Effects of dental treatment and systemic disease on oral health-related quality of life in Korean pediatric patients

Effects of dental treatment and systemic disease on oral health-related quality of life in Korean... Background: The findings that not only dental caries but also systemic disease can exert a negative effect on oral health-related quality of life (OHRQoL), and that dental treatment can improve OHRQoL have been confirmed in multiple studies. The purpose of this study is to investigate the impact of dental treatment on OHRQoL of Korean pediatric patients and the differences in OHRQoL between patients with and without systemic disease. Methods: All the primary caregivers of pediatric patients who underwent dental treatments under either general anesthesia or intravenous deep sedation at Seoul National University Dental Hospital completed abbreviated versions of the Child Oral Health Impact Profile (COHIP-14) and Family Impact Scale (FIS-12) surveys on OHRQOL pre- and post- treatment (average: 2.4 ± 1.7 months after dental treatment). This is a case control study with patients divided into two groups according to the presence or absence of systemic disease. Results: Data from 93 pediatric patients (46 male and 47 female, average patient age: 5.0 ± 3.4 years) were analyzed to compare OHRQoL before and after treatment with the Wilcoxon signed-rank test and to calculate the effect size using Cohen’s d. All of the patients exhibited an improvement in OHRQoL (COHIP-14: p < 0.001, effect size = 1.0; FIS-12: p < 0.001, effect size = 0.7). Patients with systemic diseases demonstrated lower OHRQoL in both pre- and post- treatment surveys than patients without systemic diseases (Wilcoxon Rank-sum test, both COHIP-14 and FIS-12: p < 0.05). The COHIP-14 appears to have a greater impact on the FIS-12 in patients with systemic disease than those without (explanatory power of 65.3 and 44.6%, respectively). Conclusions: Based on the primary caregivers’ perceptions, dental treatment can improve the OHRQoL in Korean pediatric patients. Systemic disease results in a reduced OHRQoL, and the awareness of patients’ oral health appeared to have a greater impact on OHRQoL for family members of patients with a systemic disease. Trial registration: KCT0002473 (Clinical Research Information Service, Republic of Korea) and 22 Sep 2017, retrospectively registered. Keywords: Child, Dental treatment, Systemic disease, Oral health-related quality of life * Correspondence: neokarma@snu.ac.kr Department of Pediatric Dentistry, Dental Research Institute, School of Dentistry, Seoul National University, Seoul National University Dental Hospital, 101, Daehakno, Jongno-gu, 03080 Seoul, Republic of Korea Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Song et al. BMC Oral Health (2018) 18:92 Page 2 of 9 Background treatment under either general anesthesia or intravenous Dental caries is the most common chronic oral disease, deep sedation at Seoul National University Dental with a high prevalence in children and adolescents Hospital pediatric department from February 2013 to worldwide [1]. The prevalence of active caries in primary February 2014. Five professors who were all experienced teeth was as high as 34.5%, and that of dental caries ex- in general anesthesia and intravenous sedation in the perience in primary teeth was as high as 62.2% in 2012 pediatric dentistry department conducted all the dental Korean study [2]. Oral health-related quality of life treatments, and standardized treatment protocols were (OHRQoL) is a multidimensional concept that includes followed. Patients who received dental treatment with- a subjective evaluation of the individual’s oral health sta- out general anesthesia or intravenous sedation were not tus, functional well-being, social and emotional included in the study. The use of general anesthesia or well-being, expectations of and satisfaction with care, intravenous sedation is decided by the anesthesiologist and sense of self-image [3]. Its importance is widely em- based on the physical condition of the airway and phasized in both research and clinical settings, given the respiratory system, not on the severity of dental caries. increasing demand for active participation of patients in Primary caregivers accompanying the patients on the the treatment process, and the lack of basic treatment day of treatment were invited to participate in the sur- for certain chronic diseases (e.g., dental caries, periodon- vey. The study was performed with the approval of the tal disease) that require long-term treatment and Seoul National University Dental Hospital Research follow-up. Nevertheless, research about the OHRQoL of Ethics Board (IRB Number: CRI12006). We fully pediatric patients in Korea has only recently been initi- explained the study to the primary caregivers only if they ated despite the high prevalence of dental caries. The were the legal guardians of the patients and only in- only study that has conducted a full-scale reliability and cluded participants with written consent on the day of validity test in Korea was reported by Ahn et al., in treatment. which a Korean version of the Child Oral Health Impact Profile (COHIP) was used in 2236 children and adoles- Study design cents aged 8−15 years [4]. This study was a case control study to compare OHR- The findings that dental caries can exert a negative effect QoL between the patients with and without systemic on OHRQoL and that dental treatment can improve OHR- disease in each cohort. Accordingly, patients were cate- QoL have been confirmed in several studies [5–9]. Pain gorized into two groups. The patient group without caused by dental caries can interfere with normal mastica- systemic disease did not exhibit conditions that encum- tory function and sleep, which can inhibit normal body bered everyday life, but required either general growth [10]. Unpleasant smiles associated with the destruc- anesthesia or intravenous deep sedation due to dental tion of tooth structure also can negatively influence the so- phobia and a large number of dental caries. The group cial life of children [11]. In addition, the perceptions and with systemic disease included patients with special attitudes of primary caregivers