ORIGINAL Almoznino ARTICLE et al
Oral Health Related Quality of Life in Young Individuals with Dental Anxiety and Exaggerated Gag Reflex Galit Almozninoa/Avraham Zinib/Doron J. Aframianc/Eliezer Kaufmanc/ Alex Lvovskyd/Avraham Hadadd/Liran Levine Purpose: To measure the oral health-related quality of life (OHRQoL) among young individuals presenting with dental anxiety and exaggerated gag reflex and to compare it to the OHRQoL among young individuals attending restorative dental treatment. Materials and Methods: Patients with dental anxiety and/or exaggerated gag reflex who were referred to the Department of Oral Medicine were included. Clinical examinations included DMFT index (Decayed, Missing and Filled Teeth) according to the WHO criteria and oral hygiene was assessed with the plaque index (PI). The survey included the validated Hebrew version of the Oral Health Impact Profile (OHIP-14). Results: Overall, 322 patients completed the study. The dental anxiety group consisted of 68 patients, the exaggerated gag reflex group of 54 patients and the control group of 200 patients. Control group patients presented with lower PI and DMFT values. Patients with dental anxiety and/or exaggerated gag exhibited worse OHIP-14 scores overall as well as on each separate subscale. PI and DMFT were found to be in strong relation to the OHIP-14. Multivariable logistic regression analysis of factors influencing the OHIP-14 scores revealed a significant influence of the DMFT score. Conclusions: Patients with dental anxiety and exaggerated gag reflex were shown to suffer considerably from impaired oral health-related quality of life. This impairment may be attributed to a higher prevalence of caries and avoidance of dental treatment. Those populations should be identified and monitored carefully as well as encouraged to seek the appropriate behavioural treatment in order to improve their dental heath and oral health related quality of life. Key words: avoidance, coping, fear, oral disease, quality of life Oral Health Prev Dent 2015;13:435-440 doi: 10.3290/j.ohpd.a33921
a
Lecturer, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine, Jerusalem; Department of Oral Medicine, Israel Defense Forces, Medical Corps, Tel-Hashomer, Israel. Principal investigator, study concept and design, data acquisition, analysis and interpretation, drafted manuscript, approved final version.
b
Professor, Department of Community Dentistry, Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel. Consulted on and performed statistical analysis and data interpretation.
c
Professor, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine, Jerusalem. Interpreted of data, contributed substantially to discussion, proofread the manuscript .
d
Dentist, Department of Oral Medicine, Israel Defense Forces, Medical Corps, Tel-Hashomer, Israel. Collected data, proofread manuscript.
e
Professor, Department of Periodontology, School of Graduate Dentistry, Rambam Health Care Campus, and Faculty of Medicine, Technion, IIT, Haifa, Israel; Section of Periodontology, Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA. Contributed substantially to study concept and design, revised and approved the final manuscript.
Correspondence: Dr. Galit Almoznino, Department of Oral Medicine, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem 91120, Israel. Tel: +972-3-737-3813, Fax: + 972-2-6447919. Email: [email protected]
Vol 13, No 5, 2015
Submitted for publication: 08.07.13; accepted for publication: 12.11.13
D
ental anxiety has been recognised as a significant health issue in many countries.11,19,22 A remarkable proportion of the population in various countries reportedly has certain degrees of anxiety about dental visits and treatment.7-8,11,15-16,19,22 The general term ‘dental anxiety’ may have diverse meanings in the dental literature, covering a rather wide range of emotions from a relatively mild feeling of apprehension to extreme anxiety and dental phobia. Dental anxiety in this study is defined as a situation-specific trait anxiety and as the disposition to experience anxiety in dental situations.15 The general perception is that dental anxiety can lead to avoidance behaviours, resulting in lack of regular dental care and delay in seeking necessary treatment.2,26 It is also widely assumed that avoidance behavioural patterns of dental care and treatment have a detrimental effect on dental health.1 However, solid evidence in the literature for these assumptions is rather scarce.15
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Almoznino et al
It has been suggested that excessive gagging during dental care in some subjects, possibly those with a high motivation for control, may be an indirect expression of their resistance to undergoing routine dental care because of stress and anxiety.25 Excessive gagging during dental care might also result in stress and anxiety. While dental anxiety is the most prevalent and most studied oral-related behavioural dysfunction, an excessive gag reflex is another commonly recognised obstacle to dental care.25 The comorbidity between gagging and dental anxiety described by Moore et al14 may be indirect evidence of gagging behaviour as an expression of dental anxiety in individuals who are reluctant to admit to being anxious about undergoing dental care.14 Despite the recent interest in the psychosocial impact of dental anxiety on daily life, there is limited information on its impact on oral health-related quality of life.3,12,15 Those reports only assessed the influence of dental anxiety, not addressing the issue of exaggerated gag reflex. Subjective oral health indicators are increasingly used to assess and compare the impact of oral disease across populations. Oral health-related quality of life has gained particular popularity since Locker9 provided a conceptual model for it that characterises structural, behavioural and psychosocial consequences of oral disease using the framework of the World Health Organization (WHO) International Classification of Impairments, Disabilities and Handicaps.13 The Oral Health Impact Profile (OHIP), originally developed by Slade and Spencer,21 is one of the most widely used oral health-related quality of life questionnaires.13,20,21 It has been used to assess the impact in different populations and is well validated. The aim of this study was to measure the oral health-related quality of life (OHRQoL) among young individuals who presented with dental anxiety and exaggerated gag reflex and to compare it to that of young individuals attending conservative dental treatment.
