|Year : 2022 | Volume
| Issue : 3 | Page : 75-81
Assessment and comparison of periodontal status and its impact on oral health-related quality of life among urban and rural adults of Uttar Pradesh: A cross-sectional study
Sasmita Dalai, Pradeep Tangade, Vikas Singh, Ankita Jain, Surbhi Priyadarshi, Jagriti Yadav
Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
|Date of Submission||11-May-2022|
|Date of Decision||25-Jun-2022|
|Date of Acceptance||07-Jul-2022|
|Date of Web Publication||16-Aug-2022|
Block A, Girls Hostel TMU, Pakwara, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Context: Periodontal diseases negatively influence people's oral health-related quality of life (OHRQoL) and despite advancements; still disparity exists among urban and rural dwellers. OHRQoL helps in a better understanding of subjective perception ensuring a better treatment plan that fits the patient's needs and concerns. Aims and Objectives: (1) To record the periodontal status of urban and rural populations of Moradabad using WHO pro forma 2013. (2) To assess and compare the OHRQoL using the oral health impact profile-14 (OHIP-14). Subjects and Methods: A cross-sectional study was conducted among the rural (350) and urban (350) population of Moradabad aged 35–44 years, chosen from the outpatient department of Teerthanker Mahaveer Dental College and Hospital. The WHO oral health assessment form for adults (2013) was used to assess the periodontal status and OHIP-14 was used for assessing OHRQoL. Statistical Analysis Used: SPSS version 19.0 was used for statistical analysis. Chi-square, Student's t-test, and multiple logistic regression analysis were employed for statistical analysis. Results: The prevalence of loss of attachment (LOA) (93.20%), presence of pocket (76.0%), and bleeding on probing (BOP) (74.0%) was significantly higher among the rural population. The mean OHIP scores were significantly higher for the rural population as compared to urban counterparts. Among the study population, OHIP 14 was significantly (P ≤ 0.05) associated with age, gender, socioeconomic status, location, and periodontal parameters (LOA, Pocket, and BOP). Conclusions: The study shows that there is a significant association between periodontal status and OHRQoL. Rural individuals had a greater impact on OHRQoL than their urban counterpart. Strategies should be planned and implemented to minimize the disparity.
Keywords: Moradabad, Oral Health Impact Profile-14, oral health, rural population, urban population
|How to cite this article:|
Dalai S, Tangade P, Singh V, Jain A, Priyadarshi S, Yadav J. Assessment and comparison of periodontal status and its impact on oral health-related quality of life among urban and rural adults of Uttar Pradesh: A cross-sectional study. J Prim Care Dent Oral Health 2022;3:75-81
|How to cite this URL:|
Dalai S, Tangade P, Singh V, Jain A, Priyadarshi S, Yadav J. Assessment and comparison of periodontal status and its impact on oral health-related quality of life among urban and rural adults of Uttar Pradesh: A cross-sectional study. J Prim Care Dent Oral Health [serial online] 2022 [cited 2023 Jan 30];3:75-81. Available from: http://www.jpcdoh.org/text.asp?2022/3/3/75/353814
| Introduction|| |
The dimension of health has been considerably expanded ever since 1948, after the addition of the concept of well-being to it by the WHO. As a result, oral health has now been taken into consideration for impacting the general well-being of an individual. Daily activities such as talking, eating, and smiling can be called determinants of the well-being of an individual. In literature, terms such as health, status of oral health, or health-related quality of life are being used interchangeably. David Locker inspired by the WHO International classification of impairment, disability and handicap, for the first time introduced a conceptual model for explaining pathways, how oral conditions and diseases impact the quality of life. Also adding that oral health is inseparable from general health.
Periodontal diseases are the outcomes of inflammatory infections, which lead to the destruction of teeth supporting structures and bone resorption, further leading to the pocket formation and recession. It is a complex relationship between specific microorganisms of dental biofilm and the host's immuno-inflammatory response. Furthermore, a number of factors such as genetic factors, environmental factors, and acquired conditions, such as smoking or systemic diseases too have an influence.
Periodontal diseases can impact the quality of life in two ways; first, it may act as a modifying factor for an existing systemic condition and second, clinical consequences of the disease itself can have a social, emotional, and functional impact. Diagnosis of periodontal diseases is usually based on clinical and radiographical examination. However, subjective evaluation of the disease should also be done to quantify the impact of the compromised oral conditions on the quality of life of an individual.