on oral health influence the health care needs, such as intellectual disability (ID), behavioral patterns regarding their child’soralhealth[12]. autism, or developmental disorders, as well as conditions Chronic disease such as dental caries in children can affect that affect everyday life (e.g., cancer, cerebral palsy, con- family life [13, 14] and patients with systemic disease have vulsive disorders, genetic disorders, and cardiovascular been shown to have low OHRQoL [15–17]. Their under- disorders) [19, 20]. Cases with dental treatments that did lying disease may be associated with poor oral health, but not involve pulp treatment or restorations—including they may also have difficulties maintaining their oral health periodontal treatment, such as scaling, or minor oral and accessing adequate dental care due to underlying dis- surgery, such as removal of supernumerary teeth—were ease [18]. There are no studies that have been conducted to excluded from the study. identify the relationship between dental caries and the Primary caregivers were asked to fill out surveys on OHRQoL of pediatric patients and their families, and to OHRQoL, pre-treatment as well as post-treatment when compare the OHRQoL between patients with and without the patients returned for a follow-up visit. As calculated systemic diseases in Korea. Therefore, this study examined from our pilot study performed in the initial stage of this the impact of dental treatment on OHRQoL of Korean study with 20 patients (10 patients without systemic dis- pediatric patients and the differences in the OHRQoL ease and 10 patients with systemic disease), the power between patient with and without systemic disease. calculation indicated that 104 cases were required to compensate for a 20% drop-out rate at 5% significance Methods level and 80% statistical power. The pre-treatment sur- Subjects vey included responses from 109 cases and follow-up This study involved all primary caregivers or parents of post-treatment surveys were completed for 93 of these pediatric dental patients who underwent dental cases within 6 months. These cases were selected for Song et al. BMC Oral Health (2018) 18:92 Page 3 of 9 analysis. Sixteen cases were excluded, as the patient did the patient were removed through an active discussion not have a follow-up appointment, a different primary between two experienced dentists [21]. The resultant caregiver accompanied the patient for the subscales and items are outlined in Tables 1 and 2.The post-treatment visit, or the primary caregiver declined to pre-treatment COHIP-14 survey assessed the frequency complete the post-treatment survey. The post-treatment of issues arising from dental disorders in pediatric survey was completed in an average of 2.4 ± 1.7 months patients from the primary caregiver’sperspective,and after dental treatment. the FIS-12 assessed the impact on everyday life activ- ities and emotions of the patient and family members Surveys in the 3 months prior to the survey. For the In order to assess OHRQoL, the Child Oral Health post-treatment survey, the primary caregivers were Impact Profile (COHIP) and Family Impact Scale (FIS) instructed to reflect on changes post-treatment when were utilized. An abbreviated version of the COHIP, completing both the COHIP-14 and FIS-12. Both mea- “COHIP-14”, which included 10 items from the Oral surements utilized a 5-point Likert scale, where the Health subscale (OH) and 4 items from the Functional COHIP-14 and the FIS-12 ranged from 0, being Limitation subscale (FL), was used in this study [21]. “Never”,to4,being “Almost every day”. Because the Similarly, the “FIS-12” scale used in the study included 5 items of COHIP-14 were negatively worded, the scores items from the Parental/Family Activity subscale (PA), 4 in COHIP-14 were reversed [22]. The scores of the items from the Parental Emotion subscale (PE), 2 items items were added to calculate subscale scores, which from the Family Conflict subscale (FC), and 1 item from were then summed to obtain the finalized COHIP-14 the Financial Burden subscale (FB) [21]. Because and FIS-12 scores. The COHIP-14 score ranged from 0 pediatric patients requiring general anesthesia or intra- to 56, while FIS-12 score ranged from 0 to 48. Higher venous sedation were usually younger than the target COHIP scores and lower FIS scores corresponded to a age of COHIP and FIS, these subscales and items were better OHRQoL. selectively chosen from the original questionnaires to be In addition to the COHIP and FIS, global ratings of reasonably assessed among the primary caregivers of OHRQoL also known as single-item ratings, were used these patients. Several items that caregivers could not to assess the general oral health of the pediatric patients answer correctly or required an active response from and their overall QoL. These questions were answered Table 1 Prevalence and mean values of the 14-item Child Oral Health Impact Profile (COHIP-14) scores before and after dental treatment (average 2.4 ± 1.7 months’ follow-up period) (n = 93) Before COHIP-14 score After COHIP-14 score Difference (after-before) Mean(SD) Mean(SD) Mean(SD) Effect size p-value COHIP-14 37.5(7.9) 45.2(7.7) 7.7(8.1) 1.0 < 0.001* Oral Health subscale (OH) 26.0(5.4) 31.9(5.7) 5.8(6.0) 1.0 < 0.001* Pain/tooth ache 2.7(1.0) 3.4(0.8) 0.7(1.2) 0.6 Breathing through mouth 2.0(1.1) 2.5(1.2) 0.5(1.2) 0.4 Discoloration of teeth 1.9(1.4) 3.4(1.1) 1.5(1.6) 0.9 Crooked teeth or spaces 2.5(1.5) 3.5(1.0) 1.0(1.6) 0.6 Sores or sore spots 3.4(0.8) 3.6(0.7) 0.2(0.8) 0.3 Bad breath 2.1(1.3) 2.8(1.2) 0.6(1.2) 0.5 Bleeding gums 3.2(1.0) 3.3(0.9) 0.1(0.9) 0.1 Food sticking 2.1(1.0) 2.5(1.1) 0.4(1.3) 0.3 Sensitivity to hot/cold 3.1(1.0) 3.6(0.7) 0.5(1.2) 0.4 Dry mouth 3.1(1.1) 3.3(0.9) 0.2(1.0) 0.2 Functional Limitations subscale (FL) 11.4(4.0) 13.3(3.0) 1.9(3.6) 0.5 < 0.001* Trouble chewing firm foods 2.3(1.5) 2.9(1.4) 0.6(1.5) 0.4 Difficulty eating 2.8(1.3) 3.3(1.0) 0.6(1.3) 0.5 Trouble sleeping due to teeth/face 3.6(0.8) 3.9(0.4) 0.3(0.8) 0.4 Difficulty keeping teeth clean 2.8(1.4) 3.2(1.2) 0.4(1.4) 0.3 Wilcoxon signed-rank test *Significant at α = 0.05 level Calculated using Cohen’s d (= difference / SD) Song et al. BMC Oral Health (2018) 18:92 Page 4 of 9 Table 2 