MATERIALS AND METHODS All patients with dental anxiety and/or exaggerated gag reflex who were referred to the Medical Corps Department of Oral Medicine between May 1, 2011 and May 31, 2012 were included in this convenience cohort group study. This department is a secondary specialists referral centre which manages dental treatment of dental anxiety and/or exaggerated gag reflex population using nitrous oxide (N2O) 436
inhalation sedation and various behavioural techniques. Consecutive individuals attending restorative dental treatment in a primary dental clinic comprised the control group which was matched for gender with the test group. The study was approved by the institutional review board and all patients provided informed consent to participate in the study. Patients who reported drug abuse, were pregnant or lactating were excluded from the study. Patients were asked to fill out a questionnaire which consisted of demographic details (age, gender, education, ethnic origin), medical background and smoking habits. The clinical examinations assessed caries experience with the DMFT index according to the WHO criteria24 and oral hygiene with the Löe and Silness plaque index (PI).10 Clinical examinations were conducted with the aid of light, mouth mirrors and a WHO probe during daylight hours. Participants were examined seated on a dental chair. Bilateral bitewing radiographs were also included. The survey included the validated Hebrew version of the OHIP-146 filled in during a face-to-face. The OHIP-14 includes seven conceptual dimensions of oral health-related quality of life: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap.20 OHIP-14 scores represent the frequency of adverse impacts on oral health, with a potential range of 0 (no adverse impacts during previous year) to 56 (all 14 impacts experienced very often during previous year). OHIP14 subscale scores were calculated for each of the dimensions by summing the response scores for the two corresponding items. Relationships between OHIP-14 score and caries experience, periodontal parameters, as well as demographic and habitual parameters were assessed.
Statistical analysis Differences between groups were calculated by univariate analysis, Pearson’s chi-square was used for categorical variables and ANOVA for numeric variables. Pearson’s correlation test was utilised as well. A multivariate logistic regression (LR) model was performed. In multivariate analysis, all the variables were entered and the presented variables were only those who reached significance (p < 0.05). Sample size was calculated according to the literature outcomes for OHIP-14 differences between groups. Value levels included were: α = 0.05, β = 0.10; the expected difference between groups
Oral Health & Preventive Dentistry
Almoznino et al
Table 1 Demographic characteristics of the study population Dental anxiety group
Exaggerated gag reflex group
Control group
18–21
31 (45.6%)
20 (37.7%)
161 (81.7%)
> 21
37 (54.4%)
33 (62.3%)
36 (18.3%)
Female
25 (36.8%)
19 (35.2%)
90 (45%)
Male
43 (63.2%)
35 (64.8%)
110 (55%)
High school
40 (58.8%)
35 (64.8%)
190 (95%)
Technician
12 (17.7%)
12 (22.2%)
4 (2%)
Academics
16 (23.5%)
7 (13.0%)
6 (3%)
Africa
14 (20.6%)
16 (29.6%)
47 (23.5%)
Asia
14 (20.6%)
7 (13.0%)
22 (11.0%)
Western
6 (8.8%)
3 (5.6%)
24 (12%)
Mixed
14 (20.6%)
13 (24.1%)
1 (0.5%)
FSU
5 (7.4%)
1 (1.9%)
29 (14.5%)
Israel
15 (22.1%)
14 (25.9%)
77 (38.5%)
68 (100%)
54 (100%)
Variable Age
p-value (between all groups)
p-value (dental anxiety vs exaggerated gag reflex)
Oral Health Related Quality of Life in Young Individuals with Dental Anxiety and Exaggerated Gag Reflex Galit Almozninoa/Avraham Zinib/Doron J. Aframianc/Eliezer Kaufmanc/ Alex Lvovskyd/Avraham Hadadd/Liran Levine Purpose: To measure the oral health-related quality of life (OHRQoL) among young individuals presenting with dental anxiety and exaggerated gag reflex and to compare it to the OHRQoL among young individuals attending restorative dental treatment. Materials and Methods: Patients with dental anxiety and/or exaggerated gag reflex who were referred to the Department of Oral Medicine were included. Clinical examinations included DMFT index (Decayed, Missing and Filled Teeth) according to the WHO criteria and oral hygiene was assessed with the plaque index (PI). The survey included the validated Hebrew version of the Oral Health Impact Profile (OHIP-14). Results: Overall, 322 patients completed the study. The dental anxiety group consisted of 68 patients, the exaggerated gag reflex group of 54 patients and the control group of 200 patients. Control group patients presented with lower PI and DMFT values. Patients with dental anxiety and/or exaggerated gag exhibited worse OHIP-14 scores overall as well as on each separate subscale. PI and DMFT were found to be in strong relation to the OHIP-14. Multivariable logistic regression analysis of factors influencing the OHIP-14 scores revealed a significant influence of the DMFT score. Conclusions: Patients with dental anxiety and exaggerated gag reflex were shown to suffer considerably from impaired oral health-related quality of life. This impairment may be attributed to a higher prevalence of caries and avoidance of dental treatment. Those populations should be identified and monitored carefully as well as encouraged to seek the appropriate behavioural treatment in order to improve their dental heath and oral health related quality of life. Key words: avoidance, coping, fear, oral disease, quality of life Oral Health Prev Dent 2015;13:435-440 doi: 10.3290/j.ohpd.a33921
