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The prevalence and severity of oral impacts on daily performances in Thai primary school children

The prevalence and severity of oral impacts on daily performances in Thai primary school children Background: Traditional methods of measuring oral health mainly use clinical dental indices and have been complemented by oral health related quality of life (OHRQoL) measures. Most OHRQoL studies have been on adults and elderly populations. There are no systematic OHRQoL studies of a population-based sample of children. The objective of this study was to assess the prevalence, characteristics and severity of oral impacts in primary school children. Methods: Cross-sectional study of all 1126 children aged 11–12 years in a municipal area of Suphanburi province, Thailand. An OHRQoL measure, Child-Oral Impacts on Daily Performances index (Child-OIDP) was used to assess oral impacts. Children were also clinically examined and completed a self-administered questionnaire about demographic information and oral behaviours. Results: 89.8% of children had one or more oral impacts. The median impact score was 7.6 and mean score was 8.8. Nearly half (47.0%) of the children with impacts had impacts at very little or little levels of intensity. Most (84.8%) of those with impacts had 1–4 daily performances affected (out of 8 performances). Eating was the most common performance affected (72.9%). The severity of impacts was high for eating and smiling and low for study and social contact performances. The main clinical causes of impacts were sensitive tooth (27.9%), oral ulcers (25.8%), toothache (25.1%) and an exfoliating primary tooth (23.4%). Conclusions: The study reveals that oral health impacts on quality of life in Thai primary school children. Oral impacts were prevalent, but not severe. The impacts mainly related to difficulty eating and smiling. Toothache, oral ulcers and natural processes contributed largely to the incidence of oral impacts. That is why Cohen and Jago considered that the greatest Background Contemporary concepts of health suggest that dental contribution of dentistry is to the improvement of quality health should be defined in physical, psychological and of life because most oral diseases and their consequences social well-being terms in relation to dental status [1,2]. interfere with, or have impacts on, daily life performances Page 1 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 [3]. Therefore, disruptions in normal physical, psycholog- mation such as age, sex and occupation of the father and ical and social functioning are important considerations mother, or male and female guardians [13] and oral in assessing oral health. Despite these suggestions, tradi- health behaviours and c) an oral examination by four cal- tional methods of measuring oral health use mainly clin- ibrated community dentists, mainly based on the WHO ical dental indices and focus on the absence or presence of guidelines [14]. Orthodontic normative treatment needs oral diseases. They do not inform us about the oral well- were assessed by the Index of Orthodontic Treatment being of people in terms of feelings about their mouths, Need (IOTN) [15]. Oral hygiene was also assessed using or, for example, their ability to chew and enjoy their food. the Simplified-Oral Hygiene Index (OHI-S) [16]. All doc- The inadequacy of the normative approach in measuring uments were translated from English to Thai and the oral health has been recognised and lead to the develop- validity was checked by a back-translation method, ment of measures of oral health-related quality of life involving blind re-translation into English. The validity of (OHRQoL) [4]. the translation was verified by experts in the use of ques- tionnaires in both languages. This was also checked after A number of socio-dental or OHRQoL measures have wording modifications, in order to ensure the conceptual been developed and used for assessing oral well-being and and functional equivalences of the questionnaires. A pilot to describe oral impacts on people's quality of life [5]. study was carried out to validate all questionnaires before Generally, they measure the extent to which oral condi- using them in the main data collection. The psychometric tions disrupt normal social role functioning and lead to properties of the Child-OIDP in terms of face, content and major changes in behaviours, such as changes in ability to concurrent validity as well as internal and test-retest relia- work or attend school, or undertake parental or house- bility were excellent. The index was also practical to use hold duties [6,7]. In addition to describing oral impacts with this age group. Full description of the validation on quality of life, some OHRQoL measures were designed process of the Child-OIDP can be found elsewhere [9]. specially to assist dental service planning by incorporating For the main data collection, test-retest reliability of data them with traditional normative measures in the process was tested by ten percent random duplication. Weighted of dental needs assessment [8,9]. kappa score for the Child-OIDP was 0.91, kappa scores of self-administered questionnaires were 0.7–1.0, and those Most studies using OHRQoL to assess oral impacts of the of intra- and inter-examiner for oral examinations were mouth and teeth have been on adults and elderly popula- 0.7–1.0 and 0.6–1.0 respectively indicating good to excel- tions. Few studies have been done on children possibly lent agreement. The SPSS and Stata programmes were because no OHRQoL measures designed for use with chil- used for statistical analysis. dren existed until recently. A single measure, dental pain, has been used on children in Malaysia [10] and in South The protocol of the study was approved by the Ethical Africa [11]. They found a high prevalence of pain that Committee of the Ministry of Public Health of Thailand. affected daily living. Similarly, a study in New Zealand Primary education and local health authorities as well as found that most school children complained of at least all primary schools in the study areas gave permission. one dental symptom [12]. To date, there are no systematic Positive consent forms and letters informing parents were OHRQoL studies of a large population-based sample of sent to parents. children. In particular, the OHRQoL of primary school Measuring oral impacts and calculating their severity children, who are frequently the main target group for dental health services, has not been assessed. Therefore Two comprehensive OHRQoL measures specifically for the objective of this study was to use an OHRQoL meas- use with pre-adolescent children have recently been devel- ure, the Child-OIDP, to assess the prevalence, characteris- oped; the Child Perceptions Questionnaire (CPQ11-14) tics and severity of oral impacts in primary school [17] and the Child Oral Impacts on Daily Performances children. (Child-OIDP) [9]. Both were validated on a cross-sec- tional study using a proxy, because no gold standard is Methods available; therefore, at this stage, they should be consid- A cross-sectional survey was carried out in a municipal ered discriminative and not