traditional clinical
health related quality of life with dental anxiety and
methods of measuring oral health status, a more
depression along with general health among people of
comprehensive assessment of the impact of oral
Bhopal district, Madhya Pradesh.
diseases on the several dimensions of subjective well-
Materials and Methods
being becomes possible.2 These dimensions include functional limitation, physical pain, psychological discomfort,
physical
disability,
A cross sectional questionnaires based survey was
psychological
conducted among the subjects of Bhopal. The survey
disability, social disability, and handicap 3 it has also
was carried among 101 subjects aging from 20-40 years.
been suggested that sex and socioeconomic status
Subjects under investigation were belonging to various
(SES) can have a moderating role on OHqOL. When
occupations. They were assigned a questionnaire. This
overall oral health is considered, there are few or no
study was done between the time period of november
differences between men and women, but sex
2012 to february 2013. The sample taken into account
differences are quite apparent when the utilization of
was a select sample which was considered as a sample
dental care services, treatment outcomes, or OHqOL
of convenience and feasibility.
are examined.4 Oral health affects people physically
Survey thus undertaken was a questionnaire survey in
and psychologically and influences how they grow,
which a specially designed questionnaire was used.
enjoy life, look, speak, chew, taste food and socialize,
Questionnaire consisted of four parts, first part consist
as well as their feelings of social well-being.5
of socio-demographic data along with dental visiting
Contemporary concepts of health suggest that oral health
should
be
defined
in
general
habits, second part has OHqOL-questionnaire, third
physical,
part has general health (sf-12) and fourth part has
psychological and social well-being terms in relation to
hospital anxiety and depression questionnaire. The
oral status.6 Research
on
health-related
behaviors
and
questionnaire was distributed among the individuals
their
and were tried to make understand each and every
correlations is of interest to public health for several
question. The questionnaire was constructed in English
reasons. First, implementation of successful health
as well as in Hindi. OHqOL questionnaire was used for
promotion programmes depends on both information
assessment of OHqOL.7 It consists of 16 questions
about the prevalence of such behaviors and an understanding
of
their
determinants.
which takes into account both effect and impact of oral
Secondly,
health on quality of life.8 The effect of oral health on
research may highlight interactions between health
quality of life has three domains - physical containing 6
related behaviors which may bring about synergistic
items and social and psychological consisting of five
effects on health status. Thirdly, information about
items each. All the respondents were made to
patterns of health related behaviors can provide
understand each question along with the effect and
important data for adjustment of health education
impact related to the questions and each of the
interventions within the context of health promotion
proposed 16 items were scored first on “effect” (with
programmes. We can relate hospital dental anxiety to
responses ranging from bad to good effect on quality of [2]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al life) and later on the “impact” of each “effect”. The
instructed not to take too long over their replies: their
impact of each effect was recorded under five
immediate reaction to each item will probably be more
categories that is No, Little, Moderate, Great and
accurate than a long thought-out response. It consists
Extreme. The score for each effect was ranging from 1
of 14 questions, seven for anxiety and seven for
to 9 with score 1 being bad effect having extreme
depression. Although it was designed for hospital
impact, score 5 representing no effect with no impact
General Medical Outpatients, it has been extensively
and 9 being good effect having extreme impact. The
used in Primary Care.2 For general health consideration
sum of individual item responses were added together
sf-12 v2 was being used, which calculates two values
to generate an overall score with possible values
PCS and MCS giving result in percentage. All
ranging from 16 to 144. All the data collected was
responses to questions in SF-12v2 are printed in a
entered into the spreadsheets.
horizontal (left-to-right) format, There is considerable
Dental anxiety and depression was measured by
empirical
Hospital Anxiety and Depression Scale. Each question
response categories substantially improve the two SF-
was provided with four options and numbering
12 role. Advantage of the SF-12v2 form over the
ranging from 0-3. This is a self screening questionnaire
original v1 form is the provision for estimating the
for depression and anxiety.1 The patient should be
eight-domain profile of scales, in addition to the PCS-
8
evidence
that
the
SF-12v2
five-choice
Table 1: Distribution of response to OHqOL - Effects & Impacts (MALES) Response s(physica l aspect)
Bad effect
Bad
Bad
Bad
Great
Great
Great
Great
of
effect of
effect of
effect of
effect of
effect of
effect of
effect of
extreme
great
moderat
little
little
moderat
great
extreme
empect
impact
e impact
impact
impact
e impact
impact
impact
None
Eating
0
0
0
0
11(10.9)
18(17.8)
5(5.0)
12(11.9)
3(3.0)
Appeara
0
0
0
0
3(3.0)
10(9.9)
15(14.9)
14(13.9)
7(6.9)
Speech
0
0
0
0
6(5.9)
11(10.9)
14(13.9)
16(15.8)
2(2.0)
General
0
1 (1.0)
0
0
9(8.9)
12(11.9)
11(10.9)
10(9.9)
6(5.9)
0
1 (1.0)
1 (1.0)
0
5(5.0)
14(13.9)
11(10.9)
11(10.9)
6(5.9)
Comfort
0
0
0
0
7(6.9)
5(5.0)
17(16.8)
15(14.9)
5(5.0)
Sleep(psy
0
0
0
1 (1.0)
6(6.0)
7(7.0)
14(14.0)
18(18.0)
3(3.0)
0
0
1 (1.0)
1 (1.0)
6(5.9)
4(4.0)
18(17.8)
11(10.9)
8(7.9)
Worky
0
0
0
0
8(7.9)
11(10.9)
14(13.9)
14(13.9)
2(2.0)
Mood
0
0
1 (1.0)
0
6(5.9)
10(9.9)
8(7.9)
16(15.8)
8(7.9)
0
0
1 (1.0)
1 (1.0)
8(7.9)
8(7.9)
13(12.9)
11(10.9)
7(6.9)
Social life
0
0
1 (1.0)
0
4(4.0)
6(5.9)
12(11.9)
13(12.9)
13(12.9)
Romantic
0
0
0
0
12(11.9)
5(5.0)
10(9.9)
13(12.9)
9(8.9)
Smiling
0
0
1 (1.0)
0
10(9.9)
7(6.9)
10(9.9)
16(15.8)
5(5.0)
Work
0
0
0
0
10(9.9)
8(7.9)
13(12.9)
11(10.9)
7(6.9)
Finance
0
0
0
1 (1.0)
8(7.9)
11(10.9)
17(16.8)
6(5.9)
6(5.9)
nce
Health Breath odor
chologica l aspect) Confiden ce
Personali ty
relation
[3]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al 12 and MCS-12 summary measures. The on-line
the past week, how much of the time has your physical
scoring software, now available for SF-12v2, also
health or emotional problems interfered with your
incorporates Quality Metric Incorporated’s MDE
social activities like visiting friends, relatives, etc. Two
algorithms which reduce the bias in estimates of
SF-12 scales, Physical functioning and general health,
missing responses, and makes it possible to compute
do not have a recall period, so are identical across acute
scale and summary scores for many respondents who
and standard forms. (sf -36. org)
would have otherwise been lost due to missing data.
