Journal of Public Health Dentistry . ISSN 0022-4006 Journal of Public Health Dentistry ISSN 0022-4006
Oral health related quality of life: a novel metric targeted to young adults Mitra Daneshvar, MPH; Tehsina Fatemah Devji, MPH; Amy B. Davis, JD, MPH; Marney A. White, PhD, MS School of Public Health, Yale University, New Haven, CT, USA
Keywords oral; oral health; quality of life; measurement; questionnaire; young adults. Correspondence Prof. Marney A. White, School of Public Health, Yale University, PO Box 208034, New Haven, CT 06520-8034. Tel.: 203-785-4349; Fax: 203-785-7855; e-mail: [email protected]. Mitra Daneshvar, Tehsina Fatemah Devji, Amy B. Davis, and Marney A. White are with the School of Public Health, Yale University. Received: 5/16/2014; accepted: 3/7/2015. doi: 10.1111/jphd.12099 of Public Public Health HealthDentistry Dentistry•• 75(2015) (2015)••–•• 298–307 Journal of
Abstract Objectives: The primary objective of the study was to develop an oral health related quality of life (OHRQoL) questionnaire for use among adults paralleling previously validated instruments, but addressing important age-specific self-perception issues in addition to physical and social impediments caused as a result of deficient oral health. Methods: An initial item pool was generated based on adherence to the three established constructs of OHRQoL: social, psychological, and physical. Experts in the field of oral health provided feedback on this initial item pool. The revised items were administered to 553 adult participants via an online questionnaire. Exploratory factor analysis was conducted to determine the final scale and subscales, and Cronbach’s alpha coefficients and correlations coefficients were generated to determine the reliability and validity of the scale. Results: The reduced-item questionnaire exhibited excellent psychometric properties (α = 0.902). Final subscales were assessed through factor loading scores and showed high reliability: a) social functioning (α = 0.852), b) physical functioning (α = 0.793), and c) self-perception and anxiety (α = 0.875). Scores on the selfperception and anxiety were the highest of the three subscales, followed by physical and social functioning. Of the exploratory items, tooth color appeared to be the most important concern. Conclusion: Our OHRqOL measurement instrument tailored to young adults demonstrates initial psychometric properties of reliability and validity among a socialnetwork derived volunteer population.
Introduction Although health-related quality of life is now a wellestablished realm of medical outcome research, oral health research has lagged behind, and there is a need for targeted measures that can survey how oral health impacts quality of life in different populations so that initiatives can be targeted toward meeting perceived needs. Oral health is defined as health associated with the mouth, which includes the mouth, teeth, gums, supporting tissues, and branches of nervous, immune, and vascular systems (1). It is estimated that worldwide the prevalence of oral health conditions is 3.9 billion (2). Although mortality due to the disease is rare, the chronic pain and potential infection resulting from dental caries represents a significant concern in terms of quality of life with an estimated average health loss of 224 years per 100,000 population (2). Recent studies in © 2015 American Association of Public Health Dentistry
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school-aged children found that children with poor oral health were more likely to miss school and have poorer academic performance further elucidating past reports of dental pain being attributed to irritability and inability to concentrate (3,4). Given the evidence, one does not have to abstractly conceive of how dental disease infringes upon one’s “functioning” through complex etiologies related to the disease, such as systemic infection or its role as a risk factor for later development of other chronic diseases; rather, the disease presents an immediate and reasonably captured diseaserelated morbidity and disturbance to one’s human right to health. Despite the specific, physical area defined as oral, there is increasing evidence that one’s oral health cannot be considered in a vacuum separate from one’s general health and is thus an important area for public health intervention (5). For example, researchers have found that an individual’s oral health is associated with both chronic health conditions such 1
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as cardiovascular disease and diabetes, and with quality of life indicators such as an individual’s self-worth, lifestyle choices, and daily physical and mental well-being (6). The usability of oral health related quality of life (OHRQoL) measures is far-reaching and can meaningfully contribute to a) clinical practice (to evaluate the effectiveness of general care and specific treatments); and b) epidemiological surveillance (for example, to evaluate OHRQoL across different demographic groups). These data are of interest to dental providers as well as indirect providers of oral health related care such as educators and policymakers (7). Despite the fact that the physical manifestations of oral disease and the absence of good oral health has not had much clout in terms of creating substantial reform in recent years, the issue is undoubtedly of huge relevance to overall well-being among Americans, with 97 percent of respondents of the Research America poll stating that oral health was “somewhat or very important to overall health” (8). From a conceptual perspective, the move toward metrics evaluating OHRQoL is extremely relevant to dental restorations and treatment, to induce or restore functionality to the dental and/or oral structure, as well as to create an aesthetic and comfortable results for the patient. In addition to clinical outcome measures, a quality of life measure allows for a more robust outcome measure that arguably facilitates a more accurate assessment of fulfillment of the goals of treatment (9). Several measures have been directed toward OHRQoL measures in older adult populations, and there has been a recent surge in modifying such scales to appropriately target a pediatric population (7,10-13). However, the young adult population remains largely uncaptured by current measures, despite the population’s dental concerns: a) physicalfunctional concerns such as tooth sensitivity, chewing difficulties, pain or impairment of mouth due to disease or trauma, bleeding or receding gums, and tangible calculus; b) social and psychosocial concerns related to oral health such as halitosis (bad breath), poor cosmetic appearance of teeth and problematic orthodontia (dental and jaw structure); and c) social reactions to oral and dental health and appearance, such as restricted smiling, laughing and talking, perceived success at work, and comfort in social and romantic situations (14-16). To this end, we sought to develop an OHRQoL measure for use with young adults aged 21-35, targeted toward both perceived functional and social impairment due to oral health as well as functionality in this oral-maxillofacial region. The young adult population being targeted is of particular concern given the population’s aforementioned unique oral and dental needs. Developing a measure for use among young adults is appropriate given striking declines in perceived appearance and eating difficulties after age 35 (5). In addition to these unique concerns, there are many treatments provided to young adults that overlap with childhood procedures but V 2C 2015 American Association of Public Health Dentistry
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that may not be adequately captured in a questionnaire targeted toward a pediatric population (17). In a child population, there are potential constraints on children’s self-concept as related to a norm and are especially vulnerable to position and acquiescence bias. It is these difficulties that have made pediatric quality of life scales difficult to validate, as they often fail to meet appropriate psychometric standards (18). Our measurement tool sought to present items around three established constructs: social, psychological, and physical using a Likert-type frequency scale that will be consistent across most items (7). This will offer a paralleled structure to items of the Oral Health Impact Profile (OHIP), which is currently the gold standard measure in middle-aged adults (19). Given the importance of norms in assessment of quality of life, especially with OHRQoL that has strong roots in aesthetics, we constructed a scale with exploratory items that will allow for identification of the factors perceived as most critical to quality of life as well as the discrepancy between individual ratings and the respective perceived norms. Our metric currently differs from other published versions in that it a) assesses quality of life globally in addition to that which is related to oral health; b) evaluates perceptions of oral health state as well as ideals; and c) asks questions only pertinent to the specific age range of the participant, thus minimizing participant burden without sacrificing comprehensiveness.