yet evaluative OHRQoL meas- area of Muang district, Suphanburi province, Thailand. ures. However, they differ mainly in their aims and The sample was all 1,126 students aged 11–12 years, in theoretical frameworks. The Child-OIDP index was devel- the final year class of all primary schools (grade 6) in the oped on a large population-based sample with the aim of area. being used for dental health service planning. Its theoret- ical framework is the same as for the original OIDP, Data were collected through: a) an interview for oral namely oral health consequences are categorised into dif- impacts using the Child-OIDP [9], by one interviewer b) ferent levels and the index measures only oral impacts on a self-administered questionnaire for demographic infor- daily performances at the ultimate level [8,9]. The Child- Page 2 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 OIDP has the advantage over the CPQ11-14 in that it another child with severe impacts (score of 6) on only 1 specifies the different clinical causes of each oral impact performance. In the former case, the child will be in the and therefore the treatments needed. Although the objec- 'very little', and in the latter one, in the 'severe' category. tive of current study is to assess oral impacts of children, a The extent refers to the number of performances with broader aim of the project was to assess the implications impacts (PWI) affecting a child's quality of life over the of using measures of oral impacts to estimate dental needs past three months. It ranges from 0 to 8 PWI. The relation- of children. Therefore the Child-OIDP was selected for ships between the impact score and intensity as well as this study as it is specifically designed to be incorporated between score and extent were statistically significant (p < into a needs system. 0.001) [18]. Intensity and extent of impacts represent an alternative method of describing or comparing oral The procedure for using the Child-OIDP began with a self- impacts on children. They are more straightforward and administered questionnaire carried out with all children could give a simpler and clearer picture of impacts than as a group in their classroom. The questionnaire contains using a single score. Therefore, they provide a more prac- a list of all oral problems that children are likely to per- tical aspect to the OHRQoL assessment making it more ceive and also include an open answer for any unexpected easily applicable to dental service planning. perceived problem. It was developed during a pilot study, as a modification from the one used in the original OIDP. Results Children were asked to identify oral problems that they 1101 of the 1126 children returned positive consent perceived in the last three months. This step aimed to forms approved by their parents. 1034 children (91.8% of focus children's attention to their oral health problems the total) completed all stages of the survey. 52.4% were and to lead to the oral impacts assessment later. Their male and 47.6% were female. Their mean age was 11.3 answers here were used only as a guide to investigate oral years (sd = 0.6). The highest percentage of their fathers impacts on daily performances in the next step and were were agricultural workers or labourers (34.5%), 30.5% referred to when they were asked about the causes of oral worked in business/private, 27.5% in governmental sec- impacts in individual interviews. Thereafter, children were tors, 2.1% did not work and 5.4% of children did not have individually interviewed, irrespective of their answers at a male guardian. The highest percentage of mothers the first step, to assess oral impacts on daily life in relation worked in business/private (38.6%), 24.5% in agriculture, to 8 daily performances. The 8 performances were: a) eat- 21.1% in governmental organisations. 14.9% did not ing, b) speaking, c) cleaning teeth, d) relaxing, including work and 1.0% did not have a female guardian. sleeping, e) smiling, laughing and showing teeth without embarrassment, f) maintaining emotional state, g) study, This population had a low level of dental caries: 43.1% including going to school and doing homework and h) were caries free and the DMFT scores ranged from 0 to 12 contact with other people. The individual interviews were with a median score of 1.0 and a mean of 1.5 (±1.8). aided by 16 pictures (negative and positive pictures for Almost all children (97.0%) had a Community Periodon- each performance). If children reported an impact on any tal Index (CPI) score of 1 or more; 84.2% had calculus. In performance, the frequency of the impact and the severity terms of oral hygiene status, 5.4% had good, 69.1% had of its effect on their daily life were scored. Children were moderate and 25.5% had poor oral hygiene. OHI-S scores also asked to identify oral problems that in their opinion, ranged from 0.5–5.5 with a median of 2.5 and mean score caused the impact. The oral problems were identified of 2.5 (±0.9), indicating a moderate level of oral hygiene. from the list complied in the first step of the assessment. The prevalence of oral impacts was high; 89.8% of chil- The oral impact score of each performance is obtained by dren had experienced some kind of oral impact on their multiplying severity and frequency scores, 0, 1, 2 or 3 daily life during the past three months. There was no dif- each, in relation to that performance. Therefore scores can ference between the prevalence of impacts in girls and range from 0 to 9 per performance. The overall impacts boys (Chi-square test). Impacts on Eating were the most score is the sum of all 8 performances (ranging from 0 to prevalent (72.9%). The prevalence of impacts on Emotion 72) divided by 72 and multiplied by 100. An alternative (58.1%), Cleaning teeth (48.5%) and Smiling (40.1%) method of reporting the severity of oral impacts, from the were also relatively high. The remaining prevalences of same data set, is to use the 'intensity' and 'extent' of impacts were lower, namely Study (15.4%), Relaxing impacts. The intensity refers to the most severe impacts on (14.7%), Contact with people (12.2%) and Speaking any of the 8 performances or the highest performance (9.9%) (Table 2). score. It is classified into 6 levels; none, very little, little, moderate, severe and very severe (Table 1). The idea Extent and Severity of impacts behind this is to differentiate between for example, a child Among the children with impacts, the extent of impacts with minor impacts (score of 1) on 6 performances and varied from 1 to 8 performances with impacts (PWI); Page 3 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 Table 1: Classification of the intensity of oral impacts on a performance The intensity of impacts Severity score Frequency score Performance score Very severe Severe (3) × Severe (3) 9 Severe Severe (3) × Moderate (2) 6 Moderate (2) Severe (3) Moderate Moderate (2) × Moderate (2) 4 Severe (3) × Little (1) 3 Little (1) Severe (3) Little Moderate (2) × Little (1) 2 Little (1) Moderate (2) Very little Little (1) × Little (1) 1 No impact None (0) × None (0) 0 Table 2: Prevalence, intensity and score of oral impacts in Thai school children Performances Oral impacts on daily