DENTAL SCIENCE, MATERIALS AND TECHNOLOGY

ORAL HEALTH
ANESTHETIC MANAGEMENT, SOCIAL
DETERMINANTS, ROLE OF NUTRITION
AND IMPACT ON QUALITY OF LIFE

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 DENTAL SCIENCE, MATERIALS AND TECHNOLOGY

ORAL HEALTH
ANESTHETIC MANAGEMENT, SOCIAL
DETERMINANTS, ROLE OF NUTRITION
AND IMPACT ON QUALITY OF LIFE

JULIA RENEE BARNES

EDITOR

New York
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 Contents

Preface vii
Chapter I Periodontal Disease and Oral Health-Related Quality of Life 1
Victor Goh, Dipti Nihalani and W. Keung Leung
Chapter II Relationship between Periodontal Health and Its Impact on the
Quality Life 33
A. L. Dumitrescu
Chapter III Exploring the Relationship between Nutrition and
Periodontal Disease 65
A. L. Dumitrescu
Chapter IV Oral Health Literacy As a Social Determinant of Oral Health 91
R. Constance Wiener
Chapter V Oral Health and Mental Health 111
Karen-Leigh Edward
Chapter VI Oral Health: Social Determinants, Role of Nutrition and Impact on
Quality of Life Determinants of Oral Health and Quality of Life of
Schizophrenic Patients 117
Frédéric Denis and Benoit Trojak
Chapter VII Oral Health and the Quality of Life for Romanian
Orthodontic Patients 139
Irina Zetu, Sorana Rosu, Liviu Zetu and Mihnea Iacob
Index 153
 Preface
Biological, psychological, sociological and ecological features of life contribute and
interact simultaneously in the development of an individual's oral health. The chapters in this
book review the effects of periodontal disease and its treatment on OHRQoL (Oral Health-
Related Quality of Life); the consequences of periodontal disease and patient perceptions of
the impact of their gingival/periodontal health on their everyday lives; the link between
nutritional factors and periodontal disease; a review of Charcot-Marie-Tooth Disease
(CMTD), the most common sensitive and motor peripheral neuropathy; the influence of
improved oral health literacy considering the circumstances in which a person has been born,
lives and works, the microbiological mechanisms, and the public's influence to improve oral
health; the complexities related to oral care of people who experience mental disorders and
the implications this may hold for their quality of life, practice, research and policy;
determinants of oral health in schizophrenic patients; and an assessment of the PIDAQ
(Psychosocial Impact of Dental Aesthetic Questionnaire), the only available tool designed
specifically to assess malocclusions.
Chapter I – Periodontal disease is an inflammatory disease initiated by mixed
opportunistic bacterial pathogens in the dental plaque biofilm. In the susceptible patient,
advancing periodontal disease often leads to loss of supporting soft and hard tissues around a
tooth. Due to the nature and progression of the disease, methods of characterizing periodontal
disease have often been based on clinical parameters such as probing pockets depths, clinical
attachment levels, bleeding on probing, mobility scores and gingival recession. Unfortunately,
such parameters show no indication of how the disease affects the patients themselves. Of
recent years, patient centered assessments such as Oral Health-Related Quality of Life
(OHRQoL) are increasingly appreciated and being applied. Such measures incorporate the
functional, psychological and social consequences of oral conditions for the individual, and
not merely signs and symptoms of the disease itself. This chapter will review the effects of
periodontal disease and its treatment on OHRQoL. Patients often report functional limitation,
physical pain and psychological disability associated with the signs and symptoms of
periodontal disease. Such effects on OHRQoL have been shown to diminish with proper
treatment. Furthermore, recent studies have also shown that the complications or outcome of
different treatment strategies have, to varying degrees, an effect on patients daily life. These
complications such as tooth loss, recession and pain are closely related and interplay to affect
the patient’s OHRQoL.
viii Julia Renee Barnes

Chapter II – Periodontal diseases are one of the common oral diseases involving
structural and functional changes in the oral cavity and in their most severe forms are
associated with formation of periodontal pockets, gingival abscesses, gingival recessions,
tooth mobility, and finally teeth loss. Periodontal diseases are one of the main reasons for
tooth loss among the population and this is furthermore related not only to alteration in
speaking and chewing functions, but also to a high impact on the patients psychological and
emotional well-being as related to daily social interactions, organ loss related trauma, self-
esteem, shame, depression, anxiety. As a consequence, a better understanding of the
consequences of periodontal disease is important in understanding patient perceptions of the
impact of their gingival/periodontal health on their everyday lives, in planning periodontal
therapy which addresses patient needs and in evaluating the results of the periodontal
treatment from the patient′s perspective. In the last decades, the relationship between
individuals' periodontal health/therapy and quality of life has been extensively examined and
this chapter reviews the current knowledge in this research field.
Chapter III – Periodontal diseases are one of the common oral diseases and it is
associated with formation of periodontal pockets, gingival abscesses, gingival recessions,
tooth mobility, and finally teeth loss. The link between nutritional factors and periodontal
disease has not been clearly established even if a highly number of studies has investigated
this possible association. As periodontitis is associated with low serum/plasma micronutrient
levels, it has been postulated that daily intake for vitamin C (ascorbic acid), vitamin E, zinc,
lycopene, vitamin B, complex vitamin D, calcium, unsaturated fats and antioxidants would
have useful adjunct benefits on the prevention and therapeutic management of periodontal
disease. Regarding various beverages, the consumption of milk, coffee or green tea was also
investigated in relationship with periodontitis. It has been showed that higher coffee
consumption is associated with a significant reduction in number of teeth with periodontal
bone loss, while green tea extract has been revealed to suppress the onset of loss of
attachment and alveolar bone resorption in a rat model of experimental periodontitis. This
chapter reviews the current knowledge in this research field, suggesting an adequate dietary
advice for patients with chronic periodontitis.
Chapter IV – Biological, psychological, sociological, and ecological features of life
contribute and interact simultaneously in the development of an individual’s oral health. For
example, a person’s oral health is influenced by culture/race/ethnicity, neighborhood/rural
area, government structure (with programs for education and healthcare), and level of social
cohesion/power (support from friends, family, church members, community members, etc.),
all of which may vary over the person’s life, as well as brushing and flossing, proper
nutrition, immunological status, saliva production, oral microbes, etc. When group variations
in preventable disease differ primarily due to social conditions, the situation is described as a
health disparity due to the social determinants of health. In the U.S., public policymakers are
expected to address such group health differences through: the promotion of education;
safe/healthy homes, schools, and workplaces; reduction of poverty; and the reduction of
discrimination (racial-based, gender-based, age-based, etc.) in addition to: the encouragement
of life-style changes to lessen risk; healthcare; and research. The purpose of this chapter is to
review the influence of improved oral health literacy considering the circumstances in which
a person has been born, lives, and works (social determinants), the microbiological
mechanisms, and the public’s influence to improve oral health.
 Preface ix

Chapter V – Mental disorders represent one of the largest burdens of disease globally.
People who experience mental illness have incrementally worse physical health compared to
the general population. While there is a movement in mental health care to consider physical
health needs of service users, the oral health needs are not routinely assessed. Compounding
the lack of routine or standardised oral health assessment in mental health services, service
users/consumers often demonstrate avoidant health seeking behaviours. Health service
avoidance for physical care needs is often compounded by prohibitive costs, stigma related to
mental disorder, unsatisfactory previous encounters with oral care practitioners and
psychiatric symptomatology impacting behaviours. This chapter will using contemporary
literature describe the complexities related to oral care of people who experience mental
disorders and the implications this may hold for their quality of life, practice, research and
policy.
Chapter VI – Schizophrenia is a severe mental disorder. It is a ubiquitous disease
affecting 1% of the world population. Delusions and hallucinations are symptoms of the
disease, but discordance and negation of the body mean these people are not always able to
make the right decisions to take care of their health. This is one reason why dental health
indicators are very high compared to the general population. Poor oral health is one of the
causes of stigma from which these people suffer greatly. Determinants of the oral health of
these patients are multiple. The neurological effects of first-generation antipsychotic drugs are
multiple (dyskinesia, extrapyramidal syndrome, myasthenia gravis, and trismus) and disrupt
the motricity of the oral region. The metabolic effects of second-generation antipsychotic
drugs (dyslipidemia, hyperglycemia, weight gain, hyperprolactinemia, and cardiovascular
ischemic disorders) and more generally anti-cholinergic pharmacopoeia worsen dental
problems further. There are also other determinants of oral health of schizophrenic patients,
such as disruption of the nociceptive pathways, taking psychoactive substances, smoking,
poor diet and lifestyle, and lower socioeconomic status. The lack of somatic care in relation to
the division between body and mind must also be mentioned. Lastly, health promotion
activities are inadequate for these populations and health professionals lack training in this
area. Studies on the subject are difficult to implement because patients do not readily consent
to the exploration of an organ with a strong symbolic and emotional component. Studies that
target only schizophrenic patients are few and far between and only concern hospitalized
patients, i.e. few patients. The state of knowledge in this area has a low level of evidence.
Outstanding issues are numerous regarding the effectiveness of preventive actions and
management of patients with very specific needs. In this context, we analyzed the impact of
poor oral health of schizophrenic patients on their overall health and quality of life through
motivational and cognitive constraints imposed by the symptoms of schizophrenia, but also
through the unique perspective of caregivers and society about this disease that is too often
stigmatized.
Chapter VII – Objectives: Psychosocial Impact of Dental Aesthetic Questionnaire
(PIDAQ) represents the only available tool for assessing the quality of life for the orthodontic
patients. The research studied the relationships between the different aspects of orthodontic
care planning, and validated the Romanian version of the PIDAQ questionnaire. Material and
methods: A transversal study was carried out on a sample of 1126 subjects, age ranging
between 6 and 28 years old. The self-evaluation of the orthodontic esthetic perception was
assessed with the PIDAQ index, and the orthodontic treatment need was measured with the
IOTN index. Results: Esthetic perception - 70% of the subjects are unsatisfied with the
x Julia Renee Barnes

appearance of their dentition. Orthodontic treatment need perception - All the subjects
consider that they need orthodontic treatment. Esthetic perception and orthodontic treatment
need relationship - 40.16% of the subjects, which were unsatisfied with their dentition
appearance, considered that they do not require an orthodontic treatment. Esthetic perception
and the esthetic component of IOTN correlation - Among the subjects, assessed as in need
severe treatment, 80% were “Unsatisfied” or ”Deeply unsatisfied” with their dentition.
Discussion: The scores of the different PIDAQ dimensions determined in our study, were
comparable with those reported by other authors. Conclusion: The PIDAQ questionnaire
remains the only tool to assess the link between the dental-maxillary anomalies and the
quality of life. Our results demonstrate that the Romanian version of the PIDAQ
questionnaire is a valid instrument in assessing the psychosocial impact of the dentition
esthetics related to the malocclusion.
In: Oral Health ISBN: 978-1-63482-832-1
Editor: Julia Renee Barnes © 2015 Nova Science Publishers, Inc.

Chapter I

Periodontal Disease and Oral Health-

Related Quality of Life

Victor Goh1,2, Dipti Nihalani1,3 and W. Keung Leung1

1
Faculty of Dentistry, The University of Hong Kong,
Hong Kong SAR, China
2
Faculty of Dentistry, The National University of Malaysia, Malaysia
3
Zircon Dental Center, Doha, Qatar

Abstract
Periodontal disease is an inflammatory disease initiated by mixed opportunistic
bacterial pathogens in the dental plaque biofilm. In the susceptible patient, advancing
periodontal disease often leads to loss of supporting soft and hard tissues around a tooth.
Due to the nature and progression of the disease, methods of characterizing periodontal
disease have often been based on clinical parameters such as probing pockets depths,
clinical attachment levels, bleeding on probing, mobility scores and gingival recession.
Unfortunately, such parameters show no indication of how the disease affects the patients
themselves. Of recent years, patient centered assessments such as Oral Health-Related
Quality of Life (OHRQoL) are increasingly appreciated and being applied. Such
measures incorporate the functional, psychological and social consequences of oral
conditions for the individual, and not merely signs and symptoms of the disease itself.
This chapter will review the effects of periodontal disease and its treatment on OHRQoL.
Patients often report functional limitation, physical pain and psychological disability
associated with the signs and symptoms of periodontal disease. Such effects on OHRQoL
have been shown to diminish with proper treatment. Furthermore, recent studies have
also shown that the complications or outcome of different treatment strategies have, to
varying degrees, an effect on patients daily life. These complications such as tooth loss,
recession and pain are closely related and interplay to affect the patient’s OHRQoL.

Keywords: Quality of Life, periodontitis

2 Victor Goh, Dipti Nihalani and W. Keung Leung

1. Introduction
Oral diseases have significant effects on one’s physical and psychological health. The
experience of pain or discomfort, difficulty with eating, smiling and other social interactions
due to damaged, missing, abnormal or diseased oral structures have profound consequences
on people's daily lives and general well-being. Such symptoms restrict activities at work,
school or even at home leading to loss of millions of productive hours annually. This is a
persistent global problem particularly among underprivileged groups in both developing and
developed countries (Reisine, 1984, Gift et al., 1992, Petersen et al., 2005).
The dental literature has in many years been dedicated to constructing and validating
sensitive and accurate indices for classifying oral diseases, or rather, the clinical picture of the
diseases. Unfortunately, they give us no indication of how these clinician-determined
parameters affect the patient’s daily lives and nothing about subjectively perceived disease
outcomes such as pain, discomfort, psychological and social impacts (Locker, 1988). As such
quality of life (QoL) measures have become an important tool to assess a patient’s physical,
psychological and social well-being (Wilson and Cleary, 1995).
The World Health Organization (WHO) defined QoL as:

“Individuals' perception of their position in life in the context of the culture and
value systems in which they live and in relation to their goals, expectations, standards and
concerns”

QoL is a multidimensional concept, incorporating in a complex way ones' physical

health, psychological state, level of independence, social relationships, personal beliefs and
their relationships to salient features of their environment.
The WHO’s definition emphasizes the fact that QoL is a broad-ranged and subjective
construct which includes both positive and negative facets of life (WHO, 1995).
As the health profession continues to see an emerging importance in incorporating
patient’s QoL in treatment planning, approval of new therapies and policy research (WHO,
1995), this chapter will discuss the importance of such measures in the dental field and how
these measures are used in understanding the impact of periodontal disease on patient’s QoL.

2. Burden of Dental Disease on Society

Periodontal disease and tooth decay have for decades been a huge burden on global oral
health. Even today, dental caries is still a major oral health problem as it affects up to 90% of
school-aged children and a vast majority of adults worldwide (Petersen et al., 2005,
Bagramian et al., 2009). In less developed regions of the world and among the less affluent
populations in industrialized countries, both children and adults suffering from severe dental
caries are often denied proper treatment. Due to social disparity, financial constraints and
inadequacy in available oral health services, decayed teeth are often left untreated or simply
extracted to relief pain (Petersen et al., 2005, Bagramian et al., 2009).
Similarly, periodontal disease is considered a major oral health problem with its severe
form affecting approximately 11% of the world’s population (Richards, 2014) with most
 Periodontal Disease and Oral Health-Related Quality of Life 3

children and adolescents worldwide having signs of gingivitis (Petersen et al., 2005). Imagine
that 1 out of 10 people may be affected by advance periodontal disease. At an individual
level, the burden of periodontal disease on daily function may not be substantial. However,
when taken at a population level, the cumulative consequences of the disease may have
significant ramifications on social function (Locker, 1988). Given the high prevalence of
periodontal diseases, work loss due to the debilitating effects of the disease, and the need for
time consuming therapy becomes substantial (Locker and Miller, 1994).
Such effects may be seen in the initial works by Reisine (1984) on dental disease and
work loss. She stated that out of 2,600 working adults interviewed, a quarter reported at least
one episode of work loss in the previous 12 months related to oral health problems and need
for dental treatment visits with an average time lost from work of 1.7 hours (Reisine, 1984).
Though a mere 1-2 hours of work loss yearly by a single person may not have severe social
implications, when such a measure is calculated at a larger population level, the impact of
dental disorders on work loss becomes significant enough to cause certain social and
economic dysfunction (Reisine, 1984, Gift et al., 1992)
Gift and co-workers (1992) reported that in 1989, at the national level, an annual work
loss of 164 million hours was accumulated by working adults in the United States due to
personal oral problems or need for dental visits. In terms of missing school hours, they stated
that more than 51 million study hours were lost in a single year by school-age children as a
result of oral diseases or dental visits. Among those who missed work or some school time, a
similar pattern was observed where females, lower socio-economic classes, and those without
health insurance were found to have lost more hours (Gift et al., 1992).
Due to vast disparities in socioeconomic status, the lower income groups have often been
denied proper oral health care as a result of financial constraints and lower education levels.
These inequalities may lead to differences in perceived needs, and attitudes about oral health
(Hosseinpoor et al., 2012, Tchicaya and Lorentz, 2014).

3. Emerging Importance of Patient Centred

Outcome Measures
Though the report by Reisine’s (1984) group was not restricted to periodontal disease, it
does shine a light upon the debilitating effects such diseases have on society. Chronic
diseases such as periodontal disease have been shown to exert substantial economic impact on
both the health care system and the individual patient (Yach et al., 2004). Vernazza and
colleagues (2012) discussed in detail the economics of treating periodontal disease. Economic
assessments are concerned with evaluating inputs with outcomes, or costs with benefits
(Vernazza et al., 2012). As the complicated scope of health economics is not the topic of
discussion here, a simpler way to look at things would be that the more benefits one could
gain for a specific cost, the more effective that treatment strategy would be. In line with the
World Health Organization’s definition of health as being a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity (WHO, 1948),
patient-reported outcomes on top of clinical measures are becoming an important focus for
researchers and policy makers alike to determine the most effective way of utilizing often
scarce resources to gain maximum benefits.
4 Victor Goh, Dipti Nihalani and W. Keung Leung

Although periodontal diseases are rarely a matter of life and death, growing indications
that oral diseases as such might have significant ramifications on social, psychological and
fiscal areas of life are making way for more complicated treatment outcome measures such as
impact on QoL to be applied in its therapy. Systematic and quantitative information on the
impact of oral disease on QoL would prove useful for several reasons (Nikias, 1985):

I. Such measures would be valuable in making decisions when allocating scarce

resources for delivery of health care.
II. For a more comprehensive understanding of oral health problems, a broader range of
knowledge regarding the consequences of disease is essential.
III. Patient’s perception regarding the social, economic, and psychological consequences
of oral diseases may play an important role in changing their oral health practices,
including routine and preventive use of dental care.

Indeed what these three points pointed out are important when selecting treatment
strategies and educating patients of specific target groups regarding oral health. For instances,
Gift and colleagues (1992) stated that perceptions of need for care and the use of home
remedies varies between socioeconomic classes. Individuals from lower socioeconomic
groups tend to use home remedies or engage in self-care more often to avoid or at least delay
the need for professional treatment, while individuals from higher socioeconomic groups
engage in self-care to complement professional care (Gift et al., 1992). Such observations
highlight the fact that patients from lower socioeconomic backgrounds may seek dental
treatment only for curative measures to relief pain as a last resort (Antunes et al., 2003). Due
to differences in oral health believes and practices, when providing treatment and educating
such patients on the need for periodontal therapy, the use of clinical measures may not matter
much. Discussion about probing depths or clinical attachment loss may not be of interest to
this patient group, but a risk of pain, disruption in their ability to eat, speak or even work due
to disease might prove to be more easily understood and appear more significant in their daily
lives. In shorter terms, for any therapy to be considered successful, both the diagnosis and the
suggested therapy must make sense in terms of the patient's lay models of illness (Helman,
1981).
When choosing treatment options for lower income groups, the growing evidence on the
impact of treatment strategies on patient reported outcome measures may also be applied. For
example, Wong et al., (2012) showed that non-surgical periodontal therapy not only was able
to improve clinical parameters of moderate-to-advance chronic periodontitis, when patient
centred outcomes were evaluated, improvements in terms of patient perceived physical pain,
etc. were observed. Mombelli et al., (2011) concluded that use of adjunctive antibiotics can
enhance the clinical outcome of non-surgical periodontal treatment, which may reduce the
need for surgery. While Flemmig and Beikler (2013) pointed out that the cost of non-surgical
periodontal treatment with adjunctive antibiotics is much lower than that of periodontal flap
surgery.
Though these treatment modalities may not be equal in efficacy, such emerging evidence
can aid clinicians and policy makers in deciding treatment strategies and allocation of
resources for lower socioeconomic groups. In this case, since both treatment modalities are
clinically effective, and non-surgical periodontal treatment alone is enough to improve patient
 Periodontal Disease and Oral Health-Related Quality of Life 5

reported outcomes at a lower cost, clinicians may emphasize on such strategies when treating
periodontal disease in less affluent groups of patients.
Oral disorders such as periodontal disease imposes a significant burden on the individual
affected, on society, nationally and globally. As current researchers delve into the task of re-
quantifying periodontal diseases so that it encompasses the view of disease in a more absolute
manner, we see an increasing interest in the use of patient-reported measures as an outcome
of care (Aslund et al., 2008). In the following section, this chapter will look into the brief
history on the development of such measures with regards to oral health and its current use in
the field of periodontology.

4. Development of QoL Measures

Even with the vast amount of evidence flooding the dental field, the limitations in
quantifying oral diseases is seen across all specialties. In periodontology, clinical indices and
examinations such as the Basic Periodontal Examination, or even the routine periodontal
charts, are essentially just measures of existing pathology or outcome of past oral diseases. To
date, these clinical measures are still unable to tell us definitely whether a clinical finding
such as an increased pocket depth is in fact a diseased entity or just a remnant of the
destructive disease that once took place.
Most importantly, as the clinician strives by all means possible to eliminate this so called
diseased periodontal pocket, the benefits of treatment may be minimal or even absent, making
the morbidity due to such treatments on the patient unwarranted. Due to limitations in the
traditional methods of quantifying disease, the concept of measuring and treating diseases has
seen some changes over the years. Related concepts in health care have been redefined and a
basic distinction drawn between disease and illness. Disease is often seen as a quantifiable
deviation from certain physical, physiological or biochemical parameters such as blood
counts, weight, height, and heart rate, accompanied by abnormalities in the structure or
function of body organs or systems. Illness, however, is seen in a more personal context,
being based largely on the patient’s perspective of their own ill-health. It is a concept that is
largely dependent upon their experience, social and cultural background as well as their
personality traits (Helman, 1981).
An important point of departure from traditional methods of quantifying disease began
with the definition of health offered by the WHO in 1948 as mentioned under section 3. With
this, a conceptual framework on measuring health as not just a disease or pathological state
but a multidimensional biophysical and socio-medical interaction was proposed by Locker
(1988). Locker’s concept was a simplified sequence of impacts or outcomes that were linked
in a linear fashion to produce an overall scheme which moves from a biological to a
behavioural and then social level of analysis. This model was an adaptation of that embraced
by the WHO as part of the International Classification of Impairments, Disabilities and
Handicaps (Locker, 1988).
Locker’s suggested model (Figure 1) of measuring oral health draws upon the concepts of
health defined by Wood (1980) in terms of impairment, functional limitation, disability and
handicap. These identify distinct areas of human experience relative to disease and its
personal and social consequences. It links concepts from both medicine and the behavioural
6 Victor Goh, Dipti Nihalani and W. Keung Leung

sciences to capture a broad spectrum of events, each of which provides the basis for specific
types of health status measure (Locker, 1988).
The categories and concepts of health as explained by Locker are discussed below.

Figure 1. Modified WHO conceptual model of disease and psychosocial outcome by D. Locker, 1988,
Community Dental Health 5, 3-18. Copyright 1988, BASCD. With permission.

4.1. Death

Death as an end-point of disease, though limited in its use with common oral diseases, is
still an essential concept in assessing health (Locker, 1988). Although estimates of
standardized mortality rates can still provide useful information on the impacts of diseases or
treatment modalities, such comparisons for different diseases have become less meaningful in
planning treatment. For example, in the case of cancers, most patients usually survive for
more than 5–10 years, and thus one must wait for a long period of time for mortality to occur
(Hung et al., 2014), and for obvious reasons, will not be popularly used as a desired outcome
of treatment.

4.2. Disease

Disease in a more traditional sense has been described by Campbell et al., (1979):

"A disease is the sum of the abnormal phenomena displayed by a group of living
organisms in association with a specified common characteristic or set of characteristics
by which they differ from the norm for their species in such a way as to place them at a
biological disadvantage"

In Locker’s model, disease was taken to be a label applied to the pathological processes
and was measured in terms of its prevalence and incidence in populations. Sources of
information may be from population surveys, cancer registrations, infectious disease reports
or even hospital discharge forms (Locker, 1988).

4.3. Impairment

Impairment has been defined as any anatomical loss, structural abnormality or

disturbances in physical or psychological processes, either present at birth or as a
 Periodontal Disease and Oral Health-Related Quality of Life 7

consequence of disease or injury (Locker, 1988). Such measures are commonly used in
dentistry. Impairments are usually represented by traditional disease based indicators of oral
health such as the DMFT index, or clinical attachment loss which as its name suggest,
measures loss of periodontal attachment (Locker, 1988, Locker and Miller, 1994).

4.4. Functional Limitation

Functional limitations are defined as restrictions in the functions customarily expected of

the body or its component organs or systems. In case of oral function, this would often refer
to the ability to chew, eat and produce intelligible speech. Clinical measures of functional
limitations are more ambiguous in nature, more difficult to evaluate and less common in
dentistry (Locker, 1988, Locker and Miller, 1994).

4.5. Discomfort

The first three concepts of health mentioned above have often been regarded as the
biophysical measures of health, referring more towards the biological consequences of
disease itself (Locker, 1988). In the conceptual model by Locker, as it approaches the end of
the continuum, health status measurements begin to merge with more subjective matters in
relation to QoL. In this model, discomfort and pain were viewed together as a socio-medical
measure because they are subjectively perceived and can be experienced even without any
identifiable pathology or physiological dysfunction (Locker, 1988, Locker and Miller, 1994).

4.6. Disability

Disability refers to any difficulty performing activities of daily living. While traditional
measures of disability focuses only on the physical restrictions one has, current health models
view disabilities as a broader range of limitations in terms of physical, psychological and
social function. Lockers conceptual model defines such limitations in terms of two
components (Locker, 1988):

I. Physical well-being: Encompassing individual activity restrictions in such areas of

life as mobility, self-care, eating, resting and so on.
II. Social well-being: Involving problems in the work place, at home and during
recreation. Measures of social well-being include social integration, social contacts
and social intimacy. The first is concerned with the extent of an individual’s
participation in community life. The second with the frequency of interaction with
the community, and the third with the quality and emotional investment during such
interactions.
8 Victor Goh, Dipti Nihalani and W. Keung Leung

4.7. Handicap

Handicap is defined as the disadvantage experienced by impaired and disabled people

because they do not conform to the normalities set by society. While disability and functional
limitations refer to the immediate personal consequences of disease, handicap is concerned
with broader social effects (Locker, 1988). It is not a direct effect of the disease itself, but
more of an indirect social consequence of disease. Any loss or abnormality of the structure or
function or the behavioural limitations involved can be a disadvantage to the individual in
terms of the quality of everyday life and long-term life chances. For instances, Tobiasen and
Hiebert (1993) stated that children with facial clefts are at higher risk of reduced social
competence such as development of friendships, progress in education, and participation in
communal events leading to an overall negative effect on their psychosocial development
(Tobiasen and Hiebert, 1993). Given the multidimensional effects of handicap, such
disadvantages are difficult to quantify (Locker, 1988).

5. The Conceptual Model

The conceptual model by Locker illustrates the various relationships between the
component parts of the overall model, linking each outcome of disease in a linear progression.
At the end of the process, handicap may be seen as an outcome of sequential events starting
from disease to impairment to functional limitation and eventually leading to life or social
disadvantages. Furthermore, handicap may not be just an outcome of these series of events,
but may be a direct consequence of impairment or functional limitations. Locker’s model
provides a theoretical framework for the empirical exploration of the relationships between
different dimensions of disease and oral health (Locker and Miller, 1994). However, one
inadequacy of the model was that there was no specific link from the defined health indicators
to QoL (Locker, 2004). Wilson and Cleary (1995) proposed a model that makes an explicit
link towards QoL. In their conceptual model, biological and physiological factors (or disease)
result in symptoms, compromised physical and psychosocial functions and negative health
perceptions leading towards a diminished QoL. As the model progresses from the basic
biological and physiological concept of disease, its functional and psychosocial outcomes and
its impact on QoL are said to be influenced by both individual and environmental
characteristics. This concept moves the perception of health from a personal biological
experience of the disease towards the impact it has on the individual as a member of society
and vice versa. At the end of the process, QoL is also seen to be influenced by a wide range of
non-medical factors such as work and education. Finally, the authors also clarified that the
absence of connectors between different levels do not imply that no such relationships exist
nor are any of the relationships unidirectional (Wilson and Cleary, 1995).

6. Changes in Assessment of Oral Health

Of recent years, as interest in the impact of oral health on the psychosocial profiles of
patients continue to grow, oral health measures that draw on the patient’s perspective
 Periodontal Disease and Oral Health-Related Quality of Life 9

previously referred to as socio-dental indicators, subjective oral health or the social impacts of
oral disease were replaced with the term Oral Health-Related Quality of Life (OHRQoL)
(Locker and Allen, 2007).
Referring back to the WHO (1995) definition of QOL as mentioned under section 1,
OHRQoL characterizes a person’s perception of how oral health influences their daily lives.
OHRQoL is assessed specifically in terms of impact on physical, emotional and
corresponding social functioning associated with performing normal roles brought about by
each individual’s oral state (McGrath and Bedi, 2001a, Ozcelik et al., 2007). To date, there is
no consensus on a generally accepted definition of OHRQoL, but most authors are in
agreement that it is a subjective construct best reported from a patient’s point of view
regarding their oral health and its effect on general well-being (Locker, 2004, Al-Harthi et al.,
2013, Brauchle et al., 2013).
If a researcher aims to assess the OHRQoL of a specific group, then it is necessary to
identify a measure whose items address various aspects of daily life that the target group in
question considers important (Locker, 2004). Some of the most widely used generic
OHRQoL instruments are: the Oral Health Impact Profile (OHIP) (Slade and Spencer, 1994);
Oral Health-Related Quality of Life Measure (OHQoL-UK©) (McGrath and Bedi, 2001b);
Oral Impacts on Daily Performance (OIDP) (Adulyanon et al., 1996) and the Geriatric Oral
Health Assessment Index (GOHAI) (Atchison and Dolan, 1990), while condition-specific
tools such as the Third Molar Health-Related Quality of Life instrument (Shugars et al.,
1996); Orthognathic Quality of Life Questionnaire (OQLQ) (Cunningham et al., 2000);
Dentine Hypersensitivity Experience Questionnaire (DHEQ) (Boiko et al., 2010) and the
Halitosis Associated Life-quality Test (HALT) (Kizhner et al., 2011) are aimed at assessing
the impact of specific oral problems on daily living. Though these measures differ in terms of
their length, scoring systems and oral health concepts addressed, they all quantify OHRQoL
in terms of numerical scores. These results can then be used to compare groups with and
without oral disease, with disease at different stages and severity or different oral diseases.
While the generic instruments are mainly used in assessing the overall impact of various oral
problems on OHRQoL, the condition-specific questionnaires focuses on effects due to a
single oral disease or problem. This makes the condition-specific instruments more sensitive
to minor, but clinically important changes in specific oral diseases (Bernabe et al., 2009,
Tsakos et al., 2010, Kizhner et al., 2011).
Most OHRQoL instruments have been tested for validity, internal consistency, reliability
and responsiveness to change (Locker, 2004). Responsiveness refers to the ability of a
measure to detect minimally important clinical changes. This allows such OHRQoL measures
to detect small meaningful changes, both in-between groups and within-subject that occurs
naturally or as a result of an intervention (Allen et al., 2001, Locker et al., 2004, Tsakos et al.,
2010). As such, changes in OHRQoL measures can be assessed and compared in terms of
their effect on patient reported psychosocial well-being before and after treatment (Locker,
2004). By using appropriate OHRQoL instruments, benefits of new, and usually expensive
therapies such as dental implants may be assessed (Allen and Locker, 2002), providing both
clinicians and policy makers more information when planning treatment and public health
strategies (Allen et al., 2001, Locker, 2004). Of late, interest in measures of OHRQoL have
been expanding in the field of periodontology and will be the topic of our next discussion.
10 Victor Goh, Dipti Nihalani and W. Keung Leung

7. Periodontal Disease and Oral Health-Related

Quality of life (OHRQoL)
Periodontal disease has been described as an inflammatory condition initiated by
bacterial complexes in the dental plaque biofilm. In the susceptible patient, advancing
periodontal disease often leads to loss of both soft and hard tissues around teeth. Due to the
nature and progression of the disease, methods of characterizing periodontal disease have
often been focused on clinical parameters such as probing pockets depths and clinical
attachment levels (Jansson et al., 2014). Unfortunately, such clinically based findings show
no indication of how the disease affects the patients themselves. To date, little is known
regarding this aspect of periodontal disease (Needleman et al., 2004, Wong et al., 2012).
Obviously, such patients’ daily lives are not going to be much affected by the knowledge of a
few deep pockets in their mouth, neither is a high plaque score going to be of much
significance to their usual routines. However, the consequences brought upon by signs and
symptoms such as pain, discomfort, functional limitation and halitosis will have some sort of
debilitating effect on their physical, social and psychological well-being (Needleman et al.,
2004).
Periodontal disease has been shown to affect OHRQoL in patients. Patients often report
functional limitation, physical pain and psychological disability associated with the disease.
Needleman et al., (2004) assessed the impact of periodontal disease on the OHRQoL of 205
such patients attending a private specialist clinic over a 6 months period. Patients under
various phases of periodontal treatment were evaluated using the OHQoL-UK©
questionnaire. Sixteen key areas of OHRQoL as described by McGrath et al., (2000) were
assessed, these were: symptoms of the disease such as comfort and bad breath; physical
aspects such as eating, appearances, general health, speech and smiling or laughing;
psychological aspects, which were relaxing, self-confidence, mood, being carefree and
personality; social aspects in work, social life, finances and romance (McGrath et al., 2000).
Responses to the OHQoL-UK© ranges from ‘‘very bad’’ (score 1) to ‘‘very good’’ (score 5)
with lower score indicating poorer OHRQoL (McGrath et al., 2000, Needleman et al., 2004,
Durham et al., 2013). Besides evaluating OHRQoL, patients were also asked to report about
the signs and symptoms of periodontal disease in the past year, in terms of experiencing
swollen, sore, or receding gums; loose teeth, drifting teeth, bad breath and toothache. The
authors reported that the impact of periodontal disease on the subjects OHRQoL was
considerable, with 90% of patients claiming that their OHRQoL was impacted by the signs
and symptoms of the disease or its outcome in one way or more. A substantial number of
patients reported bad or very bad effects on their OHRQoL. Of 205 subjects, 19% reported
such effects (bad or very bad) on their comfort, 18% on bad breath, 18% on appearances,
16% on smiling or laughing, 32% on finances, 13% on their mood and 12% said periodontal
disease detracted from their confidence. Patient’s OHQoL-UK© scores were also
significantly associated with self reported periodontal experiences of swollen, sore or
receding gums, loose teeth and drifting teeth, bad breath and toothache, with patients self-
reporting such signs and symptoms having worse OHRQoL than those who did not.
Unsurprisingly, they also found that new patients had lower OHQoL-UK© scores indicative
of diminished OHRQoL compared to those under periodontal maintenance, suggesting that
periodontal therapy may improve OHRQoL. However a few limitations in this study could be
 Periodontal Disease and Oral Health-Related Quality of Life 11

observed. Firstly, the type of periodontal disease itself was not defined, secondly, no long
term comparisons were made between treated and new patients, and no periodontally healthy
subjects were included as controls. It would have been interesting to know if patients with
either chronic or aggressive periodontitis would react differently due to the different rate of
disease progression and the relatively early onset of the latter. Furthermore, it would be of
importance to know how these patients fare before and after therapy, and if such patients do
in fact have poorer OHRQoL compared to periodontally healthy subjects. Though not without
its shortcomings, this study paved the way for a better understanding of how patients perceive
the effects of periodontal disease and its outcome on their physical, psychological and social
health.
A later report from the current group (Ng and Leung, 2006b) assessed the impact of
periodontal health on OHRQoL in 1000 Chinese subjects in Hong Kong. Subjects were
divided into a healthy/low periodontal attachment loss group (n = 584), and a high/severe
periodontal attachment loss group (n = 143). It was reported that subjects with severe
attachment loss perceived more functional limitation, physical pain, psychological
discomfort, physical disability and psychological disability compared to their healthy
counterparts. While prevalence of negative impact on the psychological domains of
discomfort and disability varied between 4.0% and 6.3%, unfavourable effects on social
disability and handicap was less prevalent. This was in slight contrast to the findings by
Needleman et al., (2004). It was postulated that differences in cultural background and health
beliefs may be the reasons accounting for such disparity. However, both reports concluded
that subjects with better periodontal health were more likely to have better OHRQoL, and
vice versa (Needleman et al., 2004, Ng and Leung, 2006b).