Methods Item generation Adhering to the three established constructs targeted in the aforementioned OHIP instrument, preliminary items for the pilot study were generated. These items were generated based on metrics of interest that have been previously identified in the literature for pediatric, adolescent, and adult populations. Following identification of key metrics, questions for each metric of interest were tailored to align with the format of questions in the gold standard OHIP questionnaire. Specifically, included questions were created in order to allow for participants to describe frequency based on a five-point frequency Likert scale. Higher OHIP scores reflected poorer oral health status. Although each item was a priori identified as corresponding to a particular dimension of our overall OHRQoL construct (functional, psychosocial, and social reactions), the final items were subjected to exploratory factor analysis for establishment of the dimensions and corresponding items used in the final questionnaire. The final questionnaire consisted of two subsets of questions: a) a standard series of prompts to be evaluated based on a Likert-type scale and b) a series of exploratory items that probed individual concerns in more detail. To make this element of the questionnaire most applicable and to reduce participant burden, participants were asked to select the characteristic 299 © 2015 American Association of Public Health Dentistry
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that represented their most prioritized oral health concern. The selection led to two further questions: the first questioning perceived norms (e.g., along a color scale, the most acceptable or ideal tooth color) and the second questioning the participant’s perception of his or her own status (in this example, his/her actual tooth color along the same color scale). The combination of Likert items and exploratory items evaluating the discrepancy between “actual” and “acceptable” oral health states were then subject to pilot testing.
Pilot study and expert feedback A pilot study was performed using a convenience sample of master’s and PhD degree candidates in the Yale School of Public Health (many of whom were also a part of the target population), additional members of the target population of study (adults 21-35), and experts in the field of oral health. Participants were recruited through the direct e-mail contact and posts on various social media websites. The specific websites used are listed in the Procedure section of the Methods. Experts within the field included practicing dentists at Yale New Haven Hospital as well as world-renowned experts within the field of OHRQoL located through a literature search of publications presented at the most recent “Assessing oral health outcomes: measuring health status and quality of life” conference supported by the Agency for Health Care Policy and Research. These experts also provided general impressions of the metric by assessing factors such as readability and helped to establish construct validity. Dental and public health experts provided semantic suggestions to ensure better clarity, simplicity, and precision of items within the instrument. Overall, there was widespread agreement among experts that we were appropriately capturing our construct and target population.
Description of final questionnaire The survey was created and administered through the use of the Qualtrics© online survey software, which provided a secure site for storage of this survey and the survey data as it was collected. After providing informed consent, participants were asked questions on demographic factors, which included: gender, race/ethnicity, education, marital status, employment status, income, perceived health status, and health insurance status. Following participant questions on demographics, the questionnaire on OHRQoL was administered. The final OHRQoL survey included 21 items. The first item asked participants to select the attribute that most affects their OHRQoL, the two following questions further assessed participants’ views of this attribute, and the following 18 items asked participants to select the answer that best represents their preference with the response choices mirroring a © 2015 American Association of Public Health Dentistry 300
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five-point Likert scale with lower scores reflecting less agreement and higher scores reflecting more agreement. The included 18 items were chosen based on relevance to the three components of interest (social function, physical function, and self-perception and anxiety). Specifically, the social function component was interested on describing oral health as it relates to daily interactions and comfort communicating with others. The physical function questions focused on tooth function and how it relates to one’s ability to complete necessary daily tasks, such as chewing, sleeping, and focus. The self-perception and anxiety component asked participant questions to elucidate how oral health affected selfappearance. A complete copy of the questionnaire can be found in Appendix 1.
Procedure Institutional approval by the Human Investigation Committee was obtained prior to data collection. Participants (n = 553) were volunteers and were instructed that their response choices were anonymous. Each survey began with the agreement to an online consent form acknowledging that the participant was at least 18 years of age. Participants were recruited through direct e-mail contact and postings to Facebook©, Twitter©, Craigslist©1, New York Times©, and other social media outlets.
Analytic plan Exploratory factor analysis Although domains of interest were articulated before administration of the survey instrument, exploratory factor analysis was employed to arrive at the most parsimonious set of factors within the OHRQoL construct of interest. The analysis also enabled explanation of the interrelationships among items. Principal component analysis was used in order to summarize interrelationships among the original variables that used a five-point Likert type scale. An orthogonal Varimax rotation was performed in SPSS Version 22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) for items Q4-Q19 (Appendix 1). Through this method, the first component extracted accounts for the greatest proportion of the variance, and each 1
Craigslist cities included over 30 cities, for example: Albany, NY; Ann Arbor, MI; Atlanta, GA; Austin, TX; Birmingham, AL; Boston, MA; Central NJ, NJ; Chicago, IL; Columbus, OH; Delaware, DE; Dallas/Ft. Worth, TX; Fairfield, CT; Hartford, CT; Madison, WI; Minneapolis, MN; New Haven, CT; New York, NY; Oklahoma City, OK; Omaha, NE; Pittsburgh, PA; Portland, ME; Richmond, VA; San Diego; CA; Seattle, WA; Washington DC, DC; Worcester, MA.
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subsequently extracted component accounts for the greatest proportion of variance after removing the previous components. Components that extracted a substantial percentage (set as greater than 50 percent) were retained in the final list of items. Reliability (Cronbach’s alpha) of the original item pool via the aforementioned factor analytic methods was computed.
Correlation analyses Pearson correlation coefficients were calculated to examine the relationships between participant characteristics and perceptions of their personal OHRQoL for the entire scale as well as each subscale. Additionally, Pearson correlation coefficients were generated to examine the associations among subscale scores. Statistical significance was defined as a P-value < 0.05. Attention was paid to the magnitude of the correlation in addition to the statistical significance.
Results Participant characteristics Participants were 553 community volunteers. The average age of our study sample was 28.9 ± 9.3 years (range 18-68). The majority (84.4 percent, n = 467) of the sample was aged 35 years or younger. The sample was predominantly female (69.8 percent)2, white (74.5 percent), single (65.0 percent), college educated (46.6 percent), employed full time (46.7 percent), living in an urban setting (56.5 percent), and had health insurance (89.5 percent). The modal report of general health status was “Very Good,” with 42.9 percent of respondents endorsing this perception.
Exploratory factor analysis Components that extracted a substantial percentage of the variance in total scores (set collectively as greater than 50 percent) were retained in the final list of items. Using this cutoff, one item (“How often have you had trouble saying words because of your teeth or mouth?”) loaded onto two factors with loadings of 0.572 (social function) and 0.522 (physical function). After removing this item, 15 items were retained, which were interpreted as a) social function, b) physical function, and c) self-perception (Table 1). Cronbach’s alpha values are reported to indicate reliabilities of each of the domains of consideration; the total alpha coefficient for the reduced questionnaire was 0.902.
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Scoring Based on the reduced item list generated via exploratory factor analysis, overall OHRQoL scores were computed by taking the average of the responses. The use of averages enables comparison across subscales even though there are different numbers of items per subscale. All items probed frequency of a negative oral health related occurrence and responses ranged from 1 (never) to 5 (very often). The subscale and overall scores could therefore range between 1 and 5. The frequency distribution of scores is reported in Figure 1. The final subscales included a) self-perception and anxiety, b) physical functioning, and c) social functioning. Self-perception and anxiety was the most important concern of the three subscales, indicated by endorsement of higher frequency response options for each of the negative situational prompts [mean = 1.87, standard deviation (SD) = 0.86]. Social functioning, marking the reaction to social situations due to oral health concerns, ranked as the lowest concern among our sample (mean = 1.35, SD = 0.52), and physical functioning, delineating pain, discomfort and impaired dental functioning, ranked in the middle of the prior two subscales with respect to concern frequency (mean = 1.49, SD = 0.58).