a
Lecturer, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine, Jerusalem; Department of Oral Medicine, Israel Defense Forces, Medical Corps, Tel-Hashomer, Israel. Principal investigator, study concept and design, data acquisition, analysis and interpretation, drafted manuscript, approved final version.
b
Professor, Department of Community Dentistry, Hebrew UniversityHadassah School of Dental Medicine, Jerusalem, Israel. Consulted on and performed statistical analysis and data interpretation.
c
Professor, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine, Jerusalem. Interpreted of data, contributed substantially to discussion, proofread the manuscript .
d
Dentist, Department of Oral Medicine, Israel Defense Forces, Medical Corps, Tel-Hashomer, Israel. Collected data, proofread manuscript.
e
Professor, Department of Periodontology, School of Graduate Dentistry, Rambam Health Care Campus, and Faculty of Medicine, Technion, IIT, Haifa, Israel; Section of Periodontology, Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA. Contributed substantially to study concept and design, revised and approved the final manuscript.
Correspondence: Dr. Galit Almoznino, Department of Oral Medicine, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem 91120, Israel. Tel: +972-3-737-3813, Fax: + 972-2-6447919. Email: [email protected]
Vol 13, No 5, 2015
Submitted for publication: 08.07.13; accepted for publication: 12.11.13
D
ental anxiety has been recognised as a significant health issue in many countries.11,19,22 A remarkable proportion of the population in various countries reportedly has certain degrees of anxiety about dental visits and treatment.7-8,11,15-16,19,22 The general term ‘dental anxiety’ may have diverse meanings in the dental literature, covering a rather wide range of emotions from a relatively mild feeling of apprehension to extreme anxiety and dental phobia. Dental anxiety in this study is defined as a situation-specific trait anxiety and as the disposition to experience anxiety in dental situations.15 The general perception is that dental anxiety can lead to avoidance behaviours, resulting in lack of regular dental care and delay in seeking necessary treatment.2,26 It is also widely assumed that avoidance behavioural patterns of dental care and treatment have a detrimental effect on dental health.1 However, solid evidence in the literature for these assumptions is rather scarce.15
435
Almoznino et al
It has been suggested that excessive gagging during dental care in some subjects, possibly those with a high motivation for control, may be an indirect expression of their resistance to undergoing routine dental care because of stress and anxiety.25 Excessive gagging during dental care might also result in stress and anxiety. While dental anxiety is the most prevalent and most studied oral-related behavioural dysfunction, an excessive gag reflex is another commonly recognised obstacle to dental care.25 The comorbidity between gagging and dental anxiety described by Moore et al14 may be indirect evidence of gagging behaviour as an expression of dental anxiety in individuals who are reluctant to admit to being anxious about undergoing dental care.14 Despite the recent interest in the psychosocial impact of dental anxiety on daily life, there is limited information on its impact on oral health-related quality of life.3,12,15 Those reports only assessed the influence of dental anxiety, not addressing the issue of exaggerated gag reflex. Subjective oral health indicators are increasingly used to assess and compare the impact of oral disease across populations. Oral health-related quality of life has gained particular popularity since Locker9 provided a conceptual model for it that characterises structural, behavioural and psychosocial consequences of oral disease using the framework of the World Health Organization (WHO) International Classification of Impairments, Disabilities and Handicaps.13 The Oral Health Impact Profile (OHIP), originally developed by Slade and Spencer,21 is one of the most widely used oral health-related quality of life questionnaires.13,20,21 It has been used to assess the impact in different populations and is well validated. The aim of this study was to measure the oral health-related quality of life (OHRQoL) among young individuals who presented with dental anxiety and exaggerated gag reflex and to compare it to that of young individuals attending conservative dental treatment.