Overall Eating Speaking Cleaning Relaxing Emotion Smiling Study Contact performances impacts teeth Prevalence (%) 89.8 72.9 9.9 48.5 14.7 58.1 40.1 15.4 12.2 Impact intensity (% of children with impacts) - Very little 15.9 27.9 37.4 33.2 37.4 43.7 25.5 57.8 49.2 - Little 31.1 39.0 33.3 38.8 44.2 37.2 28.2 31.2 38.5 - Moderate 31.7 21.8 19.2 20.8 14.3 13.9 27.4 9.7 10.7 - Severe 18.7 10.8 9.1 6.6 3.4 4.7 15.7 1.3 1.6 - Very severe 2.6 5.5 1.0 0.6 0.7 0.5 3.2 0.0 0.0 Impact score - Range 0–59.7 0–9 0–9 0–9 0–9 0–9 0–9 0–6 0–6 - Mean (sd) 8.85 (7.4) 1.87 (1.8) 0.23 (0.9) 1.13 (1.6) 0.30 (0.7) 1.17 (1.4) 1.21 (2.0) 0.25 (0.7) 0.21 (0.7) - Percentiles 2.8,7.6,12.5 0,2,2 0,0,2 0,0,0 0,0,0 0,1,2 0,0,2 0,0,0 0,0,0 (25,50,75) 16.2% had 1 PWI, 23.3% had 2, 26.9% had 3 and 18.4% 7.6 and a mean score of 8.8 (sd = 7.4). No difference in had 4 PWIs. Few children had 5 or more PWIs. About 1 in overall impact scores were identified between different 5 children had severe or very severe intensity of impacts; sexes (Mann-Whitney U test). Mean scores of impacts on 18.7% had severe and 2.6% had very severe intensity of each of the 8 performances ranged from 0.21 to 1.87 impacts.15.9% had very little, 31.1% had little and 31.7% (maximum possible score is 9). Mean impact score for had moderate intensity of impacts (Table 2). The intensity Eating (1.87) and Smiling (1.21) were the highest while of impacts on each performance showed that Eating and those for Study (0.25) and Contact (0.21) were the lowest Smiling were the most severely affected while Study and (Table 2). Contact were the least. 16.3% of children with impacts on Eating and 18.9% of those on Smiling had severe or very 'Causes' of the impacts severe impacts, while the same intensity was reported by There were various oral and dental problems that children 1.3–10.1% of children having impacts on other perform- perceived as the causes of their overall oral impacts (Table ances. 57.8% of children with impacts on Study and 3). The more prevalent problems leading to impacts were 49.2% of those on Contact had a very little or little level a sensitive tooth (27.9%), oral ulcers (25.8%), toothache of impact intensity, whereas none had a very severe inten- (25.1%) and an exfoliating primary tooth (23.4%). Fur- sity of impacts on those two performances. thermore, oral conditions that related to appearance fre- quently affected children; position of teeth (20.0%) and The distribution of overall impact scores was skewed colour of teeth (16.2%) were quite frequently cited. In (Table 2). They ranged from 0.0 to 59.7 with a median of Page 4 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 Table 3: Frequency of oral conditions perceived as causing overall addition, swollen or inflamed gums were related to over- oral impacts all impacts in 13.8% of children. Oral conditions causing overall impacts Frequency (%) The main perceived causes of impacts on each of the 8 per- formances are shown in Figure 1. Toothache and oral Toothache (t-ache) 25.1 Sensitive tooth (t-sensitive) 27.9 ulcers were among the main perceived causes of impacts Tooth decay, hole in tooth 5.0 on 6 performances. The majority of impacts on Eating Fractured permanent tooth 4.6 were caused by toothache (64.5%) and on Speaking by Colour of teeth (colour) 16.2 oral ulcers (57.8%). An exfoliating primary tooth was one Shape or size of teeth 2.7 of the main perceived causes of impacts on the following Position of teeth (position) 20.0 5 performances; Eating (17.9%), Cleaning (29.5%), Bleeding gum (bleed) 7.4 Relaxing (11.2%), Emotion (17.5%) and Study (17.6%). Swollen or inflamed gum (swollen) 13.8 Calculus 0.9 Position of teeth was among the main perceived causes of Bad breath 7.2 impacts on 3 performances; Smiling (40.7%), Contact Oral ulcer (ulcer) 25.8 (19.8%) and Emotion (10.0%). Space due to a non- Exfoliating primary tooth (exfoliat) 23.4 erupted permanent tooth (after exfoliation) was one of Tooth space (due to unerupted permanent tooth) 5.3 the main reasons for impacts on Smiling (11.1%). Bad (space) breath was the most frequent perceived cause of impacts Erupting permanent tooth 4.9 Deformity of mouth or face 0.4 on social Contact (27.0%). Missing permanent tooth 0.7 19.9 37.0 19.4 17.9 Eating t-ache t-sensitive ulcer exfoliat 11.8 12.7 57.8 Speaking t-ache position ulcer 13.7 24.3 26.9 29.5 Cleaning bleed swollen ulcer exfoliat 64.5 9.9 11.2 Sleeping t-ache ulcer exfoliat 27.1 10.0 17.0 17.5 Emotion t-ache position ulcer exfoliat 38.6 40.7 11.1 Smiling colour position space 45.3 14.5 17.6 Study t-ache ulcer exfoliat 26.2 15.9 19.8 27.0 Contact t-ache colour position bad breath 0.0 20.0 40.0 60.0 80.0 100.0 Oral conditions perceived as causes of impacts (%) Main oral conditions causing imp Figure 1 acts on each of the eight performances Main oral conditions causing impacts on each of the eight performances. Abbreviations refer to Table 3. Page 5 of 8 (page number not for citation purposes) Performances with impacts Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 position of teeth, moreover, accounted for oral impacts in Discussion The prevalence of oral impacts experienced during the 1 in 5 of all children (Table 3). Although there is no study past three months by the study population was very high documenting the extent of pre-adolescent children's con- (89.8%). This is surprising in that this was a low caries cern about their oral appearance, it is evident that the con- population in an area with a free accessible school dental cern is important when they reach adolescence [25]. For service. Although there is no study using OHRQoL index example, de Oliveira and Sheiham found that adolescents with a population-based sample of 12 year olds to com- with untreated malocclusions were significantly more pare with, findings of previous OHRQoL studies suggest likely to report oral impacts on their daily lives than those that oral impacts are very common in children of this age. who had completed orthodontic treatment [26]. Chen In Brazilian adolescent populations, the prevalence of and Hunter found that psychological impacts of oral impacts was 32% [19,20] and 62% in Uganda [21]. In health, such as avoiding laughing and being teased about child populations, a 88% prevalence of dental pain was teeth, were more prevalent in children than in adults and reported in South African 8–10-year-old school children elderly [12]. [11] and 73% of New Zealand children with good oral sta- tus had at least one dental symptom in the past year [12]. Gum problems were the other important oral conditions That was higher than the 60.1% reported in Malaysian affecting children's OHRQoL. More than one fifth of chil- children who also had good oral status and received suc- dren perceived that bleeding and swollen gums caused cessful school dental services [10]. A study using the oral impacts on their life, particularly in relation to diffi- CPQ11-14 index with paedodontic patients found that all culty cleaning, a problem experienced by nearly half of all the children had oral impacts in the past three months children (Table 3, Figure 1). Children with difficulty [17]. These findings indicate that oral impacts may be cleaning their teeth because