Results
The SF-12 was designed for applications in which health status would be measured weekly or biweekly.
Table 1 reveals that OHqOL variation between the
It was created by changing the recall period for six SF-
male candidates and they show more positive effect on
12 scales (Role Physical, Bodily Pain, Vitality, Social
OHqOL by eating, sleep and confidence in their life
Functioning, Role Emotional, and Mental Health) from
and show slight or more negative effect on smiling and
“the past four weeks” to “the past week”. For example,
mood. They feel that they are slightly affected or have
the question, “During the past four weeks, how much
a moderate effect of OHqOL on work, finance,
of the time has your physical health or emotional
personality, social life and romantic relationship.
problems interfered with your social activities like
Table 2 reveals that OHqOL variation between the
visiting friends, relatives, etc was changed as during
female candidates and they show more positive effect
Table 2: Distribution of response to OHqOL - Effects & Impacts (FEMALES) Bad
Bad
Bad
Bad
effect of
effect of
effect of
extreme
great
empect
Eating Appearanc
None
Great
Great
Great
Great
effect of
effect of
effect of
effect of
effect of
moderat
little
little
moderat
great
extreme
impact
e impact
impact
impact
e impact
impact
impact
0
0
2(2.0)
0
7(6.9)
11(10.9)
11(10.9)
16(15.8)
5(5.0)
0
0
0
0
3(3.0)
10(9.9)
17(16.8)
18(17.8)
4(4.0)
Speech
0
0
0
0
1(1.0)
10(9.9)
17(16.8)
15(14.9)
9(8.9)
General
0
1(1.0)
0
0
5(5.0)
13(12.9)
13(12.9)
14(13.9)
6(5.9)
0
1(1.0)
0
1(1.0)
6(5.9)
13(12.9)
17(16.8)
6(5.9)
8(7.9)
Comfort
0
0
0
2(2.0)
4(4.0)
10(9.9)
18(17.8)
13(12.9)
5(5.0)
Sleep(psyc
0
0
0
1(1.0)
7(7.0)
9(9.0)
17(17.0)
11(11.0)
6(6.0)
Confidence
0
0
1(1.0)
0
6(5.9)
9(8.9)
15(14.9)
15(14.9)
6(5.9)
Worky
0
0
2(2.0)
0
12(11.9)
12(11.9)
11(10.9)
12(11.9)
3(3.0)
Mood
0
0
1(1.0)
0
11(10.9)
2(2.0)
18(17.8)
13(12.9)
7(6.9)
Personality
0
0
0
0
11(10.9)
3(3.3)
16(15.8)
16(15.8)
6(5.9)
Social life
0
0
0
0
9(8.9)
6(5.9)
11(10.9)
14(13.9)
9(8.9)
Romantic
0
0
0
0
10(9.9)
9(8.9)
9(8.9)
18(17.8)
5(5.0)
Smiling
0
0
0
0
11(10.9)
8(7.9)
17(16.8)
11(10.9)
5(5.0)
Work
0
0
0
0
8(7.9)
5(5.0)
20(19.8)
12(11.9)
7(6.9)
Finance
0
0
0
0
8(7.9)
9(8.9)
17(16.8)
16(15.8)
2(2.0)
Bad effect of extreme empect
e
Health Breath odor
hological aspect)
relation
[4]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al on OHqOL by appearence, comfort and work in their
and breath odour. They feel that they are slightly
life and show slight or more negative effect on eating
affected or have a moderate effect of OHqOL on sleep,
Table 3: Distribution of response to OHqOL - Effects & Impacts (TOTAL) Bad
Bad
Bad
Bad
effect of
effect of
effect of
extreme
great
moderat
empect
impact
Eating
0
Appearance
None
Great
Great
Great
Great
effect of
effect of
effect of
effect of
effect of
little
little
moderat
great
extreme
e impact
impact
impact
e impact
impact
impact
0
2(2.0)
0
18(17.8)
29(28.7)
16(15.8)
28(27.7)
8(7.9)
0
0
0
0
6(5.9)
20(19.8)
32(31.7)
32(31.7)
11(10.9)
Speech
0
0
0
0
7(6.9)
21(20.8)
31(30.7)
31(30.7)
11(10.9)
General
0
2(2.0)
0
0
14(13.9)
25(24.9)
24(23.8)
24(23.8)
12(11.9)
Breath odor
0
2(2.0)
1(1.0)
1(1.0)
11(10.9)
27(26.7)
28(27.7)
17(16.8)
14(13.9)
Comfort
0
0
0
2(2.0)
11(10.9)
15(14.9)
35(34.7)
28(27.7)
10(9.9)
Sleep(psycho
0
0
0
2(2.0)
13(13.0)
16(16.0)
31(31.0)
29(29.0)
9(9.0)
Confidence
0
0
2(2.0)
1(1.0)
12(11.9)
13(12.9)
33(32.7)
26(25.7)
14(13.9)
Worky
0
0
2(2.0)
0
20(19.8)
23(22.8)
25(24.8)
26(25.7)
5(5.0)
Mood
0
0
2(2.0)
0
17(16.8)
12(11.9)
26(25.7)
29(28.7)
15(14.9)
Personality
0
0
1(1.0)
1(1.0)
19(18.8)
11(10.9)
29(28.7)
27(26.7)
13(12.9)
Social life
0
0
1(1.0)
3(3.0)
13(12.9)
12(11.9)
23(22.8)
27(26.7)
22(21.8)
Romantic
1(1.0)
0
0
0
22(21.8)
14(13.9)
19(18.8)
31(30.7)
14(13.9)
Smiling
0
0
1(1.0)
0
21(20.8)
15(14.9)
27(26.7)
27(26.7)
10(9.9)
Work
0
0
0
0
18(17.8)
13(12.9)
33(32.7)
23(22.8)
14(13.9)
Finance
0
0
0
1(1.0)
16(15.8)
20(19.8)
34(33.7)
22(21.8)
8(7.9)
