DOI: 10.1111/ipd.12107
Impact of oral mucosal conditions on oral health-related quality of life in preschool children: a hierarchical approach ˆ NIO MARTINS-JU´NIOR2, RAQUEL GONC ß ALVES VIEIRA-ANDRADE1, PAULO ANTO 1 PATRI´CIA CORREˆA-FARIA , LEANDRO SILVA MARQUES2, SAUL MARTINS PAIVA1 & MARIA LETI´CIA RAMOS-JORGE2 1
Department of Pediatric Dentistry and Orthodontics, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil, and 2Department of Dentistry, Federal University of Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brazil
International Journal of Paediatric Dentistry 2014; Objective. To determine the impact of oral muco-
sal conditions on OHRQoL in preschool children. Methods. A cross-sectional study was carried out
with a selected representative sample of 724 children aged 2–5 years and their parents/caregivers. Data were collected through interviews with parents/caregivers, who also answered the B-ECOHIS. A clinical oral examination was performed to determine oral mucosal conditions, dental caries, dental trauma, and malocclusion. Data analysis involved descriptive statistics, the Kolmogorov– Smirnov normality test, the Mann–Whitney U-test and hierarchically adjusted Poisson regression models (P < 0.05, 95% CI).
Introduction
Oral health-related quality of life (OHRQoL) is a multidimensional concept related to the impact of adverse oral conditions on psychosocial and functional well-being1–3. Oral mucosal conditions in preschool children have become an important issue in recent years due to the high prevalence rates as well as associations with other oral conditions, harmful habits, and social determinants, such as a low household income4–8. Some oral mucosal conditions result in pain9,10, which can affect eating, sleeping, and school performance11–14. While the interaction between oral health and quality of life in preschool children is a growing field of research worldwide13–19, the Correspondence to: Raquel Goncßalves Vieira-Andrade, St. Patag^ onia, 284, Apto 301, Sion, Belo Horizonte, Minas Gerais, ZIP 30320-080, Brazil. E-mail: [email protected]
Results. The prevalence of oral mucosal conditions was 50.7%, the most prevalent of which were melanotic macules (17.8%), oral ulcers (11.0%), Fordyce’s spots (9.4%), geographic tongue (5.2%), fissured tongue (1.9%), median rhomboid glossitis (1.8%), and fistula (1.4%). In the final multivariate model, child with 5 years of age (RR = 1.60; 95% CI: 1.08–2.38; P = 0.020), with presence of fistula (RR = 1.94; 95% CI: 1.27–2.95; P = 0.002), and with dental caries (RR = 2.58; 95% CI: 2.00–3.35; P < 0.001) had a negative impact on children’s OHRQoL. Conclusion. Child with 5 years of age, presence of fistula, and dental caries were associated with a negative impact on the quality of life of preschool children.
majority of the published studies is related to the impact of untreated dental caries, dental trauma, and malocclusion on the daily living of such individuals14,20,21. These studies, in general, demonstrate that early childhood caries (ECC) and complicated dental trauma, but not malocclusion, have a negative influence on the OHRQoL of preschool children, mainly in symptoms domain and self-image/ social interaction domain. Nevertheless, it seems that no research groups have drawn attention to the importance of oral mucosal conditions as a possible factor for contributing to the poor quality of life of preschool children. In fact, there are no published studies that evaluate the impact of oral mucosal conditions on OHRQoL in preschool children. As the assessment of quality of life has become an integral part of evaluations in health programs, the perceptions of parents/caregivers regarding how oral mucosal conditions affect the quality of life of their children can allow a better understanding of the impact of these
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1
2
R. G. Vieira-Andrade et al.
conditions in this specific age group and can contribute to the planning of strategies directed at promoting child health. The aim of this study was to determine the impact of oral mucosal conditions on the OHRQoL of preschool children and their parents/caregivers.
As the children were naturally organized in a line during the immunization campaigns, systematic sampling was adopted, in which one child was selected for examination, the next was not selected, the next was selected and so on. Twelve children who did not cooperate (crying or tantrum) during the clinical exam were excluded from the study.