of gum inflammation are higher in children than in adults. For example, compared unlikely to achieve good levels of oral hygiene because to studies using the original OIDP index [8] with other brushing may lead to bleeding, and their gum problems older age groups, the prevalence of oral impacts in a Thai would undoubtedly remain or even get worse. This prob- adult population was 73.6% [22] and 52.8% for a Thai lem would not be solved by the traditional dental treat- elderly population [23]. In a UK national survey of elderly ment without understanding the affects of oral impacts on people the prevalence of OIDP impacts was 17% for eden- behaviour. tate and 14% for dentate participants [24]. An interesting finding was that impacts relating to social Despite the fact that oral impacts were prevalent in this dimensions, such as study being affected and contact with Thai child population, they were not severe. For example, people, were less common and least severe. Schor sug- half of this population had Child-OIDP score less than gested that children's social performances rely more on 7.6 and half of those with impacts had very little or little their physical and psychological performances than adults intensity of impacts (Table 2). Moreover, many clinical [27]. causes that contributed to the prevalent impacts do not last long; that is oral ulcers, exfoliating teeth and spaces It is apparent that an important reason for the high prev- due to a non-erupted permanent tooth. alence of oral impacts in children is natural processes such as exfoliating primary teeth or spaces due to a non- This study found that eating was the most important erupted permanent tooth. They contributed largely to the aspect of OHRQoL of children. Difficulty with eating due high incidence of impacts in these pre-adolescent chil- to oral problems was the most common impact (72.9%), dren. On the other hand, these conditions were not and led to more severe oral impacts on children's quality reported as important causes of oral impacts in other age of life than impacts on other performances. Oral ulcers groups [19,22]. The findings on the other clinical causes and exfoliating primary teeth contributed to eating diffi- of oral impacts in this study was consistent with what Jaa- culties in nearly half of those with impacts. The finding far found in Malaysian children, namely, toothache and that eating was the most common performance affected is oral ulcers [10]. Moreover, it is noteworthy that despite similar to all studies using the OIDP in all age groups the fact that this was a low caries population having access [19,21-24]. They are also similar to a study using the to free dental service, sensitive teeth and toothache were CPQ11-14 with paedodontic patients where impacts on frequently reported causes across the various impacts, par- functional limitations were more common than impacts ticularly so with respect to the more common impact of on emotional and social well-being [17]. difficulties with eating. Difficulty with smiling was another important aspect of Although children could often not specify precisely which children's OHRQoL. It affected 40% of children. The most impairments led to impacts, the question of perceived prevalent cause was position of teeth. Dissatisfaction with clinical causes should exclude impacts from some Page 6 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 conditions which are definitely not related to actual readily be applied to children as well as adults [37]. There- impairments as well as to treatment needs. For example, fore, to reduce a problem with children's interpretation toothache, ulcers and conditions relating to appearance about their health or symptoms, the technique of assess- definitely require different treatment and could be easily ing HRQoL based on activities of daily living is appropri- differentiated. However, the accuracy of detecting per- ate [35]. ceived impairment is limited in a population-based study, while it can be improved at the individual level of Conclusions investigation. The prevalence of oral impacts on daily performances in this child population was very high. Oral impacts affected The specific age group under investigation, particularly in children's quality of life mainly through difficulty eating relation to their stage of development, may have influ- and smiling. There are various oral conditions that con- enced the high prevalence of oral impacts. Developmental tributed significantly to the incidence of impacts, namely, changes unavoidably affect HRQoL between childhood sensitive teeth, toothache, oral ulcers and exfoliating pri- and adolescence [28]. Maturity and an increase in age gen- mary teeth. Although the prevalence of impacts was high, erate a more sophisticated understanding and perceptions the severity was not; many children had their quality of about health and illness [29]. Therefore, perceptions life affected at low levels. This reveals a need for further about health and quality of life of children change as they longitudinal studies to better understand and interpret mature [28,30]. This might make younger children more OHRQoL measures in children. sensitive to oral symptoms than older age groups. Because of those considerations the modification of the Child- Authors' contributions OIDP addressed the main possible problems that might SG carried out all work including data collection, data arise when employing adult measures with children analysis and writing the paper. GT supervised the project [30,31]. They include the adjustment of the 8 items of and assisted writing. AS initiated the idea of, and super- daily performances, simplification of rating scales, vised the project and edited writing. decrease of the time frame and rearrangement and clarifi- cation of the complex questions that were beyond the Acknowledgements The authors acknowledge the help and contribution of Public Health Office, capability of children under 12 years according to Piaget's community hospitals and primary schools of Suphanburi province. cognitive development theory [32]. 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Greig A, Taylor J: Doing research with children London, Sage; 1999. 35. Finkelstein JW: Methods, models, and measures of health- Your research papers will be: related quality of life for children and adolescents. In Measur- available free of charge to the entire biomedical community ing health-related quality of life in children and adolescents. implications for research and practice Edited by: Drotar D. Mahwah, NJ, Lawrence Erl- peer reviewed and published immediately upon acceptance baum Associates; 1998:39-52. cited in PubMed and archived on PubMed Central 36. Fink R: Issues and problems in measuring children's health status in community health research. Soc Sci Med 1989, yours — you keep the copyright 29:715-719. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health and Quality of Life Outcomes Springer Journals

The prevalence and severity of oral impacts on daily performances in Thai primary school children

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Springer Journals