Prevalence and mean values of the 12-item Family impact scale (FIS-12) scores before and after dental treatment (average 2.4 ± 1.7 months’ follow-up period) (n = 93) Before FIS-12 score After FIS-12 score Difference (after-before) Mean(SD) Mean(SD) Mean(SD) Effect size p-value FIS-12 15.7(9.2) 10.3(8.3) 5.4(8.3) 0.7 < 0.001* Parental/family Activity subscale (PA) 7.4(4.8) 4.7(4.5) 2.7(4.7) 0.6 < 0.001* Taken time off work 0.6(1.0) 0.3(0.7) 0.3(1.0) 0.3 Required more attention 2.8(1.3) 1.9(1.5) 0.8(1.5) 0.5 Had less time for yourself 1.5(1.4) 1.0(1.4) 0.5(1.6) 0.3 Sleep disrupted 1.5(1.3) 0.8(1.1) 0.7(1.2) 0.6 Family activity interrupted 1.0(1.3) 0.6(1.0) 0.4(1.3) 0.3 Parental Emotion subscale (PE) 6.1(3.8) 4.0(3.4) 2.1(3.2) 0.7 < 0.001* Been upset 1.3(1.2) 0.9(1.0) 0.4(1.1) 0.4 Felt guilty 1.8(1.3) 1.2(1.1) 0.6(1.1) 0.5 Worried about less opportunity 2.0(1.2) 1.3(1.2) 0.7(1.1) 0.6 Felt uncomfortable 1.0(1.3) 0.7(1.0) 0.3(1.3) 0.2 Family Conflict subscale (FC) 1.4(1.7) 1.0(1.2) 0.4(1.3) 0.3 0.004* Argued with child 0.8(1.1) 0.7(1.0) 0.1(1.0) 0.1 Caused conflict in the family 0.6(0.9) 0.3(0.6) 0.3(0.8) 0.4 Financial Burden subscale (FB) 0.8(1.1) 0.6(0.8) 0.2(1.0) 0.2 0.095 Cause financial difficulties 0.8(1.1) 0.6(0.8) 0.2(1.0) 0.2 Wilcoxon’s signed-rank test *Significant at α = 0.05 level Calculated using Cohen’s d (= difference / SD) on a 6-point Likert scale from “Very bad” to “Very between FIS score and global ratings. The Wilcoxon’s good”. rank-sum test was used to compare findings in patients with and without systemic disease and to compare indi- Statistical analysis viduals of different ages and genders. This test was also Statistical analysis of the survey responses was per- used to investigate effects of treatment variables, includ- formed using SPSS 21.0 (SPSS Inc., Chicago, IL, USA). ing number of decayed teeth, number of treated teeth The missing data was 4.39% of the total response. Before and pulp treatment. statistical analysis, the missing values of COHIP and FIS Finally, to understand the correlation between the items were replaced by the variables’ means to obtain utilized scales, a structural equation model was designed sum scores. Since there were no statistically significant using IBM SPSS Amos 23.0.0 to build a Multi-indicator differences in the number of decayed teeth and the model. The hypotheses for the structural equation model results of the OHRQoL questionnaire between general were as follows. First, the subscales of COHIP and FIS anesthesia and intravenous deep sedation, we have per- could have different explanatory power on COHIP and formed statistical analysis with the combined results. FIS, and COHIP would have a significant explanatory First, the Cronbach’s alpha coefficient was used to meas- power on FIS. The rationale for these hypotheses is that ure internal consistency. As the Kolmogorov−Smirnov a chronic illness such as dental caries in children can test indicated the COHIP-14 and FIS-12 scores did not affect the quality of life of the family, which is based on follow a normal distribution, the Wilcoxon’s signed-rank the family member’s recognition of chronic diseases in test was utilized to compare OHRQoL pre- and children [13]. Second, the magnitude of the explanatory post-treatment. Cohen’s d indicated the effect size and power in the structure equation model would be differ- was calculated by dividing the average difference in ent depending on the presence or absence of systemic OHRQoL scores between pre- and post-treatment by disease. Accordingly, the individual SEMs for patients the standard deviation. An effect size of 0.2 < d ≤ 0.5 was with and without systemic disease were constructed by considered small, 0.5 < d ≤ 0.8 was considered intermedi- confirmative factor analysis. This study included COHIP ate, and d > 0.8 was considered large. To assess conver- and FIS subscales as observed variables and COHIP-14 gent validity, the partial Spearman correlation was and FIS-12 per se as latent variables. To assess the fit- examined between the COHIP and global ratings and ness of the structural equation model, the chi-square Song et al. BMC Oral Health (2018) 18:92 Page 5 of 9 p-value, Goodness of Fit Index (GFI), and Normed Fit COHIP scores were higher and FIS scores were lower Index (NFI) were calculated. In general, if the GFI and post-treatment than pre-treatment. Therefore, the abso- NFI values are above 0.9, the suggested model is appro- lute value of the difference between pre- and priate and seems to have good explanatory power. post-treatment scores was used. Each of the item, pre- and post-treatment scores, as well as the difference in scores for COHIP-14 and FIS-12 are outlined in Tables Results 1 and 2. COHIP-14 and its subscale OH and FL scores Analysis was carried out on data from 93 pediatric were significantly and clinically improved at patients (46 males and 47 females) and their primary post-treatment (all p < 0.001 and effect size = 1.0, 1.0, caregivers. Among caregiver participants, 91 (97.8%) 0.5 respectively). Before dental treatment, the most fre- were parents (81 mothers and ten fathers) and two quent dental problem pointed out in OH was discolor- (2.2%) were grandmothers. A mean age of the 93 ation of the teeth (37.6%), while discomfort during pediatric patients was 5.0 ± 3.4 years. There were 43 pa- mastication (33.3%) was indicated for FL. tients without systemic diseases (21 male and 22 female) FIS-12 and its subscale PA and PE scores were all with a mean age of 4.0 ± 2.1 years, while the remaining significantly and clinically improved post-treatment 50 patients had systemic diseases (25 male and 25 (all p < 0.001 and effect size = 0.7, 0.6, 0.7). Before female), and a mean age of 5.9 ± 3.9 years. Patients with dental treatment, the most frequently reported con- systemic disease were significantly older than those with- cerninPA was “required more attention” (66.7%), out (p = 0.012). while that in PE was “worried about less opportunity The average dmft index and the average number of in future due to dental problems” (37.6%). In all the treated teeth due to dental caries were 10.8 ± 4.8 and 8.8 subcategories of FC and FB, more than half of the ± 4.4, respectively. There was no significant difference in