Materials and methods
Data collection and clinical oral examination Ethical issues This study was carried out in compliance with international norms and national legislation on ethics in research involving human subjects. The study was independently reviewed and approved by an ethics committee. All parents/caregivers signed a statement of informed consent. Subjects A cross-sectional study was carried out in the city of Diamantina, which is located in the state of Minas Gerais, southeastern of Brazil. The study population was made up of children and their parents/guardians treated at the ten basic health units in the city during four immunization campaigns held in 2010 and 2011. Diamantina has a >90% vaccine coverage rate. The following were the inclusion criteria: children between 2 and 5 years of age (up to 71 months); either gender; adequate cooperation for the oral examination; and accompaniment by a Brazilian Portuguese-speaking parent/caregiver who lived with the child at least 12 h/day. The exclusion criteria were current orthodontic treatment, systemic disease, and physical or learning disability. The calculation of the sample size considered a 25% prevalence rate of oral mucosal conditions6, a 95% confidence interval, and 3% estimated error, which determined a minimum sample size of 560 individuals. A correction factor (cluster effect) of 1.2 was employed to enhance the precision (n = 672 children), and an additional 135 children (20%) were added to make up for possible losses, totalling a minimum sample size of 807 children for a response rate of 100.0%.
Data acquisition was performed following the immunization of the children. Parents/caregivers responded to a questionnaire addressing information on the child (age and gender) and socio-demographic data, such as marital status (married or separated parents), child’s place of residence (urban or rural area), mother’s current age, mother’s and father’s schooling (number of completed years of study), monthly household income (sum of income of active family members), and number of siblings (none, one, two or more). Parents/caregivers were also asked to answer the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS)22 in interview format. The clinical oral examinations were carried out by a team consisting of ten examiners, ten interviewers and ten assistants distributed among ten groups of three individuals (one examiner, one interviewer, and one assistant), with one group acting at each basic health unit. All ten examiners were general dentists. Prior to the fieldwork, the examiners underwent training and calibration exercise for the diagnosis of oral mucosal conditions23, dental caries24, dental trauma25, and malocclusion. The assessment of malocclusion included anterior open bite, anterior crossbite, overjet >2 mm, deep over bite, and posterior cross-bite. For each child, dental caries, dental trauma or the different types of malocclusion were categorised as 0 = absent or 1 = present. The training exercise was carried out using 40 images with different clinical situations of oral conditions. The calibration exercise involved the clinical oral examination of 20 children on two separate occasions with a 1-week interval between sessions. These children did not take part in the
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Oral mucosal conditions and quality of life
main study. Intra-examiner and interexaminer Kappa coefficients ranged from 0.81 to 1.00, demonstrating excellent agreement. A pilot study was conducted with a sample of 30 children/mothers who were visited at their homes to test and train the administration of the ECOHIS, the clinical oral examination, and the data collection method. The clinical oral examination was performed for the identification of oral mucosal conditions based on the sequence proposed by Bessa et al.6 Oral exams were carried out in a room at the basic health unit reserved for this purpose and in compliance with all biosafety norms. The child was seated facing a source of natural light. Direct observation of the oral cavity was performed with the aid of disposable tongue depressors. Oral mucosal conditions were categorized as present/absent and were recorded on a standardized clinical chart containing 23 different types of conditions. Traumatic ulcers and recurring aphthous ulcerations were recorded as oral ulcers due to the impossibility of differentiating these distinct aetiological factors in a single clinical evaluation. Single or multiple shallow lesions with erythematous borders and no signs of infection were considered oral ulcers. Melanotic macules were recorded when multifocal or diffuse melanin pigmentation was observed, especially in the region of the gingival insertion. Angular cheilitis was determined by presence of an inflammatory process located in the angle of the mouth either unilaterally or bilaterally characterized by discreet oedema, erythema, peeling, erosion, and fissures. Cases that required additional tests to confirm the diagnosis were referred to the stomatology clinic of the Federal University of Vales do Jequitinhonha e Mucuri for biopsy and were included in this study only after a definitive diagnosis was obtained. In this study, dental caries, dental trauma, and malocclusion were evaluated as these variables may confuse the outcome of the study. The structure of the ECOHIS includes questions more suitable for assessing dental caries and complicated dental trauma13,16. Malocclusions have not been associated with a negative influence on the OHRQoL of
3