Responses(p hysical aspect)
Health
logical aspect)
relation
Table 4: Anxiety and depression ratio among males Extreme in positive
Slight in positive
Sight in negative
Extreme in negative
aspect
aspect
aspect
aspect
Anxiety
29(28.7)
13(12.9)
5(5.0)
2(2.0)
Depression
22(21.8)
21(20.8)
6(5.9)
0
Anxiety
18(17.8)
20(19.8)
8(7.9)
3(3.0)
Depression
17(16.8)
24(23.8)
6(5.9)
2(2.0)
Anxiety
18(17.8)
19(18.8)
10(9.9)
2(2.0)
Depression
23(22.8)
17(16.8)
8(7.9)
1(1.0)
Anxiety
14(13.9)
29(28.7)
5(5.0)
1(1.0)
Depression
18(17.8)
23(22.8)
8(7.9)
0
Anxiety
20(19.8)
16(15.8)
8(7.9)
5(5.0)
Depression
14(13.9)
22(21.8)
13(12.9)
0
Anxiety
9(8.9)
26(25.7)
11(10.9)
3(3.0)
Depression
14(13.9)
25(24.8)
10(9.9)
0
Anxiety
18(17.8)
20(19.8)
8(7.9)
3(3.0)
Depression
18(17.8)
12(11.9)
11(10.9)
2(2.0)
[5]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al finance,
personality,
social
life
and
romantic
Table 4 reveals the anxiety and depression ratio of
relationship.
males. Males show more anxiety and depression ratio
Table 3 reveals that OHqOL variation
among
the
slight in positive aspect. Least ratio is shown in
general population and they show more positive affect
extreme in negative aspect. They show moderate ratio
of OHqOL on appearance, comfort, finance, speech
extreme in positive aspect and slight in negative aspect.
,sleep, confidence and relationship show slight
Table 5 reveals the anxiety and depression ratio among
or
more negative effect on eating and breath odor. They
females.
Females
show
the
more
anxiety
and
feel that they are slightly affected or have a moderate
depression ratio in the extreme in positive aspect. Least
effect of OHqOL on personality, social life and mood.
ratio is shown in extreme in negative aspect. They
Table 5: Anxiety and depression ratio among females Extreme in positive
Slight in positive
Sight in negative
Extreme in negative
aspect
aspect
aspect
aspect
Anxiety
23(22.8)
24(23.8)
2(2.0)
3(3.0)
Depression
25(24.8)
19(18.8)
7(6.9)
1(1.0)
Anxiety
25(24.8)
19(18.8)
5(5.0)
3(3.0)
Depression
27(26.7)
16)15.88)
7(6.9)
2(2.0)
Anxiety
25(24.7)
21(20.8)
6(5.9)
0
Depression
25(24.7)
17(16.8)
6(5.9)
3(3.0)
Anxiety
7(6.9)
35(34.7)
8(7.9)
2(2.0)
Depression
14(13.9)
24(23.8)
13(12.9)
1(1.0)
Anxiety
21(20.8)
17(16.8)
13(12.9)
1(1.0)
Depression
27(26.7)
12(11.9)
12(11.9)
1(1.0)
Anxiety
10(9.9)
27(26.8)
13(12.9)
2(2.0)
Depression
21(20.8)
22(21.8)
7(6.9)
2(2.0)
Anxiety
24(23.8)
16(15.8)
8(7.9)
2(2.0)
Depression
18(17.8)
16(15.8)
6(5.9)
5(5.0)
Table 6: Anxiety and depression ratio of all individuals Extreme in positive
Slight in positive
Sight in negative
Extreme in
aspect
aspect
aspect
negative aspect
Anxiety
52(51.5)
37(36.6)
7(6.9)
5(5.0)
Depression
47(46.5)
40(39.6)
13(12.9)
1(1.0)
Anxiety
43(42.6)
39(38.6)
13(12.9)
6(5.9)
Depression
44(43.6)
40(39.6)
13(12.9)
4(4.0)
Anxiety
43(42.6)
40(39.6)
16(15.8)
2(2.0)
Depression
48(47.5)
34(33.7)
14(13.9)
4(4.0)
Anxiety
21(20.8)
64(63.4)
13(12.9)
3(3.0)
Depression
32(31.7)
47(46.5)
21(20.8)
1(1.0)
Anxiety
41(40.6)
33(32.7)
21(20.8)
6(5.9)
Depression
41(40.6)
34(33.7)
25(24.8)
1(1.0)
Anxiety
19(18.8)
53(52.5)
24(23.8)
5(5.0)
Depression
35(34.7)
47(46.5)
17(16.8)
2(2.0)
Anxiety
42(41.6)
36(35.6)
16(15.8)
5(5.0)
Depression
36(35.6)
28(27.7)
17(16.8)
7(6.9)
[6]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al show moderate ratio slight in positive aspect and slight
Table 7: Mean and standard deviation the OHqOL
in negative aspect. Table 6 reveals the anxiety and depression values of
AGE
the males and females. They show the great impact on the slight in positive aspect. Least ratio is shown in
PCS
extreme in negative aspect. They show moderate ratio extreme in positive aspect and slight in negative
MCS
aspect. Table 7 reveals the mean and standard deviation
QT
values among the males and females. For general health males have responded more than women in
AT
both aspects. Besides for anxiety and depression and OHqOL females have responded more in both positive and negative aspects.