7.1. OHRQoL in Patients with Chronic Periodontitis

Chronic periodontitis (CP) is the most common form of periodontal disease

predominantly seen in patients aged over 30. They usually present clinically with
considerable amounts of plaque and calculus associated with marked gingival inflammation,
periodontal pockets and attachment loss. In most cases, the disease progresses slowly though
short periods of rapid periodontal destruction may occur. Although CP may be diagnosed as
either a localized or generalized form, the two patterns of disease appear to be similar with
regards to their pathogenesis and aetiology (Armitage, 1999).
CP impairs patient’s OHRQoL (Wong et al., 2012, Brauchle et al., 2013, Durham et al.,
2013, Jansson et al., 2014). A study by Durham et al., (2013) on 89 patients with CP using
both the OHIP-49 and the OHQoL-UK© questionnaires concluded that patients OHRQoL
were affected by signs and symptoms of the disease. In slight contrast to the OHQoL-UK©
questionnaire, OHIP-49, as its name suggests, contains forty nine items, to which each
response indicates the frequency of the impact on the individual, ranging from ‘‘never’’
(Score 0) to ‘‘very often’’ (Score 4). Summation of each response code generates both
domain scores and an overall summary score with higher scores indicating poorer OHRQoL
(Slade, 1998). Durham et al., (2013) reported that patients with chronic periodontitis had
significantly poorer OHRQoL compared to periodontally healthy controls. Whether
considering either OHIP-49 or OHQoL-UK©, the items with most statistically significant
differences between patients with periodontitis and periodontally healthy subjects were
12 Victor Goh, Dipti Nihalani and W. Keung Leung

related to reports of pain, halitosis, aesthetics and psychological concerns. These findings
relate well with the results by Needleman et al., (2004), further strengthening the concept that
periodontal disease negatively affects the OHRQoL of patients affected (Needleman et al.,
2004, Ng and Leung, 2006b, Durham et al., 2013, Jansson et al., 2014).
When comparing the severity of periodontal disease and its impact on OHRQoL, Jansson
and co-workers (2014) found that patients with a more severe form of CP reported poorer
OHRQoL compared to patients with lesser radiographic bone loss. Using a shorter version of
the OHIP questionnaire, OHIP-14, they evaluated the impact of periodontal disease on the
OHRQoL between three groups of patients: patients with radiographic bone loss of less than
one third of the root length (BL-), patients with radiographic bone loss of one third or more of
the root length in <30% of teeth (BL), and patients with radiographic bone loss of one third or
more of the root length in ≥30% of teeth (BL+). Patients from the third group (BL+) reported
significantly worse OHRQoL compared with the other two, supporting a possible correlation
between the degree of periodontal destruction and OHRQoL. They concluded that loss of
clinical attachment and its severity may have an impact on patients’ OHRQoL (Jansson et al.,
2014).
It seems that from the currently available literature, CP impacts a patient in more ways
than one. Not surprisingly, the consequences of disease such as pain, swelling, halitosis and
ultimately tooth loss will affect the patient physically, psychologically and socially leading to
a diminished OHRQoL.

7.2. OHRQoL in Patients with Aggressive Periodontitis

One of the less common and most severe forms of periodontal disease is aggressive
periodontitis (AgP) which is characterized by a rapid rate of progression, early onset of
disease and a tendency for familial aggregation. It typically presents itself in two forms-
Localized AgP (LAgP) and Generalized AgP (GAgP).
Clinically, the signs and symptoms of the disease are extensive loss of supporting
periodontal structures and bone resorption causing deep periodontal pockets, bleeding from
the gingival sulcus, and tooth mobility eventually leading to tooth loss (Armitage, 1999,
Armitage, 2004). LAgP has been known to be restricted to the first molars and incisors and
reported to be self-arresting.
However, GAgP has more severe symptoms and individuals suffering from it experience
considerable impact on their OHRQoL (Eltas and Uslu, 2013). Using the OHQoL-UK©
instrument, Eltas and Uslu (2013) evaluated its association with GAgP patients’ common
complaints like missing teeth, recession, bleeding gums, halitosis, pain and tooth mobility and
found that all complaints affected the OHQoL-UK© scores significantly. Deepest impact by
GAgP on OHRQoL was on discomfort, eating enjoyment and breath odour. Finances, work
and relaxation were least affected.
AgP negatively impacts patient’s OHRQoL. Though further research is needed to
compare such effects with that of CP and the general population, current evidence suggests
that periodontal disease, regardless of its form, has significant deleterious outcomes on a
patient’s OHRQoL.
 Periodontal Disease and Oral Health-Related Quality of Life 13

8. Impact of Periodontal Disease Sequelae

on OHRQoL

8.1. Tooth Loss due to Periodontal Disease

The clinical signs and symptoms of periodontitis do not overtly affect the patient in the
early stages of disease. However, the inadequately treated patient ultimately experiences tooth
loss which would affect both, function and aesthetics depending on the number and position
of tooth lost (Elias and Sheiham, 1998, Baba et al., 2008). Tooth loss may be a consequence
of untreated periodontal disease or may be a part of periodontal therapy itself. Though both
events may not affect patients OHRQoL differently, the impact of missing teeth within these
two contexts will be discussed separately.
Several studies have been conducted to evaluate the impact of tooth loss on OHRQoL.
Most have concluded that loss of teeth negatively impacts the OHRQoL of patients. Locker
(1995) in his population study showed that after controlling other variables, OHIP score
increased by 0.3 with each additional missing tooth. Similar results were reported by Steele
and co-workers (2004). Batista et al., (2014), in their cross-sectional study, assessed the
impact of tooth loss in 248 Brazilian adults aged 20 to 64 years old using the OHIP-14
questionnaire. Their analyses revealed a more severe impact on OHRQoL when the number
of teeth lost was above 13. However, when at least one anterior tooth was missing, the
severity of impact was higher than those with no or only posterior missing teeth, even when
the total number of missing teeth was less than 13. Furthermore, low family income was
associated with the prevalence of severe impact on OHRQoL (Batista et al., 2014).
When patients with periodontal disease are concerned, Durham et al., (2013) reported
that patients with untreated chronic periodontitis perceived poorer OHRQoL in the domains
of functional limitation, physical pain and overall OHIP-49 score due to tooth loss. They
stated that increased missing teeth were associated with higher negative impacts of
periodontitis on OHRQoL (Durham et al., 2013). Jansson et al., (2014) evaluated the
periodontal condition of 443 subjects and found that number of remaining teeth had a
statistically significant influence on subjects OHRQoL. Cunha-Cruz et al., (2007) stated that
increased tooth loss was another clinical outcome of untreated periodontal patients associated
with reduced OHRQoL and worse perceived oral health. Patients with ≥8 missing teeth
reported being more self-conscious and experienced more denture discomfort (Cunha-Cruz et
al., 2007). Similarly, Eltas and Uslu (2013) reported that as high as 85% of patients with
untreated GAgP complaint of missing teeth. Moreover, such patients reported negative
impacts on their comfort, eating/enjoyment of food, appearance, speech, general health,
smiling/laughing, confidence, carefree manner, mood, personality, work/usual duties,
romance and social life due to tooth loss (Eltas and Uslu, 2013).
When only posterior teeth are concerned, Käyser (1981) came to the conclusion that
patients have enough capacity to adapt when a minimum of four occluding units are present
(one unit equals to a pair of occluding premolars and two units equal to a pair of occluding
molars). This concept was termed the shortened dental arches (Käyser, 1981). A literature
review by Elias and Sheiham (1998) concluded that oral functional needs could be satisfied
by a less than complete dentition. As such, though negative impacts of tooth loss on
OHRQoL have been reported by patients with periodontal disease, the decision to restore or
14 Victor Goh, Dipti Nihalani and W. Keung Leung

not to restore missing teeth is somewhat a subjective matter and will be discussed further
down this chapter.

8.2. Gingivitis

Gingivitis is a reversible inflammatory response of the tooth-supporting tissues in

response to bacterial biofilm. Though often considered a milder less-destructive condition of
the periodontium, it can lead to uncomfortable consequences such as bleeding, swelling,
enlargement, and pain depending on its severity. Moreover, the gingival margin forms an
important part of a person’s smile and it is obvious that any condition which impairs the
aesthetics may have a negative impact on the OHRQoL. The effect of gingivitis on OHRQoL
was found to be limited or insignificant in some studies (Chen and Hunter, 1996, Tsakos et
al., 2006, Castro et al., 2011, Paula et al., 2012). However, in other studies such as the
Thailand National Oral Health Survey on 12-15 year olds using the OIDP index, the authors
reported a moderate to high impact of gingivitis on OHRQoL, especially in the psychological
domain. Negative feelings towards smiling, academic achievements and making social
interactions or low self image satisfaction resulting from gingivitis could affect the
psychological health of children and adolescents (Krisdapong et al., 2012). Tomazoni and co-
workers (2014) conducted a cross-sectional study to assess the child-OHRQoL (COHRQoL)
in 12 year old Brazilian school children. They used the Child Perceptions Questionnaire for
11 to 14 year old children (CPQ11-14) which assesses COHRQoL using four subscales
namely, oral symptoms, functional limitations, emotional well-being and social well-being.
They found that extensive gingivitis had a greater impact on the children’s self-perceived
OHRQoL as compared to those with low levels or no gingivitis. Non-white children, females,
children whose mothers did not complete primary education and those with low house hold
income were found to have higher mean scores of CPQ11-14. The correlation between
extensive gingivitis and CPQ11-14 scores was found mainly in the emotional domain which
encompasses issues related to frustration or irritation, embarrassment, and concern about what
other think about their teeth, lips or mouth (Tomazoni et al., 2014). Gingivitis in pregnancy is
also found to have significantly negative impacts on the perceived OHRQoL. Acharya and
co-workers (2009) conducted a cross-sectional study on 259 pregnant and 237 non-pregnant
rural Indian women using the OHIP-14 questionnaire to compare the perceived OHRQoL in
both groups. They found significantly higher mean number of sextants with CPITN scores of
2 and 3 and higher gingival index score in pregnant women compared to their non-pregnant
counterparts. Concurrently, the perceived OHRQoL was also significantly poorer in pregnant
women. They concluded that parity, DMFT scores and Gingival Index scores were significant
predictors for OHRQoL (Acharya et al., 2009).

8.3. Periodontal Attachment Loss/ Marginal Bone Loss, Pain, Halitosis,

Drifting of Teeth and Aesthetics

The clinical signs of periodontal disease such as ‘clinical attachment loss (CAL)’,
‘probing pocket depth’ and radiographic ‘marginal bone loss’ have been shown to be
 Periodontal Disease and Oral Health-Related Quality of Life 15

associated with OHRQoL in several studies. Recently, a few studies have also shown
significant associations between the OHRQoL and patients' self-reported symptoms. In a
study by our group (Ng and Leung, 2006b), subjects with mean full mouth CAL>3 mm were
found to have significantly higher total mean Chinese OHIP short version (OHIP-14S) scores
as compared to those with CAL ≤ 2 mm. Furthermore, there were also statistically significant
differences in scores from five domains, which were functional limitation, physical pain,
psychological discomfort, physical disability, and psychological disability between the two
groups. There were significant associations between OHIP-14S scores and occurrence of self-
reported ‘swollen gums’, ‘sore gums’, ‘receding gums’, ‘loose teeth’, ‘bad breath’, and
‘toothache’. The symptom of ‘drifting teeth’ did not affect OHRQoL in this sample (Ng and
Leung, 2006b).
Needleman et al., (2004) measured the impact of oral health on life quality using the
OHQoL-UK© instrument. Their study sample included 205 patients attending a private
periodontal clinic over 6 months. They found the OHQoL-UK© scores to be associated
significantly with high number of PD≥ 5mm with poorer life quality in such patients.
Furthermore, unlike the previously mentioned study, all the self-reported symptoms,
including ‘drifting teeth’ were significantly associated with poorer OHRQoL (Needleman et
al., 2004).
Pain even in its mildest form most inevitably affects one’s daily function. Saito’s group
(2010) reported a significant difference in experience of physical pain between individuals
with or without periodontal disease at baseline. While Cunha-Cruz and colleagues (2007)
stated that one of the three most commonly reported problems among untreated patients was
pain. These observations suggest that not only the physical functioning, but also pleasurable
life experiences, such as relaxation and social interaction, can be affected by the outcomes of
periodontal disease.
Several other signs and symptoms of periodontal disease also have significant effects on
patient’s OHRQoL. Among others, halitosis or “breath-odour” was reported by several
investigators (Needleman et al., 2004, Ng and Leung, 2006b, Durham et al., 2013, Eltas and
Uslu, 2013) to negatively impact OHRQoL considerably. Halitosis is frequently experienced
by patients and the most common causes originate from abnormalities in the oral cavity itself,
namely tongue coating, periodontal disease, pharyngitis, laryngitis (Scully and Greenman,
2008).
With a high prevalence estimate of 20% to 34% (Liu et al., 2006, Bornstein et al., 2009)
halitosis has a significant impact on the social and psychological health of the patient (Suzuki
et al., 2008, Buunk-Werkhoven et al., 2012, He et al., 2012). A study by Zaitsu and co-
workers (2011) revealed that 22.9% of patients with genuine halitosis defined as "obvious
malodour with intensity beyond a socially acceptable level is perceived" (Yaegaki and Coil,
2000) were prone to general social anxiety disorder. Moreover, subjects at high risk of social
anxiety disorder had difficulty in overcoming their anxiety about halitosis.
Similarly, possible aesthetic concerns arising from loss of interdental papilla (Cunha-
Cruz et al., 2007) and missing anterior teeth (Cunha-Cruz et al., 2007, Al-Omiri et al., 2009,
Gerritsen et al., 2010) may be driving the observed diminished OHRQoL and perceived poor
oral health seen in patients with periodontal disease (Cunha-Cruz et al., 2007). Al Omiri and
co-workers (2009) measured the Dental Impact on Daily living in 50 partially edentulous
patients with missing anterior teeth and compared them with 50 control subjects with no
missing teeth. They found significant correlations between number of missing anterior teeth
16 Victor Goh, Dipti Nihalani and W. Keung Leung

and patient’s satisfaction with appearance, oral comfort, general performance and eating
dimensions. Higher number of missing teeth was associated with lower levels of satisfaction
with dentition and daily living.
From the evidence available, the clinical presentations of periodontal disease which are
readily perceivable by individuals, such as pain, tooth mobility, drifting of teeth, unaesthetic
loss of interdental soft tissues and tooth loss (Cunha-Cruz et al., 2007) may eventually lead to
psychosocial impacts. This is seen especially in severe and generalized forms of the disease,
where patients may perceive a lack of confidence, inability to relax or feel carefree, poor
mood and personality, while encountering problems with work, relationships and social
interaction due to the biological effects of the disease (Eltas and Uslu, 2013). Furthermore,
difficulties in eating, enjoying food, and other basic functions in daily life will also lead to
worse general well-being (Ng and Leung, 2006b, Durham et al., 2013). These findings
challenge the perception of periodontal disease as a silent disease (Cunha-Cruz et al., 2007).
The relationships linking the biological outcomes of periodontal disease to physical,
psychological and social consequences will be discussed further through a theoretical
periodontal disease-OHRQoL model proposed later in this chapter.

9. Effects of Periodontal Therapy

9.1. Non-Surgical Periodontal Therapy and Its Impact on OHRQoL

Periodontal disease, be it chronic or aggressive in nature affects patients OHRQoL.

Fortunately, recent studies have begun to show promising results that such effects on
OHRQoL may diminish with proper treatment.
Initial periodontal therapy has a potential to improve OHRQoL. As mentioned in an
earlier section, non-surgical periodontal therapy may ameliorate patient’s signs and symptoms
of periodontal disease and improve perceptions of oral health (Saito et al., 2010, Wong et al.,
2012, Brauchle et al., 2013). This is seen especially in those with severe forms of the disease
(Brauchle et al., 2013).
Saito and colleagues (2010) evaluated the change in OHRQoL after conventional non-
surgical periodontal therapy in Japanese patients using the OHRQoL model for dental
hygiene (OHRQL). Respondents were asked to answer questions related to seven domains
namely pain, dry mouth, eating and chewing, speech, social function, psychological function
and health perception with a lower frequency score suggesting better OHRQoL. They found
significant improvements in most of the reported domains with greatest improvements
observed in reports of pain (44% reduction in OHRQL score post treatment), followed by
improvements in social function (31%), improvements in eating and chewing function (30%),
while psychological domain showed moderate improvements (25%) (Saito et al., 2010).
Similarly Wong and colleagues (2012) showed that non-surgical periodontal therapy was
associated with improved OHRQoL with regard to patient reported physical pain;
psychological discomfort and disability 12 months post-treatment. They concluded that
though periodontal attachment loss is somewhat irreversible, control of the disease and
maintenance of its stability could have profound effects on patients at a more personal level.
As discussed earlier, such observations reflect the need to view disease or illness in a more
 Periodontal Disease and Oral Health-Related Quality of Life 17

holistic manner and not allow clinician-determined parameters to take precedence over
patient-centred outcomes as signs of improvement. The report suggested that to motivate
patients towards receiving periodontal therapy and increase compliance towards proper
maintenance, clinicians could stress upon the positive psychological OHRQoL effects of non-
surgical periodontal treatment (Wong et al., 2012).

9.2. Surgical Periodontal Therapy and Its Impact on OHRQoL

There have been limited and varying conclusions regarding the benefits of surgical
periodontal procedures on patients OHRQoL in the dental literature. This observation is not
unusual as such treatment modalities exert significant pain, discomfort and morbidity at the
initial phase of treatment and benefits may only be seen in the long run.
Tonetti and co-workers (2004) observed the initial healing events, post-treatment
morbidity and patient perceptions of treatment outcomes of the papilla preservation flap with
and without enamel matrix derivatives (EMD). They reported that only 24% of controls and
30% of tests (with EMD) reported some interference with their daily activities for an average
of less than 4 days. At 12 months post-operatively, overall patient satisfaction for both test
and control surgical groups was good. Patients reported improvements in ‘‘gum health” and
the ‘‘ability to clean the treated area.” Most importantly, patients from both groups perceived
better oral health in terms of preserving their teeth and improvements in chewing ability
(Tonetti et al., 2004). Ozcelik et al., (2007) evaluated the immediate post-operative effects of
non-surgical (NS) periodontal treatment, flap surgery (SG) alone and flap surgery with
enamel matrix derivatives (S+EMD) on the OHRQoL of patients treated. Patients’ OHRQoL
were assessed with the GOHAI and OHIP-14 questionnaires and followed up daily up to 7
days after therapy. They found that patients treated by surgery alone reported worse OHRQoL
in terms of increased functional limitations, increased pain and discomfort, more
psychological and behavioural impacts compared to the NS and S+EMD groups (Ozcelik et
al., 2007). The Saito group (2011) followed up their patients 3-4 months after surgery and
found no significant differences in patients’ OHRQoL between post-initial therapy and post-
surgery intervals. They suggested that during the course of periodontal treatment, non-
surgical therapy relieves patient’s signs and symptoms of the disease to an extent that any
further improvements in OHRQoL would no longer be significantly reflected after surgical
treatment (Saito et al., 2011). From the evidence discussed, it would be justified to state that
adequate periodontal therapy helps diminish the negative effects of periodontal disease on
OHRQoL. However, a further look into the literature shows that the outcome of different
treatment strategies have, to varying degrees, an effect on patients OHRQoL as well. This is
indeed true to the fact that comprehensive periodontal care which involves non-surgical and
surgical therapy, extractions and even rehabilitative procedures will have both positive and
negative implications on the patient’s daily life.

9.3. Dentine Hypersensitivity and Its Impact on OHRQoL

Regardless of the type of periodontal therapy carried out, such therapeutic measures are
not without complications. One such complication is pain. Pihlstrom and colleagues (1999)
18 Victor Goh, Dipti Nihalani and W. Keung Leung

used the Heft-Parker pain scale in 52 adults with moderate periodontitis to evaluate pre and
post- scaling and root planning pain. They reported that pain after such treatment was
maximal between two to eight hours, lasted for six hours and then returned to pre-treatment
pain levels on the next day (Pihlstrom et al., 1999).
As continuous severe pain after therapy would suggest incomplete treatment, it would not
be considered in this discussion. However, one of the most common complaints reported
among patients after periodontal treatment is pain in the form of dentine hypersensitivity
(Rees et al., 2003, Tonetti et al., 2004). Dentine hypersensitivity has been reported to occur in
approximately 50%-98% of patients after periodontal treatment (Chabanski et al., 1997, von
Troil et al., 2002, Lin and Gillam, 2012). Denuded tooth surfaces leading to exposed dentine
appears to be the major cause of dentine hypersensitivity (Dowell and Addy, 1983), as such,
the high prevalence of dentine hypersensitivity among treated patients is somewhat expected
as gingival recession (von Troil et al., 2002) and removal of root cementum leading to
exposure of dentine are common complications of periodontal procedures (Jones et al., 1972,
Ritz et al., 1991).
When comparing non-surgical and surgical periodontal therapy, postoperative sensitivity
was found to be higher among patients after surgical procedures. Patients who had undergone
flap surgery and osseous re-contouring were reported to have a high degree of discomfort
probably due to increased treatment time, exposure of bone and more root surfaces (Lin and
Gillam, 2012). Studies on the effects of dentine hypersensitivity on OHRQoL are severely
lacking (Boiko et al., 2010, Lin and Gillam, 2012, Bekes and Hirsch, 2013). One study by
Bekes et al., (2009) comparing OHRQoL impairment in patients seeking treatment for
hypersensitive teeth in comparison with the general population found that most patients
seeking treatment for dentine hypersensitivity were often limited in their eating, drinking and
oral hygiene habits. They also showed that patients complaining of sensitive teeth reported
substantial impairment in their OHRQoL (Bekes et al., 2009, Bekes and Hirsch, 2013).
Though current evidence is limited, it does show that dentine hypersensitivity may have a
negative impact on OHRQoL among patients treated for periodontal disease. While the
magnitude of effect may only be mild to moderate (Lin and Gillam, 2012), dentine
hypersensitivity remains a challenge to the clinician due to its high prevalence among such
patients.

9.4. Tooth Loss after Therapy and OHRQoL

Extraction of teeth is sometimes inevitable in patients with periodontal disease. Even

treated patients with reasonably good initial treatment outcomes are at risk of further tooth
loss (Hirschfeld and Wasserman, 1978, Tonetti et al., 2000, Leung et al., 2006).
Tonetti et al., (2000) evaluated 273 patients who had completed a full range of
periodontal and restorative treatment and were placed under supervised supportive
periodontal care. They reported that even with strict maintenance, 41% of patients had lost
one or more teeth during recall. They also found that progressing periodontal disease was the
major factor associated with tooth loss in this population with 57% of extracted teeth being
lost due to severe periodontitis.
This group (Leung et al., 2006) retrospectively assessed the pattern of tooth loss in 97
Chinese subjects who had favourable responses to periodontal treatment done in a teaching
 Periodontal Disease and Oral Health-Related Quality of Life 19

hospital. These patients were discharged upon completing treatment and were responsible for
their own dental care and periodontal maintenance. It was found that the annualized tooth loss
rate for such patients was 0.25 teeth per patient per year, with upper molars and first
premolars, lower second molars and incisors more prone to loss. Furthermore, continuing
smokers, elderly patients, those wearing removable partial dentures, those with lower
education levels or not performing inter-dental cleaning were found to be more susceptible to
further periodontal breakdown and should be targeted for a strict hospital-clinic-based
maintenance regime (Leung et al., 2006).
As discussed earlier, tooth loss affects OHRQoL in patients (Gerritsen et al., 2010, Zhang
et al., 2013). However, it may seem that the replacement of such loss may not be essential in
improving or maintaining one’s OHRQoL (Elias and Sheiham, 1998, Tan et al., 2014).
As mentioned earlier, Käyser’s group concluded that at least four posterior occlusal units
preferably in a symmetrical position were sufficient to maintain adequate oral function in
shortened dental arches (Käyser, 1981, Witter et al., 1990, Kalk et al., 1993). Further studies
by this group went on to show that clinically there were no significant differences in subjects
with three to five occluding units as compared to those with a complete dentition with respect
to chewing ability, swallowing, temporomandibular joint disorders, tooth migration,
periodontal support and oral comfort (Witter et al., 1987, Witter et al., 1990, Witter et al.,
1991, Witter et al., 1994, Sarita et al., 2003, Kanno and Carlsson, 2006, Kreulen et al., 2012,
Gerritsen et al., 2013). Restoration of molar occlusion with removable partial dentures did not
appear to improve patient perceived function and may even worsen it (Käyser et al., 1987,
Witter et al., 1989, Kalk et al., 1993).
Gerritsen and colleagues (2010) reviewed the impact of tooth loss on OHRQoL. They
stated that the number of occluding pairs of teeth is important in predicting patient’s
OHRQoL, and that OHRQoL drops sharply only when the numbers of teeth present falls
below 20. As patients with a shortened dental arch do not seem to have poorer OHRQoL, they
suggested that application of the shortened dental arch approach be considered particularly in
older adults. Such a strategy may help reduce financial burden on society as oral health care
with an intervention led focus is expensive, and demand for this care, though not necessarily
beneficial, may increase as society ages (Gerritsen et al., 2010).
Tan et al., (2014) stated that Australians with four occlusal units and intact anterior teeth
reported equivalent OHRQoL to those who retained more natural teeth. They concluded that
since OHRQoL among people with shortened dental arches was not inferior to that of people
with more natural teeth, treatment goals should be changed from the costly rehabilitation of
complete dental arches towards the preservation of a reduced, natural and functional dentition
(Tan et al., 2014).
Though the maintenance of a shortened dental arch seems like a reasonable aim for the
aging population, position of missing teeth, social and psychological values all have an effect
on the OHRQoL of patients with tooth loss (Elias and Sheiham, 1998, Baba et al., 2008,
Gerritsen et al., 2010, Zhang et al., 2013, Sukumar et al., 2015). Baba and colleagues (2008)
showed that Japanese patients attending six prosthodontic clinics who lost only second molar
contacts exhibited significantly better OHRQoL than those who lost more teeth. They
concluded that patterns of missing occlusal units are likely to be related to OHRQoL
impairment. The presence of first molar contacts may have an important role in determining
OHRQoL in certain groups of patients (Baba et al., 2008). Gerritsen et al., (2010) reported
that subjects with at least one missing anterior tooth were 1.8 times more likely to report an
20 Victor Goh, Dipti Nihalani and W. Keung Leung

impact on their daily life. While Sukumar et al., (2015) found that patients reported greater
OHRQoL improvement in terms of function and aesthetics when both posterior and anterior
missing teeth were replaced.
As OHRQoL is an extremely subjective measure, it seems that the decision to restore or
not to restore missing teeth may be dependent upon the population of patient being treated.
Moreover, the type of restorative treatment carried out may also influence the satisfaction of
each patient in terms of improvements in OHRQoL and will be briefly discussed.

9.5. Oral Rehabilitation and OHRQoL

Prosthodontic rehabilitation is a heterogeneous group of treatments which may be

distinguished by location of treatment (anterior or posterior), type of replacements (fix or
removable) and type of denture-bearing structure (implant, tooth, mucosa) (Sukumar et al.,
2015). Restoration of missing teeth affects both function and appearance. Generally, it may be
regarded that treatment in the anterior spaces will mainly affect aesthetics while restoration of
posterior spaces will mostly affect function. Each of these dimensions, individually or added
together, would have a significant contribution to the one’s overall OHRQoL (John et al.,
2004, Pavel et al., 2012, Montero et al., 2013, Yu et al., 2013, Misumi et al., 2014, Aarabi et
al., 2015, Sukumar et al., 2015). John et al., (2004) assessed the change in OHRQoL of
patient receiving fixed dental prosthesis (FDP), removable partial dental prosthesis (RDP) and
complete dentures (CD). They found significantly improved OHRQoL measures in all
treatment groups post-therapy with slightly better outcome in FDP versus RDP and CD.
Similarly, Montero et al., (2012) evaluated the OHRQoL of patients receiving fixed dental
prosthesis (FDP), metal based removable partial dentures (M-RPDs), acrylic removable
partial dentures (ADs) and complete dentures (CDs) before and one month after treatment.
They reported significant improvements in OHIP-14 domain scores in terms of chewing
ability, smile aesthetics and satisfaction with the state of the mouth for all treatment groups.
FDPs were reported to be more comfortable than ADs, while M-RPDs provided significantly
better improvements in terms of ease of oral hygiene and partner relations, compared to
FDPs. Patients receiving FDPs also reported slightly better eating comfort compared to other
types of dental prosthesis (Montero et al., 2013). Similarly Aarabi and co-workers (2015)
reported that conventional prosthodontic treatment with either fixed or removable dental
prosthesis and complete dentures all yielded significant improvements in terms of OHRQoL
measures with detectable treatment effects lasting up to two years. Of recent years,
osseointegrated dental implants have become a widely acceptable means of replacing
individual tooth, or as abutments for both fix and removable prosthesis. Studies by various
authors on the different uses of dental implants have shown good treatment outcomes in terms
of OHRQoL (Thomason et al., 2007, Pavel et al., 2012, Yu et al., 2013, Misumi et al., 2014,
Oh et al., 2014). Thomason and colleagues (2007) reported that patients were more satisfied
with implant-supported overdentures than conventional complete dentures and there was
strong evidence that OHRQoL can be significantly improved using implant-supported
overdentures. Similarly, Oh et al., (2014) concluded that implant-supported overdentures
improved OHRQoL in patients with edentulous maxilla, mandible, or both, irrespective of the
type of prosthesis provided (fixed or removable) compared to complete dentures. OHRQoL
dimensions of functional limitation, physical pain, psychological discomfort, and
 Periodontal Disease and Oral Health-Related Quality of Life 21

psychological disability in the fixed prosthesis group, and functional limitation in the
removable prosthesis group showed significant improvements compared to the complete
denture group (Oh et al., 2014). In terms of implant treatment in the aesthetic area, Yu et al.,
(2013) showed that patients having their removable dentures replaced with implants in the
anterior spaces perceived better OHRQoL after treatment. Significant improvements in terms
of disability, psychological discomfort, functional limitation, pain, and discomfort were
observed after implant therapy was completed (Yu et al., 2013). From the evidence presented,
patient’s OHRQoL may be improved when missing teeth are being replaced. Though
different prosthodontic options have been shown to exert positive effects on overall
OHRQoL, fixed options or treatment with dental implants seems to have a tendency for better
improvements.

10. Adapted Model Linking Periodontal Disease

and OHRQoL
From the discussion so far, periodontal disease does in fact impact OHRQoL. Treatment
of the disease also affects OHRQoL. Such changes in OHRQoL may very well influence the
disease itself, as well as affect each individual’s systemic health and vice versa. As such, a
proposed model linking periodontal disease, OHRQoL and other associated factors seems
appropriate (Figure 2).

Figure 2. Adapted periodontal disease-OHRQoL model. Modified from D. Locker, 1988, Community Dental
Health 5, 3-18. Copyright 1988, BASCD. Adapted with permission.

From Locker’s adapted model it was explained that the biological outcome of disease can
lead to social disadvantages whereby patient’s life chances may be affected due to the
limitations he/she suffers as a consequence of disease. This series of events, though not
necessarily taking place in a consecutive manner will impact patient’s OHRQoL. From a
periodontal disease point of view, patient’s self perceived OHRQoL may inherently affect the
way he/she feels about the consequences of disease i.e. impairment, functional limitation,
discomfort, disability and handicap, leading to a change in emotions, behaviours, stress level,
coping mechanisms and ultimately a change in the presentation and outcome of disease. The
present group (Ng and Leung, 2006a) showed that high/severe attachment loss was
significantly associated with work strain, financial strain and depression. Those with high
levels of job strain or financial strain with less favourable personality dispositions,
22 Victor Goh, Dipti Nihalani and W. Keung Leung

determined from high scores of anxiety trait or depression trait, experienced more severe
periodontal tissue destruction. Conversely, those with low scores of anxiety trait or
depression trait, had less periodontal attachment loss, even though job strain or financial
strain was high (Ng and Leung, 2006a). As such, a two way relationship between one’s self
perceived OHRQoL and periodontal disease should exists.
As discussed previously, various treatment strategies for patients with periodontal disease
have undoubtedly some effects on the patients’ OHRQoL and are shown in the current
adapted model. Furthermore, patients without treatment may experience a change in
periodontal disease status, leading towards a chronic cycle of events, with each cycle
impacting the patient’s biological, psychological and social function in a different way,
leading to a further change in self-perceived OHRQoL.
In periodontal disease, death is not a likely outcome. However, relationships between
periodontal disease, systemic health and OHRQoL are possible (de Pinho et al., 2012, Cicciu
et al., 2013, Huang et al., 2013, Lindenmeyer et al., 2013). Due to the inflammatory nature of
periodontal disease, treatment strategies or even absence of treatment may improve or worsen
systemic health (Simpson et al., 2010, Chapple and Genco, 2013, Tonetti and Van Dyke,
2013, Jeffcoat et al., 2014), and is represented in the two-way arrow between therapy and
systemic health. For example, treatment of periodontal disease is shown to improve
glycaemic control in diabetic patients, and its effect is similar to adding a second diabetic
drug (Chapple and Genco, 2013).
Rationally speaking, such improvements would affect the patient’s general QoL and
OHRQoL, though further research is warranted. Jeffcoat et al., (2014) found that patients with
periodontitis with either type-2 diabetes; coronary artery disease; cerebral vascular disease or
pregnancy, incurred lower medical costs and hospitalizations after they received periodontal
therapy compared to untreated controls. In each case, the difference was statistically
significant and involved considerable finances (11%–74% lower in the treated group)
(Jeffcoat et al., 2014). Though such interventional efficacy of periodontal therapy on systemic
health is far from solid, these findings suggest a plausible link between periodontal disease;
its treatment and systemic health. These will all possibly affect one’s OHRQoL as pointed out
in the periodontal disease-OHRQoL model.
From the adapted model, though not marked by interconnecting arrows, both direct and
indirect relationships can exist between individual outcomes of periodontal disease and
OHRQoL. Such relationships can be seen in previously discussed evidence where tooth loss,
severe marginal bone loss and pockets ≥5 mm were found to be associated with negative
impacts on OHRQoL (Needleman et al., 2004, Cunha-Cruz et al., 2007, Durham et al., 2013,
Jansson et al., 2014). Though not specifically shown in the model, these findings suggest a
link between impairment (anatomical loss or structural abnormality) caused by periodontal
disease on one’s OHRQoL.
Another possible consequence of periodontal destruction (impairment) is reduction in
periodontal support around teeth, increased mobility and pain (functional limitation and
discomfort), and subsequently difficulty in eating (disability) leading towards an inability to
enjoy societal interactions (handicap). Such sequences of events draw attention to the
influence of periodontal disease on daily activities and its negative impact on overall
OHRQoL (Ng and Leung, 2006b). Similarly when tooth loss, especially in the anterior region
is concerned, individuals affected may experience social handicap in the form of diminished
 Periodontal Disease and Oral Health-Related Quality of Life 23

life chances such as employment or romance. Such a relationship between tooth loss and
sociology is by all means possible (Rousseau et al., 2014).

Conclusion
Periodontal disease negatively affects one’s OHRQoL and the extent of impact is
correlated with the severity of periodontal disease (Needleman et al., 2004, Ng and Leung,
2006a, Ng and Leung, 2006b, Aslund et al., 2008, de Pinho et al., 2012, Shanbhag et al.,
2012, Brauchle et al., 2013, Durham et al., 2013, Jansson et al., 2014). The treatment of
periodontal disease itself has varying consequences on patients physiological, psychological
and social well-being, leading to a change in overall OHRQoL (Needleman et al., 2004,
Tonetti et al., 2004, Saito et al., 2010&2011, Lin and Gillam, 2012, Shanbhag et al., 2012,
Wong et al., 2012, Jeffcoat et al., 2014). Furthermore, patients are able to better relate disease
and treatment with self-reported outcomes measures such as OHRQoL than surrogate markers
such as probing pocket depth and clinical attachment loss. Knowledge of OHRQoL can
potentially motivate patients to improve adherence to oral health practices and increase
compliance with maintenance therapy (Shanbhag et al., 2012, Wong et al., 2012). These
factors are crucial for the long-term success of periodontal treatment.
Though the multidirectional relationships between the outcomes of periodontal disease,
its treatment, systemic health and the disease itself may be oversimplified in the periodontal
disease-OHRQoL model suggested, such a model may prove useful in guiding future research
on this subject. Links between each proposed parameter in the model may be further clarified
through well-conducted trials. Indeed, to truly understand and conceptualized the effects of
periodontal disease on OHRQoL, further well-designed longitudinal studies are required.
Future research should evaluate long term OHRQoL changes in patients receiving different
forms of periodontal and/or restorative therapy. Moreover, the impacts of such treatments on
OHRQoL in patients with different forms and severities of periodontal disease and in those
with associated systemic conditions also deserve further exploration (Shanbhag et al., 2012).