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Copyright © 2004 by Gherunpong et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Quality of Life Research; Quality of Life Research
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1477-7525
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15476561
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Abstract

Background: Traditional methods of measuring oral health mainly use clinical dental indices and have been complemented by oral health related quality of life (OHRQoL) measures. Most OHRQoL studies have been on adults and elderly populations. There are no systematic OHRQoL studies of a population-based sample of children. The objective of this study was to assess the prevalence, characteristics and severity of oral impacts in primary school children. Methods: Cross-sectional study of all 1126 children aged 11–12 years in a municipal area of Suphanburi province, Thailand. An OHRQoL measure, Child-Oral Impacts on Daily Performances index (Child-OIDP) was used to assess oral impacts. Children were also clinically examined and completed a self-administered questionnaire about demographic information and oral behaviours. Results: 89.8% of children had one or more oral impacts. The median impact score was 7.6 and mean score was 8.8. Nearly half (47.0%) of the children with impacts had impacts at very little or little levels of intensity. Most (84.8%) of those with impacts had 1–4 daily performances affected (out of 8 performances). Eating was the most common performance affected (72.9%). The severity of impacts was high for eating and smiling and low for study and social contact performances. The main clinical causes of impacts were sensitive tooth (27.9%), oral ulcers (25.8%), toothache (25.1%) and an exfoliating primary tooth (23.4%). Conclusions: The study reveals that oral health impacts on quality of life in Thai primary school children. Oral impacts were prevalent, but not severe. The impacts mainly related to difficulty eating and smiling. Toothache, oral ulcers and natural processes contributed largely to the incidence of oral impacts. That is why Cohen and Jago considered that the greatest Background Contemporary concepts of health suggest that dental contribution of dentistry is to the improvement of quality health should be defined in physical, psychological and of life because most oral diseases and their consequences social well-being terms in relation to dental status [1,2]. interfere with, or have impacts on, daily life performances Page 1 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 [3]. Therefore, disruptions in normal physical, psycholog- mation such as age, sex and occupation of the father and ical and social functioning are important considerations mother, or male and female guardians [13] and oral in assessing oral health. Despite these suggestions, tradi- health behaviours and c) an oral examination by four cal- tional methods of measuring oral health use mainly clin- ibrated community dentists, mainly based on the WHO ical dental indices and focus on the absence or presence of guidelines [14]. Orthodontic normative treatment needs oral diseases. They do not inform us about the oral well- were assessed by the Index of Orthodontic Treatment being of people in terms of feelings about their mouths, Need (IOTN) [15]. Oral hygiene was also assessed using or, for example, their ability to chew and enjoy their food. the Simplified-Oral Hygiene Index (OHI-S) [16]. All doc- The inadequacy of the normative approach in measuring uments were translated from English to Thai and the oral health has been recognised and lead to the develop- validity was checked by a back-translation method, ment of measures of oral health-related quality of life involving blind re-translation into English. The validity of (OHRQoL) [4]. the translation was verified by experts in the use of ques- tionnaires in both languages. This was also checked after A number of socio-dental or OHRQoL measures have wording modifications, in order to ensure the conceptual been developed and used for assessing oral well-being and and functional equivalences of the questionnaires. A pilot to describe oral impacts on people's quality of life [5]. study was carried out to validate all questionnaires before Generally, they measure the extent to which oral condi- using them in the main data collection. The psychometric tions disrupt normal social role functioning and lead to properties of the Child-OIDP in terms of face, content and major changes in behaviours, such as changes in ability to concurrent validity as well as internal and test-retest relia- work or attend school, or undertake parental or house- bility were excellent. The index was also practical to use hold duties [6,7]. In addition to describing oral impacts with this age group. Full description of the validation on quality of life, some OHRQoL measures were designed process of the Child-OIDP can be found elsewhere [9]. specially to assist dental service planning by incorporating For the main data collection, test-retest reliability of data them with traditional normative measures in the process was tested by ten percent random duplication. Weighted of dental needs assessment [8,9]. kappa score for the Child-OIDP was 0.91, kappa scores of self-administered questionnaires were 0.7–1.0, and those Most studies using OHRQoL to assess oral impacts of the of intra- and inter-examiner for oral examinations were mouth and teeth have been on adults and elderly popula- 0.7–1.0 and 0.6–1.0 respectively indicating good to excel- tions. Few studies have been done on children possibly lent agreement. The SPSS and Stata programmes were because no OHRQoL measures designed for use with chil- used for statistical analysis. dren existed until recently. A single measure, dental pain, has been used on children in Malaysia [10] and in South The protocol of the study was approved by the Ethical Africa [11]. They found a high prevalence of pain that Committee of the Ministry of Public Health of Thailand. affected daily living. Similarly, a study in New Zealand Primary education and local health authorities as well as found that most school children complained of at least all primary schools in the study areas gave permission. one dental symptom [12]. To date, there are no systematic Positive consent forms and letters informing parents were OHRQoL studies of a large population-based sample of sent to parents. children. In particular, the OHRQoL of primary school Measuring oral impacts and calculating their severity children, who are frequently the main target group for dental health services, has not been assessed. Therefore Two comprehensive OHRQoL measures specifically for the objective of this study was to use an OHRQoL meas- use with pre-adolescent children have recently been devel- ure, the Child-OIDP, to assess the prevalence, characteris- oped; the Child Perceptions Questionnaire (CPQ11-14) tics and severity of oral impacts in primary school [17] and the Child Oral Impacts on Daily Performances children. (Child-OIDP) [9]. Both were validated on a cross-sec- tional study using a proxy, because no gold standard is Methods available; therefore, at this stage, they should be consid- A cross-sectional survey was carried