Sex
N
Mean
SD
Male
49
7.18
0.99
Female
52
5.73
0.79
Male
49
13.682
1.955
Female
52
11.084
1.537
Male
49
12.841
1.834
Female
52
9.201
1.276
Male
49
4.76
0.68
Female
52
5.79
0.80
Male
49
9.33
1.33
Female
52
8.85
1.23
psychological. This is in stark contrast to other studies, where only physical aspects of oral health were more
Discussion
frequently considered to have the greatest overall
This study shows the association between the oral
impact of life quality compared with items relating to
health status of the people, anxiety and depression
social, psychological and general health aspects. The
with the general health of the people and quality of the
reason might be because of the younger age group
life. This study is important because it is the first one in
with partial or limited exposure to life.
the context of elderly beneficiaries of social security.
Gender variations were not apparent in the study. Both
However, we have to accept that it does not allow
genders were likely to perceive oral health as it is
identifying predictive factors since the design was
impacting strongly on their quality of life. No
cross-sectional.
significant
First in this study utilizing the OHqOL questionnaire
specific oral health needs and are most likely to utilize
indicator.
It was observed that majority perceived
dental services which may be the key in understanding
their oral health as impacting on there quality of life.
oral health behavior, including dental attendance
Perhaps the greater effect of oral health on life quality
patterns.
observed here reflex the fact that OHqOL instrument
These variations varied from other studies. Previously
measured both positive and negative dimensions of
studies were done to identify associations between
oral health related quality of life. This supports the
level of dental anxiety and the impact of oral health on
findings of others, where large proportions of
quality of life (OHqOL) in Britain, controlling for socio
respondents perceived oral health as affecting there life
demographic and oral health status factors which gave
quality.
result as p < 0.001 and showed approximately two
Secondly, it is interesting that the respondents claimed
times as likely to be among those experiencing the
that their oral health status more frequently enhanced
poorest OHqOL below the population median OHqOL
their life quality as opposed to detracting from it and
score in Britain.7 Another study was done to identify
this too was evident in that OHQoL scores were
association between general health and their impact on
skewed towards positive oral health related quality of
oral health related quality of life in Califorina and
life. Existing quality of life measures in dentistry
measured as p
Quality of life with dental anxiety and depression...Shet RG et al
Association of oral health related quality of life with dental anxiety and depression along with general health among people of Bhopal district, Madhya Pradesh RGK Shet1, Gaurvi Jain2, Sohani Maroli3, Kirti Jajoo Srivastava4, Sitaram Prasad Kasina5, GS Shwetha6 1Professor,
Department of Prosthodontics, Manasarovar Dental College, Bhopal, Madhya Pradesh, India; 2Reader, Department of Prosthodontics,
Rishiraj College of Dental Sciences, Bhopal, Madhya Pradesh, India; 3Professor & Head, Department of Conservative Dentistry & Endodontics, St. Joseph Dental College, Eluru, Andhra Pradesh, India; 4Senior Lecturer, Department of Prosthodontics, Peoples Dental Academy, Bhopal, Madhya Pradesh, India; 5Senior Lecturer, Department of Prosthodontics, St. Joseph Dental College, Eluru, Andhra Pradesh, India; 6Reader, Department of Orthodontics & Dento-facial Orthopaedics, KLE Society’s Institute of Dental Sciences, Bangalore, Karnataka, India.