Acknowledgments
The work described in this chapter was partially supported by a grant from the Research
Grants Council of the Hong Kong Special Administrative Region, China (HKU 772110M).

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 Periodontal Disease and Oral Health-Related Quality of Life 27

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In: Oral Health ISBN: 978-1-63482-832-1
Editor: Julia Renee Barnes © 2015 Nova Science Publishers, Inc.

Chapter II

Relationship between Periodontal

Health and Its Impact on the
Quality Life

A. L. Dumitrescu*
Bucharest, Romania

Abstract
Periodontal diseases are one of the common oral diseases involving structural and
functional changes in the oral cavity and in their most severe forms are associated with
formation of periodontal pockets, gingival abscesses, gingival recessions, tooth mobility,
and finally teeth loss. Periodontal diseases are one of the main reasons for tooth loss
among the population and this is furthermore related not only to alteration in speaking
and chewing functions, but also to a high impact on the patients psychological and
emotional well-being as related to daily social interactions, organ loss related trauma,
self-esteem, shame, depression, anxiety. As a consequence, a better understanding of the
consequences of periodontal disease is important in understanding patient perceptions of
the impact of their gingival/periodontal health on their everyday lives, in planning
periodontal therapy which addresses patient needs and in evaluating the results of the
periodontal treatment from the patient′s perspective. In the last decades, the relationship
between individuals' periodontal health/therapy and quality of life has been extensively
examined and this chapter reviews the current knowledge in this research field.

I. Introduction
Periodontal diseases are one of the common oral diseases involving structural and
functional changes in the oral cavity and in their most severe forms are associated with

*
Corresponding author: Email: E-mail: [email protected].
34 A. L. Dumitrescu

formation of periodontal pockets, gingival abscesses, gingival recessions, tooth mobility, and
finally teeth loss (Figure 1). Periodontal diseases are one of the main reasons for tooth loss
among the population and this is furthermore related not only to alteration in speaking and
chewing functions, but also to a high impact on the patients psychological and emotional
well-being as related to daily social interactions, organ loss related trauma, self-esteem,
shame, depression, anxiety. As a consequence, a better understanding of the consequences of
periodontal disease is important in understanding patient perceptions of the impact of their
gingival/periodontal health on their everyday lives, in planning periodontal therapy which
addresses patient needs and in evaluating the results of the periodontal treatment from the
patient′s perspective.

II. Oral Health-Related Quality of Life

II.1. Quality of Life - overview

Quality of life (QoL) is a concept difficult to define accurately, as the vast majority of
definitions are centered on the notion of health as defined by the World Health Organization
as “a state of complete, physical, mental and social well-being, and not merely the absence of
disease or infirmity” (WHO, 1947; World Health Organization, 2005).
Quality of life (QoL) evaluations are providing clinicians with information regarding the
general health of patients who might otherwise go unrecognized, thereby improving patient
satisfaction and health outcomes. However, QoL measurements have not been routinely
implemented in clinical practice and research, one concern expressed by clinicians being the
questions about what QoL scales actually assess and how scores should be interpreted,
especially as various diseases states (e.g., schizophrenia, Alzheimer's disease) and events
(e.g., a stroke) may alter a person's perception of their physical and mental status, such as
alterations in his metacognitive capabilities (metacognition defined as the ability to attribute
mental states in terms of beliefs and goals to one's self and others) (Blanc et al., 2014). Self-
reported QoL might be biased also by other psychological factors, such as adaptation to the
illness. An important indicator of this adaptation process is an effect called the response shift,
defined as changes in the meaning of one's self-evaluation of QoL resulting from changes in
internal standards, values, or conceptualization (Sprangers and Schwartz, 1994a). Sprangers
and Schwartz (1994a) proposed a theoretical model to clarify and predict changes in QoL as a
result of the interaction of five major components: 1) a catalyst, 2) antecedents (e.g.
sociodemographics (e.g. gender, education) and personality (e.g. optimism, self-esteem, sense
of control, mastery), expectations or spiritual identity) , 3) mechanisms (e.g. using coping
strategies, initiating social comparisons, seeking social support, reordering goals , reframing
expectations and engaging in spiritual practice), 4) response shift and 5) perceived QoL
(Sprangers and Schwartz, 1994a). The response shift refers to a change in the meaning of
one's self-evaluation of a target construct as a result of: 1) recalibration defined as a change in
the respondent's internal standards of scale measurement, 2) reprioritization defined as a
change in the respondent's component domains constituting the target construct, QoL and 3)
reconceptualization defined as a redefinition of QoL, the target construct (Figure 2)
(Sprangers and Schwartz, 1994b). True changes of treatment effects may be over- or
 Relationship between Periodontal Health and Its Impact on the Quality Life 35

underestimated when an response shift is present, leading to biased estimates that are
challenging mainly in interventional studies, in which patients’ adaptation to treatment
toxicities or disease progression over time side may change estimates of the true treatment
effects (Sprangers and Schwartz, 1994b). Several protocols to assess response shift where
described in aim to assess one or more of the three aspects of response shift (Sprangers and
Schwartz, 1994b). Recently Vanier et al., (2015) suggested that the impact of the response
shift effect on HRQL scores could be avoided (or lessened) if questionnaires were designed
with a rule of "the least semantic and psychometric complexity" in mind.
In dental field, only a few studies have revealed the importance of taking into
consideration the response shifts when evaluating the positive impact of dental treatment
(Ring et al., 2005; Kimura et al., 2012; Reissmann et al., 2012) (Table 1).

Table 1. Impact of response shift on the assessment of dental treatment

Authors, QoL instrument

Study group Conclusion
year used
Ring et al., 117 patients (mean age 64.8; 32% male) Individualised The positive impact of denture
2005 evaluated at baseline (pre-test) and 3 months quality of life treatment for edentulous patients
after receiving high quality conventional (IQoL) measure, on IQoL was seen only when
dentures (post-test). the SEIQoL response shifts were taken into
consideration.
Kimura et 73 consecutive patients with no more than Oral Health- The significant predictor
al., 2012 eight missing teeth who received implant- Related Quality variables for the response shift
supported, fixed or removable partial dentures of Life were young age, fewer numbers
were asked to complete the full-version (OHRQoL) of replaced teeth and lower pre-
OHRQoL questionnaire before (pre-test) and test scores.
after treatment (post-test) (1 year later).
Reissmann A consecutive sample of 126 patients seeking Oral Health The response shift phenomenon
et al., prosthodontic care. Patients were asked to rate Impact Profile and its magnitude have
2012 their OHRQoL before treatment started and 1 (OHIP) important implications for dental
month after treatment was finished. practice, where patients and
dentists often assess perceived
treatment effects retrospectively

Figure 1. Radiograph showing advanced bone loss in moderate to severe periodontal disease
36 A. L. Dumitrescu

Figure 2. Methods for assessing response shift (Sprangers and Schwartz, 1994b).

II.2. Health-Related Quality of Life (HRQoL) - Overview

The term "Health-related Quality of Life" (HRQoL) is a concept frequently used in aim
to highlight on the relationship between health and quality of life. According to the Ferrans
Conceptual Model HRQoL includes four domains areas related to physical, mental and
emotional, and social functioning (Ferrans, 2005). HRQoL goes beyond the direct measures
of health and focuses on the quality-of-life consequences of health status, playing a crucial
role in clinical decision-making care, through its contribution to targeting of problems,
identification of the balance between positive and negative effects of therapy, identification of
the need for supportive care and improvement of physician-patient communication (Halyard
and Ferrans, 2008). Moreover, several regulatory agencies (e.g. International Society for
Quality of Life Research, Global Allergy and Asthma European Network (GA2LEN),
National Cancer Institute, American Society of Clinical oncology, Canadian Cardiovascular
Society) recommend assessing quality of life (QoL) in daily clinical practice in patients with
chronic illnesses (Aaronson et al., 2011; Baiardini et al., 2010; Halyard and Ferrans, 2008;
Bower et al., 2014; Boodhwani et al., 2014).
An important aspect is that, from the perspective of patients, QoL and health status are
distinct constructs and the two terms should not be used interchangeably. When rating QoL,
patients give greater emphasis to mental health than to physical functioning. However, this
model is inverted for appraisals of health status, for which mental health is less important than
physical functioning. Social functioning did not have a major impact on either construct.
These facts have a relevant research consequence as many important health status scales,
 Relationship between Periodontal Health and Its Impact on the Quality Life 37

including utility-based questionnaires and health perception indexes, may be inappropriate for
measuring QoL, while evaluations of the effectiveness of medical treatment may differ
depending on whether QoL or health status is the study outcome (Smith et al., 1999).
HRQoL include several core concepts:

 subjectively: includes the need of a subjective input from the affected person
regarding both positive and negative responses to illness and treatment (Cella and
Nowinski, 2002);
 multidimensionality: a full appreciation of the impact of illness and treatment
requires assessment of a broad spectrum of functioning and well-being, such as
symptoms, physical functioning, mood, cognition, family functioning, and social
activity (Cella and Nowinski, 2002);
 dynamism: can change over time as individual attitudes are not constant, vary with
time and experience, and are modified by psychological factors such as coping,
expectancy, optimism and adaptation (Allison et al., 1997).

There are many HRQoL models applied across different health and illness conditions,
across the lifespan,and among individuals, their families, and communities as recently
reviewed (Bakas et al., 2012; Costa and King, 2013). Three HRQoL disease-specific models
models were selected by the systematic review performed by Bakas et al., (2012):

 Wilson and Cleary’s (1995) model of HRQoL combines two paradigms, biomedical
and social science and includes five major well-defined domains: biological,
symptoms, function, general health perception, and overall HRQoL that are inter-
related with reciprocal relationships;
 Ferrans et al., (2005) model retained the five major domains of the Wilson and
Cleary’s (1995) HRQoL model, but was also revised in three substantive ways: a)
indicating that biological function is influenced by characteristics of both individuals
and environments; b) deleting nonmedical factors; and c) deleting the labels on the
arrows that tend to restrict characterization of the relationships. In addition, they
provided examples of of instruments to measure the major components of the model
(Ferrans and Powers, 1995). The revised Ferrans et al., (2005) model can be applied
to any health care discipline;
 The World Health Organization International Classification of Functioning,
Disability, and Health (WHO ICF) (World Health Organization, 1980; World Health
Organization, 2001; World Health Organization, 2007) is a model that covers various
age groups (from children and adolescents to adults) and provides a unified and
standard description of health and health states that can be used across disciplines
and cultures. The WHO ICF model includes components within two main parts: 1)
main functioning and disability (body functioning and structures, activities, and
participation), and 2) Contextual factors (environmental and personal). However, the
WHO ICF is not specific to the area of HRQoL but rather represents a mapping and
classification framework.

HRQoL assessments are divided into two general types (Patrick and Deyo, 1989; Cella
and Nowinski, 2002):
38 A. L. Dumitrescu

 Disease-specific assessments are targeted for patients with a specific condition or

treatment under study and, as a result, tend to be more responsive to clinically
important changes than generic instruments. The disadvantages of the targeted-
instruments are: 1) they may lack items pertaining to dimensions of the disease that
affects QoL, and thus are not accurately reflect patient’s QoL; 2) are not easy to be
used for the comparisons of different populations or different interventions (Patrick
and Deyo, 1989; Cella and Nowinski, 2002). Examples of specific instruments are:
Parkinson's Disease Questionnaire (Marinus et al., 2002), McGill's quality of life
questionnaire (used for persons with life-threatening illnesses)( De Maeyer et al.,
2010), Lancashire QoL profile (used for persons with mental health problems)( van
Nieuwenhuizen et al., 2001) or Inflammatory Bowel Disease Questionnaire (Irvine,
1993).
 Generic assessments have the advantage to allow for broad evaluation of overall
health across many different domains, to offer the possibility to compare results
across different groups of patients, population cohorts and interventions, and some
can provide normative or benchmark data from which to interpret results. The
disadvantages of the generic assessments are the involuntarily bias results toward or
against subsets of the general population (Patrick and Deyo, 1989; Cella and
Nowinski, 2002).

Generic instruments can be divided into single instruments and health profiles:

 Single global health measures (e.g. “How do you rate your health status”) have been
shown to be reliable and valid and have been recommended for use in health
monitoring by the US Centres for Disease Control, the WHO, the European
Commission (Salomon et al., 2009; Hennessy et al., 1994) and in the American
public health plan Healthy People 2010 (Andresen et al., 2003).
 Health profiles are instruments “that attempt to measure all important aspects of
HRQoL” (Guyatt et al., 1993). Several papers described (Cella and Nowinski, 2002;
Patrick and Deyo, 1989; Ferrans, 2005; Halyard and Ferrans, 2008; Allison et al.,
1997; Aaronson et al., 1993; Cella et al., 1997; Wu et al., 2001; Cella et al., 2007;
Haywood et al., 2005; Cagney et al., 2000) or summarized (Haywood et al., 2006;
Haywood et al., 2005a; Haywood et al., 2005b) the most common HRQoL
instruments: Dartmouth COOP Charts for Primary Care Practice, WONCA/COOP,
Functional Status Questionnaire/FSQ, Goteborg Quality of Life/GQL, Health Status
Questionnaire-12/HSQ-12, Nottingham Health Profile/NHP, Quality of Life
Index/QLI, Quality of Well-being - Self-administered/QWB-SA, Short Form 12-item
Health Survey/SF-12, Short Form 20-item Health Survey/SF-20, Short Form 36-item
Health Survey/SF-36, Sickness Impact Profile/SIP, Spitzer Quality of Life, The
sickness impact profile (SIP), World Health Organization Quality of Life (WHOQoL
Bref), EuroQoL-5D (EQ-5D) and SF-36.

When choosing a HRQoL assessment tool it is important to comprehend the background

and patient population in which the instrument was designed, because this affects the
reliability and validity of the expected QoL (Patrick and Deyo, 1989). Because no single
instrument is ideal in all situations, researchers and clinicians prefer to use a mixture of
 Relationship between Periodontal Health and Its Impact on the Quality Life 39

generic and disease-specific scales (e.g. a core generic instrument to assess the common
HRQoL dimensions associated with several targeted subscales specific to the disease,
condition, or intervention of interest) in aim to benefit from on the strengths of both, while
minimizing the limitations of each. For longitudinal use, the serial assessment of HRQoL may
be a helpful method to scrutinize disease course and response to therapy (Cella and Nowinski,
2002).

II.3. Oral Health-Related Quality of Life - Overview

As Locker mentioned since 1997: “from the point of view of contemporary definitions of
health, epidemiological measures in terms of DMFT [decayed missing filled teeth] and
CPITN [community periodontal index of treatment needs] have serious limitations in that
they tell us nothing about the functioning of the oral cavity or the person as a whole and
nothing about subjectively perceived symptoms such as pain and discomfort.”
Most oral diseases (e.g. dental caries, periodontal diseases) may cause pain and suffering,
and have physical, economical, social, and psychological consequences that can have a
critically effect on a range of aspects of life, such as appearance, oral function, and
interpersonal relationships, which ultimately prejudice the quality of life in both adults and
children (Gilbert et al., 1998; Gomes and Abegg, 2007; Masood et al., 2014). For example,
parents or guardians of 4-yrs children with severe caries revealed that oral health affects their
children's life: the children complained of toothache, had problems eating certain foods, were
absent from school, were ashamed to smile, and stopped playing with other children because
of their teeth (Feitosa et al., 2005).
Oral Health-related Quality of Life (OHRQoL) is an emerging subject of importance
during recent years and has been defined as a subset of Health-related Quality of Life
(McGrath and Bedi, 2002; John et al., 2003). OHRQoL is multidimensional and is closely
related to socio-demographic characteristics (e.g. age, gender, ethnicity), economic (e.g.
household income) and cultural aspects (McGrath and Bedi, 2002; Sisson, 2007). Moreover,
individuals with lower socioeconomic status are exposed to material deprivation which could
influence their engaging in riskier behaviors, resulting in more severe impacts on their
OHRQoL (Peres et al., 2007). Similar with HRQoL, OHRQoL is also dynamic over time and
practice (Allison et al., 1997). For example, untreated /complicated caries may lead to eating
problems, but when oral cancer has been diagnosed, the same person may have more
problems when eating, but they become less important comparing with the main diagnosis
(Allison et al., 1997). Several models of oral health and OHRQoL have been reviewed by
Brondani and MacEntee, (2014) and as most models are based on negative biomedical view
of oral disorders and do not willingly accommodate the biopsychosocial theories of oral
health, alternative emerged models showed a change in the understanding of oral health
beyond illness and included dynamically positive behaviours and adaptive strategies
(Williams et al., 1998; MacEntee, 2006).
However, there are large differences in the total number of studies on HRQoL and
OHRQoL, as the number of entries on PubMed with HRQoL and OHRQoL was on 6th
March 2015 44 823 publications (6 699 reviews), respectively 2 719 publications (399
reviews). According to the ICI web of knowledge, at the same time, the number of papers
related to the HRQoL was 44 284 while for OHRQoL was 2 353.
40 A. L. Dumitrescu

Measurements of oral health and OHRQoL have been designed in a similar way as
HRQoL scales (Inglehart, 2006; John, 2007):

A) Generic assessments were divided into single question and multi-item instruments.
 Single global health measures (e.g. “How do you rate your oral health
status?”): Pattussi et al., (2007) described this question as a simple and easy way
to collect dental health information, while Locker and Jokovic (2007) mentioned
“that these single item measures provide a summary of how people perceive their
health, both objective and subjective, and that they may be as useful as more
complex multi-item scales and indexes in health status assessments.” However,
“despite its use in medical studies, a single question of self rated oral health has
seldom been used as the primary outcome in dental studies” even it is “an
economical way of summarizing the state of a person’s oral health” (Dolan et al.,
1998). This short one-item instrument is also usually used as gold standard in
validity studies of multi-item scales (Agou et al., 2008;Allen et al., 2009; Baker,
2007; Jokovic et al., 2004; Jokovic et al., 2004; Jones et al., 2004; Li et al., 2008;
Locker et al., 2004; Locker 2008; Pahel et al., 2007; Bernabe et al., 2008; Castro
et al., 2008; Ostberg et al., 2001). Moreover, the clinical validity of Locker's
global self-reported oral health item as a global self-reported oral health measure
in young middle-aged adults was recently demonstrated by Thomson et al.,
(2012). In a similar way, the Oral Satisfaction Scale (OSS) was designed as a
visual analogue scale (0 to 10) that allows participants to evaluate their perceived
oral satisfaction, representing a measure of psychological well-being in relation
with mouth (Montero et al., 2008).
 The multi-item inventories are also called socio-dental indicators (SDIs) and
were used mainly in cross-sectional studies for psychometric evaluation and
investigation of prevalence of oral impacts in different populations (Slade et al.,
1996; Baker et al., 2006; Atchison and Dolan, 1990; Åstrøm and Okullo, 2003;
Gilchrist et al., 2014). These SDIs emphasize a range of behavioural and
functional disturbances triggerend from the dental area that affect the lives of
people from all age groups (Slade 1997). A high number of SDIs have been
developed in the last 30 years and were summarized in different studies (Slade,
1997; Jones et al., 2004; Bourgeois and Lodra 2004; Hebling and Pereira 2007;
Brondani and MacEntee, 2007; Locker and Allen, 2007; Riordain and McCreary,
2010). Among these multi-item inventories can be mentioned: the Social Impacts
of Dental Disease (SIDD), the Rand Dental questionnaire, the Geriatric Oral
Health Assessment Index (GOHAI), the Oral Health-related Quality of Life
Measure (OHQoL), the Dental Impact Profile (DIP), the Oral Health Impact
Profile (OHIP), as well many others presented in Table 2. Several of these
questionnaires were designed to assess the OHRQoL specifically in children:
Child Perception Questionnaire (CPQ 11-14), the Michigan OHRQoL scale, the
Child Oral Health Impact Profile (Child-OHIP), the Early Childhood Oral Health
Impact Scale (ECOHIS), Child Oral Impact on Daily Performance (Child-
OIDP), Scale of Oral Health Outcomes for 5-year-old children (SOHO-5), Child
Oral Health-Related Quality of Life for 8-10-year-olds (COHRQoL [8-10]) and
the Oral Health related Early Childhood Quality of Life (OH- ECQOL) scale.
 Table 2. Examples of currently available OHQoL measures

No. of
Instrument Abbreviation Original reference
items
Child Oral Health Impact Profile COHIP 34 Broder, 2007
Child Oral Health Impact Profile-Short Form 19 COHIP-SF 19 19 Broder et al., 2012
Child Oral Health Quality of Life questionnaire consists of COHQoL Jokovic et al., 2002a, Jokovic et al.,
1) Child Perception Questionnaire, 1)CPQ11–14 36 2002b, Jokovic et al., 2003,
2) Parental Perception Questionnaire, and 2)PPQ 31 Jokovic et al., 2004
3) Family Impact Scale 3)FIS 14
Child Oral Health-Related Quality of Life for 8-10-year-olds COHRQoL (8-10) 25 Humphris et al., 2005
Child-Oral Impacts on Daily Performances CHILD-OIDP 8 Gherunpong et al., 2004
DENTAL DENTAL 15 Bush et al., 1996
Dental Impact on Daily Living DIDL 36 Leao and Sheiham, 1996
Dental Impact Profile DIP 25 Strauss and Hunt, 1993
Early childhood oral health impact scale ECOHIS 13 Pahel et al., 2007
Family Impact Scale FIS 14 Locker and Allen, 2002
Geriatric (General) Oral Health Assessment Index GOHAI 12 Atchison and Dolan, 1990
OHQoL-UK(W) 16 McGrath and Bedi, 2001
OHRQOL for Dental Hygiene 56 Gadbdury-Amyot et al., 1999
OHRQoL measure OHRQoL 3 Kressin et al., 1996
Oral Health Impact Profile OHIP-49 49 Slade and Spencer, 1994
Oral Health Impact Profile OHIP-14 14 Slade, 1997
Oral Health Impact Profile (OHIP-EDENT) OHIP-20 20 Allen and Locker, 2002
Oral Health Index OHS 3 Burke et al., 2003
Oral Health Quality of life – UK (United Kingdom) OHRQoL-UK 16 McGrath and Bedi, 2001
Oral Health Quality of Life Inventory OHQol 15 Cornell et al., 1997
Oral Health related Early Childhood Quality of Life OH-ECQOL 16 Mathur et al., 2014
Oral Health-related Quality of Life Measure from the Rand Health OHQoL 3 Dolan et al., 1991
Insurance Study (Rand Dental Health Index)
 Table 2. (Continued)

No. of
Instrument Abbreviation Original reference
items
Oral Impact on Daily Performances OIDP 8 Adulyanon and Sheiham, 1997
Oral Impacts on Daily Performances index OIDP 8 Montero et al., 2008
Orthognathic Quality of Life Questionnaire OQoLQ 22 Cunningham et al., 2000
Psychosocial impact score 42 Locker and Miller, 1994
Scale of Oral Health Outcomes for 5-year-old children SOHO-5 7 Tsakos et al., 2012
Sickness Impact Profile SIP 73 Bergner et al., 1981
Social Impact of Dental Disease SIDD 14 Cushing et al., 1986
Subjective Oral Health Status Indicators (index of chewing capacity, SOHSI 28 Locker and Miller, 1994
index of the ability to speak clearly, index of oral and facial pain
symptoms, index of other oral symptoms.)
Surgical Orthodontic Outcome Questionnaire SOOQ 33 Locker et al., 2007
The DELTA 6 Jones et al., 2003

Table 3. Summary of studies evaluating the impact of gingival health status on OHQoL. Review of studies during the period 2000–2015

Study group
Author/year Country Gingival evaluation OHQoL instrument used Study result
/age
Tomazoni et Brazil 1,134 Community Child Perceptions The presence of extensive levels of
al., 2014 schoolchildren / Periodontal Index Questionnaire for 11- to 14- gingivitis might be negatively
12-year- old Year-Old Children (CPQ11- associated with how children
14) perceive their oral health and their
daily life.
Amato et al., Brazil 50 students / 11- Community Child Oral Impacts on Daily A significant improvement in the
2014 12 year old Periodontal Index and Performances (Child-OIDP) clinical status and oral hygiene was
two questions about associated with a significant decline
gingival bleeding in the Child-OIDP scores.
 Study group
Author/year Country Gingival evaluation OHQoL instrument used Study result
/age
Nanayakkara et Sri Lanka 784 children Bleeding Index Early Childhood Oral Children with more gingival
al., 2013 aged between 48- Health Impact Scale bleeding (bleeding surfaces)
72 months (ECOHIS) presented a poorer OHQoL
Cornejo et al., Argentina Eighty pregnant Gingival Index (Löe OHIP-49 Oral health status and oral health-
2013 women/ age 18- and Silness, 1963); related quality of life showed no
39 yrs depth on probing, significant association.
clinical attachment
level, bleeding on
probing
Krisdapong al., Thailand 1,100 children Community Child-Oral Impacts on Daily Children with gingivitis or calculus
2012b 12-year-old Periodontal Index Performances (Child-OIDP) in three or more sextants were twice
(CPI) as likely and children with calculus
and gingivitis in three or more
sextants were 3.5 times more likely
to report condition-specific impacts.
Zanatta et al., Brazil 330 participants Bleeding on probing Oral Health Impact Profile Anterior gingival enlargement
2012 under fixed (BOP), PD, CAL, (OHIP-14) seems to influence the OHRQoL in
orthodontic gingival enlargement subjects receiving orthodontic
treatment treatment.
Krisdapong et Thailand 871 adolescents Community Oral Impacts on Daily Adolescents with extensive
al., 2012c 15-year-old Periodontal Index Performances (OIDP) gingivitis in 3 or more mouth
(CPI) sextants were twice as likely to
experience moderate/higher
condition-specific impacts
Krisdapong et Thailand 1,063 twelve- Community Child-Oral Impacts on Daily Gingivitis was generally associated
al., 2012d year olds and Periodontal Index Performances (Child-OIDP) with any level of condition-
811 fifteen-year (CPI) and Oral Impacts on Daily specific-impacts attributed to
olds Performances (OIDP) calculus and/or gingivitis.
Condition-specific impacts were
related more to gingivitis than to
calculus.
 Table 3. (Continued)

Study group
Author/year Country Gingival evaluation OHQoL instrument used Study result
/age
Barbosa et al., Brazil 210 children Community Child Perceptions Children without gingivitis had
2009 aged 8–14 years Periodontal Index Questionnaires (CPQ8-10 CPQ8–10 higher scores for the
(CPI) and CPQ11-14) overall and emotional well-being
domains.
Acharya et al., India 259 pregnant Gingival index, Oral Health Impact Profile Gingival index scores, community
2009 women (mean Community (OHIP-14) periodontal index of treatment
age 26 +/- 5.5 Periodontal Index of needs scores and previous
yrs) Treatment Needs pregnancies were associated with
(CPITN) poorer OHRQoL scores.
Acharya, 2008 India 414 general Gingival index Oral Health Impact Profile The results of this study showed
dental patients (OHIP-14), General health that caries status, psychological
questionnaire (GHQ)-12 distress and dental anxiety had an
important effect on the OHRQoL
López and Chile 9203 high school Clinical attachment Oral Health Impact Profile Both attachment loss [OR = 2.0]
Baelum, 2007 students level, The presence of (OHIP-14) and necrotizing ulcerative gingivitis
necrotizing ulcerative [OR = 1.6] were significantly
gingivitis associated with higher impact on
the Oral Health Related Quality of
Life of adolescents.
Robinson et al., Ugand 174 children 12 Community Child Oral Health Related The number of sites with gingivitis
2005 year old Periodontal Index Quality of Life (CPQ11-14) or the presence of calculus or
(CPI) trauma were not associated with
summary measures of CPQ11-14
whereas having any dental caries or
treatment experience was associated
with higher total scores and more
impacts.
 Study group
Author/year Country Gingival evaluation OHQoL instrument used Study result
/age
Marshman et UK 89 children Community Child Perceptions Number of impacts correlated with
al., 2005 between 11 and Periodontal Index Questionnaire (CPQ11-14) the total number of missing teeth
14 years (CPI) and missing teeth due to caries. No
other relationships between clinical
and CPQ11-14 data were apparent
Needleman et UK 205 patients Check list of questions UK oral health-related OHQoL-UK scores were associated
al., 2004 attending a about their periodontal quality-of-life measure with patient's self-reported
private health over the past (OHQoL-UK) periodontal health in the past year:
periodontal clinic year experiences of "swollen gums,"
"sore gums," "receding gums,"
"loose teeth,” "drifting teeth," "bad
breath" and "toothache"
46 A. L. Dumitrescu

B) Specific impacts measures, designed for evaluation of pain, taste, impaired speech
or appearance are also commonly used in cited in oral health surveys (Reisine et al.,
1989; Gilbert et al., 1993; Krisdapong et al., 2012). Moreover, it was revealed that
condition-specific instruments have better discriminative ability than generic
OHRQoL scales (Bernabe et al., 2008; Bernabe et al., 2009). Several specific
OHQoL impacts scales have been designed:
 FACE-Q Oncology is a new patient-reported outcome instrument for HRQoL
evaluation following head and neck cancer reconstruction (Albornoz et al.,
2013);
 Quality of Life with Implant-Prostheses' (QoLIP-10) questionnaire was
developed for assessing the OHRQoL of implant-prosthesis wearers (Preciado et
al., 2013);
 Pain-related limitations of daily function in the TMD questionnaire (LDF-
TMDQ, 13 items) scale has been designed to assess oral health-related quality of
life in patients with temporomandibular disorders (TMDs) (Sugisaki et al.,
2005);
 The Liverpool Oral Rehabilitation Questionnaire (LORQ) was designed to
record patient-derived outcomes in head and neck cancer. The questionnaire
consists of 25 items about oral function and denture satisfaction (Pace-Balzan et
al., 2004);
 The Scale Assessing the Impact of Periodontal Diseases on Patients’ Quality of
Life (Musurlieva et al., 2012) contains 9 items grouped in three subscales that
assess a) the patient’s choice of food/nutrition, chewing, swallowing, b) social
relations, friends and family, professional and c) overall health. The scale
presented a Cronbach’s α coefficient = 0.883 and an average inter-item
correlation coefficient 0.507.

III. Impact of Gingival Inflammation/Gingivitis

on Oral Health-Related Quality of Life
Gingival aspect is one of the components of the smile’s harmony. The smile not only is
used to express different feelings (e.g. joy, success, kindness, sensuality, affection), but, more
important, represents one of the most important physical characteristics involved in the self-
esteem, self-confidence and self-image. People dissatisfied with their own smile are most
commonly affected with an unpleasant appearance, are less self-confident, to have a lower
self-esteem and to like themselves less than those who are satisfied (Albashaireh et al., 2009;
Van der Geld et al., 2007; Pinho et al., 2007).
Evidence shows that gingival bleeding and enlargement is associated not only with
aesthetic problems, phonetic alterations and masticatory problems, but also with alterations in
OHQoL (Table 3.).
Self-reported gingival bleeding, one of the main clinical signs of gingivitis, was
associated with higher self-focused attention (Dumitrescu et al., 2011a), body-related shame
(Dumitrescu et al., 2011b), higher values of dental anxiety and lower levels of self-esteem
(Dumitrescu et al., 2010), lower values of self-liking, self-competence and body investment
 Relationship between Periodontal Health and Its Impact … 47

(Dumitrescu et al., 2009a), lower levels of self-confidence and of self-control (Dumitrescu et

al., 2009b), higher values of social anxiety (Dumitrescu et al., 2008a), lower body
appreciation (Dumitrescu et al., 2008b), reduced social desirability (Dumitrescu et al., 2007a),
and higher perceived stress (Dumitrescu et al., 2007b).
Moreover, it was showed that self-reported gingival bleeding was associated among
undergraduate students with statistical significant higher values of self-blame and rumination,
while participants who evaluated their self-reported gingival condition as poor/very poor
scored higher values on rumination, catastrophising and lower on positive reappraisal, when
compared with students with excellent gingival condition (Dumitrescu et al., 20011c).

IV. Impact of Periodontal Health on Oral Health-

Related Quality of Life
Periodontal diseases are one of the common oral diseases involving structural and
functional changes in the oral cavity and in their most severe forms are associated with
formation of periodontal pockets, gingival abscesses, gingival recessions, tooth mobility, and
finally teeth loss. Periodontal diseases are one of the main reasons for tooth loss among the
population and this is furthermore related not only to alteration in speaking and chewing
functions, but also to a high impact on the patients psychological and emotional well-being as
related to daily social interactions, organ loss related trauma, self-esteem, shame, depression,
anxiety. As a consequence, a better understanding of the consequences of periodontal disease
is important in understanding patient perceptions of the impact of their gingival/periodontal
health on their everyday lives, in planning periodontal therapy which addresses patient needs
and in evaluating the results of the periodontal treatment from the patient′s perspective.
In dental studies, periodontal disease is usually evaluated by therapist-centered surrogate
endpoints such as bleeding on probing (BOP), probing depth PD and clinical attachment level
(CAL) (Slade et al., 1998), but rarely by patient-centered measures. However, a recent
number of studies have investigated and have demonstrated that periodontal disease does
have a negative impact on patients’ oral health quality of life due to mastication, nutritional
problems, physical pain and psychological disability (Gil-Montoya et al., 2015; DeBaz et al.,
2015; Gil-Montoya et al., 2015; Jansson et al., 2014; Brauchle et al., 2013; Sundaram et al.,
2013; Eltas A, Uslu 2013; Durham et al., 2013; Cornejo et al., 2013; Nagarajan et al., 2012;
Al Habashneh et al., 2012; Musurlieva et al., 2012; Zaitsu et al., 2011; Li et al., 2011; Tsakos
et al., 2010; Araújo et al., 2010; O'Dowd et al., 2010; Jowett et al., 2009; Cunha-Cruz et al.,
2007; Barer et al., 2007; Ng SK, Leung WK. 2006; Needleman et al., 2004; Karlsson et al.,
2009; Brennan et al., 2007 ; Lawrence et al., 2008 ; Mariño et al., 2008 ; Durham et al.,
2013), also reveled by a recent systematic review (Al-Harthi et al., 2013). It has been reported
also a correlation between extent and/or severity of periodontal disease and poorer OHRQoL,
the strength of the association being reported to be either an OR of 1.5 (95% CI = 1.02–2.19)
to 2.0 (95% CI = 1.5–2.5), or RR = 1.3 (95% CI = 1.2–1.4) (Al-Harthi et al., 2013;
Needleman et al., 2004; Ng & Leung 2006; Cunha-Cruz et al., 2007; Bernabe & Marcenes,
2010).
It was also revealed that, when the patients with periodontal disease faced the fact that it
was not possible to keep the teeth any longer, followed a period of fear, shame and denial,
48 A. L. Dumitrescu

with a direct negative effect on their social life (Johannsen et al., 2012). A qualitative study
that investigated patients' perceptions of living with periodontitis identified two main
categories: first, the patients' perception of what causes periodontitis, being given the
diagnosis, after the diagnosis and the consequences of periodontitis, and the second category
reveals the patients' perception of their own responsibility and the professionals' responsibility
(Karlsson et al., 2009). The authors suggested that acceptance and control of the disease may
cause less difficulties in the patients' daily lives and may lead to a more positive future
perspective, despite feelings of anxiety about long-term consequences such as edentations due
to tooth loss (Karlsson et al., 2009).
Patient-based outcomes (PBOs) or “true endpoints” such as OHQoL were also
investigated in periodontal therapy as patients’ opinions may differ from traditional clinical
endpoints (Aslund et al., 2008; Brauchle et al., 2013; Del Fabbro et al., 2009; Franke et al.,
2014; Jönsson and Öhrn 2014; Nagarajan and Chandra 2012; Ozcelik et al., 2007; Jowett et
al., 2009; Saito et al., 2010; Saito et al., 2011; Sundaram et al., 2013; Wong et al., 2012;
Shanbhag et al., 2012). A recent systematic review summarized these studies and revealed
that all forms of non-surgical periodontal therapy can improve the OHRQoL of adult patients
with periodontal disease in the immediate (1 week) and long-term (12 months) (Shanbhag et
al., 2012), in the domains of function, psychology and pain. In contrast, when provided alone
surgical periodontal treatment may be associated with more negative impacts and when
performed in patients who have already received non-surgical periodontal therapy does not
have a significant additional benefit on the OHRQoL (Shanbhag et al., 2012).