responders reported “never” (57.0, 60.2, 55.9%), or “al- dmft index or number of treated teeth between the most never” (11.8, 20.4, 20.4%). groups with (10.6 ± 4.5, 8.7 ± 4.7) and without (11.0 ± As shown in Table 3, partial Spearman correlations indi- 5.1, 9.0 ± 4.0) systemic diseases (p = 0.648, 0.640). Dental cated statistically significant associations between the treatment included direct resin restoration, pulp treat- COHIP-14/FIS-12 scores and the global oral health status ment, prefabricated crown restoration and early extrac- and overall QoL both before and after dental treatment. For tion of carious teeth. The average number of teeth COHIP-14 before treatment, r(s) = 0.438, p <0.001 and according to type of dental treatment was as follows: 5.6 r(s) = 0.241, p = 0.02, respectively, and for FIS-12 before ± 3.3 for direct resin restoration, 2.6 ± 2.8 for pulp treat- treatment, r(s) = − 0.251, p =0.015, r(s)= − 0.391, p < 0.001, ment, 2.7 ± 2.9 for prefabricated crown restoration, and respectively. For COHIP-14 after treatment, r(s) = 0.429, p 0.5 ± 1.3 for early extraction. There was no statistically < 0.001 and r(s) = 0.287, p = 0.005, respectively, and for significant difference between the two groups according FIS-12 after treatment, r(s) = − 0.396, p < 0.001, r(s) = − to type of treatment. 0.372, p < 0.001, respectively. Correlations with the global In the 16 patients excluded from the analysis, the oral health status were of moderate magnitude, and correla- mean age, the average dmft index and the average num- tions with the overall QoL were of low magnitude. ber of treated teeth were 5.8 ± 3.5, 11.8 ± 5.8 and 8.8 ± As shown in Table 4, the presence of systemic disease 4.4, respectively. These results were not statistically dif- accompanied lower OHRQoL. Gender did not play a sig- ferent from the results of the 93 patients included in the nificant role in pre- and post-treatment scores of either analysis (p = 0.426, 0.409 and 0.943, respectively). the COHIP-14 or FIS-12 or in improvement level (p > Cronbach’s alpha coefficient, indicating internal 0.05). Age was not a significant factor for the FIS-12 consistency, for COHIP-14, OH, and FL were 0.737, score, but improvement in the COHIP-14 was signifi- 0.624, and 0.769, respectively. For FIS-12, PA, PE, and cantly greater in patients aged 1−6 years than in those FC, the values were 0.866, 0.810, 0.770, and 0.532, 7 years or older (8.8 ± 7.9, 3.6 ± 7.4, p = 0.012). And respectively. COHIP-14 and FIS-12 were not associated with number Table 3 Partial Spearman correlations between COHIP-14 and FIS-12 scores and global oral health status and overall quality of life Global oral health status Overall quality of life r(s) p-value r(s) p-value COHIP-14 before dental treatment 0.438 < 0.001 0.241 0.02 FIS-12 before dental treatment −0.251 0.015 −0.391 < 0.001 COHIP-14 after dental treatment 0.429 < 0.001 0.287 0.005 FIS-12 after dental treatment −0.396 < 0.001 − 0.372 < 0.001 Song et al. BMC Oral Health (2018) 18:92 Page 6 of 9 Table 4 COHIP and FIS scores according to gender, age, and medical condition of patients Gender Age Systemic Disease a b Male Female < 7 years ≥ 7 years Healthy Diseased Mean(SD) COHIP-14 B 38.0(7.7) 37.0(7.1) 36.9(7.8) 39.6(8.3) 40.2(6.1) 34.9(8.6)* A 45.6(7.2) 44.7(8.3) 45.7(7.4) 43.3(9.0) 47.2(6.7) 43.3(8.2)* D 7.7(7.6) 7.7(8.6) 8.8(7.9) 3.6(7.4)* 7.0(6.9) 8.4(9.1) FIS-12 B 16.0(9.3) 15.4(9.2) 15.2(9.4) 17.5(8.2) 11.5(6.9) 19.4(9.4)* A 10.2(8.6) 10.4(8.1) 9.4(8.0) 13.5(8.9) 6.5(5.5) 13.7(8.9)* D 5.7(6.8) 5.0(9.5) 5.8(8.1) 4.0(8.8) 5.0(5.0) 5.7(10.3) Wilcoxon’s rank-sum test B: Before treatment A: After treatment D in COHIP-14: Difference between B and A (A - B) D in FIS-12: Difference between B and A (B - A) Healthy : Patients without systemic disease Diseased : Patients with systemic disease *: Significantly different between groups (p < 0.05) of decayed teeth, number of treated teeth, and pulp and the NFI score were 0.807, 0.972, and 0.937 in the treatment before and after dental treatment, respectively former model and were 0.060, 0.917, and 0.904 in the (all p > 0.05). But more than five treated teeth and pulp latter model, respectively. These results indicate excep- treatment resulted in greater improvement in the tional fitness and explanatory power of the models. COHIP-14 score (p = 0.016 and 0.024, respectively). Figures 1 and 2 shows the structure equation model Discussion flow-chart for pediatric patients without and with sys- This is the first study to examine the potential associ- temic disease respectively, as affected by COHIP and FIS ation between dental treatment and OHRQoL in variables. The coefficients estimated in this model repre- pediatric patients in Korea, using a Korean version of sent the degree of explanatory power of the independent the COHIP, which is the only questionnaire that has variable on the dependent variable, which indicates the undergone reliability and validity testing in Korean degree to which the increment of one unit in independ- pediatric patients [4]. OHRQoL is a subjective concept ent variable changes the dependent variable including that relies strongly on patient’s awareness. Particularly in the error term. If the value is large, it has stronger pediatric patients, teeth and facial development as well explanatory power. The COHIP-14 score negatively af- as psychological development vary markedly with age. fected the FIS-12 score, with explanatory power of 44.6 The age of 6 years marks the beginning of abstract and 65.3% respectively. The reason for the negative dir- thinking and self-concept [23], and the understanding of ection is that higher COHIP and lower FIS scores indi- even basic health concepts may be problematic in youn- cate better OHRQoL. The magnitude of the explanatory ger aged children, like the subjects of this study [24]. power between COHIP and COHIP subscales and be- And pediatric patients with systemic disease often tween FIS and FIS subscales was also greater in patients exhibit negative behavioral patterns during dental treat- with systemic disease compared to patients without sys- ment due to the previous experiences in the medical temic disease. The chi-square test p-value, the GFI score hospital. They may also exhibit