ABSTRACT Background: To associate oral health related quality of life with dental anxiety and depression along with general health among people of Bhopal district, Madhya Pradesh. Materials & Methods: A cross sectional questionnaires based survey was conducted among the subjects of Bhopal district, Madhya Pradesh. The survey was carried among 101 subjects aging from 20-40 years. Subjects under investigation were belonging to various occupations. They were assigned a questionnaire. Questionnaire consisted of four parts, first part consists of socio-demographic data along with dental visiting habits, second part has OHqOL-questionnaire, third part has general health (sf-12) and fourth part has hospital anxiety and depression questionnaire. Questionnaire was used for assessment of OHqOL. It consists of 16 questions which takes into account both effect and impact of oral health on quality of life. Dental anxiety and depression was measured by Hospital Anxiety and Depression Scale. Each question was provided with four options and numbering ranging from 0-3. For general health consideration sf-12 v2 was being used, which calculates two values PCS and MCS giving result in percentage. Results: A large proportion of respondent perceived oral health as having an enhanced effect on their quality of life in all three aspects that is general health, social and psychological. This is in stark contrast to other studies, where only physical aspects of oral health were more frequently considered to have the greatest overall impact of life quality compared with items relating to social, psychological and general health aspects. Conclusion: Gender variations were not apparent in the study. Both genders were likely to perceive oral health as it is impacting strongly on their quality of life. No significant gender variations are seen. But both have specific oral health needs and are most likely to utilize dental services which may be the key in understanding oral health behavior, including dental attendance patterns. Key Words: Dental anxiety and depression, general health, hospital anxiety and depression scale, OHqOL. How to cite this article: Shet RG, Jain G, Maroli S, Srivastava KJ, Kasina SP, Shwetha GS. Association of oral health related quality of life with dental anxiety and depression along with general health among people of Bhopal district, Madhya Pradesh. J Int Oral Health 2013; 5(6):1-8. Source of Support: Nil
Conflict of Interest: None Declared
Received: 11th August 2013
Reviewed: 15th September 2013
Accepted: 15th October 2013
Address for Correspondence: Dr. RGK Shet. Department of Prosthodontics, Manasarovar Dental College, Bhopal, Madhya Pradesh, India. Email: [email protected]
[1]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al Introduction
general health, as various studies are done by using HADS to measure out anxiety level and its direct and
In 1948, the World Health Organization (WHO)
indirect consequences on general health. To date most
defined health as being "complete physical, mental and
anxiety scales have received limited attention to their
social well-being, and not merely the absence of
theoretical underpinnings. Dental anxiety is not
diseases or illnesses".
unitary and has been typically conceived under three
Measures of oral health-related quality of life (OHqOL)
connected approaches: behavioral, cognitive, and
are increasingly being used in descriptive population-
physiological. Self report methods primarily assess the
based research as a means of capturing nonclinical
cognitive component which can be split into at least 2
aspects of oral health that patients deem most relevant
valid constructs.
to their overall health and well-being.1 When OHqOL
So present study was conducted to associate oral
measures are used alongside traditional clinical
health related quality of life with dental anxiety and
methods of measuring oral health status, a more
depression along with general health among people of
comprehensive assessment of the impact of oral
Bhopal district, Madhya Pradesh.
diseases on the several dimensions of subjective well-
Materials and Methods
being becomes possible.2 These dimensions include functional limitation, physical pain, psychological discomfort,
physical
disability,
A cross sectional questionnaires based survey was
psychological
conducted among the subjects of Bhopal. The survey
disability, social disability, and handicap 3 it has also
was carried among 101 subjects aging from 20-40 years.
been suggested that sex and socioeconomic status
Subjects under investigation were belonging to various
(SES) can have a moderating role on OHqOL. When
occupations. They were assigned a questionnaire. This
overall oral health is considered, there are few or no
study was done between the time period of november
differences between men and women, but sex
2012 to february 2013. The sample taken into account
differences are quite apparent when the utilization of
was a select sample which was considered as a sample
dental care services, treatment outcomes, or OHqOL
of convenience and feasibility.
are examined.4 Oral health affects people physically
Survey thus undertaken was a questionnaire survey in
and psychologically and influences how they grow,
which a specially designed questionnaire was used.
enjoy life, look, speak, chew, taste food and socialize,
Questionnaire consisted of four parts, first part consist
as well as their feelings of social well-being.5
of socio-demographic data along with dental visiting
Contemporary concepts of health suggest that oral health
should
be
defined
in
general
habits, second part has OHqOL-questionnaire, third
physical,
part has general health (sf-12) and fourth part has
psychological and social well-being terms in relation to
hospital anxiety and depression questionnaire. The
oral status.6 Research
on
health-related
behaviors
and
questionnaire was distributed among the individuals
their
and were tried to make understand each and every
correlations is of interest to public health for several
question. The questionnaire was constructed in English
reasons. First, implementation of successful health
as well as in Hindi. OHqOL questionnaire was used for
promotion programmes depends on both information
assessment of OHqOL.7 It consists of 16 questions
about the prevalence of such behaviors and an understanding
of
their
determinants.
which takes into account both effect and impact of oral
Secondly,
health on quality of life.8 The effect of oral health on
research may highlight interactions between health
quality of life has three domains - physical containing 6
related behaviors which may bring about synergistic
items and social and psychological consisting of five
effects on health status. Thirdly, information about
items each. All the respondents were made to
patterns of health related behaviors can provide
understand each question along with the effect and
important data for adjustment of health education
impact related to the questions and each of the
interventions within the context of health promotion
proposed 16 items were scored first on “effect” (with
programmes. We can relate hospital dental anxiety to
responses ranging from bad to good effect on quality of [2]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al life) and later on the “impact” of each “effect”. The
instructed not to take too long over their replies: their
impact of each effect was recorded under five
immediate reaction to each item will probably be more
categories that is No, Little, Moderate, Great and
accurate than a long thought-out response. It consists
Extreme. The score for each effect was ranging from 1
of 14 questions, seven for anxiety and seven for
to 9 with score 1 being bad effect having extreme
depression. Although it was designed for hospital
impact, score 5 representing no effect with no impact
General Medical Outpatients, it has been extensively
and 9 being good effect having extreme impact. The
used in Primary Care.2 For general health consideration
sum of individual item responses were added together
sf-12 v2 was being used, which calculates two values
to generate an overall score with possible values
PCS and MCS giving result in percentage. All
ranging from 16 to 144. All the data collected was
responses to questions in SF-12v2 are printed in a
entered into the spreadsheets.