V. Impact of Edentulism on Oral Health-Related

Quality of Life
Periodontal disease is a chronic, destructive condition characterized gums inflammation
and the gradual destruction of periodontal tissues and alveolar bone supporting the teeth. As a
consequence, periodontitis, a disease that affects a large number of the adult population, is
one of the major causes of tooth loss in adults (Papapanou, 1996; Irfan et al., 2001).
A recent systematic review provided fairly strong evidence that tooth loss impair
OHRQoL (Gerritsen et al., 2010). Tooth loss has an impact of on the quality of life through
both a physical (e.g. difficulties in eating) and social dimensions (e.g. problems in
communication with other people)(Saintrain and de Souza, 2012; Nguyen et al., 2011;
Visscher et al., 2014; Huang and Park, 2014; Dable et al., 2014; Gülcan et al., 2014; Batista et
al., 2014; Zhang et al., 2013; Pistorius et al., 2013; Singh and Brennan, 2012; Saintrain and de
Souza, 2012).
This association is independent from the OHRQoL instrument used and context (e.g.,
cultural background), but the extent and severity of impairment seems to be context
dependent. The prevalence of negative impacts increases sharply once the number of teeth
present drops below 20 (Gerritsen et al., 2010). Otherwise, the quantity of teeth lost does not
affect OHRQoL, but rather should be taken in consideration the number of occluding pairs,
location and distribution of missing teeth (Gerritsen et al., 2010; Batista et al., 2014; Somsak
and Kaewplung, 2014).
 Relationship between Periodontal Health and Its Impact … 49

Among older people, long-term routine attendance had positive impact on major tooth
loss and OHRQoL supporting the principle of encouraging annual dental attendance for
preventive checkups (Åstrøm et al., 2014).
However, the studies under analysis were mainly population based and not individual
based. Rousseau et al., (2014) revealed that while for some individuals the loss of a tooth is
relatively insignificant, for others it is devastating and disruptive. Two forms of biographical
disruption were identified: the first was connected to the meanings of tooth loss (the neglected
mouth) and denture wearing (a marker of old age), while the second disruption was embodied
and was linked to the relationship between the self and mouth in those wearing dentures (the
invaded, unreliable mouth) and could take place even where tooth loss and denture wearing
had been biographically anticipated (Rousseau et al., 2014). When the influence of
personality traits was investigated, negative affectivity was statistically and clinically
significantly higher and self-esteem was statistically significantly lower in patients reporting
worse oral comfort and OHRQoL (Özhayat, 2013). Preservation of teeth had a positive effect
on QoL as it contributes to a positive body image, self-worth, pride and achievement,
intactness, and sense of control (Niesten et al., 2012), and to a reduced vulnerability (De
Marchi et al., 2012). There seems to be a gender effect in that the men generally care less
about having natural teeth than women (Niesten et al., 2012).
The influence of the replacement of tooth loss on OHQoL was also investigated:

 One systematic review performed by Hultin et al., (2012) revealed that the oral
rehabilitation following total or partial tooth loss has positive influence on self-
perceived OHRQoL.
 When the cost-effectiveness of conventional treatment using partial dentures with
functionally orientated treatment to replace missing teeth for partially dentate elders
was compared, it was reported an improvements in OHRQoL 1 month after
completion of treatment either through conventional (e.g. removable partial dentures
to replace all missing natural teeth) or functionally orientated therapy (e.g. Shortened
Dental Arch (SDA) restoration of 10 occluding contacts using resin-bonded
bridgework)(McKenna et al., 2013).
 In completely edentulous patients, over 65 yrs of age, there was a significant change
in the quality of life in elderly after their prosthodontic rehabilitation, though the self
rated general health did not show any significant improvement (Dable et al., 2013)
with a higher increase of patient satisfaction and OHQoL in the mandibular implant-
retained overdenture compared to conventional dentures (Emami et al., 2013),
especially when frontal teeth are affected (Yu et al., 2013).
 In edentulous patients, the treatment with dental implants increased OHQoL,
improved function, self-esteem and social life (Johannsen et al., 2012);
 The evaluation of the OHQoL in a population about to receive removable dental
prostheses or fixed dental prostheses revealed that the most frequently reported
problems in all groups concerned functional limitations, discomfort and physical
disabilities. Higher age was significantly correlated with a better OHRQoL
independent of treatment modality. However, patients who received fixed dental
prostheses in one jaw in the masticatory zone only had a better OHRQoL than
participants who received removable dental prostheses in the same group (Özhayat
and Gotfredsen, 2013).
50 A. L. Dumitrescu

Conclusion
As far as we can see, periodontal disease has a tremendous impact on the patients’ quality
of life, in all of her dimensions, and it is the responsibility of the entire dental community to
understand the psychological needs of their patients under the dental care.

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Chapter III

Exploring the Relationship between

Nutrition and Periodontal Disease

A. L. Dumitrescu
Private practice, Bucharest, Romania

Abstract
Periodontal diseases are one of the common oral diseases and it is associated with
formation of periodontal pockets, gingival abscesses, gingival recessions, tooth mobility,
and finally teeth loss. The link between nutritional factors and periodontal disease has not
been clearly established even if a highly number of studies has investigated this possible
association. As periodontitis is associated with low serum/plasma micronutrient levels, it
has been postulated that daily intake for vitamin C (ascorbic acid), vitamin E, zinc,
lycopene, vitamin B, complex vitamin D, calcium, unsaturated fats and antioxidants
would have useful adjunct benefits on the prevention and therapeutic management of
periodontal disease. Regarding various beverages, the consumption of milk, coffee or
green tea was also investigated in relationship with periodontitis. It has been showed that
higher coffee consumption is associated with a significant reduction in number of teeth
with periodontal bone loss, while green tea extract has been revealed to suppress the
onset of loss of attachment and alveolar bone resorption in a rat model of experimental
periodontitis. This chapter reviews the current knowledge in this research field,
suggesting an adequate dietary advice for patients with chronic periodontitis.

1. Introduction
Periodontal diseases are one of the common oral diseases and it is associated with
formation of periodontal pockets, gingival abscesses, gingival recessions, tooth mobility, and
finally teeth loss. The link between nutritional factors and periodontal disease has not been


E-mail: [email protected]
66 A. L. Dumitrescu

clearly established even if a highly number of studies has investigated this possible
association. This chapter reviews the current knowledge in this research field, suggesting an
adequate dietary advice for patients with chronic periodontitis.

2. Definition of Terms
What is nutrition? According to The Giessen Declaration (2005), the following working
definition of the current conventional science of nutrition as a biological discipline was
adopted: “Nutrition science is ... the study of food systems, foods and drinks, and their
nutrients and other constituents; and of their interactions within and between all relevant
biological, social and environmental systems.” “The purpose of nutrition science is to
contribute to a world in which present and future generations fulfil their human potential, live
in the best of health, and develop, sustain and enjoy an increasingly diverse human, living and
physical environment.” Moreover, it was stated that “Nutrition science should be the basis for
food and nutrition policies. These should be designed to identify, create, conserve and protect
rational, sustainable and equitable communal, national and global food systems, in order to
sustain the health, well-being and integrity of humankind and also that of the living and
physical worlds” (Leitzmann & Cannon, 2005; Beauman et al., 2005; Cannon
& Leitzmann, 2005).
Dietary patterns can be characterized, according to the Scientific Report of the 2015
Dietary Guidelines Advisory Committee, in three main ways: 1) The first is by the use of an a
priori index based on a set of dietary recommendations, such as the Healthy Eating Index
(HEI)-2005 and 2010, the Alternate HEI (AHEI) and updated AHEI-2010, the Recommended
Food Score (RFS), the Dietary Approaches to Stop Hypertension (DASH) score, the
Mediterranean Diet Score (MDS), and the Alternate Mediterranean Diet Score (aMed); 2)
The second method of dietary pattern assessment is through data-driven approaches, such as
cluster (e.g. “Using the self-reported food and beverage intake data are there groups of people
with distinct (non-overlapping) dietary patterns?”) and factor analysis (e.g. “Which
components of the diet track together to explain variations in food or beverage intake across
diet patterns?”) as well as outcome-dependent approaches are, such as reduced rank
regression (e.g. “What combination of foods explains the most variation in one or more
intermediate health markers?”); 3) The third method uses qualitative self-reported behaviors
in aim to investigate participants’ eating and drinking patterns, such as vegetarianism or ovo-
lacto vegetarianism) (Dietary Guidelines Advisory Committee, 2015).
Malnutrition is an imbalance between the nutrients the body needs and the
nutrients it gets. Thus, both overnutrition (defined as consumption of too many calories or
too much of any specific nutrient—protein, fat, vitamin, mineral, or other dietary
supplement), and undernutrition (defined as a disturbance of form or function arising from
the deficiency of one or more nutrients) are forms of malnutrition (Beers & Berkow, 2004;
Schenker, 2003). Lack of nutrients can result in deficiency syndromes (e.g. pellagra) and
related disorders while excess intake of macronutrients can lead to obesity and related
disorders (Beers & Berkow, 2004).
Food-based dietary guidelines (FBDG) are simple messages on healthy eating,
indicating of what an individual should be intake in terms of foods rather than nutrients, as
 Exploring the Relationship between Nutrition and Periodontal Disease 67

well as and offering to the general public a basic support to use when setting up meals or
daily menus (WHO, 2003).
FBDG can be extensive and unspecific such as “eat plenty of fruits and vegetables,” or
more specific such as “eat five portions of fruits and vegetables a day” (WHO, 2003).
Messages may also indicate the type of food, such as “eat low fat dairy products and
drink low fat milk,” or be meal specific such as “eat breakfast every day” (EUFIC, 2009).
Dietary quality and nutritional status (defined as the extent to which nutrients are
available to meet metabolic needs) (Wirt & Collins, 2009) are important for disease
prevention and health promotion. However, associated with risk factors (e.g. smoking, lack of
physical activity) nutrition may have a negative effect on the prevalence of several chronic
diseases, such as cardiovascular disease, diabetes, obesity, cancers or osteoporosis.

3. Type of Nutrients
Macronutrients, such as carbohydrates, proteins (including essential amino acids), fats
(including essential fatty acids), macrominerals, and water, represents the largeness part of
the diet and supply energy and many essential nutrients. Micronutrients are represented by
vitamins and minerals required in minute amounts (trace minerals) (Beers & Berkow, 2004).
Nutrient-dense foods (e.g. vegetables, fruits, whole grains, fish, eggs, nuts, lean, low-fat
forms of fluid milk, meat, and poultry prepared without added solid fats or sugars) are
naturally rich in vitamins and minerals, retain naturally-occurring components such as fiber
and are low in solid fats and without added solid fats, sugars, starches, or sodium (Beers &
Berkow, 2004).

4. Current Reviews and Meta-Analyses Related on

the Role of Nutrition in Periodontal Disease
Several reviews and meta-analyses have analyzed the impact of nutrition on periodontal
health (Enwonwu et al., 2004; Enwonwu et al., 2002; Ritchie et al., 2002; Chapple, 2009;
Van der Velden et al., 2011; Neiva et al., 2003; Johnson & Curtis, 1994; Bsoul &
Terezhalmy, 2004; Enwonwu & Ritchie, 2007; Enwonwu, 1995; Sculley & Langley-Evans,
2002; Boyd & Lampi, 2001; Dorsky, 2001; Enwonwu, 1994; Boyd & Madden, 2003; Karp,
1994; Hornick, 2002; Van der Velden et al., 2011; Kulkarni et al., 2014).
The most recent systematic review, performed by Kulkarni et al., (2014), based on
PubMed and Cochrane database literature search, concluded that:

“the link between nutrients and periodontal disease has not been clearly
established. The published research reveals only a possible relationship between
vitamins and minerals and periodontal disease. Vitamin E, zinc, lycopene and
vitamin B complex may have useful adjunct benefits. However, there is inadequate
evidence to link the nutritional status of the host to periodontal inflammation. More
randomized controlled trials are needed to explore this association.”
68 A. L. Dumitrescu

A bi-directional relationship can be established between nutrition and periodontal disease

and there is an increasing emphasis on their interrelationships (Figure 1.).

Figure 1. Inter-relationship between nutrition and periodontal disease.

5. Impact of Macronutrients on the Periodontal

Disease Status
Macronutrients - are those nutrients required by the human body in large amounts
(Tucker, 2010) (Figure 2.).
When carbohydrates roles are considered, we should consider that animal research has
revealed the etiological role of dental plaque, as periodontal disease has been demonstrated to
be induced in rats and in hamsters in relation to indigenous plaque (Crawford et al., 1978;
Garant & Cho, 1979; Garant & Cho, 1980; Heijl et al., 1980; Wyss & Guggenheim, 1984;
Lekic et al., 1989; Klausen, 1991; Yamazaki, 1992). A greater incidence of periodontitis
lesions with active bone resorption was observed after 7 weeks in rats fed with a high-sucrose
diet (Keyes’ diet 2000) comparing with rats fed a normally laboratory chow diet (Garant &
Cho, 1979; Garant & Cho, 1980). Moreover, when sucrose was added in the rats’ diet (Heijl
et al., 1980; Crawford et al., 1978; Abiko & Shimono, 1989) or in their drinking water (Lekic
et al., 1989), it was revealed that a variety of microorganisms (e.g. Streptococcus sobrinus,
Actinomycesviscosus, Porphyromonas gingivalis) can be established in rats that were fed with
an ordinary food (Klausen, 1991). It was also reported that a diet with a smaller grain size is
associated with less horizontal bone loss and periodontal bone support than a regular diet
(Björnsson et al., 2003). The diet (e.g. sucrose-rich diet) seems also to be more the most
consistent factor involved in the calculus formation in different strains of rats (Tanzer &
Grant, 1993; Baer et al., 1967; Weinberg & Bral, 1999).
Few human studies have researched the potential role of dietary sugar in the etiology of
periodontal disease. In an 3-week experimental period experimental gingivitis model in young
adults, significantly higher levels of bleeding on probing scores were found when participants
were fed with a diet high in carbohydrates when compared to those on a low sugar diet, even
 Exploring the Relationship between Nutrition and Periodontal Disease 69

if no significant differences were observed with crevicular fluid flow and plaque amount (Sidi
and Ashley, 1984). These findings have been further supported by a study performed by
Baumgartner et al., (2009) who assessed the oral microbiota and clinical data in subjects
without access to traditional oral hygiene methods and who ate a diet available in the Stone
Age. The participants refrained from any oral hygiene measures and received a diet rich in
fibre, anti-oxidants, and fish oils, but low in refined sugars and. Surprisingly, at week 4, even
if dental plaque levels increased significantly (from 0.68 to 1.47, P<0.001) as well as the total
bacterial count (P<0.001), mean bleeding on probing scores decreased (34.8% to 12.6%,
P<0.001) (Baumgartner et al., 2009).

Figure 2. Macronutrients groups.

Even if total carbohydrate intake has not been related to periodontitis, the effect of dietary
intake of some foods low in glycemic index (e.g. coarsely ground whole grain bread, beans
and legumes, nuts, high-fiber fruits and vegetables) were also investigated. A large
prospective study made on 34160 male US health professionals aged 40-75 yrs, showed that
men in the highest quintile of whole-grain intake were 23% less likely to get periodontitis
than were those in the lowest quintile (RR = 0.77; 95% CI: 0.66 - 0.89; P<0.001) after
adjustment for age, smoking, body mass index, alcohol intake, physical activity, and total
energy intake (Merchant et al, 2006). A new findings was that fruit consumption may play a
protective role in periodontitis and to improve the periodontal therapy outcomes (Amaliya et
al., 2015; Zare Javid et al., 2014; Jimenez et al., 2012; Chapple et al., 2012; Feghali K et al.,
2011; Johansson et al., 1994; Blignaut & Grobler, 1992 ; Grobler & Blignaut, 1989).
Lipids are not so easily classified due to their many different structural features and
chemical properties. The main categories are: 1) Simple Lipids (e.g. oils and fats); 2)
Compound Lipids (e.g. Phospholipids, Glycolipids, Lipoproteins); 3) Derived Lipids (e.g.
sterols and glycerol; carotenoids; and the fat-soluble vitamins A, D, E, and K).
70 A. L. Dumitrescu

It was revealed that a fat-enriched diet with a reduced amount of daily dietary fibers.
known to induce inflammation-mediated insulin-resistance and glucose-intolerance (Riant et
al, 2009), is also associated with a change in the intestinal microbiota ecology characterized
by an increase in gram-negative bacteria (Turnbaugh et al., 2008; Turnbaugh et al., 2009)
which is linked to the occurrence of type 2 diabetes. Moreover, several pathogenic gram
negative bacteria are usually associated with the onset of periodontitis
(Lakhssassi et al., 2005).
The diabetogenic fat-enriched diet induced in ovariectomised mice the increase of
periodontal pathogenic microbiota like Fusobacterium nucleatum and Prevotella intermedia
as well as the development of gingival inflammation and alveolar bone loss. These effects
were prevented by chronic estrogen administration, as well as the deletion of CD14 (Blasco-
Baque et al., 2012).
Fatty acids are the main building blocks of triglycerides and can be classified by the
length of the carbon chain: 1) Saturated fatty acids; 2) Monounsaturated fatty acids (e.g. oleic
acid also known as omega-9 found in olive oil, peanut oil, almonds, pecans, and avocados);
and 3) Polyunsaturated fatty acids (PUFAs) (e.g. linoleic acid also known as omega-6 and
alpha-linolenic acid also known as omega-3)(Tucker, 2010).
It has been showed that the omega-3 and omega-6 PUFAs showed strong antimicrobial
activity against Aggregatibacter segnis KCTC 5968, Fusobacterium nucleatum subsp.
Polymorphum KCTC 5172 and Prevotella intermedia KCTC 25611, and Porphyromonas
gingivalis KCTC 381, all micro-organisms implicated in the etiology of gingivitis and
periodontitis (Choi et al., 2013).
As anti-inflammatory properties have been reported for PUFAs, several studies have
investigated their role in the modulation of gingival and periodontal disease indicating their
potential therapeutic efficacy (Kesavalu et al., 2006; Naqvi et al., 2014; Araghizadeh et al.,
2014; Choi et al., 2013; Figueredo et al., 2013; Raffaelli et al., 2008; Rosenstein et al., 2003;
Eberhard et al., 2002; Campan et al., 1997).

6. Impact of Micronutrients on the Periodontal

Disease Status
Micronutrients - are those nutrients required by the body in smaller amounts (Tucker,
2010) (Figure 3.).
Vitamin B-complex includes Vitamin B1 (thiamine), Vitamin B2 (riboflavin), (niacin or
nicotinic acid), Vitamin B5 (pantothenic acid), Vitamin B6 (pyridoxine, pyridoxal,
pyridoxamine), Vitamin B7 (biotin), Vitamin B9 (folic acid) and vitamin B12 (various
cobalamins)(Singh, 2012). Staudte et al., (2012) highlighted that patients with periodontitis
had significantly lower intake rates of folic acid than those of healthy controls, while Erdemir
& Bergstrom (2006) revealed that among patients with periodontal disease the serum folic
acid concentration is lower in smokers compared with non-smokers. Furthermore, vitamin-B
complex can positively influence periodontal wound healing processes as vitamin B-complex
supplement in combination with access flap surgery resulted in statistically significant
superior clinical attachment level gains when compared to placebo (access flap surgery alone)
in patients with generalized moderate to severe chronic periodontitis (Neiva et al., 2005).
 Exploring the Relationship between Nutrition and Periodontal Disease 71

Figure 3. Micronutrients groups.

Vitamin C, or ascorbic acid, is a powerful antioxidant associated with absorption of iron,

immunological functions (e.g. wound healing, phagocytosis) as well as in collagen formation
in connective tissue such as the periodontium (Figure 4.).
Several recent studies indicate a relationship between plasma vitamin C and
inflammation (Aguirre & May, 2008; Mohammed et al., 2014). In vitro models, vitamin C
induces periodontal ligament progenitor cell differentiation, important for maintaining the
homeostasis of PDL tissue and alveolar bone, via activation of ERK pathway mediated by
PELP1 (Yan et al., 2013), partially antagonize the hydrogen peroxide-induced cytotoxicity in
periodontal ligament cells (Wu et al., 2015) and attenuates the cytotoxic effects of
Porphyromonas gingivalis on human gingival fibroblasts (Staudte et al., 2010).
In animal models, vitamin C attenuates the degree of experimental atherosclerosis
induced by periodontitis in the rat by decreasing oxidative stress (Ekuni et al., 2009) and
provides therapeutic effects on inhibition of alveolar bone resorption and periodontal tissue
destruction (Akman et al., 2012) by down-regulating gene expression encoding inflammation,
including interleukin-1 alpha and interleukin-1 beta (Tomofuji et al., 2009).
It is well known that smokers are almost three times more likely to have advanced
periodontitis compared to the non-smokers (Johnson & Hill, 2004). Smoking is associated
with alteration of antioxidant defenses, as well as upregulation of inflammation by a number
of mechanisms leading to extensive oxidative damage and lower vitamin C levels were
reported in smokers than in non-smokers (Palanisamy et al., 2009; Morrow et al., 1995) as
well as in smokers with chronic periodontitis compared with non-smoker healthy controls and
non-smokers with chronic periodontitis (Vit C in microM/l) : 22.7 ± 0.05 vs. 39.7 ± 0.06,
respectively 28.3 ± 0.05) (Aziz et al., 2013).
The daily dietary intake of ascorbic acid may influence gingival bleeding level (Nishida
et al., 2000; Leggott et al., 1986; Staudte et al., 2005; Gokhale et al., 2013). It has been
showed that patients with periodontitis have a reduced intake of vitamin C (Staudte et al.,
2012) and lower plasma vitamin C levels (Amaliya et al., 2007; Kuzmanova et al., 2012;
72 A. L. Dumitrescu

Thomas et al., 2010; Chapple et al., 2007; Amarasena et al., 2005; Pussinen et al., 2003)
compared with healthy subjects. Moreover, single-nucleotide polymorphism rs6596473 in the
vitamin C transporter SLC23A1 is associated with aggressive periodontitis (de Jong et al.,
2014).
Vitamin C intake as an adjunct to conventional therapy such as scaling and root planing
(SRP) yielded better results compared to SRP therapy alone significantly reduces the bleeding
index (Gokhale et al., 2013) but also no adjunctive effect was reported (Abou Sulaiman et al.,
2010), suggesting that further studies need to be performed in this field.

Figure 4. Oranges, like other citrus fruits, are an excellent source of vitamin C.

Vitamin A is a group of unsaturated nutritional organic compounds that includes retinol,

retinal, retinoic acid, and several provitamin A carotenoids, among which beta-carotene is the
most important. Alpha-carotene is found in root vegetables (e.g. carrots), beta-carotene
sources are green leafy, root and fruiting vegetables, lycopene is found in fruiting vegetables
(fresh tomato), lutein in green leafy vegetables, beta-cryptoxanthin in citrus fruits, citrus fruits
and green leafy vegetables are the main source of zeaxanthin (García-Closas et al., 2004).
The positive use of vitamin A in periodontal diseases has yet to be evaluated in detail,
even if it has been reported that:

 oral administration of all-trans retinoic acid has a potential for clinical prevention of
periodontitis as it suppresses experimental periodontitis in mice by modulating the
Th17/Treg imbalance (Wang et al., 2014);
 β-cryptoxanthin, a typical carotenoid, has also a protective effect against periodontal
disease as in a mouse model of periodontitis, it suppressed bone resorption in the
mandibular alveolar bone in vitro and restored alveolar bone loss induced by
lipopolysaccharide (LPS) in vivo (Matsumoto et al., 2013). This preventive effect on
bone resorption in periodontitis is modulated through inhibition of the production of
IL-6 and IL-8 and up-regulation of osteoprotegerin (OPG) production (Nishigaki et
al., 2013).
 Exploring the Relationship between Nutrition and Periodontal Disease 73

 Lycopene, a powerful antioxidant and the main carotenoid in tomato products is also
been successfully used as an adjunct to scaling and root planing in gingivitis patients
(Chandra et al., 2007), as an adjunct treatment modality to oral prophylaxis (full
mouth scaling and root planing completed within 24 hours) in patients with moderate
periodontal disease (Belludi et al., 2013) or as a gel formulation, effective in
significant reductions in probing depths and gain in the clinical attachment levels
compared with the placebo in smoking and nonsmoking subjects with chronic
periodontitis (Chandra et al., 2012).

Vitamin D is essential for cell development, neuromuscular functioning, bone

metabolism, absorption of calcium, deposition of calcium and phosphorus in bones bone
development and inflammation control. As in periodontal inflammation, the alveolar bone re-
absorption is a major characteristic, it was possible to consider that mediators of bone
metabolism such as Vitamin D Receptor (VDR) and its genetic polymorphisms have an
important a role in the individual susceptibility to developing periodontitis (Martelli et al.,
2014). A recent meta-analysis investigated the association between vitamin D receptor
polymorphisms (including four gene loci: Taq-I, Bsm-I, Apa-I, and Fok-I) for susceptibility to
periodontitis. The results of the meta-analysis performed by Chen et al., (2012) on nineteen
case-control studies concluded that “1) the mutant allele t of the Taq-I locus may be a
protective factor for chronic but not for aggressive periodontitis in Asians, although this was
not true in whites; 2) the mutant allele F of the Fok-I locus appeared to be a risk factor for
aggressive rather than chronic periodontitis in Asians; and 3) Bsm-I and Apa-I polymorphisms
were found to have no significant associations with susceptibility to periodontitis
(chronic/aggressive).”
A significant relationship between serum and gingival crevicular fluid levels of vitamin D
and periodontitis condition and/or tooth loss were reported by several studies (Antonoglou et
al., 2015; Zhan et al., 2014; Zhang et al., 2014; Antonoglou et al., 2013; Bastos et al., 2013;
Millen et al., 2013; Zhang et al., 2013; Zhou et al., 2012; Liu et al., 2010 ; Liu et al., 2009).
Moreover, it was revealed not only an improving of the periodontal health after vitamin D
intake in patients with periodontitis (Miley et al., 2009; Van der Velden et al., 2011; Garcia et
al., 2011) but it was also suggested that vitamin D status may be critical for post-surgical
healing (Bashutski et al., 2011).
Vitamin E refers to a group of compounds that include both tocopherols and tocotrienols
mainly involved in antioxidant processes.
Carvalho et al., (2013) reported that vitamin E has the potential to reduce oxidative
damage and inflammatory response in a ligature-induced periodontitis in rats but does not
prevent alveolar bone loss. Clinical studies revealed controversial results with either failing to
support the use of vitamin E as a topical chemotherapeutic agent for the control of gingivitis
or periodontal disease (Slade et al., 1976; Cohen et al., 1991) either revealing that the
adjunctive vitamin E supplementation improves periodontal healing (Asman et al., 1994;
Singh et al., 2014).
Several studies have focused on the inter-relationship between various minerals and
periodontal health status (Table 1.).
74 A. L. Dumitrescu

Table 1. Overview of clinical studies focused on the inter-relationship between various

minerals and periodontal health status

Author, year Minerals Main findings

investigated
Shimazaki et al., Calcium The routine intake of lactic acid foods may have a beneficial
2008 effect on periodontal disease.
Nishida et al., 2000 Calcium Low dietary intake of calcium results in more severe
periodontal disease. The relationship between low dietary
calcium intake and increased levels of periodontal disease
showed an estimated odds ratio (OR) of 1.84 (95% CI: 1.36 to
2.48) for young males, 1.99 (95% CI: 1.34 to 2.97) for young
females, and 1.90 (95% CI: 1.41 to 2.55) for the older group of
males.
Ramesh et al., 2011 Calcium Postmenopausal women exhibit a reduced alveolar bone mass
and lowered levels of serum total calcium with the increasing
age.
Amarasena et al., Calcium Serum calcium may be considered a risk factor for periodontal
2008 disease progression in non-institutionalized elderly.
Kuraner et al., 1991 Calcium Patients with periodontitis had increased Ca serum levels and
decreased Ca levels in parotid saliva.
Kolte et al., 2012 Calcium and The present study exhibited reduced concentrations of, calcium
phosphorus and phosphorus in whole saliva in smokers with chronic
periodontitis.
Muñoz et al., 2001 Calcium and Multi-vitamin nutritional supplement might be a beneficial
phosphorus adjunct to the required established periodontal treatment.

Thomas et al., 2013 Copper The serum levels of copper increased in diabetes patients with
periodontitis compared to healthy individuals with and without
periodontitis.
Thomas et al., 2013 Iron The serum levels of iron increased in diabetes patients with
periodontitis compared to healthy individuals with and without
periodontitis.
Rao et al., 2013 Iron It has been concluded that periodontitis does not induce
anemia like state, as the hematological and biochemical
parameters were almost equally affected in periodontally
healthy and periodontally diseased individuals.
Chakraborty et al., Iron Iron deficiency anemia patients with chronic periodontitis have
2014 more periodontal breakdowns than patients with chronic
periodontitis.
Prakash et al., 2012 Iron The presence and severity of periodontitis may not affect the
serum iron and serum ferritin parameters of an individual.
Pushparani et al., Magnesium Patients with diabetes mellitus and periodontitis had altered
2014 metabolism of Zn and Mg.
Kolte et al., 2012 Magnesium The present study exhibited reduced concentrations of
magnesium in whole saliva in smokers with chronic
periodontitis.
Staudte et al., 2012 Magnesium Patients with periodontitis have a reduced intake of
magnesium compared with healthy subjects.
 Exploring the Relationship between Nutrition and Periodontal Disease 75

Author, year Minerals Main findings

investigated
Yoshihara et al., 2011 Magnesium A low serum Ca/Mg ratio was significantly associated with
periodontal disease progression in Japanese elderly smokers.
Meisel et al., 2005 Magnesium Nutritional magnesium supplementation may improve
periodontal health.
Tanaka et al., 2006 Magnesium Intake of magnesium is related to reduced prevalence of tooth
loss among young Japanese women.
Rodrigues et al., 2014 Phosphorus In haemodialysis patients, the periodontitis group had
phosphorus serum levels lower than the no periodontitis group.
Liu et al., 2009 Phosphorus Serum inorganic phosphorus values of patients with chronic
and aggressive periodontitis were lower than those of healthy
controls.
Thomas et al., 2013 Selenium The levels of selenium are significantly lower in diabetic
patients with periodontitis and also in healthy individuals with
periodontitis, but are highest in healthy controls, showing that
the serum levels are inversely proportional to inflammation
and tissue destruction.
Pushparani et al., Zinc Patients with diabetes mellitus and periodontitis had altered
2014 metabolism of Zn and Mg.
Thomas et al., 2013 Zinc The serum levels of zinc decreased in diabetes patients with
periodontitis compared to healthy individuals with and without
periodontitis.
Kuraner et al., 1991 Zinc Patients with periodontitis had decreased Zn serum levels.

7. Impact of Dietary Excess on Periodontal Health

Over the past 30-40 years, changes in food composition and availability have contributed
to the dramatic increase in obesity in developed and, increasingly, in developing countries
(Morris et al., 2014). Unfortunately, this global obesity epidemic has been described by the
World Health Organization as one of the most frequent but also one of the most neglected
public health problems (Stevens et al., 2012) that is associated with frequent morbidities such
as hypertension, angina, diabetes and arthritis (Shukla et al., 2014).
Both periodontal disease and obesity are among the most common chronic disorders
affecting the world's populations, and several reviews suggest a potential link between
overweight/obesity and periodontitis (Table 2.). Obesity appears to participate in the
multifactorial phenomenon of causality of periodontitis, due to the abnormal or excessive
deposition of fat in the adipose tissue that leads to a severe increase in oxidative stress,
determining not only an endothelial dysfunction but also to the increase in proinflammatory
cytokines, a negative effect that leads finally to periodontitis (Suresh et al., 2014; Boesing et
al., 2009; Pischon et al., 2007).
Physical activity also independently reduces not only the risk of several general diseases
(e.g. cardiac problems, diabetes, osteoporosis) but has been also associated with lower
periodontitis prevalence, independent of obesity (Merchant et al., 2003; Al-Zahrani et al.,
2005; Eberhard et al., 2014). Moreover, moderate and severe periodontitis were
76 A. L. Dumitrescu

independently associated with low levels of high-sensitive C-reactive protein in sedentary

men aged between 45 and 65 years (Sanders et al., 2009).

Table 2. Overview of Review Articles and Meta-Analyses focused on the inter-

relationship between obesity and periodontal disease

Author, year Type of Main conclusion

Study
Watanabe & Review Metabolic syndrome is a conglomerate of several
Cho, 2014 physical conditions/diseases that include glucose
intolerance/insulin resistance, hypertension, obesity, and
dyslipidemia. All the reviewed studies demonstrated a
positive association between periodontal disease and
metabolic syndrome.
Katz & Review Further studies are needed to support the hypothesis that
Bimstein, obesity in children may be associated with increased rates
2011 of periodontal disease.
Suvan et al., Meta-analyses Meta-analyses indicated statistically significant
2011 associations between periodontitis and body mass index
(BMI) category obese OR 1.81(1.42, 2.30), overweight
OR 1.27(1.06, 1.51) and obese and overweight combined
OR 2.13(1.40, 3.26).
Chaffee & Meta-analyses A positive association was reported with a role for
Weston, 2010 obesity in the development of periodontal disease. The
fixed-effects summary odds ratio was 1.35 (Shore-
corrected 95% confidence interval: 1.23 to 1.47), with
some evidence of a stronger association found among
younger adults, women, and non-smokers.
Keller et al., Review This systematic review suggests that overweight, obesity,
2015 weight gain and increased waist circumference may be
risk factors for development or worsening with regard to
periodontal measures.

8. Impact of Caloric Restriction on

Periodontal Health
Dietary caloric restriction has been found to reduce systemic markers of inflammation
and to protect against age-associated diseases including chronic inflammatory disorders such
as cardiovascular disease and diabetes (González et al., 2012; Ingram et al., 1990). Moreover,
several studies on animal models revealed that long-term caloric restriction has a significant
impact on reducing the extent and severity of naturally occurring chronic periodontal disease,
local inflammatory and immune responses, and periodontal microbiology (Reynolds et al.,
2009; Branch-Mays et al., 2008).
Undernutrition is defined as a disturbance of form or function arising from the
deficiency of one or more nutrients. Undernutrition can be classified as being mild or severe,
 Exploring the Relationship between Nutrition and Periodontal Disease 77

helpful (if it results in appropriate weight loss in someone who is obese), or dangerous.
Weight loss is associated not only with fat lost from adipose tissue but also with depletion of
essential nutrients, protein (apparent in two main ways: somatic protein depletion, e.g. loss of
muscular tissue, and visceral protein depletion, e.g. protein loss from the liver, pancreas and
gut) and micronutrients (Schenker, 2003).
Malnutrition-Inflammation Complex Syndrome (MICS) or Malnutrition-
inflammation atherosclerosis refers to the co-morbidity of protein-energy malnutrition and
inflammation that oare highly prevalent in maintenance haemodialysis patients. MICS is
associated with a poor outcome, including a decreased quality of life, refractory anaemia and
significantly greater rates of hospitalization and mortality (Anand et al., 2013). The
periodontal health is frequently in poor condition in haemodialysis patients and the
periodontal status often correlates with the markers of malnutrition and inflammation
(Strippoli et al., 2013; Chen et al., 2006).

9. Impact of Alcohol Use/Abuse on Periodontal

Health
Alcohol consumption in higher amounts and on a long-term basis can determine a toxic
damage of the organism through a manipulation of the host defenses causing a wide variety of
diseases such as oral and oropharyngeal cancer (Huber & Tantiwongkosi, 2014), esophageal
cancer(Franke et al., 2005), laryngeal cancer (Coca-Pelaz et al., 2013), gastric cancer
(Massarrat & Stolte, 2014), liver cirrhosis (Louvet & Mathurin, 2015), pancreatitis (Muniraj
et al., 2014), cardiovascular problems (Notara et al., 2014), obesity (Traversy & Chaput,
2015), diabetes (Kim et al., 2015), stroke (Senoo et al., 2014), and even mental disorders (e.g.
depression) (Gea et al., 2013).
A recent systematic review, performed by Amaral et al., (2009), has evaluated the studies
focused on the relationship between alcohol dependence/consumption and periodontal
disease. The research was comprehensive and included several databases such as PUBMED
Medline, Latin American and Caribean Health Science-LILACS, Scientific electronic library
online-SciELO and Cochrane Central Register of Controlled Trials-CCRT literature databases
from January 1965 to July 2008. Of the 1530 papers identified, only 11 cross-sectional and 5
longitudinal observational studies met the inclusion criteria. No meta-analysis was performed
due to the high heterogeneity among studies concerning the methods of assessment of alcohol
dependence, alcohol consumption and periodontitis (Amaral et al., 2009).
Moreover, the confounding effect of dental plaque was taken into account in only 6
studies. Based on the fact that seven of the twelve articles on alcohol consumption and 4 of
the 4 studies on alcohol dependence reported positive associations between alcohol intake and
periodontitis, Amaral et al., (2009) concluded that alcohol consumption can be considered a
risk indicator for periodontitis.
78 A. L. Dumitrescu

10. Proposed Mechanisms of How Diet May

Impact on the Periodontal Tissues
The mechanisms by which dietary factors affect inflammatory processes at a cellular and
molecular level were elucidated and presented by Chapple (2009) and by Milward
& Chapple (2015).
The periodontitis phenotype is characterized by hyperinflammation. Oxidative stress has
been proposed as a potential mechanistic link between periodontitis and systemic disease.
Increased levels of oxidative stress can be triggered not only from cellular metabolism or
from the host’s response to periodontal pathogenic bacteria such as Porphyromonas
gingivalis but also by the increased dietary intake of simple sugars or saturated fat by receptor
binding of neutrophils.
As a consequence, the levels of oxidative stress and the periodontal inflammatory
sequelae can be reduced by two modalities: 1) by the reduction of dietary refined
carbohydrates and saturated fats and 2) by the increase diet rich in antioxidants and specific
micronutrients. Examples of foods rich in antioxidants are green leafy vegetables, red beans,
red wine, berries and dark chocolate with greater than 70% cocoa (Chapple, 2009; Milward &
Chapple, 2015).

