2.oral health and the quality of life i

Behavioral Sciences and

Communication Skills

Oral Health and the Quality of Life I

Dr. Caroline Mohamed

1 Dr, Caroline Mohamed

Outline of lecture

Oral health and the quality of life

I and II

•Oral-Health-Related Quality of Life:

Definition and historical reflection.

The significance of oral health in terms of public health.

The interrelation between general well being and oral health

•How do we assess it?

•Its role in research.

•Its role in clinical practice.

•Dental/Dental hygiene education. 2 Dr, Caroline Mohamed

Is a healthy smile available for all the children around the world?

Dr, Caroline Mohamed 3

• Unfortunately no !

• Disparities in oral health have emerged as a major

public health problem because socially

disadvantaged groups and nations experience high

levels of oral diseases.

• Caries is one of the most common preventable

childhood chronic diseases. It affects 60% to 90% of

school-aged children in most industrialized

countries.


• Are oral diseases a threat for

global health?


• Yes, because :

• Oral health is an integral part of general health.

• Most oral diseases share the common environmental

and behavioral risk factors with chronic diseases

( cardio vascular disease, obesity & cancer)


Oral health

• Oral health should be assessed as not only the

absence or presence of disease; but also in terms of

its contribution to physical functioning aspects and

social and psychological well-being.


• Tell me some of the possible negative

health consequences of primarily

dental caries among children and

adolescents….


Dental caries consequences...

• such as:

• low self-esteem,

• reduced quality of life & lost school time.

• functional limitations, and

higher risk for hospitalization,

• nutrition & sleep disruption.


• They can contribute to developmental patterns by

such phenomena as obesity and decreased body

height.

• Dental caries can also have negative impacts on

growth and disability.


• Therefore approaches to promote better oral health

and to reduce the inequalities should take into account

both the interrelation between oral health and general

well-being as well as

• the individual behavioral,

• psychological determinants,

• social determinants and

• the complicated pathways

of interaction between

these factors.



ORAL HEALTH

GENERAL WELL-BEING

SOCIETY

INDIVIDUAL BEHAVIOR & PSYCHOLOGY

Definition

• Oral-health related quality of life (OHRQoL) is defined

as that part of a person's quality of life that is

affected by his person's oral health.

• Specifically, OHRQoL considers how oral health

affects the person's functioning (biting, chewing,

speaking), sensations of pain/discomfort, and

psychological (appearance, self-esteem) as well as

social well-being.


• OHRQoL focuses clinicians' attention on the patient

as a whole, and thus fosters truly patient centered

care.

• It can remind basic and clinical researchers in the oral

health sciences that the ultimate outcome of any

intervention or treatment should be an improvement of

a person's quality of life; and it can support dental

and dental hygiene educators in their efforts to train

patient-centered, culturally sensitive, future health

care providers.


• Communicating OHRQoL concerns to the public can be

a successful way to advocate for patients in need of

dental care and/ or without access to dental care.

• It is a powerful behavioral concept that can unite

clinicians, researchers, and educators in their

ultimate goal of improving patients' lives and public

health in general.


History- the dark ages- 70s • Lay persons´s perceptions of oral health conditions

should not constitute a justification for exemption from

work at the 70s, oral conditions were not regarded as

illnesses because they do not conform with the “ sick

role “(Gerson, 1972)

• Perceptions of health in UK population headaches,

rashes, burns and troubles with teeth were seen as

“ trivial “ problems - not recognized or accepted as ill

health. ( Dunnel and Cartwright, 1972)


70 s • 1st International Dental Collaborative Study ( Davis,

1976 ) - aside from pain or rare life – threatining

neoplasms, oral disease was associated only with

aesthetics or perceptions of self- esteem, rather than

effects on social roles.


70 s •The shift from defining health and disease in a purely

biological manner may have begun when the World

Health Organization offered its programmatic

definition of health as more than just physical health

in the 1940s (World Health Organization, 1948).


WHO Health difinition

• Health is not only the absence or presence of a disease;

but also “the state of complete physical, mental and

social well-being”.

• This definition underlines the fact that health is a

resource for everyday life and a positive concept

emphasizing social and personal resources, as well

as physical capacities.