horizontal (left-to-right) format, There is considerable
Dental anxiety and depression was measured by
empirical
Hospital Anxiety and Depression Scale. Each question
response categories substantially improve the two SF-
was provided with four options and numbering
12 role. Advantage of the SF-12v2 form over the
ranging from 0-3. This is a self screening questionnaire
original v1 form is the provision for estimating the
for depression and anxiety.1 The patient should be
eight-domain profile of scales, in addition to the PCS-
8
evidence
that
the
SF-12v2
five-choice
Table 1: Distribution of response to OHqOL - Effects & Impacts (MALES) Response s(physica l aspect)
Bad effect
Bad
Bad
Bad
Great
Great
Great
Great
of
effect of
effect of
effect of
effect of
effect of
effect of
effect of
extreme
great
moderat
little
little
moderat
great
extreme
empect
impact
e impact
impact
impact
e impact
impact
impact
None
Eating
0
0
0
0
11(10.9)
18(17.8)
5(5.0)
12(11.9)
3(3.0)
Appeara
0
0
0
0
3(3.0)
10(9.9)
15(14.9)
14(13.9)
7(6.9)
Speech
0
0
0
0
6(5.9)
11(10.9)
14(13.9)
16(15.8)
2(2.0)
General
0
1 (1.0)
0
0
9(8.9)
12(11.9)
11(10.9)
10(9.9)
6(5.9)
0
1 (1.0)
1 (1.0)
0
5(5.0)
14(13.9)
11(10.9)
11(10.9)
6(5.9)
Comfort
0
0
0
0
7(6.9)
5(5.0)
17(16.8)
15(14.9)
5(5.0)
Sleep(psy
0
0
0
1 (1.0)
6(6.0)
7(7.0)
14(14.0)
18(18.0)
3(3.0)
0
0
1 (1.0)
1 (1.0)
6(5.9)
4(4.0)
18(17.8)
11(10.9)
8(7.9)
Worky
0
0
0
0
8(7.9)
11(10.9)
14(13.9)
14(13.9)
2(2.0)
Mood
0
0
1 (1.0)
0
6(5.9)
10(9.9)
8(7.9)
16(15.8)
8(7.9)
0
0
1 (1.0)
1 (1.0)
8(7.9)
8(7.9)
13(12.9)
11(10.9)
7(6.9)
Social life
0
0
1 (1.0)
0
4(4.0)
6(5.9)
12(11.9)
13(12.9)
13(12.9)
Romantic
0
0
0
0
12(11.9)
5(5.0)
10(9.9)
13(12.9)
9(8.9)
Smiling
0
0
1 (1.0)
0
10(9.9)
7(6.9)
10(9.9)
16(15.8)
5(5.0)
Work
0
0
0
0
10(9.9)
8(7.9)
13(12.9)
11(10.9)
7(6.9)
Finance
0
0
0
1 (1.0)
8(7.9)
11(10.9)
17(16.8)
6(5.9)
6(5.9)
nce
Health Breath odor
chologica l aspect) Confiden ce
Personali ty
relation
[3]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al 12 and MCS-12 summary measures. The on-line
the past week, how much of the time has your physical
scoring software, now available for SF-12v2, also
health or emotional problems interfered with your
incorporates Quality Metric Incorporated’s MDE
social activities like visiting friends, relatives, etc. Two
algorithms which reduce the bias in estimates of
SF-12 scales, Physical functioning and general health,
missing responses, and makes it possible to compute
do not have a recall period, so are identical across acute
scale and summary scores for many respondents who
and standard forms. (sf -36. org)
would have otherwise been lost due to missing data.
Results
The SF-12 was designed for applications in which health status would be measured weekly or biweekly.
Table 1 reveals that OHqOL variation between the
It was created by changing the recall period for six SF-
male candidates and they show more positive effect on
12 scales (Role Physical, Bodily Pain, Vitality, Social
OHqOL by eating, sleep and confidence in their life
Functioning, Role Emotional, and Mental Health) from
and show slight or more negative effect on smiling and
“the past four weeks” to “the past week”. For example,
mood. They feel that they are slightly affected or have
the question, “During the past four weeks, how much
a moderate effect of OHqOL on work, finance,
of the time has your physical health or emotional
personality, social life and romantic relationship.