Discrepancy analysis Items with response options following an ordinal scale were included in this analysis, as such items allowed for the computation of a discrepancy score. Tooth color (nine-point scale ranging from white to yellow/brown), straightness (fourpoint scale ranging from straight to crooked), and oral-facial pain (four-point scale ranging from constant pain to no pain) were considered, and their discrepancy scores were computed by subtracting the score corresponding to self-evaluation from the score assigned to the perceived norm or ideal. Discrepancy scores were correlated with the item asking participants to rate their overall oral health on a five-point scale ranging from very poor to very good, with lower scores for positive ratings and higher scores for negative ratings.
Exploratory analyses
Reported percentages are valid percentages.
To examine whether OHRQoL scores were associated with demographic characteristics, Pearson’s correlation coefficients and t-tests were calculated. Higher levels of income [r(523) = 0.129, P < 0.01], higher levels of education [r(525) = 0.194, P < 0.01], having insurance [r(108) = 2.601, P = 0.011], and higher rating of overall health [r(206) = 0.441, P < 0.01] were associated with higher ratings of OHRQoL. Clenching or grinding of teeth and tooth color were the two attributes respondents felt affected their oral health the
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Table 1 Retained Items After Exploratory Factor Analysis, Corresponding Factor Loadings, and Cronbach’s Alpha (Reliability) Component (total items)
Items (original component variance accounted)
Social function (six items)
1. How often have you felt that problems with you teeth or mouth have affected your friendships? (0.812) 2. How often have you felt that problems with your teeth and mouth have affected your work? (0.733) 3. How often have you avoided contact with other people because of the way your teeth and mouth look? (0.723) 4. How often have you avoided eating with others because of your teeth and mouth? (0.691) 5. How often have you felt that your teeth and mouth have affected your romantic life? (0.663) 6. How often have you avoided contact with people because of the smell of your breath? (0.577) 1. How often has your focus been affected because of problems with your teeth and mouth? (0.727) 2. How often have you had a hard time chewing because of problems with your teeth or mouth? (0.713) 3. How often have you had a hard time sleeping because of tooth grinding or problems with your teeth or mouth? (0.697) 4. How often have you missed school or work because of problems with your teeth or mouth? (0.660) 5. How often have you felt that life in general was less enjoyable because of problems with your teeth or mouth? (0.636) 1. How often have you been self-conscious because of your teeth or mouth? (0.846) 2. How often have you felt that problems with your teeth or mouth have affected your appearance? (0.800) 3. How often have you been worried by problems with your teeth or mouth? (0.757) 4. How often have you avoided smiling or laughing because of problems with your teeth or mouth? (0.667)
Physical function (five items)
Self-perception and anxiety (four items)
Number of participants with specified score
most. These concerns were endorsed by 18.1 percent and 14.6 percent of participants, respectively. Tooth color closer to yellow/brown than the perceived norm was negatively correlated with ratings of overall oral health [r(75) = −0.400, 80%
71.30%
70%
50% 40% 30%
10%
Reliability (α)
0.814
0.852
0.741 0.755 0.659 0.680 0.611 0.734
0.793
0.696 0.723 0.673 0.641 0.849 0.805
0.875
0.767 0.652
P < 0.01]. Pain was not correlated with oral health ratings, most likely attributable to the fact that it did not represent a substantial concern among our participant population with only 2.2 percent of respondents selecting it as their primary concern.
Discussion
60%
20%
Final factor loadings
17.30% 9% 2.40%
0%
0.20%
Overall score Figure 1 Frequency distribution of overall scores based on factor analysis reduced 15-item instrument.
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The primary aim of the study was to develop an OHRQoL questionnaire that did not deviate substantially from previously developed and validated instruments but that addressed some of the important age-specific self-perception issues as well as physical and social impediments that may result from deficient oral health. The questionnaire was created and found to be suitable for use in all adults but with special emphasis for use in young adults (21-35 years of age). The development of an instrument specific to young adults is important as the health concerns and health needs of this population are unique to those of older adults. The current OHIP instrument used to evaluate OHRQoL focuses heavily on the health needs of older adults with over 80 percent of questions referencing dentures. Because many of the OHIP questions may not be applicable to young adults, and therefore inaccurately estimating this group’s OHRQoL, the C 2015 American Association of Public Health Dentistry 5 V
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development of a new questionnaire focused on common concerns of young adults was necessary. The cultural assumption in formulating the proposed instrument was that the extent of oral disease would be mild to moderate. Thus, the questionnaire does not probe on severe infections, oral cancer, advanced periodontal disease, or developmental dental anomalies. However, evaluating OHRQoL across different strata of oral health/disease severity remains extremely difficult due to the wide range of possible impairments related to individual conditions (7,13). The instrument developed as part of this study demonstrates face and construct validity as determined by leading experts in the OHRQoL field. The final abbreviated questionnaire shows high validity and reliability. Administration of the survey within clinical environments, where the effectiveness of an intervention may also be measured, will provide meaningful information about the impact of such interventions on patients’ quality of life. Additionally, administration of the instrument among a diverse group of individuals with different preexisting oral conditions will make the tool valuable for surveillance and as an outcome measure in assessing the impact of particular conditions. Our results show that oral health has a meaningful impact on quality of life in our target population. However, similar to other metrics evaluating OHRQoL, our instrument is subject to floor effects due to lack of endorsement of concerns at high frequencies (12). This is to be expected given the young target population and its administration within the United States, where there is a higher relative prevalence of fluoridated water and access to general and specialized dental care (20). It should be noted that the proposed instrument reflects an attempt to holistically understand OHRQoL, rooted in several etiologies and encompassing several domains of interest. However, research that seeks to understand only a certain disease, intervention, or specific reaction may not be as well served by the questionnaire. Nevertheless, this does not preclude the instrument from being administered in specialist settings. For example, an orthodontic treatment, which largely aims to improve both the appearance and the occlusion of patients, is well suited to use such a metric in order to capture the extent of treatment impact to OHRQoL. Finally, future research should simultaneously examine the OHRQoL in relation to existing measures to further examine the incremental and unique information captured by its use. One important limitation is that the validation sample is not representative of the United States or international population. However, the sample consisted of primarily young adults and is therefore an appropriate sample for the initial psychometric testing of the instrument. Furthermore, it will be important to administer the instrument among diverse populations and among patients with various underlying medical and dental conditions in order to establish its psychometric properties for use in clinical research. V 6C 2015 American Association of Public Health Dentistry
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The goal of the proposed work was to develop and establish the psychometric properties of a brief measure of OHRQoL. The measurement tool proposed demonstrates initial psychometric properties of reliability and validity. Future research may benefit from the exploratory questions administered in the preliminary questionnaire, where participants are asked to choose the concerns within oral health that are most pertinent to their quality of life, and then to compare their self-rating to that of their perceived norm. Because of the response options for these items, it was not possible to include them in the factor analysis, yet their clinical and research utility may be valuable. Incorporating this level of personalization, allowing for the articulation of norms around a particular characteristic, and being able to meaningfully incorporate these attributes within an OHRQoL score would be an important contribution to current measures.