The WHO (2003) has recognized oral health-related quality of life (OHRQoL), an important part of the Global Oral Health Program. It is a multidimensional concept, which evaluates oral health, functional and emotional well-being, expectations, and the sense of satisfaction of an individual. Assessment of OHRQoL is very important as it allows a transition from the traditional criteria of treating patients to an approach that focuses more on subjective experiences for defining the treatment outcomes.
Researches on HRQoL have flourished in medical as well as a dental field because of the following reasons:
- First, the patient's subjective evaluation and active involvement in the process of decision-making is altering the whole dynamics for clinical outcomes
- Second, evidence-based practice has become the needed in health care practices; and
- Finally, as a matter of fact, often the treatment of chronic diseases fail to completely eradicate the condition, elevates HRQoL as a salient variable for evaluating health outcomes.
Several tools for evaluating OHRQoL have been designed till date for this objective, including oral impacts on daily performance, oral health quality of life inventory, geriatric/general oral health assessment index, and oral health impact profile (OHIP). However, the psychometric properties and predictive validity of many of these evaluation tools were weak. To overcome this, the OHIP was developed by Slade and Spensor to measure disability and discomfort due to oral conditions, which became the most widely used tool for assessment. OHIP has been considered highly sophisticated tool for the subjective indicators of oral health status developed in the late 1970s. The scale has been derived through processes involving sessions of interviews with dental patients and is not the mere outcome of the experiences of the investigator. The tool uses the Likert scale for weighing individual items indicating; the obtained score would reflect frequency as well as severity. Hence, the scale represents an advancement in the field for obtaining a subjective evaluation of oral health status.
Periodontal disease among several others is the most common disease that affects oral health worldwide. Still, the impact on OHRQoL of periodontal conditions has been investigated lesser as compared to other oral problems. Therefore, a better understanding of subjective evaluation or perception regarding the impact of the diseases is needed, which would ensure a treatment plan that fits the patient's needs and concerns. Also for enhancing the knowledge and the understanding of the influences of regional factors, the present study was conducted, assessing oral health status and comparing the OHRQoL among rural and urban populations of Moradabad, using the OHIP-14 questionnaire.
| Subjects and Methods|| |
A cross-sectional epidemiologic study was conducted among the patients attending the Outdoor Patient Department of Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India.
The study pro forma was prepared using the OHIP-14 questionnaire in both English and Hindi languages to assess OHRQoL and the WHO Oral Health Assessment Form for Adults (2013) to assess the periodontal status of the population. It included the recording of demographic data such as name, age, sex, education, occupation, income, and clinical parameters such as community periodontal index (CPI) and loss of attachment (LOA). Socioeconomic status (SES) was classified according to Prasad's classification of the SES scale. The OHIP questionnaire consists of 14 items. Respondents are asked to indicate on a five-point Likert scale how frequently they experienced each problem. Response categories for the five-point scale were: “never (0), hardly ever (1), occasionally (2), fairly often (3), very often (4).”
Ethical clearance and informed consent
Before conducting the research, permission from the ethical committee of the Teerthanker Mahaveer University with reference number TMDCRC/IEC/19-20/PHD5 was obtained. Informed consent from every participant, and those willing to participate was obtained.
The sample size was calculated using the G power version 220.127.116.11 program by Franz Faul University Kiel. At 95% confidence interval, 5% margin of error, and taking prevalence of 0.30 and 0.20 for each group the sample size was estimated to be 252/group, which was increased to 350 after considering the dropout.
Individuals were selected using an easy convenient sampling method from the patients reporting to the Department of Oral Medicine and Radiology in Teerthanker Mahaveer Dental College and Research Centre. Hence, the study population was obtained for 8 months (April 2021 to November 2021).
Patients aged between 35 and 44 years, physically and mentally sound and have undergone no periodontal treatment in the past 6 months were included in the study.
Individuals with debilitating systemic conditions (such as uncontrolled diabetes, myocardial infections, congestive heart failure, chronic obstructive pulmonary disease, kidney or liver failure, or immunocompromised) were excluded from the study.
Data collection was done by the researcher and the assistant on the predecided schedule. Demographic details, including name, age, sex, occupation, and income, were recorded by the recording assistant along with the OHIP-14.
Clinical examination was performed by the examiner on the patients attending the outpatient department (OPD). The periodontal parameters, CPI and LOA were recorded for the assessment of periodontal status. Instruments used were disposable gloves, mouth masks, kidney trays, mouth mirrors, and CPITN probes in ample quantity.