problems interfered with your social activities like
Table 2 reveals that OHqOL variation between the
visiting friends, relatives, etc was changed as during
female candidates and they show more positive effect
Table 2: Distribution of response to OHqOL - Effects & Impacts (FEMALES) Bad
Bad
Bad
Bad
effect of
effect of
effect of
extreme
great
empect
Eating Appearanc
None
Great
Great
Great
Great
effect of
effect of
effect of
effect of
effect of
moderat
little
little
moderat
great
extreme
impact
e impact
impact
impact
e impact
impact
impact
0
0
2(2.0)
0
7(6.9)
11(10.9)
11(10.9)
16(15.8)
5(5.0)
0
0
0
0
3(3.0)
10(9.9)
17(16.8)
18(17.8)
4(4.0)
Speech
0
0
0
0
1(1.0)
10(9.9)
17(16.8)
15(14.9)
9(8.9)
General
0
1(1.0)
0
0
5(5.0)
13(12.9)
13(12.9)
14(13.9)
6(5.9)
0
1(1.0)
0
1(1.0)
6(5.9)
13(12.9)
17(16.8)
6(5.9)
8(7.9)
Comfort
0
0
0
2(2.0)
4(4.0)
10(9.9)
18(17.8)
13(12.9)
5(5.0)
Sleep(psyc
0
0
0
1(1.0)
7(7.0)
9(9.0)
17(17.0)
11(11.0)
6(6.0)
Confidence
0
0
1(1.0)
0
6(5.9)
9(8.9)
15(14.9)
15(14.9)
6(5.9)
Worky
0
0
2(2.0)
0
12(11.9)
12(11.9)
11(10.9)
12(11.9)
3(3.0)
Mood
0
0
1(1.0)
0
11(10.9)
2(2.0)
18(17.8)
13(12.9)
7(6.9)
Personality
0
0
0
0
11(10.9)
3(3.3)
16(15.8)
16(15.8)
6(5.9)
Social life
0
0
0
0
9(8.9)
6(5.9)
11(10.9)
14(13.9)
9(8.9)
Romantic
0
0
0
0
10(9.9)
9(8.9)
9(8.9)
18(17.8)
5(5.0)
Smiling
0
0
0
0
11(10.9)
8(7.9)
17(16.8)
11(10.9)
5(5.0)
Work
0
0
0
0
8(7.9)
5(5.0)
20(19.8)
12(11.9)
7(6.9)
Finance
0
0
0
0
8(7.9)
9(8.9)
17(16.8)
16(15.8)
2(2.0)
Bad effect of extreme empect
e
Health Breath odor
hological aspect)
relation
[4]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al on OHqOL by appearence, comfort and work in their
and breath odour. They feel that they are slightly
life and show slight or more negative effect on eating
affected or have a moderate effect of OHqOL on sleep,
Table 3: Distribution of response to OHqOL - Effects & Impacts (TOTAL) Bad
Bad
Bad
Bad
effect of
effect of
effect of
extreme
great
moderat
empect
impact
Eating
0
Appearance
None
Great
Great
Great
Great
effect of
effect of
effect of
effect of
effect of
little
little
moderat
great
extreme
e impact
impact
impact
e impact
impact
impact
0
2(2.0)
0
18(17.8)
29(28.7)
16(15.8)
28(27.7)
8(7.9)
0
0
0
0
6(5.9)
20(19.8)
32(31.7)
32(31.7)
11(10.9)
Speech
0
0
0
0
7(6.9)
21(20.8)
31(30.7)
31(30.7)
11(10.9)
General
0
2(2.0)
0
0
14(13.9)
25(24.9)
24(23.8)
24(23.8)
12(11.9)
Breath odor
0
2(2.0)
1(1.0)
1(1.0)
11(10.9)
27(26.7)
28(27.7)
17(16.8)
14(13.9)
Comfort
0
0
0
2(2.0)
11(10.9)
15(14.9)
35(34.7)
28(27.7)
10(9.9)
Sleep(psycho
0
0
0
2(2.0)
13(13.0)
16(16.0)
31(31.0)
29(29.0)
9(9.0)
Confidence
0
0
2(2.0)
1(1.0)
12(11.9)
13(12.9)
33(32.7)
26(25.7)
14(13.9)
Worky
0
0
2(2.0)
0
20(19.8)
23(22.8)
25(24.8)
26(25.7)
5(5.0)
Mood
0
0
2(2.0)
0
17(16.8)
12(11.9)
26(25.7)
29(28.7)
15(14.9)
Personality
0
0
1(1.0)
1(1.0)
19(18.8)
11(10.9)
29(28.7)
27(26.7)
13(12.9)
Social life
0
0
1(1.0)
3(3.0)
13(12.9)
12(11.9)
23(22.8)
27(26.7)
22(21.8)
Romantic
1(1.0)
0
0
0
22(21.8)
14(13.9)
19(18.8)
31(30.7)
14(13.9)
Smiling
0
0
1(1.0)
0
21(20.8)
15(14.9)
27(26.7)
27(26.7)
10(9.9)
Work
0
0
0
0
18(17.8)
13(12.9)
33(32.7)
23(22.8)
14(13.9)
Finance
0
0
0
1(1.0)
16(15.8)
20(19.8)
34(33.7)
22(21.8)
8(7.9)
Responses(p hysical aspect)
Health
logical aspect)
relation
Table 4: Anxiety and depression ratio among males Extreme in positive
Slight in positive
Sight in negative
Extreme in negative
aspect
aspect
aspect
aspect
Anxiety
29(28.7)
13(12.9)
5(5.0)
2(2.0)
Depression
22(21.8)
21(20.8)
6(5.9)
0
Anxiety
18(17.8)
20(19.8)
8(7.9)
3(3.0)
Depression
17(16.8)
24(23.8)
6(5.9)
2(2.0)
Anxiety
18(17.8)
19(18.8)
10(9.9)
2(2.0)
Depression
23(22.8)
17(16.8)
8(7.9)
1(1.0)
Anxiety
14(13.9)
29(28.7)
5(5.0)
1(1.0)
Depression
18(17.8)
23(22.8)
8(7.9)
0
Anxiety
20(19.8)
16(15.8)
8(7.9)
5(5.0)
Depression
14(13.9)
22(21.8)
13(12.9)
0
Anxiety
9(8.9)
26(25.7)
11(10.9)
3(3.0)
Depression
14(13.9)
25(24.8)
10(9.9)
0
Anxiety
18(17.8)
20(19.8)
8(7.9)
3(3.0)
Depression
18(17.8)
12(11.9)
11(10.9)
2(2.0)
[5]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al finance,
personality,
social
life
and
romantic
Table 4 reveals the anxiety and depression ratio of
relationship.
males. Males show more anxiety and depression ratio
Table 3 reveals that OHqOL variation
among
the
slight in positive aspect. Least ratio is shown in
general population and they show more positive affect
extreme in negative aspect. They show moderate ratio
of OHqOL on appearance, comfort, finance, speech
extreme in positive aspect and slight in negative aspect.
,sleep, confidence and relationship show slight
Table 5 reveals the anxiety and depression ratio among
or
more negative effect on eating and breath odor. They
females.