11. Tooth Loss and Its Impact on Dietary Intake

Advanced periodontal disease is leads to alveolar bone resorption and finally to tooth
loss. One of the most immediate and important functional consequences of edentulous tooth
loss is a reduction in chewing ability and masticatory ability, as well as several non-dental
functional impairments, such as decreased biting force and reduced saliva flow (Ono et al.,
2003; Peyron et al., 2004; Shinkawa et al., 2009; Kim et al., 2009).
When the ability to chew foods is compromised by the oral health status, having few or
no natural teeth, the individuals begin to select a diet that they can chew in comfort.
Generally, there is not only a change in food's choice (a diet low in fruits and vegetables
intake and reduced in both non-starch polysaccharide and micronutrient intakes) but also a
trend for reduced dietary intake overall (Samnieng et al., 2011; Walls & Steele, 2004).
Moreover, reduced salivary flow and function may affect also the individuals’ ability to chew
and swallow (Walls & Steele, 2004). Finally these nutritional problems will affect the general
health, the psychological and social well-being as well as the life quality (Nguyen et al., 2011;
Brennan et al., 2008).

12. Dietary Recommendations for Periodontal

Disease Management
As the periodontal scientific community is starting to understand the health benefits of
diets rich in antioxidants and omega-3 polyunsaturated fatty acids, as well as the high
 Exploring the Relationship between Nutrition and Periodontal Disease 79

problems of diets high in refined carbohydrates, the 2011 European workshop on

Periodontology (Chapple et al., 2012) recommended that:

“the dental team should consider including advice to all patients on increasing
levels of fish oils, fiber, fruit and vegetables and to reduce levels of refined sugars as
part of a periodontal prevention/treatment regime and a general health benefit
message.”

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In: Oral Health ISBN: 978-1-63482-832-1
Editor: Julia Renee Barnes © 2015 Nova Science Publishers, Inc.

Chapter IV

Oral Health Literacy As a Social

Determinant of Oral Health

R. Constance Wiener, MA, DMD, PhD

West Virginia University, School of Dentistry,
Department of Dental Practice and Rural Health;
School of Public Health, Department of Epidemiology,
Morgantown, WV

Abstract
Biological, psychological, sociological, and ecological features of life contribute and
interact simultaneously in the development of an individual’s oral health. For example, a
person’s oral health is influenced by culture/race/ethnicity, neighborhood/rural area,
government structure (with programs for education and healthcare), and level of social
cohesion/power (support from friends, family, church members, community members,
etc.), all of which may vary over the person’s life, as well as brushing and flossing,
proper nutrition, immunological status, saliva production, oral microbes, etc. When group
variations in preventable disease differ primarily due to social conditions, the situation is
described as a health disparity due to the social determinants of health.
In the U.S., public policymakers are expected to address such group health
differences through: the promotion of education; safe/healthy homes, schools, and
workplaces; reduction of poverty; and the reduction of discrimination (racial-based,
gender-based, age-based, etc.) in addition to: the encouragement of life-style changes to
lessen risk; healthcare; and research.
The purpose of this chapter is to review the influence of improved oral health
literacy considering the circumstances in which a person has been born, lives, and works
(social determinants), the microbiological mechanisms, and the public’s influence to
improve oral health.
92 R. Constance Wiener

Introduction

Definitions

The World Health Organization (WHO, 2008) defined social determinants of health as
the “circumstances in which people are born, grow up, live, work, and age, as well as the
systems put in place to deal with illness. These circumstances are in turn shaped by a wider
set of forces: economics, social policies, and politics.”
The National Institute of Dental and Craniofacial Research (NIDCR, 2005)defined oral
health literacy as the “degree to which individuals have the capacity to obtain, process and
understand basic oral health information and services needed to make appropriate health
decisions.” The Calgary Charter on Literacy (2011) further included in the definition, a
professional’s role in listening, explaining and verifying that the person receiving the message
understands the health message provided. A person may be educated, but have limited oral
health literacy; or have a limited education and have high oral health literacy. Education and
oral health literacy are not sufficient in and of themselves for good oral health.

Epidemiology

The U.S. is a culture with high literacy and skill demands (Nielsen-Bohlman, et al.,
2004). People are asked to perform disease management skills for themselves and the people
in their care which may involve activities that would have been performed by skilled
professionals in the recent past including blood pressure monitoring, wound management,
home chemotherapy regimens, and home discharge care for out-patient surgeries among
others. There are 90 million Americans with limited literacy skills (Nielsen-Bohlman, et al.,
2004) in a population of 319 million (U.S. Census, 2014). In the National Assessment of
Adult Health Literacy, 2003, 19,000 adults, ages 16 years and above, were tested for health
literacy. Fourteen percent had below basic health literacy; 22% had basic health literacy; 53%
had intermediate health literacy, and 12% had proficient health literacy (Kutner, et al., 2006).
The financial burden associated with limited health literacy is $106 billion to $238 billion
annually, or between 7-17% percent of healthcare expenditures (Vernon et al., 2007). Limited
health literacy has somatic consequences. It has been associated with:

 poorer health outcomes (Oramasionwu, et al., 2014);

 less use of preventive care (Chen, et al., 2013);
 more emergent care needs (Griffey, et al., 2014);
 errors in medication usage (O’Conor, et al., 2014); and
 misunderstandings in providing consent for treatment and/or research.

Seeking and obtaining dental care are important in oral health. Many people who do not
have adequate health literacy do not ask for help in obtaining information, or have not
developed a vocabulary to navigate the healthcare system (Schwartzberg, et al., 2005). The
role of oral health literacy in seeking and obtaining dental care is explored in this chapter.
 Oral Health Literacy As a Social Determinant of Oral Health 93

Theoretical Framework

Theoretical frameworks are used to explain what people observe as well as what is not
considered. In one current theory about health, the ecosocial theory, Krieger (2011) proposed
that the theoretical framework to explain health must not be reduced simply to biological
mechanisms (a reductionist model), since rates and patterns are known to change and the
changes cannot be adequately explained simply by a biopsychosocial model (Yamada &
Palmer, 2007); and health cannot be fully explained by how society/employers/
governments/insurance companies, etc., interact with people. Instead, she theorized an
Ecosocial Theory of Health which is dependent upon:

 “The cumulative interplay of exposure, susceptibility, and resistance across the

lifecourse;”
 embodiment (the internalization) of the influences around oneself;
 pathways of how various exposures (such as trauma, hunger, stress, toxins, tobacco,
bullying, access to healthcare, etc.) become internalized; and
 accountability and agency (how society addresses disparities) (Karger, 2011). The
Krieger Ecosocial Theory of Health is the theoretical framework for this chapter.

Historical Perspective

During the 1950’s, with the introduction of fluoride toothpastes, there was an
advancement in dental caries control through the biological mechanism by which fluoride
acts, as well as an effort to influence the large cohort of children born after World War II to
brush and floss and thereby use the fluoride toothpastes. There was an internalization of the
need to brush and floss by the dental professional community as well as the public at large.
There were many stakeholders. Dental hygienists and dentists discussed prevention with
patients, and teachers and school nurses in elementary schools taught lessons on tooth
anatomy, caries (cavities), and nutrition. Teachers asked students to record the number of
times they brushed/flossed during a week as homework assignments. Many school board
members budgeted toothbrushes, toothpaste, and disclosing tablets for students. Many state
legislators mandated oral evaluations and surveillance of children in specific grades after
which the results were aggregated and forwarded to state health departments. Fluoride
toothpaste was heavily marketed on television. Many community leaders mandated fluoride
to be added to drinking water. Important positive changes occurred that improved oral health.
Advancement in oral health (through community water fluoridation) was considered one of
the top 10 public health improvements in the 20th century (CDC, 2013). There was a social
movement with many people involved to improve oral health; people were motivated to
receive and act upon the message.
Through the years, there were changes. Some school board members in various
communities agreed to add fluoride rinse programs, school dental programs, and topical
fluoride programs. Other school board members in other communities discontinued the
programs, and discontinued providing disclosing tablets as some parents and teachers
complained that they were inconvenient, messy, and stained clothes. Some states legislators
94 R. Constance Wiener

did not recognize the value of surveillance. As a result, some surveillance programs were
discontinued. The emphasis on oral health education and prevention waned in schools as
pressure to spend time on other aspects of education increased.
There were fewer voices reinforcing the importance of oral health. Dentists and dental
hygienists continued to speak to groups as well as with patients individually about the need
for preventive care. Although the message was to a smaller number of people, members of
dental organizations continued to work toward policies to improve oral health and researchers
made many advances in improving restorative materials and dental sealants. There have been
fluctuations in dental visits for professional care, but the overall trend has been positive. In a
nationally representative study conducted in 1965, 46% of the participants self-reported
having had a dental visit within the year (O’Shea & Gray, 1968). In 2012, the number was
67.2% in a similar national study (of the states and Washington, DC), the Behavioral Risk
Factor Surveillance System survey (BRFSS, 2013). The U.S. Department of Health and
Human Services used a different data source, the Medical Expenditure Panel (MEP), to
develop health goals for 2020. For oral health, one of the Healthy Person 2020 objectives was
to improve the number of dental visits within the year from 44.5%, the 2007 MEP baseline, to
49.0% (HealthyPeople.gov, 2014).
Whether the percentage of people in the U.S. who have not had a dental visit within the
year is more than 30%, or more than 50%, neither situation should be acceptable. Dentists
conducting biannual dental examinations have found incipient caries, incipient periodontitis
(bone, ligament and gum tissue loss around teeth) and have intervened to improve patient
health. Moreover, dentists conducting head and neck cancer screenings have identified early
signs of oral and head and neck cancers. These cancers account for 6% of all malignancies in
the United States (American Academy of Otolaryngology, 2014). Early intervention is
important. Therein lies the role of oral health literacy as a social determinant of oral health,
that is, oral health literacy is “needed to make appropriate health decisions,” among which is
dental care (NIDCR, 2005).

Embodiment; Pathways to Embodiment; Interplay of Exposure/

Susceptibility/Resistance

Each individual incorporates his or her culture/society into himself/herself. (A person is

simultaneously his/her race, ethnicity, class, gender, and sex) (Krieger, 2011). Until recently,
it was difficult to consider such subgroups of the population in research. The statistical tests
to delve into subgroup differences became possible with computers with fast processing
capabilities and large databases. Asking the right questions, selecting the right variables, and
using the right statistical analyses are important concerns in research as data can be parsed
and associations found which may be spurious, happenstance, biased, confounded, and/or
wrong if the examination is flawed.
Studying populations has many vagarities. People and societies change. Their practices
and habits change. For example, in terms of concerns which influence dental care, the types
of food and the nature of food consumption in the U.S. has been changing. Fast food meals
and meals prepared away from home have been rapidly increasing from 25.9% in 1970 to
43.1% in 2012, due in part to the number of women employed outside the home, higher
family incomes, affordability, convenience (Lin, 2014), long commute times, after school
 Oral Health Literacy As a Social Determinant of Oral Health 95

activities, etc. Food away from home is often calorie dense and nutritionally deficient (Lin,
2014). The food tends to be higher in fat, and lower in calcium, fiber, and iron (Lin, 2014;
Berge, et al., 2014) and higher in sugar. Commercially pre-packaged foods, pre-packaged
ready-to-use items (pie crusts, cookie dough, etc.), recipes simplified to use pre-
packaged/modified ingredients, and foods prepared away from home have become culturally
“traditional” for many people.
Sugary drinks have also increased over the last 30 years. Half of the population over age
two drinks a sugary drink on any given day (O’Conor, et al., 2014). (Males drink an average
of 178 calories from sugary drinks daily; females drink an average of 103 calories from
sugary drinks daily) (O’Conor, et al., 2014). Non-Hispanic black children have 8.5% of their
calories from sugary drinks; Mexican Americans have 7.4% of their calories from sugary
drinks (O’Conor, et al., 2014). Children living in homes 0-130% of the Federal Poverty level
have 8.2% of their calories from sugary drinks; children living at 350% of the Federal Poverty
level have 6.7% of their calories from sugary drinks (O’Conor, et al., 2014).
The combination of refined foods and sugary drinks provides a sugary food source for the
natural bacteria in the mouth (the oral microbiome), which produce acid. Saliva has an ability
to reduce the effect of the acid, however the buffering capacity of saliva can be overwhelmed.
If the saliva’s buffers are overwhelmed, the acid can remove the calcium from teeth
(demineralize the teeth). Additionally, an inflammatory response occurs within the tooth
during the attack and once the bacteria penetrate the enamel and enter the softer dentin, they
can establish a localized infection of the tooth (caries).
Greater physiological and psychological stress associated with work, school, home,
trauma, discrimination, multimorbidities, and other conditions such as pregnancy and
depression, have also been associated with increased inflammation. When bacterial plaque is
not removed, bacteria may attack the tissue between the tooth and its supporting tissue, and
an inflammatory response may occur in the tissue around the tooth and the tooth’s supporting
bone. The inflammatory response is often greater with the aforementioned conditions of
physiological and psychological stress.
Additionally, patterns of eating and drinking frequently throughout the day, binge eating,
eating when not hungry, eating away from family/friends, and eating in front of the television
may also influence oral hygiene habits. Being away from home, tired, disbelieving in the need
for oral hygiene, having no oral hygiene aids, or being unaware of the need to brush and floss
decreases the probability of removing plaque and increases the possibilities of dental caries
and periodontitis.

Accountability and Agency Related to Poor Oral Health

Since there are many contributing factors associated with poor oral health, there are also
many approaches that may improve oral health. Krieger, in her ecosocial theory, suggests that
only focusing on lifestyle or individual factors (such as telling people to brush, floss, avoid
frequent consumption of sugary drinks, etc. where oral health is concerned) limits the
research to biomedical individualism and removes the context in which a person lives from
the analysis (decontextualizes the analysis) (Krieger, 2008). Similarly only focusing on
society and change in production and distribution to improve health, (such as removing soda
machines from schools; including high fructose corn syrup listings on packaging, placing
96 R. Constance Wiener

calorie lists on restaurant menus/menu boards, etc.) limits the research to social hierarchies
(Krieger, 2008). Both are needed.
In addressing accountability, one question to consider is who benefits, (qui bono) from
people having poor oral health or the conditions which lead to poor oral health and who will
be hurt by a change in the status quo? Although dental professionals treat the results of poor
oral health and benefit financially from such care, many take an ethical oath to do no harm
and to not over-treat. Manufacturers of professional dental products, dental devices, and
specialized dental equipment benefit with the status quo. Producers and sellers (from grocery
store owners, convenience store owners, to restaurateurs) of high sugar or high fructose corn
syrup laden products could be hurt financially by a change in purchasing patterns if people
would eat fewer refined carbohydrates. Strategies such as labeling high fructose corn syrup
differently (such as DAHLIA syrup, isoglucose, glucose-fructuose, crystalline fructose,
tapioca syrup, corn glucose fructose syrup, or corn sugar) are being used for obfuscation.
However, U.S. dental insurance companies, the U.S. government paying for dental care
in programs such as Medicaid, employers paying for dental insurance, the military (needing
military preparedness), and producers of toothpastes, tooth brushes, floss, mouth rinses, and
other oral health-related products would benefit from improved oral health. Dental
professionals would have a change in services, but many want the people in their care to have
improved oral health; additionally improved communication and dental literacy lessens the
exposure to malpractice claims as people understand the procedures and potential
consequences (Riess & Kraft-Todd, 2014).
It should be noted that although effective communication is necessary for good
healthcare, professional students with negative attitudes toward learning communication skills
undervalue or devalue the skills in their clinical practice and are less knowledgeable
concerning patient-professional interactions than students with positive attitudes (Wright, et
al., 2006). In an unpublished pilot study of dental students, those who valued communication
skills in practice learned more from a didactic course in communication (McKenzie, 2014). In
a follow-up study of dental students, a single didactic course in communication had no
significant effect on student attitudes or self-assessment (McKenzie, 2014). In a study of
medical students, female medical students had more positive attitudes toward communication
skills education than male medical students, while male students had higher scores in their
perceived competence and confidence about communicating than female students (Wright, et
al., 2006). Medical students having had clinical experience, reported higher positive attitudes
toward communication skills training than students who had yet to have clinical experience
(Wright, et al., 2006). These attitudes are barriers to quality healthcare.
There are also barriers in dental literacy resulting from stereotypes and perceptions of
dentists held by many people. In most movies, dentists are portrayed as mean, scary, sadistic,
immoral, unethical, and corrupt individuals (Glazman, 2014). The public blames dentists for
the inadequacies in policies, for being greedy, and uncompassionate (Glazman, 2014).
Dentists are under the pressure of having rising equipment costs, educational costs, and dental
spending below the rate of inflation (Carter, 2014) while assigned fees are not keeping pace
with the amount of work that is being done (Skalsky LJ, 2014; Glazman, 2014). As many
dentists turn the focus of their practice to cosmetic bleaching, Botox, couture veneers, etc.,
dentistry is demedicalized (Glazman, 2014). Dental professionals need to manage their
practices as businesses, while providing quality care and having communication skills to
explain treatment needs in an honest and ethical manner. However, if the public distrusts
 Oral Health Literacy As a Social Determinant of Oral Health 97

dentists, the communication and oral health literacy needed will fall short of the action
required for quality healthcare.
Nevertheless, many groups encourage agency/action toward quality oral healthcare.
Successful, quality healthcare involves cognitive knowledge, technical skills, and the ability
to create rapport and a therapeutic relationship through social skills (among other variables)
(Orsini & Jerez, 2014). Improving another person’s health literacy is one aspect of social
skills.
Where oral health literacy is considered, there are opportunities for many people to
become involved in increasing oral health literacy and improving oral health as well as
working to improve individual efforts toward good oral health within the social context.
School board members, teachers, public health officials, dentists, hygienists and others can
impact the knowledge, attitudes, and beliefs of students and the public at large to whom they
are responsible through education and familiarizing people with medical terminology as well
as using words that are easier to understand. One U.S. government initiative toward
improving understanding is the 2010 Plain Writing Act in which the government must have
“clear communication that the public can use and understand” in its documents (Plain
Language, http://www.plainlanguage.gov/plLaw/index.cfm). Policy makers at the U.S.
National Institutes of Health (NIH) also support the use of plain language. Plain language is
described at the NIH website as being grammatically correct and professional (NIH, 2013).
Plain language is also described at the website as not being “dumbed down” (NIH, 2013).
Plain language is clear communication which helps people to understand (NIH, 2013). Health
literacy is a part of the plain language initiative of the NIH. At the National Oral Health
Conference in 2010, the American Dental Association (ADA) developed a set of goals and a
plan for improved oral health literacy for 2010-2015 (Podschun, 2012). Throughout the
nation, efforts are underway in educating professionals about communication techniques to
improve oral health literacy.

Research in Health Literacy/Health Literacy Communications

Objective Measures: Screenings and Grade level evaluations

Health literacy may be considered a construct which cannot be measured directly (a latent
variable). Many researchers have suggested a variety of techniques to measure health literacy
(Parker, et al., 1995; Baker, et al., 1999; Kutner, et al., 2008; Davis, et al., 1993). Many
involve reading word lists.
However, there are many concerns about conducting health literacy screenings to
determine who has a high literacy level and who has a low literacy level. Poor health literacy
is associated with shame and embarrassment (Parikh, et al., 1996) and asking people to
complete a health literacy test may increase the shame and embarrassment to the point of
avoiding needed care. Many people hide their limited oral health literacy and would not be
willing to participate in such activities or research. The tests have the confounders of
medications, vision, stress, crying, accents, and distractions, among others; therefore the
usefulness of testing is brought into question (Schwartzberg, et al., 2005). There are also
concerns as to how and where the test results would be kept, and how the test would change
treatment or care, if at all (Schwartzberg, et al., 2005). Recommendations exist in which the
98 R. Constance Wiener

tests should not be used in a clinical setting unless tailored communication plans are intended
(Davis, et al., 1998).
It is known that certain groups are considered more vulnerable to limited oral health
literacy, such as individuals who have: English as a second language; chronic
illness/disability; financial challenges; challenges with age, challenges with being pregnant,
challenges with place of residence; challenges with having been incarcerated, etc. (Rivara, et
al., 2011). Also the health literacy of typically high health literate individuals may be affected
by pain, medication, illness, and finances (Evans, 2013).
As a result, there has been a shift: all people are considered to need plain language in
communications; in instructions in medications; in lay brochures, pamphlets, and at official
websites of medical and dental organizations and health related government websites.
Organizations and healthcare personnel are charged with being health literate.
In terms of objective measures and evaluation, written communications, health
communication brochures and pamphlets, and written items available on the internet should
be possible to assess. Such documents are considered inappropriate when jargon or
uncommon terminology is presented without also having explanations in the text, when too
many poly-syllabic words are present, small font, or san serif typeset is used in the document,
and when the communication is outdated or of poor quality (Wiener & Wiener-Pla, 2011).
Accuracy of message is particularly important (Wiener & Wiener-Pla, 2013).
There are several measures which may be used to evaluate the reading level of brochures
and pamphlets. Some of the methods can be done with software features that test the
document’s readability, however other methods require manual word and sentence counts.
The most common tests are the are the Flesch Reading Ease test, the Flesch-Kincaid Grade
level test, and the McLaughlin SMOG Readability Formula.
The Flesch Reading Ease test score is an analysis in which researchers determine the
average sentence length, and the average number of syllables per word to score a document
(Office Online, 2007). Scores between 60 and 70 indicate that the document is a standard
document, and higher scores reflect greater reading ease (Office Online, 2007). The formula
is:

Readability score = 206.835 – (1.015 * Average sentence length) –

(84.6 * Average number of syllables per word) (Office Online, 2007).

The Flesch-Kincaid Grade level test is a test for the school grade associated with the
reading level of the document. The formula is

Grade level score = -15.59 + (0.39 * Average sentence length) +

(11.8 * Average number of syllables per word) (Office Online, 2007).

The McLaughlin SMOG Readability Formula is more complex and involves a conversion
table for the school grade associated with the reading level of the document. Thirty sentences
are used to calculate the readability level. Ten sentences are drawn from the beginning,
middle and end of the document. The number of words with 3 or more syllables is counted in
the 30 sentences. The square root of the count (to the nearest 10) plus 3 is calculated and the
corresponding number is located on the conversion table with the reading grade level.
(Readability Formulas, nd).
 Oral Health Literacy As a Social Determinant of Oral Health 99

A problem encountered with each of the tests is, after a polysyllabic term has been
identified and explained, the term continues to be counted as a difficult term in the readability
test. For example, the term, chronic obstructive pulmonary disease, may be presented with the
acronym “COPD,” or with the words, “lung disease” following it parenthetically as: chronic
obstructive pulmonary disease (COPD, or lung disease). Similarly, the word, hypertension
may be presented with the words “high blood pressure” following it parenthetically as:
hypertension (high blood pressure). It is important that people can recognize scientific or
medical terms after the terms have been introduced and explained in a brochure or pamphlet
so that they can fully understand their conditions. In reading level analyses tests, the reading
level will be higher if scientific or medical terms are used (even if they have been explained).
This is an aspect of determining readability levels which needs to be addressed.
In addition to brochures, pamphlets, and websites, it is necessary that prescriptions,
medication instructions, and medication package inserts are written clearly and in plain
language. Many healthcare professionals now use software to write prescriptions to decrease
the misinterpretation involved with a handwritten prescription. Also, many healthcare
professionals avoid Latin terminology and Roman numerals, which were once de rigueur.
This helps to avoid confusion. However, package inserts and secondary labels on prescription
bottles are often written at high grade levels and in small font. Some medications look alike;
some medications sound alike (Wong, 2014). Drug interactions are important considerations
when people are on several medications. Medication labels may have wording which can be
understood from several points of view.
Some people may have difficulty calculating when to take medications. For example, if
the instructions are to take a medication “3 times a day,” some people may not be able to
calculate the hours in which the medication should be taken.
Some people do not understand what is meant by a “teaspoon.” Some people do not
understand why some medications can be discontinued when symptoms subside, and why
others must be continued until all of the medication is used. Other areas of confusion are why
some medications should be taken with food, and some should not be taken with food; why
some medications should not be taken if the person cannot stand or sit upright for 30 minutes;
or how much water to take with a medication. Medication compliance is identified by the
World Health Organization as a significant world-wide problem (Sabate, 2003).
Many pharmacy school professors, and owners of pharmacies are increasingly having
pharmacy students or pharmacists speak directly with people who have been given a
prescription, particularly if it is a new prescription. They explain how and when to take the
medication, and what additional effects may occur with the medication. They demonstrate the
use of syringes, or devices such as inhalers. These actions are very important and constitute
helping people to become health literate. Nevertheless, many of these activities are
perfunctory or done too rapidly for individuals who need more time to assimilate what is
being explained. This is particularly true in busy pharmacies.
Additionally, screening tools are being developed to use non-obtrusive data from
medical/dental health histories to determine if an individual may be more vulnerable to
having a medication problem (Claydon-Platt, et al., 2014). One such screening tool is to
identify people with diabetes at increased risk for medication problems (Claydon-Platt, et al.,
2014).
Much has been done, but much remains to be done as medication errors and non-
compliance continue to be significant problems.
100 R. Constance Wiener

Subjective Measures: Standardized Patients, Professorial Evaluations,

Surveys
Certain communication styles and techniques are established in rubrics for evaluating
healthcare students in their interactions with standardized patients, or through professorial
evaluations of healthcare students with their patients. Throughout the nation, simulation
laboratories are being used to teach technical skills, as well as to help students learn to
communicate with patients. Students are video-taped speaking with standardized patients. The
standardized patient concept was introduced by Howard Barrows at the University of
Southern California in 1963 (Beattie, et al., 2014). The standardized patients and the students’
instructors have criteria upon which they grade the students. The students are debriefed as to
how they could improve communications. With the simulations, the students have an
opportunity to practice appropriate communication techniques while taking histories,
providing instructions, and giving explanations to individuals who are older, younger, of a
different race/ethnicity, of a different socioeconomic status, have hearing problems or cannot
hear, need an interpreter, or speak only limited English, etc. One concern with evaluating
dental and dental hygiene students is that most of the research in oral health literacy has used
criteria in medicine and psychology, rather than specifically for dentistry (Orsini & Jerez,
2014). A dental practitioner-patient interaction skills tool has been developed recently which
has 43 indicators to evaluate a dental student’s communication skills (Orsini & Jerez, 2014).
Its use may be very helpful in addressing needs specific to dentistry and dental hygiene.
One communication skill that students develop and for which they are evaluated in
simulations is being at eye level with the person with whom they are speaking and
maintaining eye contact during the communication. An environmental barrier which is
frequently encountered in general office settings is the placement of a hard-wired computer
which is needed to input health data by the healthcare person. In such cases, it is important for
the healthcare provider to return his or her gaze and body position to the patient as often as
possible despite the inconvenience. Dental and dental hygiene students should conduct patient
instruction and have other discussions before the patient is reclined in the dental chair and
return the patient to the seated position as much as possible during waits (waits for clinical
instructor checks, waits for processing materials, etc.)
Oral healthcare personnel must speak clearly, slowly, and in plain English in their
explanations to patients. People may be primarily visual learners, auditory learners, or
kinesthetic learners. It is necessary to provide visual aids for visual learners, verbal
explanations for auditory learners, and physical, touchable aids for kinesthetic learners. It is
best to limit messages to two to three concepts at a time. The use of models is often helpful.
Words or pictures drawn on notepads help patients to understand and remember complex
information. Patients are helped when healthcare professionals verbally summarize brochures
and pamphlets and highlight or underline important concepts as the professional is speaking
with the patient. Over-the-counter medication recommendations should be provided in written
form with proper dosing, either on the office’s computer generated prescription form, or on a
sheet from a prescription pad to emphasize the importance of the over-the-counter
medication.
The students’ clinical professors also determine if students are using behavior
management techniques such as live/video modeling, tell-show-do, teach-back, positive
reinforcement/encouragement, and motivational interviewing. Live modeling is a technique
that is useful in working with children. Bandura (1967) defined modeling as a means to
 Oral Health Literacy As a Social Determinant of Oral Health 101

acquire behavior through the observation of a model (Farhat-McHayleh, et al., 2009). In a

dental setting, a parent is asked to sit in the dental chair and undergo a short procedure, such
as an examination, while the child observes and asks questions (Farhat-McHayleh, et al.,
2009). Video modeling is similar, however the procedure is watched on a screen and the
provider answers questions after the video is viewed.
Tell-show-do is another behavior management technique used in dentistry. Its
antecedents are in World War I when Charles R. Allen developed the “preparation,
presentation, application, test” model for preparing workers for specific jobs (Huntzinger,
2007; Allen, 1917). The presentation portion of his model was described as “tell, show,
illustrate” and the application portion was described as “do” by the Bureau of Training, War
Manpower Commission in 1944 (Huntzinger, 2007). Harold Addelston used the phrase “tell,
show, do” to describe a direct interaction between the dental healthcare person and the patient
in which the patient is told what will be done, is shown the instruments, or may receive a
demonstration of how the instrument feels on the hand so that a sense of control is felt by the
patient and the patient is not surprised by the procedure (Roberts, et al., 2010; Glazman,
2014; Hendrie, 2014).
Teach-back is a technique of checking that the message received was the one intended.
The healthcare person says something to the effect of “I want to check that I have explained
everything the way that I intended to explain it. Would you tell me how you are going to
answer your family when they ask you about what I said to you?”(National Patient Safety
Foundation, 2014).
In positive reinforcement/encouragement, the dental healthcare professional supports the
patients’ efforts to cooperate; he or she uses “I” statements and describes the situation. For
example, an “I” statement to a child may have the form of: “I really like it when you keep
your hands on your lap while I am working. It makes my job so much easier. Thank you.” A
descriptive statement may be: “Your hands have stayed in your lap for the whole procedure.
What a good job at keeping your hands in your lap!”
Members of the National Patient Safety Foundation (2014) suggest providers need to
teach patients to use “Ask me 3.” Patients have the right to have these 3 important questions
answered after a visit:

 What is my main problem?

 What do I need to do?
 Why is it important for me to do this?” (National Patient Safety Foundation, 2014).

Motivational interviewing is a technique to encourage changes to improve health (Miller

& Rollnick, 2013). When people are considering change, they often need someone to discuss
their situation and listen to their concerns. In the conversation, they need to address the
reasons that they:

 want to change or modify a poor health behavior;

 the manner in which they will change to a healthier behavior; and,
 the importance of making the change to a healthier behavior.
102 R. Constance Wiener

A healthcare professional helps by listening. A healthcare professional helps by listening.

Much of motivational interviewing is focusing the conversation on change, using open-ended
questions, and listening. When the person has finished speaking, the healthcare professional
summarizes the person’s concerns and ambivalence, and then makes a reflective statement
about what is being planned. The reflective statement would have the form of: “You plan
to..;” or “You think you will…” followed by a rephrasing of what the person would like to
accomplish. Motivational interviewing is often used with smoking cessation. Having their
smoking patients consider smoking cessation or decrease the number of cigarettes smoked are
concerns for dental professionals. Motivational interviewing has had mixed results in recent
studies in smoking cessation and/or decreasing the number of cigarettes smoked (Mujika, et
al., 2014; Ridner, et al., 2014; Pelletier, et al., 2014; Rohsenow, et al., 2014).
Other behavioral management techniques include voice modulation, distraction, asking
for help in follow-up, nudges, and prompts. Certain words are commonly used when working
with children to help alleviate their concerns about being in the dental office. Some examples
are: “sleepy juice” instead of injection; “numbing jelly” instead of topical anesthetic; “Mr.
Whistle” instead of high speed handpiece; and “Mr. Bumpy” instead of slow speed
handpiece. It is important that the dental professional engages the parent/guardian to be
supportive and that the parent or guardian avoids saying anxiety-provoking words, such as
“shot” or “pulling teeth,” or make comments that undermine the trust between the child and
the healthcare professional.
To evaluate oral health literacy skills of dentists and dental hygienists after they have
graduated is difficult. Outside of academia, the number of dental professionals who use the
health literacy suggestions is only known through surveys of self-report. Self-reports are
fraught with problems. The skills that are needed for health literacy competence are the same
ones needed to evaluate competence, or any skill (Kruger & Dunning, 1999). People tend to
overinflate self-appraisals (Kruger & Dunning, 1999); therefore, many researchers have
eschewed using self-reports.
In one such self-report study, researchers determined that the most common
communication technique used by participating Maryland dentists was the use of simple
language (Maybury, et al., 2013). There were 93.4% of general dentists and 97.4% of
pediatric dentists who reported using simple language (Maybury, et al., 2013). The second
most common technique was to speak slowly; there were 77.4% of general dentists and
83.3% of pediatric dentists who reported speaking slowly (Maybury, et al., 2013).

A Walk through the Maze

Dentists and dental hygienists can improve their provision of oral health literacy within
their clinical area by evaluating the steps needed to access their care. They should consider if
their telephone is answered quickly. If telephone options are presented to the caller, they
should decide if the options are clear or confusing. The office website should be evaluated for
patient friendliness and easy navigability. Outdoor signs should be clear and have words that
are easy to understand. The doctor’s name should be listed on inside directories. Questions
that should be considered are:
 Oral Health Literacy As a Social Determinant of Oral Health 103

 Does the office staff member who presents forms to patients also offer to help?
 Are there policies in place for working with someone who does not speak English or
who is deaf or hard of hearing?
 Do the brochures have plain language? Are they up to date? Is the font large enough
for someone to read who has difficulty with vision?
 Are the models adequate to explain different oral conditions?
 Are there notepads to write explanations?
 Are oral dosing syringes prescribed or recommended for use rather than teaspoons?
 Are prescriptions written in such a way that there is little confusion about dosing?

Researchers recently studied 8,000 prescriptions and found that 73% had incomplete data
(missing name, dosage form, dose and measuring unit, administration route, or intervals of
administration); 15% had transcribing errors; 1/3 had administration errors; and there were
1.4-2.2% dispensing errors (Saghafi, & Zargarzadeh, 2014). Incomplete health histories, due
to limited health literacy may also lead to errors in treatment. And difficulty navigating to the
office may result in late or missed appointments.
Although a dental team may have good signage, easy to complete forms, and good
brochures, there is also a need to walk through the maze of cultural differences. Many
immigrants and non-native English speakers have cultural, religious, and dietary beliefs or
views that may be different from the dental professional. It is important that the dental
professional becomes familiar with the religious and cultural beliefs of the people they serve
and develop cultural skills to improve communication. Different cultures have different
metaphors and it is important to learn what patients mean when their descriptions use
terminology and points of view from a different perspective.