Reliability and validity of the questionnaire
To check the reliability and validity of the OHIP-14, a pilot study on 50 participants was done, who were chosen according to the set inclusion criteria. Cronbach's coefficient was 0.85 for both urban and rural populations. For assessing face validity, it was observed that 91% of the participants found the questionnaire to be easy. However, the data obtained from this trial study was not included in the main research.
Training and calibration of examiners
Training and calibration of the examiner were performed in the department of public health dentistry on selected individuals with several sessions. The researcher was accompanied by an assistant dental doctor to pen down the data during the examination. The assistant was instructed and graded with the recording standards; for the indices to be used in the study in the Department of Public Health Dentistry. Before commencing the study, intraexaminer reliability checked was equivalent to 85%.
The obtained data were compiled and entered into Microsoft Excel, 2007 (Microsoft Corp., USA). For data analysis, SPSS version 19.0 (IBM SPSS Statistical Inc., Chicago, IL, USA) was used. Independent variables included CPI and LOA. Dependent variables were OHIP-14 with its domains. Descriptive statistics included the calculation of means and standard deviations. The Chi-square test and Student's t-test were used for the intergroup comparison of all clinical indicators between age, gender, and SES. Logistic regression analysis was applied to OHIP-14 and its domains. The significance level was set at 5%.
| Results|| |
The study sample consists of 700 individuals, 350 each obtained from rural and urban zones, respectively. Among the urban group, 42.3% were male and 57.7% were female and among the rural group 44.9% were male and 55.1% were female. A higher proportion of the individuals belonged to the lower middle socioeconomic class, in both the groups rural (31.1%) and urban (31.7%), respectively [Table 1].
The prevalence of LOA was significantly higher in the rural population among 326 (93.20%) individuals, followed by the presence of pockets (76.0%) and bleeding on probing (BOP) (74.0%) while among urban individuals LOA was present among 72.5% individuals, BOP in 67.4% and pockets among 60.6% of the individuals [Table 2].
|Table 2: Intergroup comparison based on the oral health status among urban and rural population|
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The mean OHIP scores were significantly higher for the rural population when compared to its urban counterpart. In terms of functional limitation, psychological disability, physical disability, psychological discomfort and physical pain, social disability, and physically disabled [Table 3].
The mean OHIP score for all seven domains was significantly higher in the 35–37 years age groups as compared to the 38–40 years of age group and above 40 years of age group. Among the rural–urban comparison, the OHIP score for each dimension was significantly higher in the rural group as compared to the urban group. When the intergroup comparison was made between the males and females the OHIP score of each dimension showed significantly higher values for males than the female counterpart. Among the individuals with gingival bleeding, periodontal pockets, and individuals with higher LOA scores the OHIP score of each domain-functional limitation, pain, psychological discomfort, physical disability, psychological discomfort, social handicap, and physically disabled was significantly higher than the individuals without gingival bleeding, periodontal pockets, and individuals with lower LOA scores [Table 4] and [Table 5].
|Table 4: Association of oral health impact profile-14 and its domains (mean±standard deviation) with several independent variables among study individuals|
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|Table 5: Multivariate logistic regression with oral health impact profile as dependent variable (0=oral health impact profile score ≤6, 1=oral health impact profile score >6), divided by various demographic and clinical characteristics|
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| Discussion|| |
In context to global health, the term health, corresponding to the 1947 WHO definition; ranges from optimal functioning of physical and mental health to social well-being as well. Hence, health-related quality of life has been acknowledged as a multidimensional concept that, besides physical, social, and psychological components also depends on role functioning and subjective perceptions.
First scientific research done by Ng and Leung clearly indicated the importance of understanding subjective perspective on the clinical parameters used for diagnosing, as it would ensure better insight of daily life outcomes. Another major contribution in this field was done by Cunha-Cruz et al. The author reported through the study, that periodontal status was not simple and linearly associated with OHRQoL, and self-assessment of oral status. Subjective perception might vary for the same condition; again emphasizing the importance of including subjective measures in clinical practice.
The association between geographic distribution and health inequalities has been proved in various studies. High frequency of ill health was prominent among socially deprived and materially disadvantaged individuals. Many researches have been conducted for assessing OHRQoL among periodontitis patients and identifying urban–rural disparity worldwide; however, according to the researcher's best knowledge no such study has been done for the Moradabad population. Hence, the present study was carried out in an effort to explore the impact of oral health status on OHRQoL and identify urban–rural disparity among the population of Moradabad.