out in a municipal ered discriminative and not yet evaluative OHRQoL meas- area of Muang district, Suphanburi province, Thailand. ures. However, they differ mainly in their aims and The sample was all 1,126 students aged 11–12 years, in theoretical frameworks. The Child-OIDP index was devel- the final year class of all primary schools (grade 6) in the oped on a large population-based sample with the aim of area. being used for dental health service planning. Its theoret- ical framework is the same as for the original OIDP, Data were collected through: a) an interview for oral namely oral health consequences are categorised into dif- impacts using the Child-OIDP [9], by one interviewer b) ferent levels and the index measures only oral impacts on a self-administered questionnaire for demographic infor- daily performances at the ultimate level [8,9]. The Child- Page 2 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 OIDP has the advantage over the CPQ11-14 in that it another child with severe impacts (score of 6) on only 1 specifies the different clinical causes of each oral impact performance. In the former case, the child will be in the and therefore the treatments needed. Although the objec- 'very little', and in the latter one, in the 'severe' category. tive of current study is to assess oral impacts of children, a The extent refers to the number of performances with broader aim of the project was to assess the implications impacts (PWI) affecting a child's quality of life over the of using measures of oral impacts to estimate dental needs past three months. It ranges from 0 to 8 PWI. The relation- of children. Therefore the Child-OIDP was selected for ships between the impact score and intensity as well as this study as it is specifically designed to be incorporated between score and extent were statistically significant (p < into a needs system. 0.001) [18]. Intensity and extent of impacts represent an alternative method of describing or comparing oral The procedure for using the Child-OIDP began with a self- impacts on children. They are more straightforward and administered questionnaire carried out with all children could give a simpler and clearer picture of impacts than as a group in their classroom. The questionnaire contains using a single score. Therefore, they provide a more prac- a list of all oral problems that children are likely to per- tical aspect to the OHRQoL assessment making it more ceive and also include an open answer for any unexpected easily applicable to dental service planning. perceived problem. It was developed during a pilot study, as a modification from the one used in the original OIDP. Results Children were asked to identify oral problems that they 1101 of the 1126 children returned positive consent perceived in the last three months. This step aimed to forms approved by their parents. 1034 children (91.8% of focus children's attention to their oral health problems the total) completed all stages of the survey. 52.4% were and to lead to the oral impacts assessment later. Their male and 47.6% were female. Their mean age was 11.3 answers here were used only as a guide to investigate oral years (sd = 0.6). The highest percentage of their fathers impacts on daily performances in the next step and were were agricultural workers or labourers (34.5%), 30.5% referred to when they were asked about the causes of oral worked in business/private, 27.5% in governmental sec- impacts in individual interviews. Thereafter, children were tors, 2.1% did not work and 5.4% of children did not have individually interviewed, irrespective of their answers at a male guardian. The highest percentage of mothers the first step, to assess oral impacts on daily life in relation worked in business/private (38.6%), 24.5% in agriculture, to 8 daily performances. The 8 performances were: a) eat- 21.1% in governmental organisations. 14.9% did not ing, b) speaking, c) cleaning teeth, d) relaxing, including work and 1.0% did not have a female guardian. sleeping, e) smiling, laughing and showing teeth without embarrassment, f) maintaining emotional state, g) study, This population had a low level of dental caries: 43.1% including going to school and doing homework and h) were caries free and the DMFT scores ranged from 0 to 12 contact with other people. The individual interviews were with a median score of 1.0 and a mean of 1.5 (±1.8). aided by 16 pictures (negative and positive pictures for Almost all children (97.0%) had a Community Periodon- each performance). If children reported an impact on any tal Index (CPI) score of 1 or more; 84.2% had calculus. In performance, the frequency of the impact and the severity terms of oral hygiene status, 5.4% had good, 69.1% had of its effect on their daily life were scored. Children were moderate and 25.5% had poor oral hygiene. OHI-S scores also asked to identify oral problems that in their opinion, ranged from 0.5–5.5 with a median of 2.5 and mean score caused the impact. The oral problems were identified of 2.5 (±0.9), indicating a moderate level of oral hygiene. from the list complied in the first step of the assessment. The prevalence of oral impacts was high; 89.8% of chil- The oral impact score of each performance is obtained by dren had experienced some kind of oral impact on their multiplying severity and frequency scores, 0, 1, 2 or 3 daily life during the past three months. There was no dif- each, in relation to that performance. Therefore scores can ference between the prevalence of impacts in girls and range from 0 to 9 per performance. The overall impacts boys (Chi-square test). Impacts on Eating were the most score is the sum of all 8 performances (ranging from 0 to prevalent (72.9%). The prevalence of impacts on Emotion 72) divided by 72 and multiplied by 100. An alternative (58.1%), Cleaning teeth (48.5%) and Smiling (40.1%) method of reporting the severity of oral impacts, from the were also relatively high. The remaining prevalences of same data set, is to use the 'intensity' and 'extent' of impacts were lower, namely Study (15.4%), Relaxing impacts. The intensity refers to the most severe impacts on (14.7%), Contact with people (12.2%) and Speaking any of the 8 performances or the highest performance (9.9%) (Table 2). score. It is classified into 6 levels; none, very little, little, moderate, severe and very severe (Table 1). The idea Extent and Severity of impacts behind this is to differentiate between for example, a child Among the children with impacts, the extent of impacts with minor impacts (score of 1) on 6 performances and varied from 1 to 8 performances with impacts (PWI); Page 3 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 Table 1: Classification of the intensity of oral impacts on a performance The intensity of impacts Severity score Frequency score Performance score Very severe Severe (3) × Severe (3) 9 Severe Severe (3) × Moderate (2) 6 Moderate (2) Severe (3) Moderate Moderate (2) × Moderate (2) 4 Severe (3) × Little (1) 3 Little (1) Severe (3) Little Moderate (2) × Little (1) 2 Little (1) Moderate (2) Very little Little (1) × Little (1) 1 No impact None (0) × None (0) 0 Table 2: Prevalence, intensity and score of oral impacts in