preschool children13,16. Also, it is important to note that no children in this study had untreated complicated dental trauma. Therefore, only dental caries was evaluated as variable that may confuse the outcome of the study. Early Childhood Oral Health Impact Scale The Brazilian version of the ECOHIS was administered to parents/caregivers in interview form to assess OHRQoL among the children22. The ECOHIS consists of 13 items distributed between the child impact section and family impact section. The child impact section has four subscales: symptoms, function, psychology, and self-image/social interaction. The family impact section has two subscales: parental distress and family function. The questionnaire is scored using a simple 5-point scale, with responses ranging from ‘never’ to ‘very often’ (equivalent to scores of 0 and 4, respectively). The scores for the individual subscales are calculated as a simple sum of the response codes. The total score ranges from 0 to 52, with higher scores denoting a greater impact. The number of ‘I don’t know’ responses was counted, but they were excluded from the total ECOHIS score for each patient. Questionnaires on which parents/caregivers responded ‘don’t know’ to two or more items on the child impact section, or one or more items on the family impact section were excluded from the analysis. Data analysis The data were analysed using the Statistical Package for Social Sciences (SPSS for Windows, version 20.0; SPSS Inc., Chicago, IL, USA). Descriptive statistics and frequency distribution were determined for all oral mucosal conditions, ECOHIS scores and responses to each item. Subscale scores were analysed for differences among the most frequent types of oral mucosal conditions. In this initial analysis, the Kolmogorov–Smirnov test was used to determine the normality of the data distribution. As the data were not normally distributed, the nonparametric Mann–Whitney U-test was
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4
R. G. Vieira-Andrade et al.
used, with the level of significance set to 5% (P < 0.05). The independent variables were child’s gender, child’s age, and socio-demographic data (marital status, child’s place of residence, mother’s current age, mother’s and father’s schooling, monthly household income, household crowding and number of siblings). A hierarchical approach to variable selection was used26,27. The variables were grouped into a hierarchy of categories ranging from distal to proximal determinants. The categories were child’s characteristics, sociodemographic factors, oral mucosal conditions, and dental caries (in that order). For each level, Poisson regression analysis with robust variance was performed to correlate the overall mean ECOHIS score with the child’s characteristics, socio-demographic factors, oral mucosal conditions, and dental caries. This analysis was performed to exclude variables with a P-value > 0.20. Explanatory variables were selected for the final models only if they had a P-value of
Impact of oral mucosal conditions on oral health-related quality of life in preschool children: a hierarchical approach ˆ NIO MARTINS-JU´NIOR2, RAQUEL GONC ß ALVES VIEIRA-ANDRADE1, PAULO ANTO 1 PATRI´CIA CORREˆA-FARIA , LEANDRO SILVA MARQUES2, SAUL MARTINS PAIVA1 & MARIA LETI´CIA RAMOS-JORGE2 1
Department of Pediatric Dentistry and Orthodontics, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil, and 2Department of Dentistry, Federal University of Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brazil
International Journal of Paediatric Dentistry 2014; Objective. To determine the impact of oral muco-
sal conditions on OHRQoL in preschool children. Methods. A cross-sectional study was carried out
with a selected representative sample of 724 children aged 2–5 years and their parents/caregivers. Data were collected through interviews with parents/caregivers, who also answered the B-ECOHIS. A clinical oral examination was performed to determine oral mucosal conditions, dental caries, dental trauma, and malocclusion. Data analysis involved descriptive statistics, the Kolmogorov– Smirnov normality test, the Mann–Whitney U-test and hierarchically adjusted Poisson regression models (P < 0.05, 95% CI).
Introduction
Oral health-related quality of life (OHRQoL) is a multidimensional concept related to the impact of adverse oral conditions on psychosocial and functional well-being1–3. Oral mucosal conditions in preschool children have become an important issue in recent years due to the high prevalence rates as well as associations with other oral conditions, harmful habits, and social determinants, such as a low household income4–8. Some oral mucosal conditions result in pain9,10, which can affect eating, sleeping, and school performance11–14. While the interaction between oral health and quality of life in preschool children is a growing field of research worldwide13–19, the Correspondence to: Raquel Goncßalves Vieira-Andrade, St. Patag^ onia, 284, Apto 301, Sion, Belo Horizonte, Minas Gerais, ZIP 30320-080, Brazil. E-mail: [email protected]
Results. The prevalence of oral mucosal conditions was 50.7%, the most prevalent of which were melanotic macules (17.8%), oral ulcers (11.0%), Fordyce’s spots (9.4%), geographic tongue (5.2%), fissured tongue (1.9%), median rhomboid glossitis (1.8%), and fistula (1.4%). In the final multivariate model, child with 5 years of age (RR = 1.60; 95% CI: 1.08–2.38; P = 0.020), with presence of fistula (RR = 1.94; 95% CI: 1.27–2.95; P = 0.002), and with dental caries (RR = 2.58; 95% CI: 2.00–3.35; P < 0.001) had a negative impact on children’s OHRQoL. Conclusion. Child with 5 years of age, presence of fistula, and dental caries were associated with a negative impact on the quality of life of preschool children.