Females
show
the
more
anxiety
and
feel that they are slightly affected or have a moderate
depression ratio in the extreme in positive aspect. Least
effect of OHqOL on personality, social life and mood.
ratio is shown in extreme in negative aspect. They
Table 5: Anxiety and depression ratio among females Extreme in positive
Slight in positive
Sight in negative
Extreme in negative
aspect
aspect
aspect
aspect
Anxiety
23(22.8)
24(23.8)
2(2.0)
3(3.0)
Depression
25(24.8)
19(18.8)
7(6.9)
1(1.0)
Anxiety
25(24.8)
19(18.8)
5(5.0)
3(3.0)
Depression
27(26.7)
16)15.88)
7(6.9)
2(2.0)
Anxiety
25(24.7)
21(20.8)
6(5.9)
0
Depression
25(24.7)
17(16.8)
6(5.9)
3(3.0)
Anxiety
7(6.9)
35(34.7)
8(7.9)
2(2.0)
Depression
14(13.9)
24(23.8)
13(12.9)
1(1.0)
Anxiety
21(20.8)
17(16.8)
13(12.9)
1(1.0)
Depression
27(26.7)
12(11.9)
12(11.9)
1(1.0)
Anxiety
10(9.9)
27(26.8)
13(12.9)
2(2.0)
Depression
21(20.8)
22(21.8)
7(6.9)
2(2.0)
Anxiety
24(23.8)
16(15.8)
8(7.9)
2(2.0)
Depression
18(17.8)
16(15.8)
6(5.9)
5(5.0)
Table 6: Anxiety and depression ratio of all individuals Extreme in positive
Slight in positive
Sight in negative
Extreme in
aspect
aspect
aspect
negative aspect
Anxiety
52(51.5)
37(36.6)
7(6.9)
5(5.0)
Depression
47(46.5)
40(39.6)
13(12.9)
1(1.0)
Anxiety
43(42.6)
39(38.6)
13(12.9)
6(5.9)
Depression
44(43.6)
40(39.6)
13(12.9)
4(4.0)
Anxiety
43(42.6)
40(39.6)
16(15.8)
2(2.0)
Depression
48(47.5)
34(33.7)
14(13.9)
4(4.0)
Anxiety
21(20.8)
64(63.4)
13(12.9)
3(3.0)
Depression
32(31.7)
47(46.5)
21(20.8)
1(1.0)
Anxiety
41(40.6)
33(32.7)
21(20.8)
6(5.9)
Depression
41(40.6)
34(33.7)
25(24.8)
1(1.0)
Anxiety
19(18.8)
53(52.5)
24(23.8)
5(5.0)
Depression
35(34.7)
47(46.5)
17(16.8)
2(2.0)
Anxiety
42(41.6)
36(35.6)
16(15.8)
5(5.0)
Depression
36(35.6)
28(27.7)
17(16.8)
7(6.9)
[6]
Journal of International Oral Health. Nov-Dec 2013; 5(6):1-8
ORIGINAL RESEARCH
Quality of life with dental anxiety and depression...Shet RG et al show moderate ratio slight in positive aspect and slight
Table 7: Mean and standard deviation the OHqOL
in negative aspect. Table 6 reveals the anxiety and depression values of
AGE
the males and females. They show the great impact on the slight in positive aspect. Least ratio is shown in
PCS
extreme in negative aspect. They show moderate ratio extreme in positive aspect and slight in negative
MCS
aspect. Table 7 reveals the mean and standard deviation
QT
values among the males and females. For general health males have responded more than women in
AT
both aspects. Besides for anxiety and depression and OHqOL females have responded more in both positive and negative aspects.
Sex
N
Mean
SD
Male
49
7.18
0.99
Female
52
5.73
0.79
Male
49
13.682
1.955
Female
52
11.084
1.537
Male
49
12.841
1.834
Female
52
9.201
1.276
Male
49
4.76
0.68
Female
52
5.79
0.80
Male
49
9.33
1.33
Female
52
8.85
1.23
psychological. This is in stark contrast to other studies, where only physical aspects of oral health were more
Discussion
frequently considered to have the greatest overall
This study shows the association between the oral
impact of life quality compared with items relating to
health status of the people, anxiety and depression
social, psychological and general health aspects. The
with the general health of the people and quality of the
reason might be because of the younger age group
life. This study is important because it is the first one in
with partial or limited exposure to life.
the context of elderly beneficiaries of social security.
Gender variations were not apparent in the study. Both
However, we have to accept that it does not allow
genders were likely to perceive oral health as it is
identifying predictive factors since the design was
impacting strongly on their quality of life. No
cross-sectional.
significant
First in this study utilizing the OHqOL questionnaire
specific oral health needs and are most likely to utilize
indicator.
It was observed that majority perceived
dental services which may be the key in understanding
their oral health as impacting on there quality of life.
oral health behavior, including dental attendance
Perhaps the greater effect of oral health on life quality
patterns.
observed here reflex the fact that OHqOL instrument
These variations varied from other studies. Previously
measured both positive and negative dimensions of
studies were done to identify associations between
oral health related quality of life. This supports the
level of dental anxiety and the impact of oral health on
findings of others, where large proportions of
quality of life (OHqOL) in Britain, controlling for socio
respondents perceived oral health as affecting there life
demographic and oral health status factors which gave
quality.
result as p < 0.001 and showed approximately two
Secondly, it is interesting that the respondents claimed
times as likely to be among those experiencing the
that their oral health status more frequently enhanced
poorest OHqOL below the population median OHqOL
their life quality as opposed to detracting from it and
score in Britain.7 Another study was done to identify
this too was evident in that OHQoL scores were
association between general health and their impact on
skewed towards positive oral health related quality of
oral health related quality of life in Califorina and
life. Existing quality of life measures in dentistry
measured as p