cognitive impairment, Fig. 1 Structure Equation Model of COHIP and FIS in pediatric patients without systemic disease Song et al. BMC Oral Health (2018) 18:92 Page 7 of 9 Fig. 2 Structure Equation Model of COHIP and FIS in pediatric patients with systemic disease which makes it difficult to understand their cognitive malocclusion are not directly related to the caregiver’s processes and consequently results in unreliable meas- daily care. urement of QoL [7]. Therefore, studies on pediatric Among the items in the COHIP, the most evident im- patients’ OHRQoL often rely on the awareness of their provements were reported in the items of “discoloration primary caregivers [25]. Previous studies have shown of teeth” and “difficulty chewing firm food” before dental that there was greater agreement for observable oral treatment, which are easy-to-notice changes for primary conditions and lesser agreement for non-observable oral caregivers. This observation was slightly different from conditions between ratings of children’s OHRQoL made what was reported by Ahn et al. [4], where improvement by parents and the children themselves [25]. In this con- in discoloration was reported at a low frequency, while text, the COHIP-14 and FIS-12 questionnaires used in improvements in food sticking in the teeth, crooked this study were shortened from the original measure- teeth, spaces between teeth, and difficulty in maintaining ments for the primary caregiver to respond more appro- oral hygiene had high frequency. The age difference in priately. In order to supplement the modifications of the the patient cohorts, as well as the targets of the investi- items, internal consistency and convergent validity were gation, patients versus primary caregivers, could account confirmed in this study. for the differences observed. The COHIP and FIS scores of pediatric patients were According to the study by Abanto et al. [5], dental car- significantly and clinically improved after dental treat- ies exhibited a negative impact on the total FIS score ments under general anesthesia or intravenous deep sed- and PA, PE and FB subscales. These are similar to our ation (Tables 1 and 2). These results were in agreement results except for the FB subscales. In our study, there with those of previous studies that reported reduced was little change observed in the FB subscale, with the OHRQoL due to a large number of dental caries [5, 6, 26] most frequent responses being “never” or “almost never” and assessed the OHRQoL of pediatric patients treated in items of the FB subscale. In cases where treatment is under general anesthesia [7–9, 16, 27–29]. These previous carried out under general anesthesia or intravenous deep studies showed statistical and clinical improvements in sedation at Seoul National University Hospital, there is a all subscales including oral symptoms and function. possibility that the primary caregivers could either bear And the effect size of FL was lower than that of OH, the financial burden for the treatment or received finan- this is probably because the caregivers might have diffi- cial support from outside organizations. Among the culties to recognize oral function objectively. This ten- items in the FIS, most evident improvements in this dency is also observed in previous studies in which the study were reported in the items of “required more caregivers responded to the questionnaire [7–9, 27, 29]. attention” and “worried about less opportunity”. These In contrast to these consistent results about dental car- results are also similar to those of Abanto et al.. ies on OHRQoL, the results of dental trauma and mal- The results of Table 4 indicate that OHRQoL is lower occlusion, which are also common oral disorders in in patients with systemic disease before and after dental young pediatric patients, exhibited somewhat conflict- treatment. These findings were in accordance with pre- ing results [26, 30–32]. Overall, dental caries seems to vious reports that found that patients with systemic dis- have a greater impact on OHRQoL than dental trauma eases, such as cerebral palsy [17, 33], autism [34, 35], or malocclusion in young pediatric patients. This is cancer [10, 36], and craniofacial anomalies [37], suffered likely because the OHRQoL questionnaires for young from a lower OHRQoL. children are mostly completed by their caregivers, and Gender was not an important factor in OHRQoL, in dental caries in children are strongly influenced by the agreement with reports by Broder et al. in 2007 and de caregiver’s daily oral hygiene care, but the trauma and Paula et al. in 2015 [22, 38]. Greater improvement in the Song et al. BMC Oral Health (2018) 18:92 Page 8 of 9 COHIP score in patients aged 6 years or younger may in patients with systemic diseases, and thus treating den- be related to the significantly higher average number of tal caries in these patients will greatly improve the OHR- treated teeth compared to patients aged 7 years or older QoL of the family members. (9.9 vs. 4.9, p < 0.001). And this is consistent with the results that a large number of treated teeth and pulp Abbreviations COHIP-14: Child oral health impact profile; FB: Financial burden subscale; treatments showed greater improvement in COHIP-14. FC: Family conflict subscale; FIS-12: Family impact Scale; FL: Functional A previous study reported that age is not an important limitation subscale; GFI: Goodness of fit index; NFI: Normed fit index; factor, but that study did not consider the number of OH: Oral Health subscale; OHRQoL: Oral health-related quality of life; PA: Parental/family activity subscale; PE: Parental emotion subscale treated teeth when considering the effect of age [6]. The COHIP-14 appears to have a greater impact on Funding the FIS-12 in patients with systemic disease (Figs. 1 and This research was supported by a grant of the Korea Health Technology R&D 2). Therefore, the diagnosis and understanding of oral Project through the Korea Health Industry Development Institute (KHIDI), health would exert a greater impact on the family’s funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI15C1503). OHRQoL for patients with systemic disease. In other words, dental treatment and improvement in oral health can result in an