majority of the published studies is related to the impact of untreated dental caries, dental trauma, and malocclusion on the daily living of such individuals14,20,21. These studies, in general, demonstrate that early childhood caries (ECC) and complicated dental trauma, but not malocclusion, have a negative influence on the OHRQoL of preschool children, mainly in symptoms domain and self-image/ social interaction domain. Nevertheless, it seems that no research groups have drawn attention to the importance of oral mucosal conditions as a possible factor for contributing to the poor quality of life of preschool children. In fact, there are no published studies that evaluate the impact of oral mucosal conditions on OHRQoL in preschool children. As the assessment of quality of life has become an integral part of evaluations in health programs, the perceptions of parents/caregivers regarding how oral mucosal conditions affect the quality of life of their children can allow a better understanding of the impact of these
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1
2
R. G. Vieira-Andrade et al.
conditions in this specific age group and can contribute to the planning of strategies directed at promoting child health. The aim of this study was to determine the impact of oral mucosal conditions on the OHRQoL of preschool children and their parents/caregivers.
As the children were naturally organized in a line during the immunization campaigns, systematic sampling was adopted, in which one child was selected for examination, the next was not selected, the next was selected and so on. Twelve children who did not cooperate (crying or tantrum) during the clinical exam were excluded from the study.
Materials and methods
Data collection and clinical oral examination Ethical issues This study was carried out in compliance with international norms and national legislation on ethics in research involving human subjects. The study was independently reviewed and approved by an ethics committee. All parents/caregivers signed a statement of informed consent. Subjects A cross-sectional study was carried out in the city of Diamantina, which is located in the state of Minas Gerais, southeastern of Brazil. The study population was made up of children and their parents/guardians treated at the ten basic health units in the city during four immunization campaigns held in 2010 and 2011. Diamantina has a >90% vaccine coverage rate. The following were the inclusion criteria: children between 2 and 5 years of age (up to 71 months); either gender; adequate cooperation for the oral examination; and accompaniment by a Brazilian Portuguese-speaking parent/caregiver who lived with the child at least 12 h/day. The exclusion criteria were current orthodontic treatment, systemic disease, and physical or learning disability. The calculation of the sample size considered a 25% prevalence rate of oral mucosal conditions6, a 95% confidence interval, and 3% estimated error, which determined a minimum sample size of 560 individuals. A correction factor (cluster effect) of 1.2 was employed to enhance the precision (n = 672 children), and an additional 135 children (20%) were added to make up for possible losses, totalling a minimum sample size of 807 children for a response rate of 100.0%.