References 1. Locker D, Allen F. What do measures of “oral health-related quality of life” measure? Community Dent Oral Epidemiol. 2007;35(6):401-11. 2. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, Murray CJL. Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res. 2013;92(7): 592-7. 3. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health. 2011;101(10):1900-6. 4. Long S. Children’s dental health affects school performance and psychosocial development. J Pediatr. 2012;161(6):1153-9. 5. Sheiham A. Oral health, general health and quality of life. Bull World Health Organ. 2005;83(9):644. 6. Allen PF. Assessment of oral health related quality of life. Health Qual Life Outcomes. 2003;1:40. 7. Locker D, Allen F. What do measures of “oral health-related quality of life” measure? Community Dent Oral Epidemiol. 2007;35(6):401-11. 8. Fisher-Owens SA, Barker JC, Adams S, Chung LH, Gansky SA, Hyde S, Weintraub JA. Giving policy some teeth: routes to reducing disparities in oral health. Health Aff. 2008;27(2): 404-12. 9. Jokovic A, Locker D, Tompson B, Guyatt G. Questionnaire for measuring oral health-related quality of life in eight- to ten-year-old children. Pediatr Dent. 2004;26(6):512-8. 10. De Andrade FB, Lebrao ML, Santos JLF, Teixeira DSD, Duarte YAD. Relationship between oral health-related quality of life, oral health, socioeconomic, and general health factors in elderly Brazilians. J Am Geriatr Soc. 2012;60(9):1755-60. 11. Fernandes MJ, Ruta DA, Ogden GR, Pitts NB, Ogston SA. Assessing oral health-related quality of life in general dental practice in Scotland: validation of the OHIP-14. Community Dent Oral Epidemiol. 2006;34(1):53-62. 303 © 2015 American Association of Public Health Dentistry
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12. Gift HC, Atchison KA, Dayton CM. Conceptualizing oral health and oral health-related quality of life. Soc Sci Med. 1997;44(5):601-8. 13. Kieffer JM, Hoogstraten J. Linking oral health, general health, and quality of life. Eur J Oral Sci. 2008;116(5):445-50. 14. Baens-Ferrer C, Roseman MM, Dumas HM, Haley SM. Parental perceptions of oral health-related quality of life for children with special needs: impact of oral rehabilitation under general anesthesia. Pediatr Dent. 2005;27(2):137-42. 15. Baskirt EA, Ak G, Zulfikar B. Oral and general health-related quality of life among young patients with haemophilia. Haemophilia. 2009;15(1):193-8. 16. Feu D, Oliveira BH, Celeste RK, Miguel JAM. Influence of orthodontic treatment on adolescents’ self-perceptions of
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esthetics. Am J Orthod Dentofacial Orthop. 2012;141(6): 743-50. Falcao CB, Oliveira CA, Ahid FJM, Lima DM, Vaz LG. Influence of different methods of porcelain surface treatment on orthodontic brackets bonding. J Dent Res. 2003;82:164. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res. 2002;81(7):459-63. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health. 1994;11(1):3-11. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr. 2002;2(2):141-7.
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Appendix 1 Oral Health Quality of Life Survey Oral Health Quality of Life Survey Administered on Qualtrics – Survey active from: March 11, 2013-April 1, 2013 Q1. Select one of the attributes listed below that you feel most affects your dental/oral health. ○ Tooth color ○ Bleeding gums ○ Painful jaw ○ Tooth shape (i.e. square, round) ○ Gum pain ○ Clenching or grinding of teeth ○ Tooth size ○ Loose teeth ○ Other ___ ○ Teeth alignment ○ Tooth sensitivity ○ I do not have any of the above dental concerns ○ Smell of breath ○ Scores inside mouth or tongue (If tooth color selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable color of a person’s teeth:
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I consider the following to be the color of my teeth:
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(If tooth shape selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable shape of a person’s teeth: Too Round More Round shaped than Square More Square shaped than Round ○ ○ ○ I consider the following to be the shape of my teeth: Too Round More Round shaped than Square More Square shaped than Round ○ ○ ○ (If tooth shape selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable size of a person’s teeth: Very Large Large Small ○ ○ ○ I consider the following to be the size of my teeth: Very Large Large Small ○ ○ ○ (If teeth alignment selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable alignment of a person’s teeth: Very Straight Moderately Straight Moderately Crooked ○ ○ ○ I consider the following to be the alignment of my teeth: Very Straight Moderately Straight Moderately Crooked ○ ○ ○ (If smell of breath selected in Q1) Please select the option that best represents your preference. I consider the following to represent an acceptable smell of someone else’s breath: Very Fresh Moderately Fresh Moderately Stale ○ ○ ○ I consider the following to represent the smell of my breath: Very Fresh Moderately Fresh Moderately Stale ○ ○ ○ (If bleeding gums selected in Q1) Please select the option that best represents your preference. I consider the following to be acceptable gum bleeding: No bleeding Bleeding when brushing or flossing ○ ○ I consider the following to be the gum bleeding I experience: No bleeding Bleeding when brushing or flossing ○ ○
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Too Square ○ Too Square ○
Very Small ○ Very Small ○
Very Crooked ○ Very Crooked ○
Very Stale ○ Very Stale ○
Spontaneous bleeding ○ Spontaneous bleeding ○
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Appendix 1 Continued (If gum pain selected in Q1) Please select the option that best represents your preference. I consider the following to represent an acceptable amount of gum pain: Constant Pain Frequent Pain Occasional Pain ○ ○ ○ I consider the following to represent the amount of gum pain I experience: Constant Pain Frequent Pain Occasional Pain ○ ○ ○ (If loose teeth selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable number of loose teeth: 0 1-2 3-4 ○ ○ ○ I consider the following to be the number of loose teeth I have: 0 1-2 3-4 ○ ○ ○
No pain ○ No pain ○
5 or more ○ 5 or more ○
(If tooth sensitivity selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable level of tooth sensitivity: No sensitivity Sensitive upon eating or drinking Sensitive at times other than just when eating or drinking ○ ○ ○ I consider the following to represent the tooth sensitivity I experience: No sensitivity Sensitive upon eating or drinking Sensitive at times other than just when eating or drinking ○ ○ ○ (If tooth sores selected in Q1) Please select the option that best represents your preference. I consider the following to represent the number of sores on an individual’s mouth or tongue: 0 1 2 3 or more ○ ○ ○ ○ I consider the following to represent the number of sores on my mouth or tongue: 0 1 2 3 or more ○ ○ ○ ○ (If painful jaw selected in Q1) Please select the option that best represents your preference. I consider the following to represent an acceptable amount of jaw pain: Constant Pain Frequent Paint Occasional Pain No pain ○ ○ ○ ○ I consider the following to be the amount of jaw pain I experience: Constant Pain Frequent Paint Occasional Pain No pain ○ ○ ○ ○ (If clenching or grinding of teeth selected in Q1) Please select the option that best represents your preference. What do you consider appropriate tooth clenching or grinding behavior? Not applicable Only when sleeping Only when awake When sleeping and awake ○ ○ ○ ○ What describes your tooth clenching or grinding behavior? Not applicable Only when sleeping Only when awake When sleeping and awake ○ ○ ○ ○ Q4-Q19: Select the one response that best represents your current opinion. How often have you avoided contact with other people because of the way your teeth and mouth look? How often have you avoided contact with other people because of the way your teeth and mouth look? How often have you avoided contact with people because of the smell of your breath? How often have you felt that your teeth and mouth has affected your romantic life? How often have you felt that problems with your teeth and mouth affect your work? How often have you felt that problems with your teeth and mouth have affected your friendships (making friends or maintaining friends)?