MATERIALS AND METHODS All patients with dental anxiety and/or exaggerated gag reflex who were referred to the Medical Corps Department of Oral Medicine between May 1, 2011 and May 31, 2012 were included in this convenience cohort group study. This department is a secondary specialists referral centre which manages dental treatment of dental anxiety and/or exaggerated gag reflex population using nitrous oxide (N2O) 436
inhalation sedation and various behavioural techniques. Consecutive individuals attending restorative dental treatment in a primary dental clinic comprised the control group which was matched for gender with the test group. The study was approved by the institutional review board and all patients provided informed consent to participate in the study. Patients who reported drug abuse, were pregnant or lactating were excluded from the study. Patients were asked to fill out a questionnaire which consisted of demographic details (age, gender, education, ethnic origin), medical background and smoking habits. The clinical examinations assessed caries experience with the DMFT index according to the WHO criteria24 and oral hygiene with the Löe and Silness plaque index (PI).10 Clinical examinations were conducted with the aid of light, mouth mirrors and a WHO probe during daylight hours. Participants were examined seated on a dental chair. Bilateral bitewing radiographs were also included. The survey included the validated Hebrew version of the OHIP-146 filled in during a face-to-face. The OHIP-14 includes seven conceptual dimensions of oral health-related quality of life: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap.20 OHIP-14 scores represent the frequency of adverse impacts on oral health, with a potential range of 0 (no adverse impacts during previous year) to 56 (all 14 impacts experienced very often during previous year). OHIP14 subscale scores were calculated for each of the dimensions by summing the response scores for the two corresponding items. Relationships between OHIP-14 score and caries experience, periodontal parameters, as well as demographic and habitual parameters were assessed.
Statistical analysis Differences between groups were calculated by univariate analysis, Pearson’s chi-square was used for categorical variables and ANOVA for numeric variables. Pearson’s correlation test was utilised as well. A multivariate logistic regression (LR) model was performed. In multivariate analysis, all the variables were entered and the presented variables were only those who reached significance (p < 0.05). Sample size was calculated according to the literature outcomes for OHIP-14 differences between groups. Value levels included were: α = 0.05, β = 0.10; the expected difference between groups
Oral Health & Preventive Dentistry
Almoznino et al
Table 1 Demographic characteristics of the study population Dental anxiety group
Exaggerated gag reflex group
Control group
18–21
31 (45.6%)
20 (37.7%)
161 (81.7%)
> 21
37 (54.4%)
33 (62.3%)
36 (18.3%)
Female
25 (36.8%)
19 (35.2%)
90 (45%)
Male
43 (63.2%)
35 (64.8%)
110 (55%)
High school
40 (58.8%)
35 (64.8%)
190 (95%)
Technician
12 (17.7%)
12 (22.2%)
4 (2%)
Academics
16 (23.5%)
7 (13.0%)
6 (3%)
Africa
14 (20.6%)
16 (29.6%)
47 (23.5%)
Asia
14 (20.6%)
7 (13.0%)
22 (11.0%)
Western
6 (8.8%)
3 (5.6%)
24 (12%)
Mixed
14 (20.6%)
13 (24.1%)
1 (0.5%)
FSU
5 (7.4%)
1 (1.9%)
29 (14.5%)
Israel
15 (22.1%)
14 (25.9%)
77 (38.5%)
68 (100%)
54 (100%)
Variable Age
p-value (between all groups)
p-value (dental anxiety vs exaggerated gag reflex)