Data acquisition was performed following the immunization of the children. Parents/caregivers responded to a questionnaire addressing information on the child (age and gender) and socio-demographic data, such as marital status (married or separated parents), child’s place of residence (urban or rural area), mother’s current age, mother’s and father’s schooling (number of completed years of study), monthly household income (sum of income of active family members), and number of siblings (none, one, two or more). Parents/caregivers were also asked to answer the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS)22 in interview format. The clinical oral examinations were carried out by a team consisting of ten examiners, ten interviewers and ten assistants distributed among ten groups of three individuals (one examiner, one interviewer, and one assistant), with one group acting at each basic health unit. All ten examiners were general dentists. Prior to the fieldwork, the examiners underwent training and calibration exercise for the diagnosis of oral mucosal conditions23, dental caries24, dental trauma25, and malocclusion. The assessment of malocclusion included anterior open bite, anterior crossbite, overjet >2 mm, deep over bite, and posterior cross-bite. For each child, dental caries, dental trauma or the different types of malocclusion were categorised as 0 = absent or 1 = present. The training exercise was carried out using 40 images with different clinical situations of oral conditions. The calibration exercise involved the clinical oral examination of 20 children on two separate occasions with a 1-week interval between sessions. These children did not take part in the
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Oral mucosal conditions and quality of life
main study. Intra-examiner and interexaminer Kappa coefficients ranged from 0.81 to 1.00, demonstrating excellent agreement. A pilot study was conducted with a sample of 30 children/mothers who were visited at their homes to test and train the administration of the ECOHIS, the clinical oral examination, and the data collection method. The clinical oral examination was performed for the identification of oral mucosal conditions based on the sequence proposed by Bessa et al.6 Oral exams were carried out in a room at the basic health unit reserved for this purpose and in compliance with all biosafety norms. The child was seated facing a source of natural light. Direct observation of the oral cavity was performed with the aid of disposable tongue depressors. Oral mucosal conditions were categorized as present/absent and were recorded on a standardized clinical chart containing 23 different types of conditions. Traumatic ulcers and recurring aphthous ulcerations were recorded as oral ulcers due to the impossibility of differentiating these distinct aetiological factors in a single clinical evaluation. Single or multiple shallow lesions with erythematous borders and no signs of infection were considered oral ulcers. Melanotic macules were recorded when multifocal or diffuse melanin pigmentation was observed, especially in the region of the gingival insertion. Angular cheilitis was determined by presence of an inflammatory process located in the angle of the mouth either unilaterally or bilaterally characterized by discreet oedema, erythema, peeling, erosion, and fissures. Cases that required additional tests to confirm the diagnosis were referred to the stomatology clinic of the Federal University of Vales do Jequitinhonha e Mucuri for biopsy and were included in this study only after a definitive diagnosis was obtained. In this study, dental caries, dental trauma, and malocclusion were evaluated as these variables may confuse the outcome of the study. The structure of the ECOHIS includes questions more suitable for assessing dental caries and complicated dental trauma13,16. Malocclusions have not been associated with a negative influence on the OHRQoL of
3
preschool children13,16. Also, it is important to note that no children in this study had untreated complicated dental trauma. Therefore, only dental caries was evaluated as variable that may confuse the outcome of the study. Early Childhood Oral Health Impact Scale The Brazilian version of the ECOHIS was administered to parents/caregivers in interview form to assess OHRQoL among the children22. The ECOHIS consists of 13 items distributed between the child impact section and family impact section. The child impact section has four subscales: symptoms, function, psychology, and self-image/social interaction. The family impact section has two subscales: parental distress and family function. The questionnaire is scored using a simple 5-point scale, with responses ranging from ‘never’ to ‘very often’ (equivalent to scores of 0 and 4, respectively). The scores for the individual subscales are calculated as a simple sum of the response codes. The total score ranges from 0 to 52, with higher scores denoting a greater impact. The number of ‘I don’t know’ responses was counted, but they were excluded from the total ECOHIS score for each patient. Questionnaires on which parents/caregivers responded ‘don’t know’ to two or more items on the child impact section, or one or more items on the family impact section were excluded from the analysis. Data analysis The data were analysed using the Statistical Package for Social Sciences (SPSS for Windows, version 20.0; SPSS Inc., Chicago, IL, USA). Descriptive statistics and frequency distribution were determined for all oral mucosal conditions, ECOHIS scores and responses to each item. Subscale scores were analysed for differences among the most frequent types of oral mucosal conditions. In this initial analysis, the Kolmogorov–Smirnov test was used to determine the normality of the data distribution. As the data were not normally distributed, the nonparametric Mann–Whitney U-test was
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4
R. G. Vieira-Andrade et al.
used, with the level of significance set to 5% (P < 0.05). The independent variables were child’s gender, child’s age, and socio-demographic data (marital status, child’s place of residence, mother’s current age, mother’s and father’s schooling, monthly household income, household crowding and number of siblings). A hierarchical approach to variable selection was used26,27. The variables were grouped into a hierarchy of categories ranging from distal to proximal determinants. The categories were child’s characteristics, sociodemographic factors, oral mucosal conditions, and dental caries (in that order). For each level, Poisson regression analysis with robust variance was performed to correlate the overall mean ECOHIS score with the child’s characteristics, socio-demographic factors, oral mucosal conditions, and dental caries. This analysis was performed to exclude variables with a P-value > 0.20. Explanatory variables were selected for the final models only if they had a P-value of