• Modern concept of health has a number of dimensions

(such as physical, mental, emotional, social).


70 s In medicine, Engel (1977) introduced his now famous

biopsychosocial model of health. This model stressed a

holistic approach to patient care and reflected on the

value of treating patients instead of "body parts." It

views biological processes, psychological factors, and

social forces as interrelated influences all three forces

affect and are affected by one another.


“Plaque-Host-Substrate” theory

Host

21 D Caroline Mohamed

Socio economic situation

Family Education

70 s • Around this same time, a change occurred in the way the

term " quality of life" was used in the social sciences.

• Until the 1970s, quality of life had been largely used to

describe societies. Starting in the 1970s, the term began

to be used when analyzing individuals' well-being.

• In psychology, wellness began to be considered as a

crucial aspect of a person's life, and health

psychology began to develop as an independent area

of research around this time.


70 s •The research community in the US started focusing on the

concept of quality of life, although patients' interactions

with the health care system were always motivated by

quality of life issues such as suffering from pain or not

being able to function.


70s

Patients encountered new cancer treatments (e.g.,

chemotherapy) that were likely to prolong their lives but

reduced the quality of their lives drastically, which led

them to reflect on the cost and benefit of such treatment

and to consider quality of life as a crucial factor for their

decisions.


70 s In dentistry, the National Institute of Dental and

Craniofacial Research (NIDCR) played a major role in

introducing the concept of oral-health related quality of

life (OHRQoL) to the scientific community by funding

two major conferences centered on this term and

supporting significant numbers of research studies on

this topic.

The first conference was organized by Slade in 1996 and

focused on the measurement of OHRQoL.


2000 The second conference was organized as as an

interdisciplinary workshop on OHRQoL at the University

of Michigan.

The participants worked together with researchers from

dentistry, medicine, nursing, psychology, and public

health to reflect on the role of OHRQoL for clinicians,

basic, clinical, and behavioral researchers as well as

dental educators in the oral health sciences.



These two meetings have inspired

numerous research studies since then and

made the term "OHRQoL" widely used.

2000 In the year 2000, the first-ever Surgeon General's Report

on Oral Health was published in the United States.In her

foreword to this report, the secretary of the U.S. Department

of Health and Human Services, Donna E. Shalala, wrote,

"oral health problems can lead to needless pain and

suffering, causing devastating complications to an

individual's well-being, with financial and social costs

that significantly diminish quality of life and burden

American society". (US. Department of Health and Human Services, 2000).


There was a focus on the relevance of dental health for a

person's quality of life reflecting programmatic shift away

from viewing oral health and disease merely as the

number of decayed, missing, and filled teeth due to

caries, or in terms of attachment loss or pocket depth

due to periodontal disease to a truly patient centered

perspective of oral health, by directing the attention

from the oral cavity to the person as a whole..



Oral-Health-Related

Quality of Life-How Do We

Assess It?

One major step in establishing a new concept in a scientific

field is to develop measurement instruments. Slade

(2002) provides an excellent overview of the three ways

OHRQoL is assessed, namely with:

a) social indicators,

b) global self-ratings of OHRQoL,

and

c) multiple item surveys of OHRQoL.


a) Social indicators of OHRQoL such as:

• the days of restricted work due to dental visits or

• days of work missed because of dental pain or

• children's restricted activity days due to dental

problems or dental visits

can serve an important function by showing that oral

disease has a clear impact on society as a whole.


b) Global self-ratings of OHRQoL usually ask respondents

in surveys such as the third National Health and Nutrition

Examination Survey (NHANES) of the US adult population

to rate their dental health on a five-point scale ranging

from 1 = poor to 5 = excellent.

Such a global assessment can allow comparisons

between different population groups in one country, or

even between countries.


c) Multiple item surveys of OHRQoL.

One of the most widely used instruments is the Oral Health

Impact Profile (OHIP; Slade & Spencer, 1994). It consists of forty-nine

questions concerned with the respondents' functioning;

pain; physical, psychological, and social disability; and

handicap.

The items are answered on five-point rating scales. A

short version of this scale, the OHIP-14, is available as

well (Slade, 1997b).