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Appendix 1 Continued
How often have you avoided smiling or laughing because of your teeth or mouth? How often have you avoided eating with others because of your teeth or mouth? How often have you had a hard time chewing because of problems with your teeth or mouth? How often have you had trouble saying words because of problems with your teeth or mouth? How often have you felt that your teeth and mouth affect your appearance? How often have you been worried by problems with your teeth or mouth? How often have you been self-conscious because of your teeth or mouth? How often have you had a hard time sleeping because of tooth grinding or problems with your teeth or mouth? How often has your focus been affected because of problems with your teeth or mouth? How often have you missed school or work because of problems with your teeth or mouth? How often have you felt that life in general was less enjoyable because of problems with your teeth or mouth?
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Oral health related quality of life: a novel metric targeted to young adults Mitra Daneshvar, MPH; Tehsina Fatemah Devji, MPH; Amy B. Davis, JD, MPH; Marney A. White, PhD, MS School of Public Health, Yale University, New Haven, CT, USA
Keywords oral; oral health; quality of life; measurement; questionnaire; young adults. Correspondence Prof. Marney A. White, School of Public Health, Yale University, PO Box 208034, New Haven, CT 06520-8034. Tel.: 203-785-4349; Fax: 203-785-7855; e-mail: [email protected]. Mitra Daneshvar, Tehsina Fatemah Devji, Amy B. Davis, and Marney A. White are with the School of Public Health, Yale University. Received: 5/16/2014; accepted: 3/7/2015. doi: 10.1111/jphd.12099 of Public Public Health HealthDentistry Dentistry•• 75(2015) (2015)••–•• 298–307 Journal of
Abstract Objectives: The primary objective of the study was to develop an oral health related quality of life (OHRQoL) questionnaire for use among adults paralleling previously validated instruments, but addressing important age-specific self-perception issues in addition to physical and social impediments caused as a result of deficient oral health. Methods: An initial item pool was generated based on adherence to the three established constructs of OHRQoL: social, psychological, and physical. Experts in the field of oral health provided feedback on this initial item pool. The revised items were administered to 553 adult participants via an online questionnaire. Exploratory factor analysis was conducted to determine the final scale and subscales, and Cronbach’s alpha coefficients and correlations coefficients were generated to determine the reliability and validity of the scale. Results: The reduced-item questionnaire exhibited excellent psychometric properties (α = 0.902). Final subscales were assessed through factor loading scores and showed high reliability: a) social functioning (α = 0.852), b) physical functioning (α = 0.793), and c) self-perception and anxiety (α = 0.875). Scores on the selfperception and anxiety were the highest of the three subscales, followed by physical and social functioning. Of the exploratory items, tooth color appeared to be the most important concern. Conclusion: Our OHRqOL measurement instrument tailored to young adults demonstrates initial psychometric properties of reliability and validity among a socialnetwork derived volunteer population.
Introduction Although health-related quality of life is now a wellestablished realm of medical outcome research, oral health research has lagged behind, and there is a need for targeted measures that can survey how oral health impacts quality of life in different populations so that initiatives can be targeted toward meeting perceived needs. Oral health is defined as health associated with the mouth, which includes the mouth, teeth, gums, supporting tissues, and branches of nervous, immune, and vascular systems (1). It is estimated that worldwide the prevalence of oral health conditions is 3.9 billion (2). Although mortality due to the disease is rare, the chronic pain and potential infection resulting from dental caries represents a significant concern in terms of quality of life with an estimated average health loss of 224 years per 100,000 population (2). Recent studies in © 2015 American Association of Public Health Dentistry
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school-aged children found that children with poor oral health were more likely to miss school and have poorer academic performance further elucidating past reports of dental pain being attributed to irritability and inability to concentrate (3,4). Given the evidence, one does not have to abstractly conceive of how dental disease infringes upon one’s “functioning” through complex etiologies related to the disease, such as systemic infection or its role as a risk factor for later development of other chronic diseases; rather, the disease presents an immediate and reasonably captured diseaserelated morbidity and disturbance to one’s human right to health. Despite the specific, physical area defined as oral, there is increasing evidence that one’s oral health cannot be considered in a vacuum separate from one’s general health and is thus an important area for public health intervention (5). For example, researchers have found that an individual’s oral health is associated with both chronic health conditions such 1
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as cardiovascular disease and diabetes, and with quality of life indicators such as an individual’s self-worth, lifestyle choices, and daily physical and mental well-being (6). The usability of oral health related quality of life (OHRQoL) measures is far-reaching and can meaningfully contribute to a) clinical practice (to evaluate the effectiveness of general care and specific treatments); and b) epidemiological surveillance (for example, to evaluate OHRQoL across different demographic groups). These data are of interest to dental providers as well as indirect providers of oral health related care such as educators and policymakers (7). Despite the fact that the physical manifestations of oral disease and the absence of good oral health has not had much clout in terms of creating substantial reform in recent years, the issue is undoubtedly of huge relevance to overall well-being among Americans, with 97 percent of respondents of the Research America poll stating that oral health was “somewhat or very important to overall health” (8). From a conceptual perspective, the move toward metrics evaluating OHRQoL is extremely relevant to dental restorations and treatment, to induce or restore functionality to the dental and/or oral structure, as well as to create an aesthetic and comfortable results for the patient. In addition to clinical outcome measures, a quality of life measure allows for a more robust outcome measure that arguably facilitates a more accurate assessment of fulfillment of the goals of treatment (9). Several measures have been directed toward OHRQoL measures in older adult populations, and there has been a recent surge in modifying such scales to appropriately target a pediatric population (7,10-13). However, the young adult population remains largely uncaptured by current measures, despite the population’s dental concerns: a) physicalfunctional concerns such as tooth sensitivity, chewing difficulties, pain or impairment of mouth due to disease or trauma, bleeding or receding gums, and tangible calculus; b) social and psychosocial concerns related to oral health such as halitosis (bad breath), poor cosmetic appearance of teeth and problematic orthodontia (dental and jaw structure); and c) social reactions to oral and dental health and appearance, such as restricted smiling, laughing and talking, perceived success at work, and comfort in social and romantic situations (14-16). To this end, we sought to develop an OHRQoL measure for use with young adults aged 21-35, targeted toward both perceived functional and social impairment due to oral health as well as functionality in this oral-maxillofacial region. The young adult population being targeted is of particular concern given the population’s aforementioned unique oral and dental needs. Developing a measure for use among young adults is appropriate given striking declines in perceived appearance and eating difficulties after age 35 (5). In addition to these unique concerns, there are many treatments provided to young adults that overlap with childhood procedures but V 2C 2015 American Association of Public Health Dentistry
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that may not be adequately captured in a questionnaire targeted toward a pediatric population (17). In a child population, there are potential constraints on children’s self-concept as related to a norm and are especially vulnerable to position and acquiescence bias. It is these difficulties that have made pediatric quality of life scales difficult to validate, as they often fail to meet appropriate psychometric standards (18). Our measurement tool sought to present items around three established constructs: social, psychological, and physical using a Likert-type frequency scale that will be consistent across most items (7). This will offer a paralleled structure to items of the Oral Health Impact Profile (OHIP), which is currently the gold standard measure in middle-aged adults (19). Given the importance of norms in assessment of quality of life, especially with OHRQoL that has strong roots in aesthetics, we constructed a scale with exploratory items that will allow for identification of the factors perceived as most critical to quality of life as well as the discrepancy between individual ratings and the respective perceived norms. Our metric currently differs from other published versions in that it a) assesses quality of life globally in addition to that which is related to oral health; b) evaluates perceptions of oral health state as well as ideals; and c) asks questions only pertinent to the specific age range of the participant, thus minimizing participant burden without sacrificing comprehensiveness.