Thai school children Performances Oral impacts on daily Overall Eating Speaking Cleaning Relaxing Emotion Smiling Study Contact performances impacts teeth Prevalence (%) 89.8 72.9 9.9 48.5 14.7 58.1 40.1 15.4 12.2 Impact intensity (% of children with impacts) - Very little 15.9 27.9 37.4 33.2 37.4 43.7 25.5 57.8 49.2 - Little 31.1 39.0 33.3 38.8 44.2 37.2 28.2 31.2 38.5 - Moderate 31.7 21.8 19.2 20.8 14.3 13.9 27.4 9.7 10.7 - Severe 18.7 10.8 9.1 6.6 3.4 4.7 15.7 1.3 1.6 - Very severe 2.6 5.5 1.0 0.6 0.7 0.5 3.2 0.0 0.0 Impact score - Range 0–59.7 0–9 0–9 0–9 0–9 0–9 0–9 0–6 0–6 - Mean (sd) 8.85 (7.4) 1.87 (1.8) 0.23 (0.9) 1.13 (1.6) 0.30 (0.7) 1.17 (1.4) 1.21 (2.0) 0.25 (0.7) 0.21 (0.7) - Percentiles 2.8,7.6,12.5 0,2,2 0,0,2 0,0,0 0,0,0 0,1,2 0,0,2 0,0,0 0,0,0 (25,50,75) 16.2% had 1 PWI, 23.3% had 2, 26.9% had 3 and 18.4% 7.6 and a mean score of 8.8 (sd = 7.4). No difference in had 4 PWIs. Few children had 5 or more PWIs. About 1 in overall impact scores were identified between different 5 children had severe or very severe intensity of impacts; sexes (Mann-Whitney U test). Mean scores of impacts on 18.7% had severe and 2.6% had very severe intensity of each of the 8 performances ranged from 0.21 to 1.87 impacts.15.9% had very little, 31.1% had little and 31.7% (maximum possible score is 9). Mean impact score for had moderate intensity of impacts (Table 2). The intensity Eating (1.87) and Smiling (1.21) were the highest while of impacts on each performance showed that Eating and those for Study (0.25) and Contact (0.21) were the lowest Smiling were the most severely affected while Study and (Table 2). Contact were the least. 16.3% of children with impacts on Eating and 18.9% of those on Smiling had severe or very 'Causes' of the impacts severe impacts, while the same intensity was reported by There were various oral and dental problems that children 1.3–10.1% of children having impacts on other perform- perceived as the causes of their overall oral impacts (Table ances. 57.8% of children with impacts on Study and 3). The more prevalent problems leading to impacts were 49.2% of those on Contact had a very little or little level a sensitive tooth (27.9%), oral ulcers (25.8%), toothache of impact intensity, whereas none had a very severe inten- (25.1%) and an exfoliating primary tooth (23.4%). Fur- sity of impacts on those two performances. thermore, oral conditions that related to appearance fre- quently affected children; position of teeth (20.0%) and The distribution of overall impact scores was skewed colour of teeth (16.2%) were quite frequently cited. In (Table 2). They ranged from 0.0 to 59.7 with a median of Page 4 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 Table 3: Frequency of oral conditions perceived as causing overall addition, swollen or inflamed gums were related to over- oral impacts all impacts in 13.8% of children. Oral conditions causing overall impacts Frequency (%) The main perceived causes of impacts on each of the 8 per- formances are shown in Figure 1. Toothache and oral Toothache (t-ache) 25.1 Sensitive tooth (t-sensitive) 27.9 ulcers were among the main perceived causes of impacts Tooth decay, hole in tooth 5.0 on 6 performances. The majority of impacts on Eating Fractured permanent tooth 4.6 were caused by toothache (64.5%) and on Speaking by Colour of teeth (colour) 16.2 oral ulcers (57.8%). An exfoliating primary tooth was one Shape or size of teeth 2.7 of the main perceived causes of impacts on the following Position of teeth (position) 20.0 5 performances; Eating (17.9%), Cleaning (29.5%), Bleeding gum (bleed) 7.4 Relaxing (11.2%), Emotion (17.5%) and Study (17.6%). Swollen or inflamed gum (swollen) 13.8 Calculus 0.9 Position of teeth was among the main perceived causes of Bad breath 7.2 impacts on 3 performances; Smiling (40.7%), Contact Oral ulcer (ulcer) 25.8 (19.8%) and Emotion (10.0%). Space due to a non- Exfoliating primary tooth (exfoliat) 23.4 erupted permanent tooth (after exfoliation) was one of Tooth space (due to unerupted permanent tooth) 5.3 the main reasons for impacts on Smiling (11.1%). Bad (space) breath was the most frequent perceived cause of impacts Erupting permanent tooth 4.9 Deformity of mouth or face 0.4 on social Contact (27.0%). Missing permanent tooth 0.7 19.9 37.0 19.4 17.9 Eating t-ache t-sensitive ulcer exfoliat 11.8 12.7 57.8 Speaking t-ache position ulcer 13.7 24.3 26.9 29.5 Cleaning bleed swollen ulcer exfoliat 64.5 9.9 11.2 Sleeping t-ache ulcer exfoliat 27.1 10.0 17.0 17.5 Emotion t-ache position ulcer exfoliat 38.6 40.7 11.1 Smiling colour position space 45.3 14.5 17.6 Study t-ache ulcer exfoliat 26.2 15.9 19.8 27.0 Contact t-ache colour position bad breath 0.0 20.0 40.0 60.0 80.0 100.0 Oral conditions perceived as causes of impacts (%) Main oral conditions causing imp Figure 1 acts on each of the eight performances Main oral conditions causing impacts on each of the eight performances. Abbreviations refer to Table 3. Page 5 of 8 (page number not for citation purposes) Performances with impacts Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 position of teeth, moreover, accounted for oral impacts in Discussion The prevalence of oral impacts experienced during the 1 in 5 of all children (Table 3). Although there is no study past three months by the study population was very high documenting the extent of pre-adolescent children's con- (89.8%). This is surprising in that this was a low caries cern about their oral appearance, it is evident that the con- population in an area with a free accessible school dental cern is important when they reach adolescence [25]. For service. Although there is no study using OHRQoL index example, de Oliveira and Sheiham found that adolescents with a population-based sample of 12 year olds to com- with untreated malocclusions were significantly more pare with, findings of previous OHRQoL studies suggest likely to report oral impacts on their daily lives than those that oral impacts are very common in children of this age. who had completed orthodontic treatment [26]. Chen In Brazilian adolescent populations, the prevalence of and Hunter found that psychological impacts of oral impacts was 32% [19,20] and 62% in Uganda [21]. In health, such as avoiding laughing and being teased about child populations, a 88% prevalence of dental pain was teeth, were more prevalent in children than in adults and reported in South African 8–10-year-old school children elderly [12]. [11] and 73% of New Zealand children with good oral sta- tus had at least one dental symptom in the past year [12]. Gum problems were the other important oral conditions That was higher than the 60.1% reported in Malaysian affecting children's OHRQoL. More than one fifth of chil- children who also had good oral status and received suc- dren perceived that bleeding and swollen gums caused cessful school dental services [10]. A study using the oral impacts on their life, particularly in relation to diffi- CPQ11-14 index with paedodontic patients found that all culty cleaning, a problem experienced by nearly half of all the children had oral impacts in the past three months children (Table 3, Figure 1). Children with difficulty [17]. These findings indicate