In addition to these general OHRQoL scales, condition-

specific scales such as the Xerostomia Related Quality of

Life Scale (Henson et al., 2001) were developed as well.



How can we measure OHRQoL in

children or patients whose

special needs may make it

difficult to communicate, such

as in patients with autism or

dementia?

In this case, proxy measurement, namely asking

a significant other to evaluate the child's or

adult's OHRQoL, may be a solution.

Is proxy measurement a valid

way to determine OHRQoL?


YES! Research showed that parents' assessment of their

child's OHRQoL correlated significantly with objective

oral health indicators such as decayed, missing, and

filled teeth due to caries and decayed, missing, and filled

surfaces due to caries scores (see Filstrup et al., 2003), as

well as with their children's self-assessments.



An additional benefit of asking parents or care givers about

another person's OHRQoL may be that it could engage the

patient in reflecting on the importance of oral health for

his or her quality of life.

Oral-Health-Related Quality of Life-Its Role

in Research Research concerning oral health issues ranges from:

• basic science research,

• to clinical research,

• behavioral research, and

• public health-related studies,

and it addresses quite diverse topics

ranging from tissue regeneration to access to care issues.

•OHRQoL can play an important role in all these different

types of research.


•In order to develop therapies that have more predictable

outcomes and truly enhance patients' oral health and

quality of life, many factors such as the pain involved for

the patient and esthetic concerns need to be addressed.

•Sommerman ( 2002) arguments focused on breaking basic

science research out of its relative isolation, by demonstrating

that the ultimate goal of enhancing oral health and quality

of life can only be reached in an interconnected effort

with other researchers, clinicians, and educators.


•Concerning basic science research, Somerman (2002)

made a powerful argument when she pointed to the fact that

the outcome of all research endeavors is the

improvement of orocraniofacial health and ultimately

quality of life, and that basic science research cannot

reach this outcome in isolation.

BASIC SCIENCE RESEARCH

OHRQoL


•She described how basic science research has to

become part of an interwoven cycle of activity, where it

connects with translational, clinical, behavioral, and

health services research as well as with clinical practice

and education to ultimately reach the goal of improving

oral health.

•She illustrated this vision of the interconnectedness of

basic science research by using one specific area of

research in the oral health sciences, namely the

regeneration of orocraniofacial tissues as an example.

•.


Her analysis of this research field led her to argue that while

considerable progress has been made in the areas of

biomimetics, biomaterials, and tissue engineering, the

existing therapies based on this research have

limitations.

SCIENCE RESEARCH

THERAPIES BASED ON THIS RESEARCH


•OHRQoL in her argument is not merely the ultimate

outcome of basic research, but guides it by providing

additional factors that need to be considered on the way

to new therapies.

•Clinical research quite obviously needs to consider

OHRQoL as one important short- and long-term

outcome of certain treatments.

•In addition, OHRQoL can make an important argument

for or against adopting a treatment approach.

•Henson et al. (2001) showed, for example, how

preserving salivary output in head and neck cancer

patients by using parotid-sparing radiotherapy

affected these patients' quality of life quite

significantly.

•Patients who had been treated with the traditional

radiotherapy had significantly worse quality of life

scores than patients treated with the new approach.


In other instances, quality of life concerns can provide an

argument against using a new treatment approach-

despite its clinical effectiveness.

Flamenbaum et al. (2003) showed, for example, that

chemomechanical caries removal in children may not be

preferable compared to the traditional technique.

These authors used a randomized controlled clinical trial to

compare the clinical efficacy, operator perspective, and

patient perspective of chemomechanical and traditional

caries removal of twenty-two first and second occlusally

cavitated deciduous molars respectively.



They found that the new technique took significantly

more time than the older method. This fact may explain

why the operators reported significantly worse ratings of

the children's behavior in the chemomechanical condition

than in the traditional condition, and why the children did

not respond positively to the new treatment.

If effectiveness alone would have been the criteria to

evaluate this new technique, it would have resulted in a

quite favorable evaluation.

However, the consideration of how the new technique

affected the pediatric patients' quality of life can be a

powerful consideration for clinicians who consider the

adoption of such a new technique.

Clinical research also needs to carefully assess long-term

outcomes of certain treatments. One example for OHRQoL

research with this objective in mind is research on the

quality of life of denture patients.