Methods Item generation Adhering to the three established constructs targeted in the aforementioned OHIP instrument, preliminary items for the pilot study were generated. These items were generated based on metrics of interest that have been previously identified in the literature for pediatric, adolescent, and adult populations. Following identification of key metrics, questions for each metric of interest were tailored to align with the format of questions in the gold standard OHIP questionnaire. Specifically, included questions were created in order to allow for participants to describe frequency based on a five-point frequency Likert scale. Higher OHIP scores reflected poorer oral health status. Although each item was a priori identified as corresponding to a particular dimension of our overall OHRQoL construct (functional, psychosocial, and social reactions), the final items were subjected to exploratory factor analysis for establishment of the dimensions and corresponding items used in the final questionnaire. The final questionnaire consisted of two subsets of questions: a) a standard series of prompts to be evaluated based on a Likert-type scale and b) a series of exploratory items that probed individual concerns in more detail. To make this element of the questionnaire most applicable and to reduce participant burden, participants were asked to select the characteristic 299 © 2015 American Association of Public Health Dentistry
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that represented their most prioritized oral health concern. The selection led to two further questions: the first questioning perceived norms (e.g., along a color scale, the most acceptable or ideal tooth color) and the second questioning the participant’s perception of his or her own status (in this example, his/her actual tooth color along the same color scale). The combination of Likert items and exploratory items evaluating the discrepancy between “actual” and “acceptable” oral health states were then subject to pilot testing.
Pilot study and expert feedback A pilot study was performed using a convenience sample of master’s and PhD degree candidates in the Yale School of Public Health (many of whom were also a part of the target population), additional members of the target population of study (adults 21-35), and experts in the field of oral health. Participants were recruited through the direct e-mail contact and posts on various social media websites. The specific websites used are listed in the Procedure section of the Methods. Experts within the field included practicing dentists at Yale New Haven Hospital as well as world-renowned experts within the field of OHRQoL located through a literature search of publications presented at the most recent “Assessing oral health outcomes: measuring health status and quality of life” conference supported by the Agency for Health Care Policy and Research. These experts also provided general impressions of the metric by assessing factors such as readability and helped to establish construct validity. Dental and public health experts provided semantic suggestions to ensure better clarity, simplicity, and precision of items within the instrument. Overall, there was widespread agreement among experts that we were appropriately capturing our construct and target population.
Description of final questionnaire The survey was created and administered through the use of the Qualtrics© online survey software, which provided a secure site for storage of this survey and the survey data as it was collected. After providing informed consent, participants were asked questions on demographic factors, which included: gender, race/ethnicity, education, marital status, employment status, income, perceived health status, and health insurance status. Following participant questions on demographics, the questionnaire on OHRQoL was administered. The final OHRQoL survey included 21 items. The first item asked participants to select the attribute that most affects their OHRQoL, the two following questions further assessed participants’ views of this attribute, and the following 18 items asked participants to select the answer that best represents their preference with the response choices mirroring a © 2015 American Association of Public Health Dentistry 300
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five-point Likert scale with lower scores reflecting less agreement and higher scores reflecting more agreement. The included 18 items were chosen based on relevance to the three components of interest (social function, physical function, and self-perception and anxiety). Specifically, the social function component was interested on describing oral health as it relates to daily interactions and comfort communicating with others. The physical function questions focused on tooth function and how it relates to one’s ability to complete necessary daily tasks, such as chewing, sleeping, and focus. The self-perception and anxiety component asked participant questions to elucidate how oral health affected selfappearance. A complete copy of the questionnaire can be found in Appendix 1.
Procedure Institutional approval by the Human Investigation Committee was obtained prior to data collection. Participants (n = 553) were volunteers and were instructed that their response choices were anonymous. Each survey began with the agreement to an online consent form acknowledging that the participant was at least 18 years of age. Participants were recruited through direct e-mail contact and postings to Facebook©, Twitter©, Craigslist©1, New York Times©, and other social media outlets.
Analytic plan Exploratory factor analysis Although domains of interest were articulated before administration of the survey instrument, exploratory factor analysis was employed to arrive at the most parsimonious set of factors within the OHRQoL construct of interest. The analysis also enabled explanation of the interrelationships among items. Principal component analysis was used in order to summarize interrelationships among the original variables that used a five-point Likert type scale. An orthogonal Varimax rotation was performed in SPSS Version 22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) for items Q4-Q19 (Appendix 1). Through this method, the first component extracted accounts for the greatest proportion of the variance, and each 1
Craigslist cities included over 30 cities, for example: Albany, NY; Ann Arbor, MI; Atlanta, GA; Austin, TX; Birmingham, AL; Boston, MA; Central NJ, NJ; Chicago, IL; Columbus, OH; Delaware, DE; Dallas/Ft. Worth, TX; Fairfield, CT; Hartford, CT; Madison, WI; Minneapolis, MN; New Haven, CT; New York, NY; Oklahoma City, OK; Omaha, NE; Pittsburgh, PA; Portland, ME; Richmond, VA; San Diego; CA; Seattle, WA; Washington DC, DC; Worcester, MA.
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subsequently extracted component accounts for the greatest proportion of variance after removing the previous components. Components that extracted a substantial percentage (set as greater than 50 percent) were retained in the final list of items. Reliability (Cronbach’s alpha) of the original item pool via the aforementioned factor analytic methods was computed.
Correlation analyses Pearson correlation coefficients were calculated to examine the relationships between participant characteristics and perceptions of their personal OHRQoL for the entire scale as well as each subscale. Additionally, Pearson correlation coefficients were generated to examine the associations among subscale scores. Statistical significance was defined as a P-value < 0.05. Attention was paid to the magnitude of the correlation in addition to the statistical significance.
Results Participant characteristics Participants were 553 community volunteers. The average age of our study sample was 28.9 ± 9.3 years (range 18-68). The majority (84.4 percent, n = 467) of the sample was aged 35 years or younger. The sample was predominantly female (69.8 percent)2, white (74.5 percent), single (65.0 percent), college educated (46.6 percent), employed full time (46.7 percent), living in an urban setting (56.5 percent), and had health insurance (89.5 percent). The modal report of general health status was “Very Good,” with 42.9 percent of respondents endorsing this perception.