Anticipatory Guidance: A Holistic Approach to Oral Health

The dental community is asked to provide anticipatory guidance through the life course.
Even before pregnancy, women of childbearing age are encouraged by healthcare
professionals to eat a healthful diet, to brush at least twice daily with fluoridated toothpaste,
to floss daily, and to have routine dental care. Additionally, healthcare professionals are
concerned about injury prevention, the need to wear seatbelts and to not engage in smoking,
heavy drinking or illicit drug use. During pregnancy, expectant mothers are encouraged to
have preventive care and to have needed emergency care in addition to proper nutrition and
home care. Early in the pregnancy women may be advised to use toothpastes which are less
bubbly to help with an increased gag reflex, and may be advised to limit snacking. Healthcare
professionals encourage breastfeeding for the health and nutrition of babies for the first year
of life. When solid food is introduced to infants, parents/guardians are advised to not blow on
the baby’s food, or share spoons or forks. If a pacifier is used, parents/guardians are advised
not to place the pacifier in his or her mouth as bacteria from the parents may be transferred to
the child if they do so. (Casamassimo & Holt, 2004). Pacifiers should be made as one unit of
flexible, firm material; they should not be tied to the baby with a ribbon or string; and they
should not be dipped into sugar/honey/syrup (Casamassimo & Holt, 2004). Anticipatory
guidance in terms of injury prevention includes discussions with parents of newborns to place
their baby to sleep on his or her back; to remove toys, bumper pads, etc. from the crib; to have
a crib that meets current safety recommendations; to not put baby to bed with a bottle; to have
104 R. Constance Wiener

the appropriate car seat; to avoid small items which may pose safety hazards (aspiration or
swallowing); to keep one hand on the baby when he or she is on a high surface; and not to
place the baby in a shopping cart (Casamassimo & Holt, 2004).
As the baby becomes a toddler, anticipatory guidance includes having the baby have his
or her first dental visit by age one year. In the dental home, anticipatory guidance can be
provided about nutrition, weaning, frequent snacking, limiting juices and sweet drinks as well
as car seats and vaccinations. Parents/guardians should be asked to do a monthly screening of
the child’s teeth and be taught what would be considered suspicious. Parents/guardians need
to know that children do not brush and floss adequately until age 6 or 7 and need help as well
as supervision (ADA Division of Communications, 2002). A smear of toothpaste should be
used until age 2; and a pea-sized amount of toothpaste should be used afterwards, at least
twice daily. Injury prevention discussions may focus on having emergency contact
information available; securing cabinets with household cleaners, medications, etc. inside,
etc; keeping cords out of the reach of the child; using safety gates and toilet locks; keeping
pet food/pet dishes away from the baby; and keeping the baby away from a pet while eating
(Casamassimo & Holt, 2004). Parents should be advised that, should an injury to the face
occur in which a primary tooth is lost, the primary tooth should not be re-implanted before the
child is taken to the dentist. Anticipatory guidance also involves community activism to keep
playgrounds and playground equipment maintained and safe (Casamassimo & Holt, 2004).
Through the years, discussions will need to continue about nutrition and daily oral health
care. Older children begin to play sports, and sports injuries to the face and teeth are common.
Therefore, a discussion of helmets and mouthguards is important. Parents spend a lot of
money on sports shoes, but there is often reticence to spend the same amount of money on
custom mouthguards. Custom mouthguards are as essential as specialty shoes. Should a
permanent tooth be lost, parents/guardians should be prepared to gently rinse it with water,
identify the front (facial) of the tooth and re-implant it before taking the child to the dentist.
Adolescents often are under orthodontic care, and mouthguards are particularly necessary for
teeth that are being moved. Also, for adolescents in orthodontic care, the need for good oral
health care should be stressed by many people in the family and the child’s dental health
profession contacts.
Adolescents often engage in risk-taking behavior, therefore anticipatory guidance is
needed in discussions with parents, and with adolescents concerning vehicular crashes, oral
sequale which may be associated with oral sex, smoking, alcohol, and drug abuse and their
effects on teeth and gingival tissue. Oral piercings and jewelry can fracture teeth, irritate and
destroy gum (gingival) tissue. Dental healthcare professionals cannot assume that their
adolescent patients are health literate from attending school, or having routine well child
visits in which all of these topics have already been discussed. Although often difficult to
breach this topic, bad breath also needs to be discussed. Many people find malodor socially
offensive or disgusting and avoid people with bad breath. People may be unaware of the
resulting social isolation. This is particularly important for adolescents.
As a person matures, the importance of oral health care often is considered in terms of
aesthetics. Tooth whitening products are available as strips, gels, in toothpastes, sticks, and in
dental offices. Their use and overuse should be discussed as anticipatory guidance.
Older adults who may be considering dentures need to have guidance in understanding
the need for oral cancer screenings even after the dentures are in place, the need to evaluate
the dentures for fit as there are bone changes over time, the potential for candida infections
 Oral Health Literacy As a Social Determinant of Oral Health 105

and angular cheilitis; the oral effects of common medications such as having a dry mouth, and
altered taste, and nutritional needs.

Conclusion
Some people are fortunate. They have had daily oral hygiene practices from infancy; they
have had routine care, and dental sealants; they have had any needed orthodontic care. Their
circumstances and education have been bright and hopeful. Their smile and fresh breath may
have helped them secure a job. Their genetics, nutrition, and oral microbiome are healthful.
Other people are not as fortunate. Drugs, alcohol, smoking, stress, trauma, discrimination,
poor nutrition, bullying, social pressures, inadequate home care, as well as an acidogenic oral
microbiome affected their oral health. The disparity involves social determinants in an
ecosocial context.
Improving oral health literacy skills in oral healthcare professionals is one social policy
among many which may help improve the nation’s people’s oral health and overall health.

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In: Oral Health ISBN: 978-1-63482-832-1
Editor: Julia Renee Barnes © 2015 Nova Science Publishers, Inc.

Chapter V

Oral Health and Mental Health

Karen-Leigh Edward, PhD

Director, St Vincent's Private Hospital Melbourne Nursing Research Unit
Associate Professor of Nursing Research, School of Nursing,
Midwifery & Paramedicine| Australian Catholic University
Visiting Professor, School of Human & Health Sciences|
University of Huddersfield, United Kingdom

Abstract
Mental disorders represent one of the largest burdens of disease globally. People who
experience mental illness have incrementally worse physical health compared to the
general population. While there is a movement in mental health care to consider physical
health needs of service users, the oral health needs are not routinely assessed.
Compounding the lack of routine or standardised oral health assessment in mental health
services, service users/consumers often demonstrate avoidant health seeking behaviours.
Health service avoidance for physical care needs is often compounded by prohibitive
costs, stigma related to mental disorder, unsatisfactory previous encounters with oral care
practitioners and psychiatric symptomatology impacting behaviours. This chapter will
using contemporary literature describe the complexities related to oral care of people who
experience mental disorders and the implications this may hold for their quality of life,
practice, research and policy.

Keywords: Mental health, mental illness, oral effects of psychotropic medications, oral
health, oral hygiene, periodontitis, xerostomia


Mailing Address: Faculty of Health Sciences, Australian Catholic University, Melbourne Campus, Locked Bag
4115 FITZROY MDC 3065, Australia, T: +61 3 94117338, E: [email protected]
112 Karen-Leigh Edward

Introduction
This chapter will introduce you to the oral health needs of people experiencing mental
illness. The chapter begins with an examination of co- occurring mental and physical health
conditions with a focus on the oral condition of individuals. The assessment and intervention
of oral health care will be discussed and a vignette will be offered to help the reader to
assimilate their learning and reflect on their own practice. Some useful websites will be
highlighted for the reader as points of reference to use for further learning.

Mental and Physical Health-Barriers to Care

Co-existing conditions are associated with poorer health outcomes and are characterised
by higher rates of severe illness trajectory, frequent hospitalisations, higher rates of
aggressive behaviour, relapse, suicidal behaviours, social isolation, family or care giver
distress, homelessness and higher rates of mortality (Edward, Felstead, & Mahoney, 2012;
Salamone, Yacoub, Mahoney, & Edward, 2013). While the physical health care of people
who are receiving mental health services is a prominent focus of mental health care delivery,
practice remains varied across countries and services. Some of the issues related to the lack of
a standard approach to the physical care of people in mental health services relates to
differences in governance, differences in funding support from governments for such
initiatives and other impacts such as stigma and environmental barriers to receiving such care.

Oral Heath in People Who Live with Mental Illness

About 14% of the global burden of disease is attributed to mental illness (Prince et al.,
2007; WHO, 2008). Among this number of people oral health care is not routinely sought by
consumers or provided by mental health clinicians. Avoidant behaviours related to oral care
and seeking an oral health practitioner presents as a significant barrier to help seeking
behaviours of consumers. For example people who have had encounters with oral
practitioners that were unsatisfactory or who found the costs associated with oral care
prohibitive will postpone or avoid altogether attendance to receive oral care. Additionally,
symptoms of mental illness such as amotivation, avolition, agitation or akathesia can also
impact on the ability of the person to seek oral health consultation when in the community.
Up to 90% of people who have mental disorders receive medication management as part
of their treatment. However, these drugs can impact the physical state of the individual and
requires vigilant management by clinicians involved in the person’s care. For example, the
first generation antidepressant medications, tricyclic antidepressants (TCA’s) were widely
used and can bring about unwanted effects such as a dry mouth (xerostomia). This is related
to the neurochemical actions of TCA’s which block histaminic, cholinergic and alpha-1-
adrenergic neuroreceptor sites. In the second generation antidepressants (such as serotonin
reuptake inhibitors -SSRI’s) the xerogenic impact is less than that seen in the TCA’s. Dry
mouth otherwise known as xerostomia occurs in 14% people taking SSRI’s and 45% of
people taking TCA’s.
 Oral Health and Mental Health 113

Mental disorders and the medications to treat these can be associated with common types
of oral health concerns that the treating clinician can look for when undertaking a physical
assessment of the individual. Common oral manifestations of major depression include:
dental caries, poor oral hygiene, xerostomia, toothlessness, periodontal disease and poor
nutrition (Edward, Hemingway, & Stephenson, 2012). The oral manifestations of the manic
phase of bipolar affective disorder may include: worn down (abraded) oral mucosa and
cervical tooth abrasion (due to over vigorous brushing or use of dental floss). In relation to
antipsychotic medications the anticholinergic effects such as dry mouth experienced by up to
44% of patients.
People with mental disorders may choose unhealthy lifestyle choices or due to their own
circumstance have fewer social supports or skills and as a result have higher rates of
morbidity and mortality (Robson & Gray, 2007) and worse oral conditions (Persson, Axtelius,
Söderfeldt, & Östman, 2009; Stevens, Spoors, Hale, & Bembridge, 2010). Such
considerations commonly seen in people living with a mental illness can impact the person’s
oral condition for example taking psychoactive medications (Ponizovsky, Zusman, &
Grinshpoon, 2009), smoking, poor diet, poor hydration and suboptimal hygiene behaviours.
The prevalence of substance use disorders in people with early psychosis is relatively high
with rates between 40-50% and the associated oral implications are substantial. The oral
concerns related to substance abuse or misuse pertain to xerostomia (due to atrophy of the
salivary glands), impaired wound healing due to liver damage, higher incidence of oral
cancers due to heavy smoking and poor oral hygiene due to reduced brushing and flossing
practices. Oral care is important to all people but especially those who experience mental
disorders as poor oral condition can negatively impact the way in which the person relates to
others in their social environment. Importantly, poor oral hygiene can amplify the prevalence
of morbidity and mortality in patients (Berry, Davidson, Masters, & Rolls, 2007).
Oral bacteria, poor oral health care, and periodontitis appear to impact upon the incidence
of infections (such as pneumonia), especially those infections acquired in a hospital (Paju &
Scannapieco, 2007). The available evidence suggests systemic inflammation as seen in
infections could represent a link between oral health and cardiovascular disease (CVD) (de
Oliveira, Watt, & Hamer, 2010; Fisher, Borgnakke, & Taylor, 2010). A study of 11,000
adults highlights a significant increase in development of heart disease with people who only
brushed their teeth once per day (de Oliveira, et al., 2010) as compared to those who brushed
more. Importantly, cost efficient clinical care practices can alter patient outcomes, such as the
implementation of a simple, low-cost oral care regime of flossing and brushing to decrease
these risks for patients (Mori et al., 2006) where such interventions can also offer
improvements in the persons quality of life (Buunk Werkhoven, Dijkstra, Schaub, Van Der
Schans, & Spreen, 2010).

Oral Assessment in Mental Health Settings and Oral Condition

Terminology

Oral assessment is not routinely undertaken in mental health in-patient or community

settings. The reasons for this potentially relate to confusion related to roles of responsibility
for oral care (clinician responsibility versus the consumer’s responsibility), clinician and/or
patient knowledge gaps related to oral conditions and confusing oral condition terminology
114 Karen-Leigh Edward

(for example, the terms stomatitis and mucositis have been used interchangeably when
describing inflammatory oral conditions). Finally there are a range of instruments available to
undertake oral assessment however some require education in the first instance and generally
few clinical staff outside of the speciality of oral health care are not provided undergraduate
education related to the existence of such tools or the integration of such practices in routine
care delivery.
Some of the available oral assessment instruments include the Oral Assessment Guide
(OAG) (Eilers, Berger, & Petersen, 1987), the Oral Mucositis Index (OMI) (Eilers & Epstein,
2004), and the Oral Health Assessment Tool (OHAT) (Chalmers, King, Spencer, Wright, &
Carter, 2005). Available oral health assessment tools often focus on the state of the mucosa
including gingival, tongue, lips and the presence of breakdown or bleeding. The state of
dentition is also often a focus where teeth are counted and surfaces are measured for signs of
decay. Not all instruments take into consideration the social impacts of oral health problems
or the ability of the consumer to self manage their oral care.

From the Mental Health Consumer’s Perspective – Tony’s Story

Tony has a diagnosis of schizophrenia and at 45 years old he has lived in the community
independently for many years with the support of the local mental health community clinic.
Tony lives alone and he has a case manager who visits him at home once a fortnight. Tony
lives in a flat that is central to shops and public transport. He is on high dose antipsychotic
medication to manage his psychotic condition and often experiences a dry mouth as an
adverse effect of the medication. Tony has a brother who also has a mental illness and they
don’t see each other very often. His case worker notices Tony does not own a refrigerator and
asks him how he keeps his food fresh. Tony says his diet consists of coffee, jam sandwiches
and the occasional steak. Tony says he shops daily so there is no need for a fridge. He doesn’t
eat fruit or drink anything other than black coffee. Tony lives on a pension and smokes 2
packets of cigarettes per day.

Ask Yourself!

1. As the case worker do you think it is important to inspect Tony’s oral condition
during home visitations?
2. Who is the person to contact if Tony needs to have oral care needs addressed?
3. Is there any additional support you can offer Tony related to optimal oral care that he
can perform himself?

Clinical reflection
Using the standard assessment forms available in mental health care provides an opportunity to
assess and document the oral condition of mental health consumers.

The importance of inspecting oral condition in people who live with mental illness relates to –
increasing the potential to retain teeth; early detection of poor oral health such as ulcers or even
oral cancers; an opportunity to provide cost effective dental hygiene and potentially to identify
where referral may be required.
 Oral Health and Mental Health 115

Opening up dialogue with mental health consumers about their oral condition can provide an
opportunity to provide education related to maintaining oral health such as –

brushing teeth twice a day,

use of toothpaste,
flossing and the benefits of gum health for teeth minimising sugary drinks,
keeping a healthy diet, and
options for regular oral health checks via a dental practitioner such as dentist or a dental
hygienist.

While cost for dental practitioners may be prohibitive for people identification of early oral
problems may offer a means of prevention of severe oral problems.

Conclusion
Oral health in mental health settings is usually a low priority. This is due in the main to
competing priorities in the clinical care of people who use specialist areas when the principal
specialist health issue is primary, when there exist knowledge gaps, avoidant behaviours of
consumers and stigma related to poor oral hygiene and/or mental health. However, cost
effective strategies can be used in clinical practice in any setting that can improve the
person’s oral hygiene (brushing teeth and flossing) and timely referral to oral practitioners
such as oral hygienist can improve oral health. Oral assessment tools are also available for
clinical staff to use and these range from the complex to the simple to use. Improving
physical condition can positively impact on an individual’s mental wellbeing, including care
for oral health.

Useful Websites
The burden of oral disease available at http://www.cdc.gov/chronicdisease/
resources/publications/aag/doh.htm
Caring for my teeth available at http://www.dentalhealth.org/tell-me-about/topic/caring-for-
teeth/caring-for-my-teeth
Impacts on oral health – people living with mental illness available at
http://oralhealthplan.com.au/tags/people-living-mental-illness

References
Berry, A., Davidson, P., Masters, J., & Rolls, K. (2007). Systematic literature review of oral
hygiene practices for intensive care patients receiving mechanical ventilation. AmeriCan.
J.ournal of Critical Care, 16(6), 552.
116 Karen-Leigh Edward

Buunk Werkhoven, Y., Dijkstra, A., Schaub, R., Van Der Schans, C., & Spreen, M. (2010).
Oral health related quality of life among imprisoned Dutch forensic psychiatric patients.
Journal of Forensic Nursing, 6(3), 137-143.
Chalmers, J. M., King, P. L., Spencer, A. J., Wright, F., & Carter, K. D. (2005). The oral
health assessment tool—validity and reliability. Australian Dental Journal, 50(3), 191-
199.
de Oliveira, C., Watt, R., & Hamer, M. (2010). Toothbrushing, inflammation, and risk of
cardiovascular disease: results from Scottish Health Survey. British Medical Journal,
340(may27 1), c2451.
Edward, K.-l., Hemingway, S., & Stephenson, J. (2012). Oral health–a key assessment skill
for mental health nurses: a pilot evaluation of an educational intervention. Mental Health
Nursing, 32(6), 12-16.
Edward, K., Felstead, B. M., & Mahoney, A. M. (2012). Hospitalized mental health patients
and oral health. Journal of Psychiatric & Mental Health Nursing, 19(5), 419-425.
Eilers, J., Berger, A., & Petersen, M. (1987). Development, testing, and application of the
oral assessment guide. Paper presented at the Oncology nursing forum.
Eilers, J., & Epstein, J. B. (2004). Assessment and measurement of oral mucositis. Paper
presented at the Seminars in oncology Nursing.
Fisher, M. A., Borgnakke, W. S., & Taylor, G. W. (2010). Periodontal disease as a risk
marker in coronary heart disease and chronic kidney disease. Current Opinion in
Nephrology and Hypertension, 19(6), 519.
Mori, H., Hirasawa, H., Oda, S., Shiga, H., Matsuda, K., & Nakamura, M. (2006). Oral care
reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive care
medicine, 32(2), 230-236.
Paju, S., & Scannapieco, F. A. (2007). Oral biofilms, periodontitis, and pulmonary infections.
Oral diseases, 13(6), 508-512.
Persson, K., Axtelius, B., Söderfeldt, B., & Östman, M. (2009). Monitoring oral health and
dental attendance in an outpatient psychiatric population. Journal of Psychiatric and
Mental Health Nursing, 16(3), 263-271.
Ponizovsky, A., M, Zusman, S., P, & Grinshpoon, A. (2009). Oral Health and Hygiene
Among Persons With Severe Mental Illness: Reply. Psychiatric Services, 60(10), 1402.
Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M., & Rahman, A. (2007).
No health without mental health. The Lancet, 370(9590), 859-877.
Robson, D., & Gray, R. (2007). Serious mental illness and physical health problems: a
discussion paper. International Journal Of Nursing Studies, 44(3), 457-466.
Salamone, K., Yacoub, E., Mahoney, A.-M., & Edward, K.-l. (2013). Oral Care of
Hospitalised Older Patients in the Acute Medical Setting. Nursing Research and
Practice, 2013.
Stevens, T., Spoors, J., Hale, R., & Bembridge, H. (2010). Perceived oral health needs in
psychiatric in-patients: impact of a dedicated dental clinic. Psychiatric Bulletin, 34(12),
518.
WHO. (2008). The global burden of disease: 2004 update. In W. H. Organisation (Ed.).
Geneva: World Health Organisation.
In: Oral Health ISBN: 978-1-63482-832-1
Editor: Julia Renee Barnes © 2015 Nova Science Publishers, Inc.

Chapter VI

Oral Health: Social Determinants,

Role of Nutrition and Impact
on Quality of Life Determinants of Oral
Health and Quality of Life of
Schizophrenic Patients

Frédéric Denis1*, DDS, MSC,

and Benoit Trojak2, MD, PhD
1
La Chartreuse Psychiatric Center, Dijon, France
University Hospital of Besançon, Besançon, France
EA 481, Laboratory of Integrative and Clinical Neurosciences,
Besançon, France
2
Department of psychiatry and addictology University Hospital of Dijon, Dijon, France

Abstract
Schizophrenia is a severe mental disorder. It is a ubiquitous disease affecting 1% of
the world population. Delusions and hallucinations are symptoms of the disease, but
discordance and negation of the body mean these people are not always able to make the
right decisions to take care of their health. This is one reason why dental health indicators
are very high compared to the general population. Poor oral health is one of the causes of
stigma from which these people suffer greatly.
Determinants of the oral health of these patients are multiple. The neurological
effects of first-generation antipsychotic drugs are multiple (dyskinesia, extrapyramidal
syndrome, myasthenia gravis, and trismus) and disrupt the motricity of the oral region.
The metabolic effects of second-generation antipsychotic drugs (dyslipidemia,
hyperglycemia, weight gain, hyperprolactinemia, and cardiovascular ischemic disorders)

*
[email protected].
118 Frédéric Denis and Benoit Trojak

and more generally anti-cholinergic pharmacopoeia worsen dental problems further.

There are also other determinants of oral health of schizophrenic patients, such as
disruption of the nociceptive pathways, taking psychoactive substances, smoking, poor
diet and lifestyle, and lower socioeconomic status. The lack of somatic care in relation to
the division between body and mind must also be mentioned. Lastly, health promotion
activities are inadequate for these populations and health professionals lack training in
this area.
Studies on the subject are difficult to implement because patients do not readily
consent to the exploration of an organ with a strong symbolic and emotional component.
Studies that target only schizophrenic patients are few and far between and only concern
hospitalized patients, i.e. few patients. The state of knowledge in this area has a low level
of evidence. Outstanding issues are numerous regarding the effectiveness of preventive
actions and management of patients with very specific needs. In this context, we analyzed
the impact of poor oral health of schizophrenic patients on their overall health and quality
of life through motivational and cognitive constraints imposed by the symptoms of
schizophrenia, but also through the unique perspective of caregivers and society about
this disease that is too often stigmatized.

Introduction
Schizophrenia is a ubiquitous disease that affects 1% of the world population [1]. This is
a severe mental disorder characterized by a diverse set of symptoms of varying intensity: the
most impressive are delusions, hallucinations, and mental dissociation and for the most
disabling of them, and also social withdrawal, negation of the body and cognitive difficulties
[2]. In essence, schizophrenic patients are not always able to perceive their health problems
and / or make the right decisions to solve them autonomously [3]. This results in the
coexistence of psychiatric disorders and many organic comorbidities [4-6]. Two-way
relationships are clearly established: mental illness that causes organic diseases and organic
diseases that can be complicated by psychiatric disorders. Thus, among the usual somatic
comorbidities of these patients, we mention, metabolic disorders or "metabolic syndrome"
(diabetes, hypertension, dyslipidemia, and abdominal obesity), malnutrition, poor lifestyle,
and poor oral health [5, 7-10]. The latter is often found by carers. It is one of the causes of
stigma cruelly suffered by these patients (2). Also, antipsychotic medications have side
effects that are combined with all the co-morbidities to which they are exposed [11]. This is
one of the reasons why schizophrenic patients have a lower life expectancy of 15 to 20 years
compared to the general population, with the exception of suicide [12]. Improving the
management of somatic disorders is therefore a major public health issue.

1. Schizophrenia
Schizophrenia is a serious mental disorder, chronic and complex, whose occurrence
depends on the presence of genetic and environmental factors. It affects around 0.7% to 1%
of the world population [1]. It occurs in all regions of the world, but is more frequent in urban
areas and among migrants, most often between 15 and 25 years. In humans, schizophrenia
symptoms typically begin in adolescence around 15-16 years; in women a little later at the
 Oral Health 119

age of 20 or early 30s [13, 14]. The diagnosis of schizophrenia can be defined from the
description of the symptoms of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-V; 5th revised edition), a work that is the subject of broad consensus [15].
Schizophrenia is characterized by a break in contact with the surrounding world, withdrawal
from reality, and autistic thinking. Specifically, there is a disruption of the usual balance of
emotions and thoughts. This severe mental illness is characterized by many symptoms, which
can vary from one person to another and are not always present at the same time. They are
classified into three categories:
Positive symptoms consist of abnormally active productions of the mind, such as
hallucinations, delusions, thought disorders, and behavioral disorders.
Negative symptoms correspond to a decrease or lack of reaction or the usual response to a
given situation. The patient spends a lot of time in bed, is unwilling to participate in daily
tasks, and is limited to basic needs (food, sleep, etc.). The warning signs of these symptoms
are social withdrawal, lack of energy and motivation, reduced emotional expression, or
expression of ideas.
Cognitive symptoms affect the person’s ability to understand, analyze, and remember
information. The person has difficulty concentrating or staying focused on a specific task.
Short-term memory can be affected and the patient often finds difficulties in implementing
activities in their daily lives (medication and personal and dental hygiene). The schizophrenic
is ambivalent, disinterested in the surroundings, and has difficulty making decisions. This is
in association with social dysfunction, ambivalence, loss of control, and attention and
memory problems that interfere with learning in some individuals [16].

Causes

Research has highlighted that there is not just one simple cause, but rather several
important variables factors that interact with each other to cause the disease and its relapses.
Interaction between biological and environmental factors contributes to the disease. Among
the biological factors that appear to contribute to schizophrenia are the recurrence of the
disease in the family, brain abnormalities, neuropsychological fragility, biological
disturbances of brain neurotransmitter (serotonin and dopamine), etc. Environmental causes
include emotional upheaval, professional or academic pressures related to performance,
inadequate social support, negative emotions expressed by the entourage (hostile, intrusive
attitude, and aggressiveness), alcohol and drug abuse issues, etc. It is important to note that
many people suffer such stress on a daily basis; however, they will not develop schizophrenia
if there are no biological predisposing factors for this disease [17].

Treatment

Treatment of schizophrenia is based on antipsychotic drugs combined with various

psychotherapeutic modalities, including rehabilitation and reintegration programs. These
programs are intended to help the person with schizophrenia to reintegrate into professional
and social life. The aim is to overcome the deficits and disabilities caused by the disease and
allow patients to maintain their identity, dignity, and self-esteem [18].
120 Frédéric Denis and Benoit Trojak

Schizophrenia and Mortality

Mortality of schizophrenic patients is 4.5 times higher than in the general population for
all ages, sexes, and causes (natural or not) [16]. The leading cause of death among
schizophrenic patients is suicide (4.2%) followed by cancer pathologies (2.2%), particularly
breast cancer in women and lung cancer in men, and cardiovascular disease (2%). The
mortality rate by "natural" causes is 2.5 times higher than in the general population; life
expectancy is reduced by 20% [20]. However, premature death from "natural" causes seems
linked to the adverse lifestyles of patients and associated factors, such as exposure to tobacco,
alcohol, psychoactive substances, poor social conditions, and adverse effects of antipsychotic
treatment (metabolic syndrome, cardiovascular disease, etc.) [12].

2. Co-Morbidities Frequently Associated

with Schizophrenia and Adverse Effects
of Antipsychotic Drugs

2.1. Schizophrenia and Cardiovascular Disease

Risk Factors
In schizophrenic patients, the prevalence of risk factors for cardiovascular disease is
higher than in the general population: [21]

 Obesity: 42% of schizophrenic patients of the US population have a body mass index
(BMI) greater than or equal to 27 compared to 27% for patients from the same
population
 Smoking: the prevalence is 75%, compared to 25% in the general population
 Diabetes: the prevalence is 13% compared to 3% in the general population
 High blood pressure (hypertension): affects 27% against 17% in the general
population
 Physical inactivity
 Hypercholesterolemia

The risk of coronary heart disease is between 2 and 3.6 times higher in schizophrenic
patients compared to the general population [22].

Coronary Heart Disease

A correlation exists between antipsychotic drugs and an increased fluctuation in blood
pressure [22]. Studies also show that antipsychotic factors contribute to cardiovascular risks,
such as obesity, dyslipidemia, diabetes, and hypertension. In addition, some treatments
(olanzapine) have a greater impact on the risk of developing coronary artery disease at 10
years compared to other atypical antipsychotic drugs [22].
 Oral Health 121

Ventricular Arrhythmias and Prolongation of the QTc Interval

All antipsychotic drugs can generate prolongation of ventricular repolarization, signaled
by a prolongation of the QTc interval on the electrocardiogram (ECG). This conduction
disorder runs the risk of torsades de pointes as ventricular arrhythmias may be complicated by
ventricular fibrillation and risk of sudden death [23].

Myocarditis
Several case studies have reported the occurrence of myocarditis under clozapine [24].
Although infrequent, it is potentially fatal in 10% of cases. Myocarditis consecutive to
treatment with clozapine exposes the risk of developing cardiomyopathy after approximately
6-8 months of treatment with this molecule [24].

2.2. Schizophrenia and Addictive Behavior

Severe mental disorders like schizophrenia generate significant suffering. The

simultaneous use of alcohol or drugs (cannabis, tobacco, etc.) is common [25]. The subjects
seek in these consumptions easing of mental disorders, stimulation of intellectual capacity,
and improved negative symptoms. Comorbidities caused by addictive behaviors are numerous
(neuronal degeneration, and liver, pancreatic, dental, and periodontal problems, etc.) related
to the toxicity of the substances used [10, 26]. The percentage of smokers in the population of
schizophrenic patients is twice that of smokers in the general population and consumption is
often greater. Furthermore, the presence of addiction associated with schizophrenia increases
the risk of hetero-aggressive violence [27].

2.3. Schizophrenia and Metabolic Syndrome

Metabolic syndrome is defined by a combination of carbohydrate, vascular, and lipid

disorders or is associated with being overweight. Combinations of the metabolic disorders
may act synergistically in the body and cause type 2 diabetes, predisposing the patient to the
risk of atherosclerosis and potential complications.

Table 1. Definition of metabolic syndrome according to the International

Diabetes Federation

Overweight
Waist size greater than or equal to 102 cm for Eurasian males and 88 cm for females
Mandatory criterion
At least two of the following four parameters:
Triglycerides > 150mg / dl or current specific treatment
HDL < 40 mg / dL in males and < 50 mg / dL in females or current specific treatment
Blood pressure: ≥ 130 mmHg systolic and
≥ 85 mmHg diastolic
Or current specific treatment
Hyperglycemia > 100 mg / dl or current specific treatment for type 2 diabetes
122 Frédéric Denis and Benoit Trojak

This is not in itself a disease entity, but a set of clinical and biological disturbances easy
to diagnose in daily practice. There are many definitions of this syndrome. We retain that of
the International Diabetes Federation (Table 1). Schizophrenics are more likely to have
metabolic syndrome. The risk of metabolic syndrome varies with the antipsychotic molecule
used to treat the patient [5] (Table 2).

2.4. Schizophrenia and Glycemic Control Disorder

Antipsychotic drugs act on the metabolism of glucose and insulin. They may cause
diabetes. Second-generation antipsychotic drugs (APIIG) have a 1.3 times higher risk of
causing diabetes than first-generation antipsychotic drugs (API) [28]. The risk of developing
diabetes in APIIG is also linked to being overweight. The prevalence of type 2 diabetes in
schizophrenic patients is 2-3 times higher than in the general population [29]. Predisposition
to a malfunction of the insulin-glucose homeostasis exists even in patients not treated with
antipsychotic drugs [30]. Schizophrenia would thus be an independent risk factor for the
development of diabetes [30]. In this case, even controlling the behavioral and physiological
risk factors involved in diabetes, genetic factors involved in schizophrenia may influence
metabolic control [29, 30].

Table 2. Risk of developing the metabolic syndrome according to the antipsychotic drug
(adapted from De Hert et al., 2011) [45]

Treatment Risk of metabolic syndrome

Chlorpromazine (CN) High (limited data)
Clozapine (CN) High
Olanzapine High
Quetiapine (APA) Moderate
Amisulpride (CN) Average
Risperidone (APA) Average
Aripiprazole (APA) Low
Haloperidol (CN) Low
CN: conventional neuroleptics, APA: Atypical antipsychotics.

2.5. Schizophrenia and Dyslipidemia

Antipsychotic treatment may induce a decrease in HDL-cholesterol, and an increase in

LDL cholesterol, total cholesterol, and triglycerides [22]. The risk of dyslipidemia is higher in
descending order with olanzapine, clozapine, and quetapine than with risperidone and
aripiprazole [31].

2.6. Obesity and Schizophrenia

Schizophrenics are 2.8 to 3.5 times more likely to become obese [32]. The risk of weight
gain in APIIG or APIG affects between 15% and 72% of patients [29]. The risk of weight
 Oral Health 123

gain with antipsychotic drugs corresponds to neurobiological mechanisms. Among the

assumptions, a change in affinity to receptors promoting weight gain (H1, 5HT2C, and D2),
influences the hormones regulating appetite, diet, and lifestyle factors, and increases appetite
and / or food intake [33].

2.7. Schizophrenia and Osteoporosis

A decrease in bone mineral density in schizophrenic patients is observed compared to

controls of about 40% and 72% according to studies [10, 34] and leads to a higher risk of
fracture [35].
The risk factors are:

 High levels of prolactin

 Physical inactivity
 Smoking, alcohol, and drugs
 Diet deficient in vitamins
 Decreased sun exposure
 Polydipsia

2.8. Schizophrenia and Respiratory Diseases

An increased incidence of death by suffocation has been described. It is linked to tardive

dyskinesia, tachyphagies, or false routes [36]. A high frequency of obstructive sleep apnea
occurs of which one of the causes is obesity [37]. Finally, there is a higher prevalence of
angina and respiratory symptoms and altered respiratory function compared to the general
population [38, 39].

2.9. Schizophrenia and Cancers

Studies on the prevalence of cancer in schizophrenics are conflicting. For breast cancer,
13 studies conducted between 1986 and 2008 and involving more than 6000 patients showed
different results ranging from a 52% increase to a 40% decrease of cancers observed [40]. For
lung cancer, several studies report an increased risk [41, 42] while others contradicted these
data [43]. The results for digestive cancers are similar [43, 44]. However, no studies have
identified on the prevalence of oral cavity cancers in schizophrenic patients.

2.10. Schizophrenia and Neurological Disorders

APIG are more often the cause of extrapyramidal disorders than APIIG. Their occurrence
is associated with the affinity of D2 dopamine receptors; 5-HT 2A serotonin is dose
dependent [45]. Tardive dyskinesia is predominantly orofacial (dystonia, dyskinesia,
124 Frédéric Denis and Benoit Trojak

stereotyping, etc.), but sometimes affect other parts of the body in the form of uncontrollable
movements of the legs (akathisia). These disturbances persist even after discontinuation of
treatment [46].

2.11. Schizophrenia and Hematological Disorders

The risk of hematologic disorders such as neutropenia by agranulocytosis under

clozapine is well documented. Agranulocytosis is lethal in 5% to 10% of cases. Other
antipsychotic drugs are either devoid of possible hematologic complications of the leukocyte
lineage [47].

2.12. Schizophrenia and Exposure to HIV, HCV, HBV, and Tuberculosis

The prevalence of hepatitis C in patients with psychiatric disorders is between 6.8% and
8.5%, i.e. much higher values than in the general population, particularly in France [48, 49].
The prevalence of HIV and tuberculosis is also higher. This is explained by overexposure by
risky sexual behavior with multiple partners and the use of alcohol and drugs with multiple
partners [50].

2.13. Schizophrenia and Immune Weakness

The set of co-morbid disorders suffered by these patients, i.e. the metabolic syndrome,
nutritional deficiencies, non-compliance with lifestyle and dietary rules, treatment side effects
(neutropenia with agranulocytosis), addictive behavior (alcohol, drugs, etc.), smoking, risky
behavior, over-exposure to HIV and HCV, and insecurity, means that these patients are
predisposed to immune weakness [51, 52].

2.14. Schizophrenia and Violence

Hetero-aggressive risk is attributable to addictive disorders more than mental disorders

[53]. The increased risk of violence is higher among schizophrenic women than men and the
risk of being arrested for violence is 23 times higher in women, whereas it is 4.6 times in men
compared to the general population [54].

2.15. Schizophrenia and Pain

For a long time it was considered that schizophrenic patients were insensitive to pain.
Recent studies have shown that this is not the case [55]. Diagnostic delays are sometimes
observed related to, firstly, confusion in reading the pain signs that are clouded by the
symptoms of schizophrenia and, secondly, the lack of verbalization of pain by the patient.
 Oral Health 125

This lack of response is due to indifference to pain rather than insensitivity [56]. In this case,
it often leads to "somatic disorders" indifference by patients and to detrimental treatment
delays for the patient [57].

2.16. Schizophrenia and a Lifestyle Unfavorable to Health

The main causes of mortality are of cardiovascular somatic origin. Factors influencing
this mortality are related to lifestyle caused by the psychiatric pathology. It leads to an
unhealthy lifestyle (diet rich in carbohydrates, low in vegetables and fish, physical inactivity,
and smoking), negation of the body (neglect of personal hygiene and lack of exercise), and
risky behavior (drugs and alcoholism). There are also side effects of psychotropic medication
of which patients are misinformed by caregivers, insecurity, difficulty for them to invest in
the preservation of their physical health, and poor capacity to respond to care systems in
general for their specific needs [45, 58].

3. Schizophrenia and Oral Health

Excessive consumption of alcohol, smoking, and poor eating habits can affect oral health.
These behaviors may contribute to the development of caries and infectious periodontal
disease (dental plaque) [59]. Social, environmental factors, and lifestyle, especially
marginalization, are also factors of poor oral health [60]. In the absence of treatment, they
lead to early tooth loss. Frequent consumption of sugary drinks and foods and inadequate
fluoride exposure increase the risk of caries. Smoking, diabetes, and immune deficiency
mainly contribute to periodontal disease [60, 61]. Oral health is an important determinant of
the quality of life and overall health [62, 63].
In this area, research in recent years has focused mainly on the possible repercussions of
oral disorders on the health of individuals and the manifestations of general diseases in the
oral sphere. The existence of a relationship between metabolic disorders and oral infectious
diseases has gradually imposed firstly with the evolution of knowledge on the
pathophysiology of metabolic syndrome, and secondly by finding that certain oral sphere
infectious diseases, such as periodontal disease, had already been associated with each of the
metabolic syndrome components (periodontal disease and diabetes, periodontal disease and
cardiovascular disease, tooth loss and obesity, etc.) in the general population [64, 68].