that oral impacts may be cleaning their teeth because of gum inflammation are higher in children than in adults. For example, compared unlikely to achieve good levels of oral hygiene because to studies using the original OIDP index [8] with other brushing may lead to bleeding, and their gum problems older age groups, the prevalence of oral impacts in a Thai would undoubtedly remain or even get worse. This prob- adult population was 73.6% [22] and 52.8% for a Thai lem would not be solved by the traditional dental treat- elderly population [23]. In a UK national survey of elderly ment without understanding the affects of oral impacts on people the prevalence of OIDP impacts was 17% for eden- behaviour. tate and 14% for dentate participants [24]. An interesting finding was that impacts relating to social Despite the fact that oral impacts were prevalent in this dimensions, such as study being affected and contact with Thai child population, they were not severe. For example, people, were less common and least severe. Schor sug- half of this population had Child-OIDP score less than gested that children's social performances rely more on 7.6 and half of those with impacts had very little or little their physical and psychological performances than adults intensity of impacts (Table 2). Moreover, many clinical [27]. causes that contributed to the prevalent impacts do not last long; that is oral ulcers, exfoliating teeth and spaces It is apparent that an important reason for the high prev- due to a non-erupted permanent tooth. alence of oral impacts in children is natural processes such as exfoliating primary teeth or spaces due to a non- This study found that eating was the most important erupted permanent tooth. They contributed largely to the aspect of OHRQoL of children. Difficulty with eating due high incidence of impacts in these pre-adolescent chil- to oral problems was the most common impact (72.9%), dren. On the other hand, these conditions were not and led to more severe oral impacts on children's quality reported as important causes of oral impacts in other age of life than impacts on other performances. Oral ulcers groups [19,22]. The findings on the other clinical causes and exfoliating primary teeth contributed to eating diffi- of oral impacts in this study was consistent with what Jaa- culties in nearly half of those with impacts. The finding far found in Malaysian children, namely, toothache and that eating was the most common performance affected is oral ulcers [10]. Moreover, it is noteworthy that despite similar to all studies using the OIDP in all age groups the fact that this was a low caries population having access [19,21-24]. They are also similar to a study using the to free dental service, sensitive teeth and toothache were CPQ11-14 with paedodontic patients where impacts on frequently reported causes across the various impacts, par- functional limitations were more common than impacts ticularly so with respect to the more common impact of on emotional and social well-being [17]. difficulties with eating. Difficulty with smiling was another important aspect of Although children could often not specify precisely which children's OHRQoL. It affected 40% of children. The most impairments led to impacts, the question of perceived prevalent cause was position of teeth. Dissatisfaction with clinical causes should exclude impacts from some Page 6 of 8 (page number not for citation purposes) Health and Quality of Life Outcomes 2004, 2:57 http://www.hqlo.com/content/2/1/57 conditions which are definitely not related to actual readily be applied to children as well as adults [37]. There- impairments as well as to treatment needs. For example, fore, to reduce a problem with children's interpretation toothache, ulcers and conditions relating to appearance about their health or symptoms, the technique of assess- definitely require different treatment and could be easily ing HRQoL based on activities of daily living is appropri- differentiated. However, the accuracy of detecting per- ate [35]. ceived impairment is limited in a population-based study, while it can be improved at the individual level of Conclusions investigation. The prevalence of oral impacts on daily performances in this child population was very high. Oral impacts affected The specific age group under investigation, particularly in children's quality of life mainly through difficulty eating relation to their stage of development, may have influ- and smiling. There are various oral conditions that con- enced the high prevalence of oral impacts. Developmental tributed significantly to the incidence of impacts, namely, changes unavoidably affect HRQoL between childhood sensitive teeth, toothache, oral ulcers and exfoliating pri- and adolescence [28]. Maturity and an increase in age gen- mary teeth. Although the prevalence of impacts was high, erate a more sophisticated understanding and perceptions the severity was not; many children had their quality of about health and illness [29]. Therefore, perceptions life affected at low levels. This reveals a need for further about health and quality of life of children change as they longitudinal studies to better understand and interpret mature [28,30]. This might make younger children more OHRQoL measures in children. sensitive to oral symptoms than older age groups. Because of those considerations the modification of the Child- Authors' contributions OIDP addressed the main possible problems that might SG carried out all work including data collection, data arise when employing adult measures with children analysis and writing the paper. GT supervised the project [30,31]. They include the adjustment of the 8 items of and assisted writing. AS initiated the idea of, and super- daily performances, simplification of rating scales, vised the project and edited writing. decrease of the time frame and rearrangement and clarifi- cation of the complex questions that were beyond the Acknowledgements The authors acknowledge the help and contribution of Public Health Office, capability of children under 12 years according to Piaget's community hospitals and primary schools of Suphanburi province. cognitive development theory [32]. Moreover, the use of pictures as aids is considered of value when interviewing * Readers are welcome to request the Child-OIDP questionnaire including children [33,34]. In addition to the modification, another pictures of daily performances from the authors. advantage of the Child-OIDP lies in its conceptual frame- work where oral health consequences are divided into References three levels; the first level represents oral problems (such 1. WHO definition of health: . [http://www.who.int/about/definition/en/ ]. as tooth decay), the second or intermediate level repre- 2. Engel GL: The clinical application of biopsychosocial model . sents symptoms (such as pain) and the third or "ultimate Am J Psychiatry 1980, 137:535-544. level" represents difficulty in daily performances. The 3. Cohen K, Jago JD: Toward the formulation of socio-dental indicators. Int J Health Serv 1976, 6: :681-687. index measures impact at the ultimate level only, which 4. 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