Exploratory factor analysis Components that extracted a substantial percentage of the variance in total scores (set collectively as greater than 50 percent) were retained in the final list of items. Using this cutoff, one item (“How often have you had trouble saying words because of your teeth or mouth?”) loaded onto two factors with loadings of 0.572 (social function) and 0.522 (physical function). After removing this item, 15 items were retained, which were interpreted as a) social function, b) physical function, and c) self-perception (Table 1). Cronbach’s alpha values are reported to indicate reliabilities of each of the domains of consideration; the total alpha coefficient for the reduced questionnaire was 0.902.
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Scoring Based on the reduced item list generated via exploratory factor analysis, overall OHRQoL scores were computed by taking the average of the responses. The use of averages enables comparison across subscales even though there are different numbers of items per subscale. All items probed frequency of a negative oral health related occurrence and responses ranged from 1 (never) to 5 (very often). The subscale and overall scores could therefore range between 1 and 5. The frequency distribution of scores is reported in Figure 1. The final subscales included a) self-perception and anxiety, b) physical functioning, and c) social functioning. Self-perception and anxiety was the most important concern of the three subscales, indicated by endorsement of higher frequency response options for each of the negative situational prompts [mean = 1.87, standard deviation (SD) = 0.86]. Social functioning, marking the reaction to social situations due to oral health concerns, ranked as the lowest concern among our sample (mean = 1.35, SD = 0.52), and physical functioning, delineating pain, discomfort and impaired dental functioning, ranked in the middle of the prior two subscales with respect to concern frequency (mean = 1.49, SD = 0.58).
Discrepancy analysis Items with response options following an ordinal scale were included in this analysis, as such items allowed for the computation of a discrepancy score. Tooth color (nine-point scale ranging from white to yellow/brown), straightness (fourpoint scale ranging from straight to crooked), and oral-facial pain (four-point scale ranging from constant pain to no pain) were considered, and their discrepancy scores were computed by subtracting the score corresponding to self-evaluation from the score assigned to the perceived norm or ideal. Discrepancy scores were correlated with the item asking participants to rate their overall oral health on a five-point scale ranging from very poor to very good, with lower scores for positive ratings and higher scores for negative ratings.
Exploratory analyses
Reported percentages are valid percentages.
To examine whether OHRQoL scores were associated with demographic characteristics, Pearson’s correlation coefficients and t-tests were calculated. Higher levels of income [r(523) = 0.129, P < 0.01], higher levels of education [r(525) = 0.194, P < 0.01], having insurance [r(108) = 2.601, P = 0.011], and higher rating of overall health [r(206) = 0.441, P < 0.01] were associated with higher ratings of OHRQoL. Clenching or grinding of teeth and tooth color were the two attributes respondents felt affected their oral health the
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Table 1 Retained Items After Exploratory Factor Analysis, Corresponding Factor Loadings, and Cronbach’s Alpha (Reliability) Component (total items)
Items (original component variance accounted)
Social function (six items)
1. How often have you felt that problems with you teeth or mouth have affected your friendships? (0.812) 2. How often have you felt that problems with your teeth and mouth have affected your work? (0.733) 3. How often have you avoided contact with other people because of the way your teeth and mouth look? (0.723) 4. How often have you avoided eating with others because of your teeth and mouth? (0.691) 5. How often have you felt that your teeth and mouth have affected your romantic life? (0.663) 6. How often have you avoided contact with people because of the smell of your breath? (0.577) 1. How often has your focus been affected because of problems with your teeth and mouth? (0.727) 2. How often have you had a hard time chewing because of problems with your teeth or mouth? (0.713) 3. How often have you had a hard time sleeping because of tooth grinding or problems with your teeth or mouth? (0.697) 4. How often have you missed school or work because of problems with your teeth or mouth? (0.660) 5. How often have you felt that life in general was less enjoyable because of problems with your teeth or mouth? (0.636) 1. How often have you been self-conscious because of your teeth or mouth? (0.846) 2. How often have you felt that problems with your teeth or mouth have affected your appearance? (0.800) 3. How often have you been worried by problems with your teeth or mouth? (0.757) 4. How often have you avoided smiling or laughing because of problems with your teeth or mouth? (0.667)
Physical function (five items)
Self-perception and anxiety (four items)
Number of participants with specified score
most. These concerns were endorsed by 18.1 percent and 14.6 percent of participants, respectively. Tooth color closer to yellow/brown than the perceived norm was negatively correlated with ratings of overall oral health [r(75) = −0.400, 80%
71.30%
70%
50% 40% 30%
10%
Reliability (α)
0.814
0.852
0.741 0.755 0.659 0.680 0.611 0.734
0.793
0.696 0.723 0.673 0.641 0.849 0.805
0.875
0.767 0.652
P < 0.01]. Pain was not correlated with oral health ratings, most likely attributable to the fact that it did not represent a substantial concern among our participant population with only 2.2 percent of respondents selecting it as their primary concern.
Discussion
60%
20%
Final factor loadings
17.30% 9% 2.40%
0%
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Overall score Figure 1 Frequency distribution of overall scores based on factor analysis reduced 15-item instrument.
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The primary aim of the study was to develop an OHRQoL questionnaire that did not deviate substantially from previously developed and validated instruments but that addressed some of the important age-specific self-perception issues as well as physical and social impediments that may result from deficient oral health. The questionnaire was created and found to be suitable for use in all adults but with special emphasis for use in young adults (21-35 years of age). The development of an instrument specific to young adults is important as the health concerns and health needs of this population are unique to those of older adults. The current OHIP instrument used to evaluate OHRQoL focuses heavily on the health needs of older adults with over 80 percent of questions referencing dentures. Because many of the OHIP questions may not be applicable to young adults, and therefore inaccurately estimating this group’s OHRQoL, the C 2015 American Association of Public Health Dentistry 5 V
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development of a new questionnaire focused on common concerns of young adults was necessary. The cultural assumption in formulating the proposed instrument was that the extent of oral disease would be mild to moderate. Thus, the questionnaire does not probe on severe infections, oral cancer, advanced periodontal disease, or developmental dental anomalies. However, evaluating OHRQoL across different strata of oral health/disease severity remains extremely difficult due to the wide range of possible impairments related to individual conditions (7,13). The instrument developed as part of this study demonstrates face and construct validity as determined by leading experts in the OHRQoL field. The final abbreviated questionnaire shows high validity and reliability. Administration of the survey within clinical environments, where the effectiveness of an intervention may also be measured, will provide meaningful information about the impact of such interventions on patients’ quality of life. Additionally, administration of the instrument among a diverse group of individuals with different preexisting oral conditions will make the tool valuable for surveillance and as an outcome measure in assessing the impact of particular conditions. Our results show that oral health has a meaningful impact on quality of life in our target population. However, similar to other metrics evaluating OHRQoL, our instrument is subject to floor effects due to lack of endorsement of concerns at high frequencies (12). This is to be expected given the young target population and its administration within the United States, where there is a higher relative prevalence of fluoridated water and access to general and specialized dental care (20). It should be noted that the proposed instrument reflects an attempt to holistically understand OHRQoL, rooted in several etiologies and encompassing several domains of interest. However, research that seeks to understand only a certain disease, intervention, or specific reaction may not be as well served by the questionnaire. Nevertheless, this does not preclude the instrument from being administered in specialist settings. For example, an orthodontic treatment, which largely aims to improve both the appearance and the occlusion of patients, is well suited to use such a metric in order to capture the extent of treatment impact to OHRQoL. Finally, future research should simultaneously examine the OHRQoL in relation to existing measures to further examine the incremental and unique information captured by its use. One important limitation is that the validation sample is not representative of the United States or international population. However, the sample consisted of primarily young adults and is therefore an appropriate sample for the initial psychometric testing of the instrument. Furthermore, it will be important to administer the instrument among diverse populations and among patients with various underlying medical and dental conditions in order to establish its psychometric properties for use in clinical research. V 6C 2015 American Association of Public Health Dentistry
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The goal of the proposed work was to develop and establish the psychometric properties of a brief measure of OHRQoL. The measurement tool proposed demonstrates initial psychometric properties of reliability and validity. Future research may benefit from the exploratory questions administered in the preliminary questionnaire, where participants are asked to choose the concerns within oral health that are most pertinent to their quality of life, and then to compare their self-rating to that of their perceived norm. Because of the response options for these items, it was not possible to include them in the factor analysis, yet their clinical and research utility may be valuable. Incorporating this level of personalization, allowing for the articulation of norms around a particular characteristic, and being able to meaningfully incorporate these attributes within an OHRQoL score would be an important contribution to current measures.