3.1. Epidemiology

Studies on oral health determinants of mental health patients are relatively common,
except those related to schizophrenia. A literature search using PubMed data / Medline, with
the keywords “schizophrenia,” “dental status,” and “oral health surveys” in the period from
2000 to 2014 returns 10 studies related to oral health schizophrenic patients. These studies
were performed in nine different countries (Spain, People's Republic of China, Turkey,
United Kingdom, Denmark, Israel, Iran, India, and Japan).
 Table 3. Literature review

Study Year Country Outpatients or N Average DMF (1) Periodontal Other

hospitalized age indices
patients
McCreadie et 2004 UK Outpatient 428 43 _____ ______ Associated variables
al.,[78] studies
Chu et al.,[75] 2010 Taiwan Hospitalized 1103 50.8 13.9 ______ Associated variables
studies
Arnaiz et 2011 Spain Outpatient 66 schizophrenic patients66 40 DMF: 2.321.04 PANSS-P (2)
al.,[69] control patients 13.51DMF: 7.80 correlated with lower
DMFT
Chu et al.,[74] 2011 Taiwan Hospitalized 878 50.6 13.9 _____ BMI (3): 24.7
Nielsen et 2011 Denmark Outpatient 21 417 for 200618 892 42.5341.7 _____ _____ correlated with lower
al.,[77] between 2004 and 2006 0 DMFT
Chu et al., [70] 2012 Taiwan Hospitalized 1103 50.8 13.9 35.9% CPI(4) ≥ ____
3vs. 5% control
Tani et al.,[76] 2012 Japan Hospitalized 523 55.6 18.8 for 40-59 ______ Associated variables
years studies
Eltas et al.,[71] 2013 Turkey Outpatient 33 patients with hypo 31.8 8.4 PI(5) 80% ±39 Salivary flow
salivation-inducing BP(6) 73%± 32 0.23ml/mn
medication
20 patients with hyper PI 58± 41
salivation-inducing 8.2 BP 49±37 1.12ml/mn
medication
Nikfarjam et 2013 Iran Hospitalized 123 38.81 19.43 _____ PANSS-N correlated
al., [72] with higher DMF
Chu et al.,[73] 2013 Taiwan Hospitalized 1103 50.8 _____ _____ 37.5% needed fixed
prostheses and 65%
needed dentures
1-DMF: Decay, Missing, Filled.
2-PANSS: Positive and Negative Syndrome Scale.
3-BMI: Body Mass Index.
4-CPI: Community Periodontal Index.
4-PI: Papillary index.
5-BI: Blending index.
 Oral Health 127

Analysis of these data was performed using two indices, the DMF (Decay, Missing,
Filled) and the CPI index (Community Periodontal Index) (Table 3).
The DMF reference index was used to evaluate dental health. It assesses the carious
pathology. The CPI index measures the oral hygiene status and periodontal disease through
evaluation of three parameters (bleeding, subgingival plaque, and periodontal pocket). The
CPI index is the reference index of the World Health Organization (WHO).

For the DMF

Analysis of publications shows that the DMF is twice higher in schizophrenic patients
compared to a matched control group. Arniaz et al., (2011) compared the DMF index and CPI
of a group of 66 patients followed up as outpatients with a matched group of the general
population. They found a DMF of 13.51 vs. 7.27, respectively [69]. In another study of 1108
hospitalized subjects, Chu et al., (2012) found a DMF of 13.94 vs. 8.39 for their control group
of 2660 subjects [70].
The number of missing teeth is high compared to the number of treated teeth, and the
need for functional rehabilitation (denture or fixed) is significant in relation to the need of the
general population [69, 71, 72]. Chu et al., (2013) reported three factors favorable to
rehabilitation with a removable prosthesis for psychiatric patients: a low level of education,
length of stay, and age [73]. Chu et al., (2011) showed that of 1103 schizophrenic patients,
37% needed a fixed prosthesis and 63% needed a removable prosthesis [74].

For the CPI

The CPI is twice that observed in a control group and is high compared to the general
population [69, 70]. Arnaiz et al., found a CPI of 2.32 in patients followed up as outpatients
against 1.04 in a matched control group [69]. 90.7% of the hospitalized schizophrenic patients
studied by Chu et al., (2012) had a CPI ≥ 2 [70]. This means that most patients with
schizophrenia have a need for periodontal care (learn hygiene and scaling). Eltas et al., (2012)
showed that the periodontal status changed by the absorption of antipsychotic drugs. This
study involved two matched groups of patients: the first group took medication causing
xerostomia (risperidone, quetiapine, and olanzapine); the second group took drugs stimulating
the salivary flow (clozapine). Periodontal health was more degraded in the first group with
more bleeding on probing and plaque. The small amount of saliva correlated with a high
plaque index and bleeding index [71].
Chu et al., (2011) studied the relationship between body mass index and the risk of caries
in schizophrenic patients treated with APIIG. They found no relationship between treatment
with antipsychotic drugs and oral condition. However, taking into account the patient's age,
they showed that the oral condition deteriorated in the leanest and eldest patients [74].
Scientists have studied the relationship between negative and positive symptoms of
schizophrenia assessed by the PANSS (Positive and Negative Syndrome Scale) and oral
health. They noticed that patients with higher negative symptoms and a high DMF had a
greater number of missing and decayed teeth compared to patients with positive symptoms.
The results were similar with the need for periodontal care; patients with high negative
PANSS had more need for care than the others [69, 71, 72, 75].
More generally, all studies agree on the need to care for these populations, which in
addition to limited financial resources and limited access to health systems, frequently smoke
and present side effects of antipsychotic treatments. All authors agree on the need to build
128 Frédéric Denis and Benoit Trojak

specific prevention programs related to the needs of these populations [72, 75-78]. However,
the results of these studies are limited because the populations studied are often hospitalized
patients who are in acute decompensation of the disease or are too deficient. We can therefore
assume that the data collected only partially reflect the oral health status of these populations.
In France, only 20% of the population suffering from schizophrenia is hospitalized [79].
Moreover, in all studies, patients were included without selection, which induces an obvious
bias. We can assume for example that patients who are not willing to participate in these
studies are likely to be reluctant to have a dental checkup because of their poor oral health. In
this case, the real DMF and CPI score in schizophrenic patients would be higher than the
results announced.

3.2. Difficulties of Good Oral Health of Schizophrenic Patients

3.2.1. Impact of Mental Illness

The symptoms of schizophrenia reduce the planning and implementation capacity of the
hygienic procedures of everyday life, such as oral hygiene.
These disorders result from a disturbance in executive functions. We also note that the
default context analysis and reasoning errors associated with cognitive impairment cause
patients not to perceive the importance of their health problems and not to take appropriate
decisions to resolve them [80, 81]. In this context, 60% of schizophrenic patients do not
perceive their problems and are not motivated seek care or even oppose it [82]. In general, the
disruption of the train of thought related to mental illness is that patients do not perceive these
needs and are therefore slow to consult. In this case, it is important to anticipate in order to
identify health problems because the intensity of cognitive disorders correlates with lack of
initiative [83]. This problem is even more important than the learning capacity of the
population. Several studies have shown the effectiveness of the principles of "social skills
training" in improving adherence to therapeutic treatments and improving social skills in
schizophrenic patients (skills at work, social functioning, etc.) [84]. Ponizovsky et al., (2009)
saw an improvement of the oral health status of hospitalized patients undergoing regular
dental follow-up by benefitting all patients hospitalized for more than year from regular
monitoring by a dentist [85].

3.2.2. Weight of Iatrogenic Factors (Table 4)

 The link between periodontal disease and metabolic syndrome is unclear. It follows
from the combination of an imbalance of intracellular oxidative mechanisms with an
increase of inflammatory mechanisms related to metabolic dysfunction. Insulin
resistance is a consequence of disturbances of oxidative mechanisms, which can be
improved or aggravated by factors such as smoking, alcohol, age, diet, physical
activity, and socio-economic level [64, 67, 68]. Studies should explore the nature of
this link with schizophrenic patients with significant metabolic deregulation [21].
 First-generation antipsychotic-induced extra pyramidal syndrome (inhibition of
dopamine D2 receptors and serotonin 5HT2A) disturbs the dexterity required to
achieve effective brushing and it manifests at the orofacial level by dystonias and
 Oral Health 129

dyskinesias that disrupt the oral function, such as phonation and deglutition [86]. We
distinguish acute dystonia manifested by the contraction of the muscles of the neck,
face, throat, and eyes. The mandible can be locked in the open position with
protrusive tongue or on locked in the closed position (lockjaw) with retrusive tongue.
Moreover, airways are sometimes blocked by laryngospasm and a swollen tongue.
The second side effect is pseudo-parkinsonian symptoms: antipsychotic drugs can
cause a decrease in blinking of the eyes, drooling, and monotonous speech [87].
 Dry mouth induced by antipsychotic drugs (Table 4) favors the occurrence of caries,
gingivitis, and periodontal disease. This factor added to others, such as poor oral and
food hygiene, smoking, and poor dental monitoring, contributes to poor oral health in
schizophrenic patients [76].
 Salivation induced by antipsychotic drugs, such as clozapine, promotes perlèche and
drooling. Parotitis is also seen under clozapine [88].

Table 4. Main side effects of drugs used in mental health that affect oral health
according to the British Society for Disability and Oral Health [94]

suppression
Drowsiness
Xerostomia

dyskinesia

cytopenia
Agranulo

Thrombo

Immuno
syncope
Tardive

Tremor

Apathy
tension
cytosis

Amitryptiline  Hypo-
  
Benzo   
diazépine
Cannabis 
Chlorpro    
mazine
Chlordiaze 
poxide
Dexamphe  
tamine sulfate
Clozapine Hypersalivation  
Dothiepin 
Fluphenazine   
deconate
Fluoxetine Aggression
Haloperidole  
Lithium carbonate  
Lofepramine   
Methylphen   
idate
hydrochloride
Mono-amine    
Oxidase inihibitors
Prochlorpe    
razine
Procyclidine  
Promazine   
hydrochloride
Risperidone   
Thioridazine   
130 Frédéric Denis and Benoit Trojak

3.2.4. Insufficient Dental Care Management: Reasons

 The mouth is an intimate part of the body, full of symbolism and representation and
to which access is difficult for caregivers because of the symptoms of the disease.
This is an area of little investment by professionals. Moreover, prevention and
promotion programs based on knowledge of the general population have not proven
to be highly effective once transposed to patients with severe psychiatric disorders
[4, 89].
 Early detection is important to identify health problems. Indeed, the lack of initiative
is correlated with the severity of cognitive impairment. The sickest patients do not
seek treatment voluntarily and will have little incentive to change their behavior in
order to have a healthy lifestyle and good oral hygiene [90].
 Professionals are adverse to caring for these patients (fear of mental illness, lack of
training) and patients to the health care system in general (difficult access to the
district environment, cost, etc.), which are additional barriers to somatic care.
Finally, misuse of the care system is detected in these patients, explaining the late
appearance at consultations, and lack of visits and follow-up: this may be due to
apathy, poor initiative, and repeated forgetfulness by these patients. The executive
functions disorder may partly explain the difficulty these patients have to get to a
given place at a given time. Other symptoms such as anxiety, phobia of transport, or
limited financial resources are factors that contribute to the lack of access to the
health care system.
 Finally, the overall approach to mental health patients is rarely included in
institutional care projects. But the obvious link between metabolic disturbance, oral
health, and schizophrenia should guide practices toward comprehensive care
including nutrition, diabetic control, monitoring of cardiovascular disorders, and the
concerted effort of care teams.

4. Oral Disease Management

The Cochrane review (Khokhar et al., 2011) aimed to identify studies with a high level of
evidence of effective oral health tips for improving the quality of oral health of schizophrenic
patients. The authors of the review note that there is no high-level evidence study to support
the direction of current practices [91]. Thus, the recommendations for practice of the "British
Society for Disability and Oral Health" are therefore based on expert consensus. But in the
light of this report, the co-occurrences between oral disease, schizophrenia, and the somatic
disorders associated with it are many. Improving oral health concerns improving overall
health and vice versa. In this context, it is important to consider comprehensive care
management. Indeed, poor diet, smoking, and drug interactions can lead to loss of nutritional
intake and be an aggravating factor of periodontal disease [92]. It is also important to consider
lifestyle because it is possible to prevent and treat a set of individual (brushing motivation),
community (destigmatization), and professional (personal training) measures. This is an area
of action with often little investment due to a sense of powerlessness to act on these factors.
However, there are studies showing that it is possible to intervene successfully on some of
 Oral Health 131

these determinants, seeking the collaboration of patient care programs through motivational
approaches [93, 85] They address how to help patients manage their smoking, a sedentary
lifestyle, their dietary imbalances, and their dental hygiene. The identification of somatic
problems where patients live, especially when living in a community, is also essential. For
this, it is necessary to train people that may frequently interact with patients, especially the
family environment, social services, and medical workers, district nurses, and GPs.

Conclusion
Studies show that patients with severe mental disorders have many somatic comorbidities
and a life expectancy of 15 to 20 years less than in the general population. Oral health,
although often overlooked, is intimately linked to these somatic comorbidities, which also
shares many risk factors. It therefore appears obvious to act simultaneously on these common
risk factors in order to improve overall health and therefore oral health. However, unlike the
general population where prevention programs have proven effective in patients with severe
mental disorders, the mechanisms of motivation and identification needs are different. Oral
health assessment tools adapted to these populations remain to be developed. Moreover,
research is required to specify the type of prevention and promotion programs tailored to the
specific needs of these populations.

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In: Oral Health ISBN: 978-1-63482-832-1
Editor: Julia Renee Barnes © 2015 Nova Science Publishers, Inc.

Chapter VII

Oral Health and the Quality of Life

for Romanian Orthodontic Patients

Irina Zetu, Sorana Rosu, Liviu Zetu and Mihnea Iacob

“Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania

Abstract
Objectives: Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ)
represents the only available tool for assessing the quality of life for the orthodontic
patients. The research studied the relationships between the different aspects of
orthodontic care planning, and validated the Romanian version of the PIDAQ
questionnaire.
Material and methods: A transversal study was carried out on a sample of 1126
subjects, age ranging between 6 and 28 years old. The self-evaluation of the orthodontic
esthetic perception was assessed with the PIDAQ index, and the orthodontic treatment
need was measured with the IOTN index.
Results: Esthetic perception - 70% of the subjects are unsatisfied with the appearance
of their dentition.
Orthodontic treatment need perception - All the subjects consider that they need
orthodontic treatment.
Esthetic perception and orthodontic treatment need relationship - 40.16% of the
subjects, which were unsatisfied with their dentition appearance, considered that they do
not require an orthodontic treatment.
Esthetic perception and the esthetic component of IOTN correlation - Among the
subjects, assessed as in need severe treatment, 80% were “Unsatisfied” or ”Deeply
unsatisfied” with their dentition.
Discussion: The scores of the different PIDAQ dimensions determined in our study,
were comparable with those reported by other authors.
Conclusion: The PIDAQ questionnaire remains the only tool to assess the link
between the dental-maxillary anomalies and the quality of life.


Corresponding author: Sorana Rosu. E-mail: [email protected].
140 Irina Zetu, Sorana Rosu, Liviu Zetu et al.

Our results demonstrate that the Romanian version of the PIDAQ questionnaire is a
valid instrument in assessing the psychosocial impact of the dentition esthetics related to
the malocclusion.

Introduction
Psychosocial Impact of Dental Aesthetic Questionnaire PIDAQ, developed in 2006 by
Klages and co-workers, represents the only available tool designed specifically to assess
malocclusions [1].
PIDAQ represents a validated indicator for assessing the quality of life in relation to the
oral health, specific to the field of orthodontics. This self-administered questionnaire was
assembled by the means of the preliminary studies by Klages and co-workers, in 2004 and
2005 [191], which were inspired by OQLQ (Orthognatic Quality of Life Questionnaire) or
Cunningham and co-workers Questionnaire [2].
PIDAQ’s main objective is to evaluate the psycho-social impact of the dental aesthetics.
It may also be used to assess: the orthodontic treatment need, the orthodontic treatment
results, the orthodontic treatment gains at psycho-social levels and also as a research tool for
studies related to the oral health of the orthodontic patient.
Initially developed and tested on groups of young adults, these concepts seem to be
equally useful for children and adolescents.
PIDAQ analyses four fundamental fields:

 Self-confidence;
 Social impact;
 Psychological impact;
 Aesthetic needs.

Each field comprises of a different number of items, six for ”self-confidence,” eight for
“social impact,” six for “psychological impact” and three for “aesthetic needs.” PIDAQ
includes in total 23 items that the patient must assess, using a Likert type scale in five steps:
total disagree, disagree, no option, agree, total agree.
Our research had as primary objectives to assess the relationships between the different
aspects of the orthodontic care forecasts (the psychometric properties of the questionnaire)
and to validate the Romanian version of the PIDAQ questionnaire.

Material and Methods

A transversal study was conducted using a group of 1126 subjects.

The orthodontic aesthetic self-perception and the orthodontic treatment need of each
subject were assessed with the help of Psycho-social Impact of Dental Aesthetic (PIDAQ).
The same questionnaire was used to record the potential impact of malocclusion on each
subject quality of life.
 Oral Health and the Quality of Life for Romanian Orthodontic Patients 141

We also evaluated each subject’s need of orthodontic treatment by means of the Index of
Orthodontic treatment Need - IOTN.
The study group consisted of 1126 subjects, some of which had already undergone
orthodontic treatment. Most subjects were first evaluated by an orthodontics specialist.
The subjects’ ages ranged from 6 to 28 years old. All study participants were volunteers,
who had received exhaustive information about the study and signed an informed consent
form.
Data gathering: Four types of data were gathered from all the study group subjects:

 Social-demographics (age, sex)

 Orthodontic aesthetics perception
 Orthodontic treatment need
 Malocclusion- quality of life relationship

Table I presents the used variables and their nature. The qualitative variables (sex, the
orthodontic treatment need described by IOTN – AC and DHC) were presented as absolute
actual value and as percentage. The importance of the potential association, between these
variables, was evaluated using the χ2 (Khi-2) test.
The scores of the different PIDAQ’s questionnaire parameters presented a normal
distribution, as they were evaluated with the Kolmogorov-Smirnov test. They were described
as mean values and ecart-types. The independent samples t test was used to assess the
association between the dependent and independent variables (sex, aesthetic perception,
orthodontic treatments need self-perception, and orthodontic treatment needs are indicated by
IOTN).
The other quantitative variables (the personal perception of the orthodontic aesthetics, the
subjective orthodontic treatment need or request) were regarded as quantitative systematized
variables. They were described by absolute value and percentage. Their association was tested
by a Spearman correlation.

Table 1. The list of the studied variables

Parameter Variable Variables Nature Measure Unit

IOTN AC
Orthodontic treatment need Qualitative binary Without
IOTN DHC
Social – Demographic Sex Qualitative binary Without
Variable Age Quantitative continue Years
Self confidence
Social Impact
Life quality (PIDAQ) Quantitative continue Without
Psychological Impact
Aesthetic needs
Aesthetic perception Quantitative continue Without
Orthodontic treatment need
Quantitative continue Without
self-perception
142 Irina Zetu, Sorana Rosu, Liviu Zetu et al.

The Personal Perception of

Orthodontic Aesthetics
The perception, which the patient had about his/hers dental arches alignment (the
orthodontic aesthetic), was evaluated by the question –“Are you satisfied with the alignment
of your teeth”

 “unsatisfied”
 “a bit satisfied”
 “moderately satisfied”
 “satisfied”
 “very satisfied”

The Subjective Perception of

the Orthodontic Treatment Need
Even if some of the patients were already investigated for orthodontic issues, we
considered it important to also test the subjective perception of an orthodontic treatment need,
by the question – “Do you believe that you need orthodontic treatment?”
The possible choices were:

“No, not at all”

 “No, I don’t think so”
 “I believe I do”
 “Yes, I am sure”

We found the patient was not always the one requesting the appointment with the
orthodontist. This was the case for the small children, but also for some adults, who had been
pressured by their entourage.

The Normative Evaluation of

the Orthodontic Treatment Need
The normative evaluation of the orthodontic treatment needed was evaluated with the
IOTN index. This index comprises an aesthetic component, which involves a photographic
ten steps scale, and a dental health scale, which assesses five levels of malocclusion, missing
teeth, over jet, overbite and open bite.
In the first stage the orthodontic aesthetics was evaluated by the investigator, using the
photographic scale, where the photo number 1 was the most attractive occlusion, and photo
number ten, the least attractive. The doctor evaluated the occlusion, with no treatment
 Oral Health and the Quality of Life for Romanian Orthodontic Patients 143

prognosis involved, discarding the teeth colorations, the cavities, gingival problems, the
evaluation being only aesthetic.
The dental health component of the IOTN was registered with a special ruler.

PIDAQ Questionnaire Validation

In order to validate the PIDAQ questionnaire, we used the version that included 23
elements, grouped in four domains: aesthetic aspect, psychological impact, social impact, and
self-confidence.
The PIDAQ questionnaire was translated from English into Romanian by two translators,
who worked separately and then together for the final version. This final version was again
translated into English.
Two orthodontists and one dentist, who were previously calibrated using the PIDAQ,
conducted the clinical examinations and the filling out of the questionnaires.

PIDAQ Validation Study Group

In order to validate the Romanian version of the PIDAQ, we selected a study group of
152 dental medicine students, from the School of Dental Medicine “Grigore T. Popa”
University, Iasi. The conclusion was that the Romanian version of the questionnaire was
correctly translated and adapted.

Evaluation of the Validity and

Viability of PIDAQ Romanian Version
The exclusion criteria were: subjects with cavities or traumas on the frontal teeth, dental
hypoplasia, fluoride-induced lesions, and subjects undergoing orthodontic treatment.

IOTN Evaluation

The aesthetic component of the IOTN was utilized, the clinical examination being
conducted by two orthodontists and one dentist, previously calibrated (Kappa >0.85).
The results were separated into three groups: score 1-4, 5-7 and 8-10.

Statistical Analysis

We used the SPSS 20.0 for Windows for the statistical analysis. The results were
obtained by descriptive analysis (mean and standard deviation for each variable). Internal
consistency, measured with Cronbach´s alpha test, was also calculated.
144 Irina Zetu, Sorana Rosu, Liviu Zetu et al.

The PIDAQ viability was calculated by measuring the interclass correlation coefficient.
The validity was determined by comparing the IOTN-AC scores with the scores for each
subscale and the whole PIDAQ test. The mean values were compared with the ANOVA test.

Ethical Consideration

The study was approved by the Ethics Commission of the “Grigore T. Popa” University,
Iasi.

Results
The internal consistency index of the questionnaire, determined by the Cronbach´s alpha
test was 0.926, while the minimal standard value is 0.912, which signifies that the Romanian
version of the PIDAQ questionnaire presented a good degree of viability (Table 2).
The values obtained for the questionnaire’s question ranged between 0.39 and 0.69. The
mean viability for the under scales was 0.855 for confidence, 0.932 for social impact, 0.919
psychological impact and 0.880 aesthetic aspect. The correlation coefficient was >0.397.

PIDAQ Questionnaire Validity

The test Kaiser-Meyer-Olkin valued 0.929, and Bartlett´s test scored 6271.919 (p = 0.00)
(Table 3). The common factor 1 contains the question from the social impact section
(questions 7-14) (eigenvalue = 0.148) and sustains 0.65% of the variables. The common
factor 2 contains the question from the confidence section (questions 1-6 (eigenvalue = 3.5))
and sustains 15.5% of the variables.
The common factor 3 contains the question from the psychosocial impact section
(questions 15-20) (eigenvalue = 0.5) and sustains 0.12% of the variables. The common factor
4, questions 21-23, the aesthetic aspect section (eigenvalue = 0.015) explains 0.066% of the
variant.

Reproducibility

The reproducibility of the PIDAQ was assessed by determining the degree of interclass
correlation index, which scored 0.926, ranging between 0.908 and 0.942 for the four scales
below (Table 5).

Table 2. The viability degree analysis

Cronbach's Alpha Cronbach's Alpha Based on Standardized Items N of Items

.926 .912 22
 Oral Health and the Quality of Life for Romanian Orthodontic Patients 145

Table 3. KMO and Bartlett's Test

Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .929

Approx. Chi-Square 6271.919
Bartlett's Test of Sphericity df 253
Sig. .000

Table 4. Presents the results for each separate question

Table VII.4 Rotated Component Matrixa

Component
1 2 3 4
. I am proud of my teeth. .872
I like to show my teeth when I smile. .873
I am pleased when I see my teeth in the mirror. .903
My teeth are attractive to others. .896
. I am satisfied with the appearance of my teeth. .789
. I find my tooth position to be very nice .801
. I hold myself back when I smile so my teeth don’t show so much. .913
. If I don’t know people well I am sometimes concerned what they might think about
.948
my teeth.
I’m afraid other people could make offensive remarks about my teeth. .952
. I am somewhat inhibited in social contacts because of my teeth. .933
. I sometimes catch myself holding my hand in front of my mouth to hide my teeth. .934
Sometimes I think people are staring at my teeth. .905
Remarks about my teeth irritate me even when they are meant jokingly. .956
I sometimes worry about what members of the opposite sex think about my teeth. .916
I envy the nice teeth of other people. .891
. I am somewhat distressed when I see other people’s teeth. .937
. Sometimes I am somewhat unhappy about the appearance of my teeth. .919
I think most people I know have nicer teeth than I do. .935
. I feel bad when I think about what my teeth look like. .936
. I wish my teeth looked better .894
. I envy the nice teeth of other people. .885
. I am somewhat distressed when I see other people’s teeth. .875
. Sometimes I am somewhat unhappy about the appearance of my teeth. .886
Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser
Normalization.a
a
Rotation converged in 5 iterations.

Results and Discussions

The scores for the different PIDAQ domains are indicated in Table 6. As absolute value,
the social impact presented the highest score (13.72), but it also includes the highest items
number.
In order to avoid the item number influence, the rate between the scores mean and the
maximum possible score was calculated. The aesthetic needs present the biggest impact, with
146 Irina Zetu, Sorana Rosu, Liviu Zetu et al.

a rate of 0.47. For this type of evaluation, confidence presents the lowest impact. The
intraclass coefficient ranges from 0.72 for “Social Impact” to 0.90 for “Aesthetic needs”
(Table 7).

Table 5. Intraclass Correlation Coefficient

Intraclass 95% Confidence Interval F Test with True Value 0

Correlationb Lower Bound Upper Bound Value df1 df2 Sig
Single Measures .362a .308 .424 13.462 151 3171 0.000
Average
.926c .908 .942 13.462 151 3171 0.000
Measures
For all the statistic tests the significance limit was set at p≤ 0.05.

Table 6. Scores and Viability (internal coherence and PIDAQ questionnaire

reproducibility)

Maximum possible Mean / maxim

Dimensions (items number) Mean ± Ecart Type
score score
Confidence (6) 6.84±6.1 30 0.23
Social Impact(8) 13.72±13.33 40 0.34
Psychological Impact (6) 12.21±10.42 30 0.40
Aesthetic need (3) 7.07±4.36 15 0.47
The internal coherence of the items for each domain varies from 0.67 for “Aesthetic needs” to 0.87 for
“Social Impact.”

Table 7. PIDAQ’s domains viability

Viability
Dimensions (Items number) Internal coherence Reproducibility
Coefficient α Cronbach Intra-class correlation coefficient
Confidence (6) 0.71 0.73
Social Impact(8) 0.87 0.72
Psychological Impact (6) 0.79 0.85
Aesthetic perception (3) 0.67 0.90

The association between the different domains of the PIDAQ, the aesthetic perception,
and the perceived need was tested by a Spearman correlation.
Table 7 shows the correlation matrix between these different variables. The patient
perception of their dental alignment is significantly correlated with three domains of the
PIDAQ (Social Impact, Psychological Impact and Aesthetic needs). On the other hand, the
perceived need is not significantly correlated with any of the PIDAQ needs.

Study Results

Social – Demographic Characteristics

Table 9 presents the social-demographic distribution. Females represent 50.03% of the

included subjects; most females in the study group were older than the boys, but there was no
 Oral Health and the Quality of Life for Romanian Orthodontic Patients 147

statistically significant difference between the males and females mean ages (p = 0,25). The
males mean age was also inferior to the study groups mean age.

Aesthetic Perception

Table 10 presents the distribution of the degree of subject satisfaction regarding their
occlusion. It seems that almost 70% are, at different rates, unsatisfied with the orthodontic
aesthetics of their occlusion.

Table 8. Spearman correlation matrix

Aesthetic perception rho (p) Perceived need rho (p)

Confidence (6) 0.20 (0.20) -0.05 (0.74)
Social Impact (8) -0.35* (0.02) 0.29 (0.16)
Psychological Impact (6) -0.34* (0.02) 0.20 (0.19)
Aesthetic perception (3) -0.43* (0.004) 0.22 (0.16)

Table 9. Social- demographic variables distribution

Age Test t. p Value

Male (n = 559)
Sex Female (n = 567) 0.25
Total (n = 1126)

Table 10. Perceived orthodontic aesthetics - Scores distribution

Test χ2
Subjects perception of their occlusion %
Value p
Very Moderately
Unsatisfied Satisfied Very satisfied
M (n = 559) unsatisfied satisfied
224 (40.07) 126 (22.54) 17 (3.04) 77 (13.77) 117 (20.58)
0.25
F (n = 567) 217 (38.27) 182 (32.08) 38 (6.7) 17 (2.99) 113 (19.96)
Total
441 (41) 308 (27.35) 55 (4.88) 94 (8.34) 230 (20.42)
(n = 1126)

Table 11. Scores for perceived treatment need

Test χ2
Orthodontic treatment need perception n%
Value p
No. I don’t Yes. I am sure
M No. Not at all No option Yes. I think so
think so of it
(n = 559)
20 (3.67) 55 (9.83) 125 (22.36) 134 (23.97) 225 (40.17)
F 0.68
53 (9.34) 76 (13.40) 60 (10.58) 151 (26.63) 227 (40.05)
(n = 567)
Total
73 (6.48) 131 (11.63) 185 (16.42) 285 (25.31) 452 (40.16)
(n = 1126)
148 Irina Zetu, Sorana Rosu, Liviu Zetu et al.

This dissatisfaction interests 70.35% of the females, and 62.61% of the males. The χ2 test
presents no significant difference (p = 0.25).

Orthodontic Treatment Needs Perception or the Perceived or Requested

Treatment Need

All the subjects included into this study presume or are sure that their occlusion requires
orthodontic treatment. Of these, 45% are certain that they need treatment (Table 11).
Belonging to a specific group does not influence the perceived orthodontic treatment need (p
= 0.68).

Aesthetic Perception and Requested Need Relationship

Interestingly, 40.16% of the subjects who are very unsatisfied with their teeth alignment
are not certain that an orthodontic treatment is necessary (Figure 1).
The subjects that are very satisfied or moderately satisfied with their teeth alignment
declared that they require orthodontic treatment (Figure 1). Aesthetic perception analysis
shows that it does not significantly influence the treatment request or the perceived need
(p = 0.30).

Aesthetic Perception and the Normative Treatment Need (IOTN-AC)

Relation

Eighty percent of the subjects, whose evaluation of the aesthetic component of the IOTN
classified as a severe need of treatment, are very unsatisfied or unsatisfied with their
occlusions. The rest of the subjects are moderately satisfied with their dental arch alignment.
Almost half of the subjects who do not require orthodontic treatment, as evaluated by the
IOTN (AC), declared that they are very satisfied with their dental alignment (Figure 2).
The association between the orthodontic aesthetic perception and the normative treatment
need (IOTN) is not significant.

Discussion
Different aspects of the orthodontic treatment need forecast, were analysed – aesthetics,
perceived or required need, normative need and the quality of life.

Limitations
One of the limitations of this study is related to the fact that many subjects were seeking
orthodontic treatment. In fact, some of them had already started an orthodontic treatment.
 Oral Health and the Quality of Life for Romanian Orthodontic Patients 149
Count of aesthetic concerns

Categories

Figure 1. Aesthetic perception and requested need relationship.

Aesthetic of IOTN

Categories

Figure 2. Aesthetic perceptions and the normative treatment need (IOTN-AC) relation.

It might be presumed that the motivation of these patients is strong. In fact, many times,
the beneficiary of the orthodontic treatment is not the person who initiated the appointment.
For children and adolescents, the parents are the ones who seek the best facial and dental
appearance for their offspring [3, 4]. In adult patients, the pressure can often come from the
immediate entourage (husband, brother), orthodontic treatment not being the patients chief
concern. Another limitation is related to the fact that the studied population, comprised
mainly of adolescent and adult patients, some of whom had already been engaged in
orthodontic treatment, and the gathered data describe a situation that they already
encountered. A positive fact is that only a small number of the subjects were in this situation,
and, also, recent research has reported that individuals keep intact memories involving their
150 Irina Zetu, Sorana Rosu, Liviu Zetu et al.

morphological anomalies for a long period of time [5]. It also should be noted that the male
and female subjects were almost equally distributed, reflecting the percentages encountered
for the orthodontic adult patients.

Aesthetics, Perceived Need and Normative Need

The evaluation by the patients of the degree of satisfaction related to their dental
alignment (The orthodontic aesthetics) shows that 80% are unsatisfied. The question “Do you
think that you need an orthodontic treatment” received 100% affirmative answers.
The perceived need involves all the patients, but 20% of them are not unsatisfied with
their dental alignment. If we consider that the orthodontic aesthetics remains the principal
motive for seeking treatment [6], we might ask ourselves what was the motivation for this
particular group of patients. It might be the situation of patients referred by the dentist, with
important malocclusions (lateral cross bite, posterior tooth agenesis), but who do not
necessarily present aesthetic issues. The scores for the different PIDAQ domains calculated in
our study are comparable with those reported in the orthodontic literature [7, 8]. The
traditional orthodontic diagnosis avoids starting clinically unjustified treatments. An analysis
of the relationship between the perceived and the normative need shows that differences are
present. The perceived need, as evaluated by this study, is greater than the normative need.
These differences were reported in large samples of population studies [9, 10, 11].

Conclusion

 until now, the PIDAQ questionnaire remains the only specific instrument for
orthodontics, which relates malocclusion and the quality of life
 the result analysis demonstrates that PIDAQ has a very good psychometrical quality,
and a good viability
 the internal coherence is very good, and the reproducibility is almost perfect, with an
intra-class coefficient, which ranges from 0.72 for social-impact to 0.90 for aesthetic
perception
 the scores of the different PIDAQ in our research domains are comparable to the
other three studies, which used PIDAQ
 the Romanian version of the PIDAQ represents a useful tool for evaluation of the
psycho-social impact of the dental aesthetic in relation with the malocclusion, in
order to appreciate the quality of life of the Romanian orthodontic patients.