overall increase in the OHRQoL of fam- Availability of data and materials The datasets used and/or analyzed during the current study are available ilies of patients with systemic disease. from the corresponding author on reasonable request. General anesthesia or intravenous deep sedation was performed by a single anesthesiologist. However, dental Authors’ contributions treatment was performed by five professors in pediatric JS and YK conceived the ideas, TS is the anesthesiologist who performed dentistry working at Seoul National University Dental general anesthesia and intravenous deep sedation in this study, and contributed to collect anesthesia related data. JS and HH contributed to statistical analysis of Hospital. Therefore, the follow-up period varied among the collected data and led the writing. All authors have revised the manuscript, the dentists, resulting in inconsistent time-lapses be- and have approved the final manuscript prior to its submission. tween pre- and post-treatment surveys. To minimize the effect of the inconsistencies, only cases in which the dur- Authors’ information ation between surveys was less than 6 months were Dr. Ji-Soo Song is a specialist of pediatric dentistry and a clinical professor in included for analysis. In addition, we removed several the department of pediatric dentistry, Seoul National University Dental Hospital. items from original COHIP and FIS questionnaires to Dr. Hong-Keun Hyun is a specialist of pediatric dentistry and an associate compensate the differences of patient age and respon- professor in the department of pediatric Dentistry, dental research institute, dents to the questionnaire. Despite of the validity and school of dentistry, Seoul National University, Seoul National University Dental Hospital. reliability tests conducted in this study, the COHIP-14 Dr. Teo Jeon Shin is an anesthesiologist and an associate professor in the and FIS-12 were not fully validated. And the magnitude department of pediatric Dentistry, dental research institute, school of dentistry, of correlations between the COHIP-14/FIS-12 and the Seoul National University, Seoul National University Dental Hospital. Dr. Young-Jae Kim is a specialist of pediatric dentistry, a professor and the overall QoL were low. This is probably because more chairman in the department of pediatric Dentistry, dental research institute, than half of the patients had systemic disease, and sys- school of dentistry, Seoul National University, Seoul National University temic disease itself, apart from oral health status, could Dental Hospital. have a negative impact on the overall QoL. Therefore, further research to confirm the overall reliability and val- Ethics approval and consent to participate The study was performed with the approval of the Seoul National University idity of COHIP-14 and FIS-12 are required. A difference Dental Hospital Research Ethics Board (IRB Number: CRI12006), and we fully in the mean age of patients with and without systemic explained the study to the primary caregivers only if they were the legal disease and the fact that there was no equivalent cohort guardians of the patients and only included participants with written consent on the day of treatment. of children with similar systemic condition who were treated without general anesthesia or intravenous deep Competing interests sedation may be other confounders. The authors declare that they have no competing interests. Conclusion Dental treatment under either general anesthesia or Publisher’sNote intravenous deep sedation can improve the OHRQoL in Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Korean pediatric patients, which can be recognized by their primary caregivers. Systemic disease results in re- Author details duced OHRQoL, and the COHIP-14 appears to have a Department of Pediatric Dentistry, Seoul National University Dental Hospital, 101, Daehakno, Jongno-gu, 03080 Seoul, Republic of Korea. Department of greater impact on the FIS-12 in patients with systemic Pediatric Dentistry, Dental Research Institute, School of Dentistry, Seoul disease than on patients without. In other words, the im- National University, Seoul National University Dental Hospital, 101, Daehakno, pact on the OHRQoL of the family is more pronounced Jongno-gu, 03080 Seoul, Republic of Korea. Song et al. BMC Oral Health (2018) 18:92 Page 9 of 9 Received: 29 September 2017 Accepted: 18 May 2018 24. Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson LM. Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5). Health Qual Life Outcomes. 2012;10:62. 25. Eiser C, Morse R. Can parents rate their child's health-related quality of life? 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Parental perceptions of oral health-related quality of life for children with special needs: impact of oral rehabilitation under general anesthesia. Pediatr Dent. 2005;27:137–42. 17. Abanto J, Ortega AO, Raggio DP, Bonecker M, Mendes FM, Ciamponi AL. Impact of oral diseases and disorders on oral-health-related quality of life of children with cerebral palsy. Spec Care Dent. 2014;34:56–63. 18. Espinoza KM, Heaton LJ. Communicating with patients with special health care needs. Dent Clin N Am. 2016;60:693–705. 19. American Academy of Pediatric Dentistry. Management of dental patients with special health care needs. Pediatr Dent. 2017;39:229–34. 20. Glassman P. Interventions focusing on children with special health care needs. Dent Clin N Am. 2017;61:565–76. 21. Chang J, Patton LL, Kim HY. Impact of dental treatment under general anesthesia on the oral health-related quality of life of adolescents and adults with special needs. Eur J Oral Sci. 2014;122:363–71. 22. Broder HL, Wilson-Genderson M. Reliability and convergent and discriminant validity of the child oral health impact profile (COHIP Child's version). Community Dent Oral Epidemiol. 2007;35(Suppl 1):20–31. 23. Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res. 2002;81:459–63. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Oral Health Springer Journals

Effects of dental treatment and systemic disease on oral health-related quality of life in Korean pediatric patients

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Abstract