Gray, Inglehart, & Sarment (2002) showed for example that

quite a considerable percentage of the 120 research

respondents with conventional dentures who had

received their dentures between five months and nine

years before they participated in the study reported either

discomfort (20%) or strong discomfort (20%) caused by

their dentures.



Understanding what may affect whether denture patients

have a positive or poor OHRQoL is therefore a crucial

question.


Public health researchers studying oral health issues can also

see the benefit of considering OHRQoL indicators (Eklund

& Burt, 2002). Understanding how oral health disparities

and lack of access to care affect the quality of life of

millions of citizens.

Needs should be carefully documented to inform

politicians and the public in general about the status quo.

It also can be potentially a powerful tool for advocates who

want to reduce these disparities and bring more social

justice to the health care system.

Oral Health-Related Quality of Life and

Clinical Practice OHRQoL can affirm a clinician's patient-centered

approach to providing care, and thus ultimately improve

patient-provider interactions.

Clinicians should reflect on the meaning of the term "quality

care" and the role QHRQoL issues could play when

providing quality care for all patients.

From the moment patients schedule appointments to the

time when they leave the dental office and return to their

regimen of oral health promotion at home, OHRQoL can

be of considerable importance.



•Providing quality care may begin with taking a medical and

dental history that includes questions concerning how oral

health affects the patient‘s quality of life thus showing

genuine interest in the patient.

•Understanding the relevance of a patient's chief complaint

for this patient's quality of life can be crucial in getting a

clear sense of the patient's expectations concerning the

treatment outcome.

•Assuring that treatment is provided in a way that pain is

avoided to the degree possible, and providing pain

medication in such a way that pain is managed well are

just two instances that show that a clinician considers the

patient's quality of life issues.

•Ultimately, such a consideration will not merely benefit the

patient, but will be positive for all persons involved in

the clinical interaction.


A recent study with adolescent orthodontic patients showed,

for example, that the best predictor of the number of

missed appointments (as determined in a clinical chart

review) was the pain these patients reported to have

experienced during their orthodontic appointments

(Khan et al., 2004).

The more pain they reported to have suffered, the more

missed appointments they had.



This finding is just one of many research results that shows

that patients' quality of life concerns can shape their

seeking or avoiding dental care, and can affect their

cooperation with treatment recommendations.

Even when providing oral hygiene instructions and

health education in general, a consideration of the

patient's quality of life may be one crucial factor that

will ultimately determine if the patient will engage in the

recommended course of action or not.

Oral-Health-Related Quality of Life and

Dental/Dental Hygiene Education

The Institute of Medicine, 1995 published a report on the

future of dental education, which included some clear

recommendations.

Some of them were concerned with educating future

health care providers in such a way that they will provide

truly patient-centered care, will be culturally literate and

sensitive to diversity issues, and will be able to work

with an interdisciplinary perspective that sees oral

health in the context of a patient's overall health. (Institute of

Medicine, 1995).



Inglehart, Tedesco, and Valacovic (2002) took these

recommendations as a starting point to reflect which role

OHRQoL issues could play in this situation.

They started with an analysis of survey data from 1,864

respondents consisting of dental school faculty as well as

directors in hospital programs, dental hygiene and dental

assistant programs, who had rated the importance of

these recommendations.

Their results provided insight into whether there is a

willingness in the educational community to base its

educational efforts on these recommendations.

Their findings showed that the respondents rated the

importance of offering patient-centered education rather

highly.

Given this finding/ the next question is how dental/dental

hygiene educators can translate this objective into their

classroom and clinic activities.



Inglehart et al. (2002) argued that OHRQoL could serve as a

portal to patient-centered education by shaping the

content and thus the focus of educational efforts in

classrooms/ clinics/ and community settings.

Explicitly encouraging students to reflect on how health

and disease affect patients' quality of life, and which role

quality of life concerns can play for their patient's

utilization versus avoidance of health care services may

be a valuable way to educate patient-centered future

providers.

Thank you!!


Activities

• Make a resume of the most important points of this lecture and

bring to the next class.


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Available online: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

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http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

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2.oral health and the quality of life i