References
[1] Cunningham, S. J., Hunt, N. P. Are pre-treatment psychological characteristics
influenced by pre-surgical orthodontics? Eur. J. Orthod. 2001;23:751–758.
 Oral Health and the Quality of Life for Romanian Orthodontic Patients 151

[2] Birkeland, K., Bøe, O. E., Wisth, P. J. Relationship between occlusion and satisfaction
with dental appearance in orthodontically treated and untreated groups. A longitudinal
study. Eur. J. Orthod. 2000;22:509–518.
[3] World Health Organization (WHO). Oral Health Surveys: Basic Methods. 4th ed.
Geneva: WHO; 1997.26.
[4] Jenny, J., Cons, N. C. Guidelines for Using the DAI: A Supplement to DAI—The Dental
Aesthetic Index. Iowa City, Iowa: College of Dentistry, University of Iowa; 1988.
[5] Oliveira, B. H., Nadanovsky, P. Psychometric properties of the Brazilian version of the
Oral Health Impact Profile-short form. Community Dent. Oral Epidemiol. 2005; 33:
307–314.
[6] Klages, U., Claus, N., Wehrbein, H., Zentner, A. Development of a questionnaire for
assessment of the psychosocial impact of dental aesthetics in young adults. Eur. J.
Orthod. 2006;28:103–111.
[7] O’Brien, C. O., Benson, P. E., Marshman, Z. Evaluation of a quality of life measure for
children with malocclusion. J. Orthod. 2007; 34:185–193.
[8] Birkeland, K., Bøe, O. E., Wisth, P. J. Orthodontic concern among 11-year-old
children, and their parents compared with orthodontic treatment need assessed by Index
of Orthodontic Treatment Need. Am. J. Orthod. Dentofacial. Orthop. 1996; 110:197–
205.
[9] Slade, G. D., Dewey, M. E., Newton, T., Brodie, P., Kiemle, G. Development and
preliminary validation of the Body Satisfaction Scale (BSS). Psychol. Health. 1990;3:
213–220.
[10] Mandall, N. A., McCord, J. F., Blinkhorn, A. S., Worthington, H. V., O’Brien, K. D.
Perceived aesthetic impact of malocclusion and oral self-perceptions in 14- to 15-year-
old Asian and Caucasian children in greater Manchester. Eur. J. Orthod. 1999; 21:175–
183.
[11] Al-Sarheed, M., Bedi, R., Hunt, N. P. Orthodontic treatment need and self-perception of
11- to 16-year-old Saudi Arabian children with a sensory impairment attending special
schools. J. Orthod. 2003; 30:39–44.
 Index

almonds, 70
# alveolar bone resorption, viii, 65, 71, 78, 79
ambivalence, 102, 119
20th century, 93
amine, 129
21st century, 85
amino acid, 67
amputation, 56
A anemia, 74, 81
angina, 75, 123
abscesses, viii, 33, 34, 47, 65 ANOVA, 144
activism, 104 anticholinergic, 113
ADA, 97, 104, 105, 108 anticholinergic effect, 113
adaptation, 5, 34, 37, 52, 53 antidepressant(s), 112
adipose tissue, 75, 77 antidepressant medication, 112
adolescents, 3, 14, 37, 43, 44, 51, 52, 57, 58, 59, 60, antimicrobial therapy, 28
104, 131, 140, 149 antioxidant(s), viii, 65, 71, 73, 78, 79, 81, 87, 88, 89
adult literacy, 106 antipsychotic, ix, 113, 114, 117, 118, 119, 120, 121,
adults, 2, 3, 13, 18, 19, 24, 26, 29, 37, 39, 40, 48, 50, 122, 123, 124, 127, 128, 129, 133, 136
51, 52, 54, 56, 58, 60, 61, 63, 76, 84, 88, 92, 104, antipsychotic drugs, ix, 117, 119, 120, 121, 122, 123,
105, 106, 113, 133, 134, 136, 142 124, 127, 129
adverse effects, 120 anxiety, viii, 15, 22, 31, 33, 34, 44, 46, 47, 48, 81,
aesthetic(s), 12, 13, 14, 15, 20, 21, 30, 46, 104, 140, 102, 130
141, 142, 143, 144, 145, 146, 147, 148, 150, 151 anxiety disorder, 15, 31
aetiology, 11 APA, 122
affective disorder, 113 apples, 83
age, viii, ix, 3, 29, 35, 37, 39, 40, 42, 43, 44, 45, 49, appraisals, 36, 102
55, 69, 74, 76, 80, 84, 86, 91, 92, 95, 98, 103, Argentina, 43
104, 119, 126, 127, 128, 139, 141, 147 aripiprazole, 122
aggregation, 12 arthritis, 75
aggressiveness, 119 ascorbic acid, viii, 65, 71, 83, 84
aging population, 19 aspiration, 104
agranulocytosis, 124 assessment, vii, ix, 24, 30, 35, 37, 38, 52, 53, 55, 56,
airways, 129 60, 62, 66, 77, 106, 111, 112, 113, 114, 115, 116,
akathisia, 124 131, 136, 151
alcohol consumption, 77, 79, 84 assessment tools, 56, 114, 115, 131
alcohol dependence, 77, 79 atherosclerosis, 71, 77, 82, 121, 135
alcoholism, 125 atrial fibrillation, 87
allele, 73 atrophy, 113
allergy, 51
154 Index

attachment, vii, viii, 1, 4, 7, 10, 11, 12, 14, 16, 21, cancer screening, 104
23, 28, 43, 44, 47, 65, 70, 73 candida, 104
attitudes, 3, 37, 59, 96, 97 cannabis, 121
avoidance, ix, 111 carbohydrate(s), 67, 68, 69, 78, 96, 121, 125
carbon, 70
cardiac risk, 132
B cardiomyopathy, 121
cardiovascular disease, 30, 67, 76, 113, 116, 120,
bacteria, 70, 78, 95, 103, 113
125
bacterial pathogens, vii, 1
cardiovascular disorders, 130
barriers, 96, 112, 130
cardiovascular risk, 83, 120
basic needs, 119
caregivers, ix, 118, 125, 130
bedding, 80
caries, 2, 39, 44, 45, 55, 88, 93, 94, 95, 125, 127, 129
behavioral disorders, 119
carotene, 72
behaviors, 39, 54, 55, 66, 121, 125
carotenoids, 69, 72
beneficial effect, 74
case study(s), 121, 137
benefits, viii, 3, 5, 9, 17, 65, 67, 78, 96, 114
catalyst, 34
beta-carotene, 72
causality, 75
beverages, viii, 65
CDC, 93, 105
biological consequences, 7
Charcot-Marie-Tooth Disease, vii
biomarkers, 86, 87
cheilitis, 105
biotin, 70
chemical properties, 69
bipolar disorder, 132, 133, 134
chemotherapeutic agent, 73
bleaching, 96
chemotherapy, 92
bleeding, vii, 1, 12, 14, 42, 43, 46, 47, 54, 63, 68, 71,
chewing functions, viii, 33, 34, 47
72, 87, 114, 127
childhood, 41, 59
blood pressure, 92, 99, 120
children, 2, 3, 8, 14, 24, 25, 27, 30, 37, 39, 40, 42,
board members, 93, 97
43, 44, 45, 51, 55, 56, 57, 58, 60, 62, 76, 93, 95,
body image, 49
100, 102, 104, 140, 142, 149, 151
body mass index (BMI), 49, 69, 76, 120, 126, 127,
Chile, 44
135, 136
China, 1, 23, 125
bone(s), viii, 12, 14, 18, 22, 35, 48, 65, 68, 70, 71,
cholesterol, 122
72, 73, 74, 78, 79, 81, 82, 84, 85, 86, 94, 95, 104,
chronic diseases, 31, 67
123
chronic illness, 36, 53, 98
bone mass, 74, 86
chronic kidney disease, 79, 80, 116
bone resorption, viii, 12, 65, 68, 71, 72, 78, 79, 85,
chronic obstructive pulmonary disease, 90, 99
86
cigarette smokers, 108
brain abnormalities, 119
cigarette smoking, 86
Brazil, 42, 43, 44, 53, 55
classification, 24, 31, 37, 53, 62, 108
breakdown, 19, 114
cleaning, 19
breast cancer, 62, 120, 123, 134
clinical examination, 143
breastfeeding, 103
clinical presentation, 16
building blocks, 70
clinical trials, 50, 51
Bulgaria, 59
clozapine, 121, 122, 124, 127, 129, 133
bullying, 93, 105
CMTD, vii
CNS, 134
C cocoa, 78
coffee, viii, 65, 114
calcium, viii, 65, 73, 74, 79, 83, 84, 86, 89, 95 coffee consumption, viii, 65
calculus, 11, 27, 43, 44, 58, 68, 80, 88 cognition, 37, 85, 136
caloric restriction, 76, 86 cognitive impairment, 128, 130
calorie, 81, 95, 96 coherence, 146, 150
cancer, 6, 39, 52, 55, 77, 83, 85, 104, 120, 123, 134 collaboration, 131
 Index 155

collagen, 71, 80 demographic characteristics, 39

communication, 36, 48, 96, 97, 98, 100, 102 denial, 47
communication skills, 96, 100 dental care, 4, 19, 30, 50, 62, 92, 94, 96, 103, 136
community(s), viii, 7, 28, 37, 39, 44, 50, 78, 79, 91, dental caries, 2, 24, 39, 44, 60, 83, 93, 95, 113, 135,
93, 103, 104, 112, 113, 114, 130, 133 136
comorbidity, 133 dental implants, 9, 20, 49
complement, 4 dental offices, 104
complexity, 35 dental plaque, vii, 1, 10, 68, 69, 77, 125
compliance, 17, 23, 99, 124 dentin, 24, 95
complications, vii, 1, 17, 18, 121, 124 dentist, 104, 114, 128, 143, 150
composition, 75, 84 dentition, x, 13, 16, 19, 56, 114, 139, 140
compounds, 73 dentures, 19, 20, 26, 27, 28, 31, 35, 49, 55, 57, 60,
conceptual model, 6, 7, 8, 31, 51, 55 104, 126
conceptualization, 34 Department of Health and Human Services, 94, 105,
confounders, 97 106
connective tissue, 71 deposition, 73, 75
consensus, 9, 25, 30, 119, 130 depression, viii, 21, 33, 34, 47, 77, 83, 95
consent, ix, 92, 118 deprivation, 39
consumers, ix, 111, 112, 114, 115 depth, 5, 14, 23, 43, 47
consumption, viii, 65, 66, 69, 77, 80, 83, 88, 94, 95, deregulation, 128
106, 121, 125 derivatives, 17
control group, 86, 127 destruction, 11, 12, 22, 48, 71, 75
controlled trials, 67 detectable, 20
controversial, 73 detection, 114, 130
COPD, 99 developed countries, 2
coping strategies, 34 developing countries, 75, 131
copper, 74, 88 deviation, 5
coronary artery disease, 22, 120 diabetes, 22, 25, 26, 27, 29, 67, 74, 75, 76, 77, 83,
coronary heart disease, 116, 120, 132 84, 88, 99, 106, 118, 120, 121, 122, 125, 131,
correlation(s), x, 12, 14, 15, 46, 47, 120, 139, 141, 133, 135
144, 146, 147 diabetic patients, 22, 58, 75
correlation coefficient, 46, 144, 146 Diagnostic and Statistical Manual of Mental
cosmetic, 96 Disorders, 119
cost, 3, 4, 5, 30, 49, 59, 113, 114, 115, 130 diagnostic criteria, 25
CPI, 43, 44, 45, 126, 127, 128 diet, ix, 66, 67, 68, 70, 78, 80, 81, 83, 85, 86, 89,
criminal violence, 135 103, 113, 114, 118, 123, 125, 128, 130
criticism, 54 dietary fat, 87
cross-sectional study, 13, 14, 51, 59, 63, 81, 131, 136 dietary fiber, 70
crystalline, 96 Dietary Guidelines, 66, 82, 87
cultural beliefs, 103 dietary intake, 69, 71, 74, 78, 89
cultural differences, 103 direct measure, 36
cytokines, 75 disability, vii, 1, 5, 7, 8, 10, 11, 15, 16, 21, 22, 37,
cytotoxicity, 71, 89 47, 52, 58, 61, 62, 98
discomfort, 2, 7, 10, 11, 12, 13, 15, 16, 17, 18, 20,
21, 22, 39, 49
D discrimination, viii, 91, 95, 105
disease progression, 11, 35
daily living, 7, 9, 16, 24, 58
diseases, viii, 2, 3, 5, 6, 9, 33, 34, 47, 60, 65, 75, 76,
deaths, 133
77, 82, 83, 116, 118, 125, 137
debridement, 57
disorder, 15, 121, 130
decay, 2, 114
dissatisfaction, 148
defects, 30
dissociation, 118
deficiency, 66, 74, 76, 81, 85, 125
distress, 112
degradation, 80
156 Index

distribution, 48, 95, 146, 147 European Commission, 38

DMF, 126, 127, 128 everyday life, 8, 128
dopamine, 119, 123, 128 evidence, ix, 4, 5, 12, 16, 17, 18, 20, 22, 24, 26, 48,
dosage, 103 50, 51, 52, 58, 67, 76, 113, 118, 130
dosing, 100, 103 evolution, 125
dough, 95 examinations, 5, 94
drinking pattern(s), 66 exclusion, 143
drinking water, 68, 80, 93 executive function, 128, 130
drug abuse, 104, 119 expenditures, 92
drug interaction, 130 exposure, 18, 93, 96, 120, 123, 124, 125
drugs, ix, 112, 117, 120, 121, 122, 123, 124, 125,
127, 129, 133, 134
dynamism, 37 F
dyslipidemia, ix, 76, 117, 118, 120, 122
facial pain, 42
dystonia, 123, 129
factor analysis, 66
family environment, 131
E family functioning, 37
family income, 13, 94
ecology, 70 fat, 66, 67, 69, 70, 75, 77, 80, 86, 95
economics, 3, 92 fatty acids, 70, 80, 81
edentulous patients, 15, 35 fiber, 67, 69, 79, 85, 95
education, viii, 3, 8, 14, 19, 34, 91, 92, 94, 96, 97, fibroblasts, 71, 83, 87
105, 114 financial, 2, 3, 19, 21, 92, 98, 127, 130
elders, 49, 59 financial resources, 127, 130
electrocardiogram (ECG), 121 first generation, 112
elementary school, 93 first molar, 12, 19, 89
emergency, 103, 104, 107 fish, 67, 69, 79, 125
emotion, 54, 106 fish oil, 69, 79
emotion regulation, 54 fitness, 82
emotional intelligence, 54 fluctuations, 94
emotional well-being, viii, 14, 33, 34, 44, 47 fluid, 67, 69, 73, 87, 90
employment, 23 folic acid, 70, 82
enamel, 17, 95 food, 13, 16, 46, 66, 67, 68, 75, 78, 82, 84, 85, 94,
encoding, 71 95, 99, 103, 104, 106, 114, 119, 123, 129
encouragement, viii, 91, 100, 101 food intake, 84, 123
endothelial dysfunction, 75 formation, viii, 33, 34, 47, 65, 68, 71, 80, 88
end-stage renal disease, 53, 63 formula, 98, 108
environment(s), 2, 28, 37, 130 fragility, 119
environment factors, 28 fructose, 95, 96
environmental characteristics, 8 fruits, 67, 69, 72, 78
environmental factors, 118, 119, 125 functional changes, viii, 33, 47
enzymes, 88
epidemic, 75
epidemiology, 60, 85 G
error detection, 108
gel, 73, 81, 82
esophageal cancer, 77
gene expression, 71
esophagus, 83
genetic factors, 122
essential fatty acids, 67
genetics, 85, 105, 133
esthetic perception, ix, 139
gingival, vii, viii, 1, 11, 12, 14, 18, 33, 34, 42, 43,
esthetics, x, 60, 140
46, 47, 54, 63, 65, 70, 71, 73, 80, 87, 88, 90, 104,
estrogen, 70
114, 143
ethnicity, viii, 39, 91, 94, 100
gingival recessions, viii, 33, 34, 47, 65
etiology, 68, 70, 85
 Index 157

gingivitis, 3, 14, 27, 30, 42, 43, 44, 46, 58, 62, 68, household income, 39
70, 73, 80, 81, 82, 84, 87, 129 human body, 68
glucose, 70, 76, 86, 96, 122, 133 human experience, 5
glucose regulation, 133 hydrogen peroxide, 71, 89
glycerol, 69 hygiene, 16, 18, 20, 42, 55, 62, 69, 80, 95, 100, 105,
governance, 112 111, 113, 114, 115, 119, 127, 128, 129, 130, 131
grain size, 68 hyperglycemia, ix, 117
green tea, viii, 65 hyperprolactinemia, ix, 117
guidance, 103, 104 hypersensitivity, 18, 24, 25, 29
guidelines, 66, 89, 134 hypertension, 75, 76, 99, 118, 120
guilt, 54 hypoplasia, 143
hypothesis, 76

H
I
halitosis, 10, 12, 15, 25, 30, 31
hallucinations, ix, 117, 118, 119 IL-8, 72
hard tissues, vii, 1, 10 illicit drug use, 103
harmony, 46 imbalances, 131
hazards, 104 immigrants, 103
HBV, 124 immune response, 76
head and neck cancer, 46, 94 immunization, 84
healing, 17, 73 impairments, 78
Health and Human Services, 107 implants, 20, 28, 56
health care, 3, 4, 5, 37, 104, 112, 130, 133, 135, 136, improvements, 4, 16, 17, 20, 22, 49, 93, 113
137 in vitro, 29, 72
health care system, 3, 130 in vivo, 72
health disparity, viii, 91 incisors, 12, 19
health information, 40, 92 income, 3, 4, 14
health insurance, 3 independent variable, 141
health problems, 118, 128, 130 India, 44, 53, 125
health promotion, ix, 67, 118 individualism, 95
health seeking behaviours, ix, 111 individuals, viii, 4, 12, 15, 16, 22, 28, 33, 37, 39, 49,
health services, ix, 2, 111, 112 54, 55, 74, 75, 78, 87, 88, 92, 96, 98, 99, 100,
health status, 6, 7, 36, 38, 40, 42, 43, 51, 53, 56, 60, 112, 119, 125, 149
61, 73, 74, 87, 136 induction, 88
healthcare, viii, 26, 91, 92, 93, 96, 97, 98, 99, 100, industrialized countries, 2
101, 102, 103, 104, 105, 106 inequality, 26, 134
heart disease, 113 infancy, 105
heart rate, 5 infants, 103
heavy drinking, 103 infection, 81, 95
height, 5 inflammation, 11, 48, 67, 70, 71, 73, 75, 76, 77, 79,
hemodialysis, 81, 88 81, 85, 86, 95, 113, 116
hepatitis, 124, 134 inflammatory bowel disease, 56
heterogeneity, 77 inflammatory disease, vii, 1, 83
high blood pressure, 99 inflation, 96
high school, 44 informed consent, 141
HIV, 124, 134 inhibition, 71, 72, 128
homelessness, 112 initiation, 83
homeostasis, 71, 122 injury(s), 7, 84, 103, 104
Hong Kong, 1, 11, 23, 29 injury prevention, 103
hormones, 123 insecurity, 124, 125
hospitalization, 77 insulin, 70, 76, 86, 122
hospitalized patients, ix, 118, 126, 128, 136 insulin resistance, 76, 86
158 Index

intelligence, 54 locus, 73
interface, 80 longitudinal study, 151
interference, 17 lung cancer, 120, 123
interferon, 134 lung disease, 99
internal consistency, 9, 144 lutein, 72
internalization, 93 lycopene, viii, 65, 67, 72, 80, 81
interpersonal relationships, 39
intervention, 9, 19, 39, 89, 94, 112, 116
Iran, 80, 85, 125, 126, 136 M
iron, 71, 74, 81, 86, 88, 95
macronutrients, 66
isolation, 104, 112
magnesium, 74, 75, 84, 86, 89
Israel, 125, 135
magnitude, 18, 35
Italy, 132
major depression, 113
malignancy, 134
J malnutrition, 66, 77, 79, 81, 82, 118
malocclusion(s), vii, x, 140, 142, 150, 151
Japan, 29, 61, 86, 125, 126 management, viii, ix, 52, 65, 92, 100, 101, 102, 112,
Japanese women, 75 118, 130, 132, 137
Java, 79 mandible, 20, 129
job strain, 21 manic, 113
manipulation, 77
mapping, 37
L marginalization, 125
Marshall Islands, 109
labeling, 96
matrix, 17, 146, 147
lack of confidence, 16
maxilla, 20
lactic acid, 74
measurement(s), 7, 34, 53, 57, 116
laryngeal cancer, 77, 82
meat, 67
laryngitis, 15
mechanical properties, 89
laryngospasm, 129
mechanical ventilation, 115
Latin America, 77
Medicaid, 96
LDL, 122
medical, 5, 7, 8, 22, 37, 40, 96, 97, 98, 99, 131, 133,
learning, 96, 112, 119, 128
137
lesions, 68, 135, 143
medication, 89, 92, 98, 99, 100, 106, 112, 114, 119,
level of education, 127
125, 126, 127, 132, 133, 134, 136
life course, 103
medicine, 5, 60, 100, 106, 116, 143
life expectancy, 26, 118, 120, 131
mellitus, 26, 74, 75, 83, 86, 88
life experiences, 15
mental disorder, vii, ix, 77, 111, 112, 113, 117, 118,
life quality, 15, 28, 59, 78
121, 124, 131, 133, 134, 135
ligament, 71, 86, 89, 94
mental health, ix, 36, 38, 111, 112, 113, 114, 115,
ligature-induced periodontitis, 73, 81
116, 125, 129, 130, 133, 135
light, 3, 130
mental illness, ix, 111, 112, 113, 114, 115, 116, 118,
linoleic acid, 70
119, 128, 130, 133, 134, 137
lipid peroxidation, 85
mental state(s), 34
lipids, 86
messages, 66, 100
literacy, vii, viii, 91, 92, 94, 96, 97, 98, 100, 102,
meta-analysis, 26, 55, 61, 73, 77, 81, 133, 136
103, 105, 106, 107, 108
metabolic disorder(s), 118, 121, 125
liver, 77, 84, 113, 121
metabolic dysfunction, 128
liver cirrhosis, 77
metabolic syndrome, 76, 89, 118, 120, 121, 122, 124,
liver damage, 113
125, 128, 131, 132
liver disease, 84
metabolism, 73, 74, 75, 78, 122
loci, 73
mice, 70, 72, 80, 86, 89
lockjaw, 129
microbiota, 69, 70
 Index 159

micronutrient levels, viii, 65

micronutrients, 77, 78
O
microorganisms, 68, 82
obesity, 54, 66, 67, 75, 76, 77, 80, 81, 84, 85, 87, 88,
migrants, 118
89, 118, 120, 123, 125, 133, 135
migration, 19
obstructive sleep apnea, 123, 133
military, 96
occlusion, 19, 142, 147, 148, 151
models, 4, 7, 37, 39, 51, 52, 53, 71, 76, 89, 100, 103
oil, 70
moisture, 87
olanzapine, 120, 122, 127
morbidity, 5, 17, 30, 77, 113
old age, 49, 54
mortality, 6, 77, 88, 112, 113, 120, 125, 131, 132
oleic acid, 70
mortality rate, 6, 120
olive oil, 70
motivation, 119, 130, 131, 149, 150
omega-3, 70, 78, 80
mucosa, 20, 113, 114
oral cancers, 113, 114
muscles, 129
oral care, vii, ix, 111, 112, 113, 114
muscular tissue, 77
oral care practitioners, ix, 111
mutant, 73
oral cavity, viii, 15, 33, 39, 47, 123
myasthenia gravis, ix, 117
oral diseases, viii, 2, 3, 4, 5, 6, 9, 28, 33, 39, 47, 57,
myocardial infarction, 86
58, 65, 135
myocarditis, 121
oral effects of psychotropic medications, 111
oral health problems, 3, 4, 114
N Oral Health-Related Quality of Life (OHRQoL), v,
vii, 1, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
National Center for Education Statistics, 106 21, 22, 23, 34, 35, 39, 40, 41, 46, 47, 48, 49, 52,
National Institutes of Health, 97, 107 56, 63
National Research Council, 108 oral hygiene, 111
natural killer cell, 134 oral microbes, viii, 91
neck cancer, 94 organ(s), viii, ix, 5, 7, 33, 34, 47, 118
negative affectivity, 49, 60 organic compounds, 72
negative attitudes, 96 organic disease, 118
negative effects, 17, 36 organism, 77
negative emotions, 119 orthodontic treatment(s), ix, x, 43, 50, 52, 63, 139,
neglect, 125 140, 141, 142, 143, 147, 148, 149, 150, 151
neuroleptics, 122 osteoporosis, 67, 75, 133
neurotransmitter, 119 outpatient(s), 116, 127
neutropenia, 124 overnutrition, 66
neutrophils, 78 overweight, 75, 76, 88, 121, 122
New Zealand, 25 oxidative damage, 71, 73
niacin, 70 oxidative stress, 71, 75, 78, 80, 82, 86, 88
nicotinic acid, 70
non-institutionalized, 74, 79
non-smokers, 70, 71, 76, 79, 81
P
non-surgical therapy, 17
pain, vii, 1, 2, 4, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18,
normal distribution, 141
20, 22, 25, 39, 46, 47, 48, 51, 61, 98, 124
nurses, 93, 107, 116, 131, 132
pancreas, 77
nursing, 116
pancreatitis, 77, 85
nutrient(s), 66, 67, 68, 70, 76, 85, 88, 137
pantothenic acid, 70
nutrition, viii, 46, 66, 67, 68, 80, 81, 83, 84, 87, 89,
parents, 39, 57, 93, 103, 104, 131, 149, 151
91, 93, 103, 104, 105, 113, 130
parotid, 74, 84
nutritional assessment, 87
parotitis, 137
nutritional deficiencies, 124
participants, 40, 47, 49, 66, 68, 94, 141
nutritional factors, vii, viii, 65
path analysis, 54
nutritional status, 67
pathogenesis, 11
160 Index

pathogens, 81 premature death, 120

pathology, 5, 7, 125, 127 premolars, 13, 19
pathophysiology, 85, 125 preschool children, 59
pathway(s), ix, 71, 85, 89, 93, 118 preschoolers, 59
patient care, 131 preservation, 17, 19, 125
pellagra, 66 prevention, viii, 31, 65, 67, 72, 79, 85, 86, 93, 94,
perfectionism, 54 103, 104, 114, 128, 130, 131
periodontal flap surgery, 4 primate, 81, 83
periodontitis, viii, 1, 4, 11, 12, 13, 18, 22, 24, 25, 26, professionals, ix, 48, 69, 92, 96, 97, 99, 100, 102,
27, 29, 30, 48, 50, 51, 54, 55, 57, 58, 61, 62, 65, 103, 104, 105, 118, 130
66, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, progenitor cell, 71, 89
80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 94, 95, prolactin, 123
111, 113, 116, 135, 137 prophylactic, 80
peripheral neuropathy, vii prophylaxis, 73
personal hygiene, 125 prostheses, 20, 28, 46, 49, 60, 126, 127
personality, 5, 10, 13, 16, 21, 34, 49, 62 protective role, 69
personality traits, 5, 49 proteins, 67
Peru, 52 psychiatric disorder(s), 118, 124, 130
phagocytosis, 71 psychiatric hospitals, 137
pharyngitis, 15 psychiatric patients, 116, 127, 132, 134, 135
phenotype, 78 psychiatric side effects, 134
phobia, 130 psychiatry, 117, 132, 134
phosphorus, 73, 74, 75 psychological distress, 44
physical activity, 67, 69, 79, 85, 128 psychological health, 2, 14, 15
physical care needs, ix, 111 psychological processes, 6
physical characteristics, 46 psychological stress, 95
physical environment, 66 psychological value, 19
physical health, ix, 2, 111, 112, 116, 125, 132 psychological well-being, 10, 40
physical inactivity, 125 psychology, 48, 100, 106
physiological factors, 8 psychometric properties, 140
PIDAQ, vii, ix, 139, 140, 141, 143, 144, 145, 146, psychopathology, 137
150 psychosis, 113
pilot study, 25, 29, 60, 61, 96 psychosocial development, 8
placebo, 70, 73, 81, 82 psychosocial factors, 54, 60
plaque, 10, 11, 68, 69, 95, 127 Psychosocial Impact of Dental Aesthetic
pneumonia, 113, 116, 134 Questionnaire, vii, ix, 139, 140
policy makers, 3, 4, 9 psychotropic drugs, 137
polymorphism(s), 73, 82 psychotropic medications, 111
polysaccharide, 78 public health, 9, 24, 38, 56, 75, 93, 97, 118
polyunsaturated fat, 78, 81, 82, 83, 86 public policy, viii, 91
polyunsaturated fatty acids, 78, 81, 82, 83 public sector, 134
population, viii, ix, 2, 3, 6, 12, 13, 18, 20, 24, 25, 27, pyridoxine, 70
29, 30, 31, 33, 34, 38, 47, 48, 49, 50, 58, 59, 60,
62, 63, 87, 92, 94, 95, 111, 116, 117, 118, 120,
121, 122, 123, 124, 125, 127, 128, 130, 131, 134, Q
136, 149, 150
questionnaire, ix, 10, 11, 12, 13, 14, 26, 35, 38, 40,
positive attitudes, 96
41, 44, 46, 50, 51, 57, 58, 60, 61, 139, 140, 141,
positive reinforcement, 100, 101
143, 144, 146, 150, 151
potassium, 89
quetiapine, 127
poultry, 67
predictor variables, 35
pregnancy, 14, 22, 95, 103
prejudice, 39
 Index 161

scarce resources, 3, 4
R schizophrenia, ix, 34, 114, 118, 119, 121, 122, 124,
125, 127, 128, 130, 131, 132, 133, 134, 135, 136,
race, viii, 91, 94, 100
137
receptor (s), 73, 78, 80, 123, 128
schizophrenic patients, vii, ix, 118, 120, 121, 122,
recession, vii, 1, 12, 18
123, 124, 125, 126, 127, 128, 129, 130, 134, 136
reciprocal relationships, 37
school, viii, 2, 3, 14, 25, 39, 91, 93, 94, 95, 98, 99,
reconstruction, 46, 50
104, 151
recreation, 7
school activities, 95
recurrence, 119
science, 37, 66, 80, 81, 82, 84
red wine, 78
second generation, 112, 133
regions of the world, 2, 118
second language, 98
regression, 66
second molar, 19
regulatory agencies, 36
sedentary lifestyle, 131
rehabilitation, 19, 20, 49, 56, 86, 119, 127
selenium, 75, 88
relapses, 119
self-assessment, 96
relaxation, 12, 15
self-confidence, 10, 46, 47, 54, 140, 143
reliability, 9, 38, 51, 55, 57, 116
self-consciousness, 54
relief, 2, 4
self-control, 47
researchers, 3, 5, 38, 94, 97, 98, 102
self-efficacy, 105
resistance, 70, 93, 128
self-esteem, viii, 33, 34, 46, 47, 49, 60, 119
resources, 4, 115, 137
self-image, 46
response, 11, 14, 34, 35, 36, 39, 54, 60, 61, 62, 73,
self-monitoring, 54
78, 80, 95, 119, 125, 134
self-perceptions, 151
responsiveness, 9, 27, 58
self-reports, 102
restoration, 20, 49
self-worth, 49
restorative material(s), 94
sensitivity, 18, 24, 25, 27, 30
restrictions, 7
serotonin, 112, 119, 123, 128
retinol, 72
serum, viii, 65, 70, 73, 74, 75, 79, 80, 81, 86, 87, 88,
RFS, 66
89, 134
riboflavin, 70
serum ferritin, 74
risk(s), viii, 4, 8, 15, 18, 28, 59, 67, 73, 74, 75, 76,
sex, 94, 104, 141, 145
77, 82, 85, 86, 87, 91, 99, 104, 106, 113, 116,
sexual behavior, 124
120, 121, 122, 123, 124, 125, 127, 131, 132, 134,
shame, viii, 33, 34, 46, 47, 54, 97
135
shift mask(s), 60
risk factors, 67, 76, 82, 85, 120, 122, 123, 131
showing, 35, 75, 130
risk-taking, 104
side effects, 118, 124, 125, 127, 129, 133
risperidone, 122, 127
signs, vii, 1, 3, 10, 11, 12, 13, 14, 15, 16, 17, 46, 55,
Romania, 33, 54, 65, 139
94, 102, 114, 119, 124
root, 12, 18, 27, 28, 29, 30, 57, 72, 73, 87, 98
simulation(s), 100
routes, 123
single-nucleotide polymorphism, 72
routines, 10
skills training, 96
rubrics, 100
smog, 108
smoking, ix, 67, 69, 73, 82, 83, 84, 102, 103, 104,
S 105, 107, 108, 113, 118, 124, 125, 128, 129, 130,
134
saliva, viii, 74, 78, 84, 91, 95, 127 smoking cessation, 102, 107, 108
salivary gland(s), 113 snacking, 103, 104
SAR, 1 social anxiety, 15, 47
Sartorius, 132, 136 social comparison, 34
saturated fat(s), 78 social competence, 8
Saudi Arabia, 151 social consequences, vii, 1, 5, 16
scaling, 18, 28, 29, 72, 73, 87, 127 social context, 97
162 Index

social desirability, 47 suppression, 129

social environment, 113 surveillance, 51, 56, 93, 94
social inequalities, 61 survival, 134
social integration, 7 survivors, 52, 62
social interaction(s), viii, 2, 14, 15, 16, 33, 34, 47 susceptibility, 73, 84, 93
social life, 10, 13, 48, 49, 119 Sweden, 55, 83
social policy, 105 swelling, 12, 14
social relations, 2, 46 Switzerland, 24, 25
social relationships, 2 symbolism, 130
social services, 131 symptoms, vii, ix, 1, 2, 8, 10, 11, 12, 13, 14, 15, 16,
social skills, 97, 128 17, 25, 29, 37, 39, 42, 55, 99, 112, 117, 118, 119,
social skills training, 128 121, 123, 124, 127, 128, 129, 130, 136
social support, 34, 113, 119 syndrome, ix, 76, 79, 86, 117, 121, 122, 125, 128
social withdrawal, 118, 119
society, ix, 3, 5, 8, 19, 93, 94, 95, 118
socioeconomic background, 4 T
socioeconomic status, ix, 3, 28, 39, 100, 118
Taiwan, 126, 136
sociology, 23
tardive dyskinesia, 123
sodium, 67
target, ix, 4, 9, 34, 118
software, 98, 99
teachers, 93, 97
speech, 7, 10, 13, 16, 46, 129
teams, 130
Sprague-Dawley rats, 80
techniques, 54, 97, 100, 102
Sri Lanka, 43, 59
teeth, viii, 2, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20,
stakeholders, 93
22, 24, 26, 29, 30, 31, 33, 34, 35, 39, 45, 47, 48,
standard deviation, 143
49, 59, 60, 61, 63, 65, 78, 94, 95, 102, 104, 105,
starch, 78
113, 114, 115, 127, 142, 143, 145, 148
state(s), ix, 2, 3, 5, 9, 17, 20, 34, 37, 40, 74, 82, 86,
telephone, 102
93, 94, 112, 114, 118, 135
temporomandibular disorders, 46, 61
statistic test, 146
tension, 129
statistics, 132
test scores, 35
stereotypes, 96
testing, 52, 55, 97, 116
stereotyping, 124
testosterone, 84
sterile, 85
Thailand, 14, 43, 57, 87
sterols, 69
therapeutic effect(s), 71
stigma, ix, 111, 112, 115, 117, 118, 131
therapeutic relationship, 97
stigmatized, ix, 118
therapist, 47
stimulation, 121
therapy, viii, 3, 4, 10, 13, 16, 17, 18, 20, 22, 23, 25,
stomach, 83
26, 27, 29, 30, 31, 33, 34, 36, 39, 47, 48, 49, 51,
stomatitis, 114
52, 53, 59, 61, 62, 69, 72, 80, 83, 84, 89, 107
stress, 17, 21, 28, 47, 54, 78, 85, 93, 95, 97, 105, 119
third molar, 29
stroke, 34, 77
thoughts, 119
structural equation modeling, 51
tissue, 22, 71, 75, 80, 94, 95, 104
structure, viii, 5, 8, 20, 91
tobacco, 93, 120, 121, 133
style(s), viii, 91, 100
tocopherols, 73
subgroups, 94
tooth loss, vii, viii, 1, 12, 13, 16, 18, 19, 22, 24, 26,
substance abuse, 113, 135
29, 30, 33, 34, 47, 48, 49, 51, 54, 55, 56, 60, 61,
substance use disorders, 113
73, 75, 78, 83, 88, 125
sucrose, 68, 79
topical anesthetic, 102
suicide, 118, 120
total cholesterol, 122
sulfate, 129
total energy, 69
Sun, 89, 90
toxicity, 121, 134
supervision, 104
toys, 103
supplementation, 73, 75, 81, 83, 84, 85, 87
training, ix, 118, 130
 Index 163

trajectory, 112 vocabulary, 92

transport, 114, 130 vulnerability, 49
trauma, viii, 33, 34, 44, 47, 93, 95, 105
tricyclic antidepressant(s), 112
triglycerides, 70, 122 W
tuberculosis, 124
Washington, George, 108
Turkey, 125, 126
waste disposal, 55
type 2 diabetes, 70, 83, 86, 121, 122, 135
water, 67, 93, 99, 104
weakness, 124
U weapons, 82
websites, 98, 99, 112
U.S. Department of Agriculture, 106 weight gain, ix, 76, 117, 122, 133
undergraduate education, 114 weight loss, 77
undernutrition, 66 well-being, 2, 3, 7, 9, 14, 16, 23, 34, 37, 55, 66, 78
urban areas, 118 withdrawal, 119
US Department of Health and Human Services, 107 workers, 3, 12, 13, 14, 15, 17, 20, 55, 80, 101, 131,
140
World Health Organization (WHO), 2, 3, 5, 6, 9, 28,
V 30, 34, 37, 38, 62, 63, 67, 75, 89, 92, 99, 108,
112, 116, 127, 151
vaccinations, 104
World War I, 93, 101
variables, 13, 31, 62, 82, 94, 97, 119, 126, 141, 144,
wound healing, 70, 71, 85, 113
146, 147
variations, viii, 66, 91
vegetables, 67, 69, 72, 78, 79, 125 X
ventricular arrhythmias, 121
ventricular fibrillation, 121 xerostomia, 51, 111, 112, 113, 127, 129
violence, 121, 124
vision, 97, 103
vitamin A, 72 Y
vitamin B, viii, 65, 67, 70, 82
young adults, 68, 140, 151
vitamin B1, 70, 82
vitamin B12, 70, 82
vitamin C, viii, 65, 71, 72, 79, 81, 82, 84, 85, 86, 87, Z
88, 89
vitamin D, viii, 65, 73, 80, 83, 84, 90 zinc, viii, 65, 67, 75, 84, 86, 88
vitamin E, viii, 65, 73, 80, 82
vitamins, 67, 69, 123