Background: The findings that not only dental caries but also systemic disease can exert a negative effect on oral health-related quality of life (OHRQoL), and that dental treatment can improve OHRQoL have been confirmed in multiple studies. The purpose of this study is to investigate the impact of dental treatment on OHRQoL of Korean pediatric patients and the differences in OHRQoL between patients with and without systemic disease. Methods: All the primary caregivers of pediatric patients who underwent dental treatments under either general anesthesia or intravenous deep sedation at Seoul National University Dental Hospital completed abbreviated versions of the Child Oral Health Impact Profile (COHIP-14) and Family Impact Scale (FIS-12) surveys on OHRQOL pre- and post- treatment (average: 2.4 ± 1.7 months after dental treatment). This is a case control study with patients divided into two groups according to the presence or absence of systemic disease. Results: Data from 93 pediatric patients (46 male and 47 female, average patient age: 5.0 ± 3.4 years) were analyzed to compare OHRQoL before and after treatment with the Wilcoxon signed-rank test and to calculate the effect size using Cohen’s d. All of the patients exhibited an improvement in OHRQoL (COHIP-14: p < 0.001, effect size = 1.0; FIS-12: p < 0.001, effect size = 0.7). Patients with systemic diseases demonstrated lower OHRQoL in both pre- and post- treatment surveys than patients without systemic diseases (Wilcoxon Rank-sum test, both COHIP-14 and FIS-12: p < 0.05). The COHIP-14 appears to have a greater impact on the FIS-12 in patients with systemic disease than those without (explanatory power of 65.3 and 44.6%, respectively). Conclusions: Based on the primary caregivers’ perceptions, dental treatment can improve the OHRQoL in Korean pediatric patients. Systemic disease results in a reduced OHRQoL, and the awareness of patients’ oral health appeared to have a greater impact on OHRQoL for family members of patients with a systemic disease. Trial registration: KCT0002473 (Clinical Research Information Service, Republic of Korea) and 22 Sep 2017, retrospectively registered. Keywords: Child, Dental treatment, Systemic disease, Oral health-related quality of life * Correspondence: neokarma@snu.ac.kr Department of Pediatric Dentistry, Dental Research Institute, School of Dentistry, Seoul National University, Seoul National University Dental Hospital, 101, Daehakno, Jongno-gu, 03080 Seoul, Republic of Korea Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Song et al. BMC Oral Health (2018) 18:92 Page 2 of 9 Background treatment under either general anesthesia or intravenous Dental caries is the most common chronic oral disease, deep sedation at Seoul National University Dental with a high prevalence in children and adolescents Hospital pediatric department from February 2013 to worldwide [1]. The prevalence of active caries in primary February 2014. Five professors who were all experienced teeth was as high as 34.5%, and that of dental caries ex- in general anesthesia and intravenous sedation in the perience in primary teeth was as high as 62.2% in 2012 pediatric dentistry department conducted all the dental Korean study [2]. Oral health-related quality of life treatments, and standardized treatment protocols were (OHRQoL) is a multidimensional concept that includes followed. Patients who received dental treatment with- a subjective evaluation of the individual’s oral health sta- out general anesthesia or intravenous sedation were not tus, functional well-being, social and emotional included in the study. The use of general anesthesia or well-being, expectations of and satisfaction with care, intravenous sedation is decided by the anesthesiologist and sense of self-image [3]. Its importance is widely em- based on the physical condition of the airway and phasized in both research and clinical settings, given the respiratory system, not on the severity of dental caries. increasing demand for active participation of patients in Primary caregivers accompanying the patients on the the treatment process, and the lack of basic treatment day of treatment were invited to participate in the sur- for certain chronic diseases (e.g., dental caries, periodon- vey. The study was performed with the approval of the tal disease) that require long-term treatment and Seoul National University Dental Hospital Research follow-up. Nevertheless, research about the OHRQoL of Ethics Board (IRB Number: CRI12006). We fully pediatric patients in Korea has only recently been initi- explained the study to the primary caregivers only if they ated despite the high prevalence of dental caries. The were the legal guardians of the patients and only in- only study that has conducted a full-scale reliability and cluded participants with written consent on the day of validity test in Korea was reported by Ahn et al., in treatment. which a Korean version of the Child Oral Health Impact Profile (COHIP) was used in 2236 children and adoles- Study design cents aged 8−15 years [4]. This study was a case control study to compare OHR- The findings that dental caries can exert a negative effect QoL between the patients with and without systemic on OHRQoL and that dental treatment can improve OHR- disease in each cohort. Accordingly, patients were cate- QoL have been confirmed in several studies [5–9]. Pain gorized into two groups. The patient group without caused by dental caries can interfere with normal mastica- systemic disease did not exhibit conditions that encum- tory function and sleep, which can inhibit normal body bered everyday life, but required either general growth [10]. Unpleasant smiles associated with the destruc- anesthesia or intravenous deep sedation due to dental tion of tooth structure also can negatively influence the so- phobia and a large number of dental caries. The group cial life of children [11]. In addition, the perceptions and with systemic disease included patients with special attitudes of primary caregivers on oral health influence the health care needs, such as intellectual disability (ID), behavioral patterns regarding their child’soralhealth[12]. autism, or developmental disorders, as well as conditions Chronic disease such as dental caries in