The study focused on the indexed age group of 35–44 years as it is considered standard group for monitoring the full effect of ill oral health as well as of provided care; according to WHO. According to the National Oral Health Study and Fluoride Mapping (2002–2003), the prevalence rate for 35–44 years of the age group of periodontal disease was recorded at 89.2%. For assessing OHRQoL for periodontal diseases of the study participants, OHIP-14 was used. This short version of OHIP was developed in the year 1997 by Slade. The questionnaire has been validated in multiple study settings worldwide; China, England, Sri Lanka, and Scotland for its use on the adult population. OHIP-14 consists of seven domains and each domain was expressed with two sets of questions. For appraising each question, Likert scale was used; with the value ranging from 0 to 4 per question and 0–8 for each domain. The total score for OHIP-14 was obtained as a sum of individual responses; which ranged between 0 and 56. A higher score indicated poor OHRQoL and vice versa.
Analyzing demographic details showed that the majority of study individuals were female from both urban (57.7%) and rural groups (55.1%) which simulate a study conducted by Fotedar et al. on OPD patients HP GDC, Shimla. According to the author, usually females avail dental services more often and the gender differences are also evident in relation to treatment outcomes. Also according to a study conducted by Vaidya et al, female subjects had a greater tendency for availing dental services than the male counterpart. For deciding the SES of the study participants prasad scale was used. Among both the groups, urban and rural; it was however seen that majorly the sample belonged to the lower middle class, 31.7% and 31.1% from urban and rural, respectively. This finding can be attributed to the fact that in dental colleges the treatment fees is usually less and affordable. Moreover, there are ample amount of literature showing an association between SES oral health behaviors. According to a study conducted by Park et al upon Korean population, demonstrated that SES does have an impact on the oral health behaviour. The study also showed that subjects belonging to higher SES group used secondary oral hygiene aids like dental floss, interdental brush etc.
The study revealed a decrease in the mean score for OHIP-14 with an increase in the age which is contradictory to many of the available researches done. According to a study done by Zucoloto et al., increase in age was significantly associated with poorer OHRQoL, owing to the fact that with the advance in age, impact of systemic diseases too increases. However, in our study, the result might have been, due to the narrow age group chosen.
On intergroup comparison for the gender, the OHIP score was found significantly higher in males than the female counterpart. Our findings can be supported by a study of Sanadhya et al., they showed males suffered threefold more impacts than females. The finding of the present study is contradictory to the ample number of available literatures as a study by Caglayan et al., the QoL of females tends to be easily affected by poor oral status. However, according to some literature OHIP is not significantly related to gender; as is shown in the study done by Fernandes et al. As each sex undergoes through a different course of life, hence gender differences for OHRQoL cannot be understood solely by assessing the status of oral health.
On intergroup comparison of mean OHIP scores, a significantly higher score was noticed for the rural population than for the urban group and for all the seven domains with functional limitation and physical disability showing the highest significance, P = 0.001. Grover et al. conducted a similar study on the Punjab population that showed a higher OHIP-14 score for the rural population and also found significant differences for functional limitation and physical disability just in accord with the present study.
Sanadhya et al. did a similar study for assessing the impact of the oral health status on OHRQoL and for comparing the impacts on urban and rural groups. The study depicted poor OHRQoL for rural population owing to a lack of accessibility to medical facilities. According to Gaber et al.(2018); even after adjusting for predisposing factors, rurality had a significantly higher association with poor OHRQoL than the urban counterpart.
As the present study followed cross-sectional design, hence effect causal relationship cannot be investigated. Sample selection for the present research was done from the patients attending the OPD of the dental hospital; and as OHRQoL is dependent on subjective evaluation of their condition, which might be different from the general population.
| Conclusions|| |
The present study was conducted for assessing the periodontal status and comparing their impacts on the quality of life of the urban and rural populations of Moradabad. The study shows that there is a significant association between periodontal status and OHRQoL. Moreover, independent variables like gender, age, and geographical distribution too had an impact. Rural individuals had a greater predilection for periodontal diseases which was evident from all the parameters (LOA, bleeding, and pocket) assessed. For the rural group, the prevalence rate for LOA was 93.20%, bleeding was 74.0% and for the presence of pocket, it was 76.0%. The reason might be attributed to the fact that rurality is usually associated with poor accessibility. Using the Pearson correlation test, a significant association was observed between OHIP scores and periodontal parameters. There was a significant urban–rural disparity for all seven different domains of OHRQoL when assessed through OHIP 14. Hence, there is a need for the development of strategies and policies to eradicate disparities and promote oral health status, specifically for rural dwellers. More studies are advocated on the general population including nonpatient and targeting a larger sample size with a wider age group for better generalization of the results.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]