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Appendix 1 Oral Health Quality of Life Survey Oral Health Quality of Life Survey Administered on Qualtrics – Survey active from: March 11, 2013-April 1, 2013 Q1. Select one of the attributes listed below that you feel most affects your dental/oral health. ○ Tooth color ○ Bleeding gums ○ Painful jaw ○ Tooth shape (i.e. square, round) ○ Gum pain ○ Clenching or grinding of teeth ○ Tooth size ○ Loose teeth ○ Other ___ ○ Teeth alignment ○ Tooth sensitivity ○ I do not have any of the above dental concerns ○ Smell of breath ○ Scores inside mouth or tongue (If tooth color selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable color of a person’s teeth:
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I consider the following to be the color of my teeth:
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(If tooth shape selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable shape of a person’s teeth: Too Round More Round shaped than Square More Square shaped than Round ○ ○ ○ I consider the following to be the shape of my teeth: Too Round More Round shaped than Square More Square shaped than Round ○ ○ ○ (If tooth shape selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable size of a person’s teeth: Very Large Large Small ○ ○ ○ I consider the following to be the size of my teeth: Very Large Large Small ○ ○ ○ (If teeth alignment selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable alignment of a person’s teeth: Very Straight Moderately Straight Moderately Crooked ○ ○ ○ I consider the following to be the alignment of my teeth: Very Straight Moderately Straight Moderately Crooked ○ ○ ○ (If smell of breath selected in Q1) Please select the option that best represents your preference. I consider the following to represent an acceptable smell of someone else’s breath: Very Fresh Moderately Fresh Moderately Stale ○ ○ ○ I consider the following to represent the smell of my breath: Very Fresh Moderately Fresh Moderately Stale ○ ○ ○ (If bleeding gums selected in Q1) Please select the option that best represents your preference. I consider the following to be acceptable gum bleeding: No bleeding Bleeding when brushing or flossing ○ ○ I consider the following to be the gum bleeding I experience: No bleeding Bleeding when brushing or flossing ○ ○
8 C 2015 American Association of Public Health Dentistry V
Too Square ○ Too Square ○
Very Small ○ Very Small ○
Very Crooked ○ Very Crooked ○
Very Stale ○ Very Stale ○
Spontaneous bleeding ○ Spontaneous bleeding ○
© 2015 American Association of Public Health Dentistry 305
M. Daneshvar et al. quality of life Oral health related
Oral health related quality of M. Daneshvar etlife al.
Appendix 1 Continued (If gum pain selected in Q1) Please select the option that best represents your preference. I consider the following to represent an acceptable amount of gum pain: Constant Pain Frequent Pain Occasional Pain ○ ○ ○ I consider the following to represent the amount of gum pain I experience: Constant Pain Frequent Pain Occasional Pain ○ ○ ○ (If loose teeth selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable number of loose teeth: 0 1-2 3-4 ○ ○ ○ I consider the following to be the number of loose teeth I have: 0 1-2 3-4 ○ ○ ○
No pain ○ No pain ○
5 or more ○ 5 or more ○
(If tooth sensitivity selected in Q1) Please select the option that best represents your preference. I consider the following to be an acceptable level of tooth sensitivity: No sensitivity Sensitive upon eating or drinking Sensitive at times other than just when eating or drinking ○ ○ ○ I consider the following to represent the tooth sensitivity I experience: No sensitivity Sensitive upon eating or drinking Sensitive at times other than just when eating or drinking ○ ○ ○ (If tooth sores selected in Q1) Please select the option that best represents your preference. I consider the following to represent the number of sores on an individual’s mouth or tongue: 0 1 2 3 or more ○ ○ ○ ○ I consider the following to represent the number of sores on my mouth or tongue: 0 1 2 3 or more ○ ○ ○ ○ (If painful jaw selected in Q1) Please select the option that best represents your preference. I consider the following to represent an acceptable amount of jaw pain: Constant Pain Frequent Paint Occasional Pain No pain ○ ○ ○ ○ I consider the following to be the amount of jaw pain I experience: Constant Pain Frequent Paint Occasional Pain No pain ○ ○ ○ ○ (If clenching or grinding of teeth selected in Q1) Please select the option that best represents your preference. What do you consider appropriate tooth clenching or grinding behavior? Not applicable Only when sleeping Only when awake When sleeping and awake ○ ○ ○ ○ What describes your tooth clenching or grinding behavior? Not applicable Only when sleeping Only when awake When sleeping and awake ○ ○ ○ ○ Q4-Q19: Select the one response that best represents your current opinion. How often have you avoided contact with other people because of the way your teeth and mouth look? How often have you avoided contact with other people because of the way your teeth and mouth look? How often have you avoided contact with people because of the smell of your breath? How often have you felt that your teeth and mouth has affected your romantic life? How often have you felt that problems with your teeth and mouth affect your work? How often have you felt that problems with your teeth and mouth have affected your friendships (making friends or maintaining friends)?
© 2015 American Association of Public Health Dentistry 306
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C 2015 American Association of Public Health Dentistry 9 V
Oral health related M. Daneshvar et al. quality of life
M. Daneshvar al. Oral health related quality ofetlife
Appendix 1 Continued
How often have you avoided smiling or laughing because of your teeth or mouth? How often have you avoided eating with others because of your teeth or mouth? How often have you had a hard time chewing because of problems with your teeth or mouth? How often have you had trouble saying words because of problems with your teeth or mouth? How often have you felt that your teeth and mouth affect your appearance? How often have you been worried by problems with your teeth or mouth? How often have you been self-conscious because of your teeth or mouth? How often have you had a hard time sleeping because of tooth grinding or problems with your teeth or mouth? How often has your focus been affected because of problems with your teeth or mouth? How often have you missed school or work because of problems with your teeth or mouth? How often have you felt that life in general was less enjoyable because of problems with your teeth or mouth?
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307 © 2015 American Association of Public Health Dentistry