children can affect that affect everyday life (e.g., cancer, cerebral palsy, con- family life [13, 14] and patients with systemic disease have vulsive disorders, genetic disorders, and cardiovascular been shown to have low OHRQoL [15–17]. Their under- disorders) [19, 20]. Cases with dental treatments that did lying disease may be associated with poor oral health, but not involve pulp treatment or restorations—including they may also have difficulties maintaining their oral health periodontal treatment, such as scaling, or minor oral and accessing adequate dental care due to underlying dis- surgery, such as removal of supernumerary teeth—were ease [18]. There are no studies that have been conducted to excluded from the study. identify the relationship between dental caries and the Primary caregivers were asked to fill out surveys on OHRQoL of pediatric patients and their families, and to OHRQoL, pre-treatment as well as post-treatment when compare the OHRQoL between patients with and without the patients returned for a follow-up visit. As calculated systemic diseases in Korea. Therefore, this study examined from our pilot study performed in the initial stage of this the impact of dental treatment on OHRQoL of Korean study with 20 patients (10 patients without systemic dis- pediatric patients and the differences in the OHRQoL ease and 10 patients with systemic disease), the power between patient with and without systemic disease. calculation indicated that 104 cases were required to compensate for a 20% drop-out rate at 5% significance Methods level and 80% statistical power. The pre-treatment sur- Subjects vey included responses from 109 cases and follow-up This study involved all primary caregivers or parents of post-treatment surveys were completed for 93 of these pediatric dental patients who underwent dental cases within 6 months. These cases were selected for Song et al. BMC Oral Health (2018) 18:92 Page 3 of 9 analysis. Sixteen cases were excluded, as the patient did the patient were removed through an active discussion not have a follow-up appointment, a different primary between two experienced dentists [21]. The resultant caregiver accompanied the patient for the subscales and items are outlined in Tables 1 and 2.The post-treatment visit, or the primary caregiver declined to pre-treatment COHIP-14 survey assessed the frequency complete the post-treatment survey. The post-treatment of issues arising from dental disorders in pediatric survey was completed in an average of 2.4 ± 1.7 months patients from the primary caregiver’sperspective,and after dental treatment. the FIS-12 assessed the impact on everyday life activ- ities and emotions of the patient and family members Surveys in the 3 months prior to the survey. For the In order to assess OHRQoL, the Child Oral Health post-treatment survey, the primary caregivers were Impact Profile (COHIP) and Family Impact Scale (FIS) instructed to reflect on changes post-treatment when were utilized. An abbreviated version of the COHIP, completing both the COHIP-14 and FIS-12. Both mea- “COHIP-14”, which included 10 items from the Oral surements utilized a 5-point Likert scale, where the Health subscale (OH) and 4 items from the Functional COHIP-14 and the FIS-12 ranged from 0, being Limitation subscale (FL), was used in this study [21]. “Never”,to4,being “Almost every day”. Because the Similarly, the “FIS-12” scale used in the study included 5 items of COHIP-14 were negatively worded, the scores items from the Parental/Family Activity subscale (PA), 4 in COHIP-14 were reversed [22]. The scores of the items from the Parental Emotion subscale (PE), 2 items items were added to calculate subscale scores, which from the Family Conflict subscale (FC), and 1 item from were then summed to obtain the finalized COHIP-14 the Financial Burden subscale (FB) [21]. Because and FIS-12 scores. The COHIP-14 score ranged from 0 pediatric patients requiring general anesthesia or intra- to 56, while FIS-12 score ranged from 0 to 48. Higher venous sedation were usually younger than the target COHIP scores and lower FIS scores corresponded to a age of COHIP and FIS, these subscales and items were better OHRQoL. selectively chosen from the original questionnaires to be In addition to the COHIP and FIS, global ratings of reasonably assessed among the primary caregivers of OHRQoL also known as single-item ratings, were used these patients. Several items that caregivers could not to assess the general oral health of the pediatric patients answer correctly or required an active response from and their overall QoL. These questions were answered Table 1 Prevalence and mean values of the 14-item Child Oral Health Impact Profile (COHIP-14) scores before and after dental treatment (average 2.4 ± 1.7 months’ follow-up period) (n = 93) Before COHIP-14 score After COHIP-14 score Difference (after-before) Mean(SD) Mean(SD) Mean(SD) Effect size p-value COHIP-14 37.5(7.9) 45.2(7.7) 7.7(8.1) 1.0 < 0.001* Oral Health subscale (OH) 26.0(5.4) 31.9(5.7) 5.8(6.0) 1.0 < 0.001* Pain/tooth ache 2.7(1.0) 3.4(0.8) 0.7(1.2) 0.6 Breathing through mouth 2.0(1.1) 2.5(1.2) 0.5(1.2) 0.4 Discoloration of teeth 1.9(1.4) 3.4(1.1) 1.5(1.6) 0.9 Crooked teeth or spaces 2.5(1.5) 3.5(1.0) 1.0(1.6) 0.6 Sores or sore spots 3.4(0.8) 3.6(0.7) 0.2(0.8) 0.3 Bad breath 2.1(1.3) 2.8(1.2) 0.6(1.2) 0.5 Bleeding gums 3.2(1.0) 3.3(0.9) 0.1(0.9) 0.1 Food sticking 2.1(1.0) 2.5(1.1) 0.4(1.3) 0.3 Sensitivity to hot/cold 3.1(1.0) 3.6(0.7) 0.5(1.2) 0.4 Dry mouth 3.1(1.1) 3.3(0.9) 0.2(1.0) 0.2 Functional Limitations subscale (FL) 11.4(4.0) 13.3(3.0) 1.9(3.6) 0.5 < 0.001* Trouble chewing firm foods 2.3(1.5) 2.9(1.4) 0.6(1.5) 0.4 Difficulty eating 2.8(1.3) 3.3(1.0) 0.6(1.3) 0.5 Trouble sleeping due to teeth/face 3.6(0.8) 3.9(0.4) 0.3(0.8) 0.4 Difficulty keeping teeth clean 2.8(1.4) 3.2(1.2) 0.4(1.4) 0.3 Wilcoxon signed-rank test *Significant at α = 0.05 level Calculated using Cohen’s d (= difference / SD) Song et al. BMC Oral Health (2018) 18:92 Page 4 of 9 Table 2 Prevalence and mean values of the 12-item Family impact scale (FIS-12) scores before and after dental treatment (average 2.4 ± 1.7 months’ follow-up period) (n = 93) Before FIS-12 score After FIS-12 score Difference (after-before) Mean(SD) Mean(SD) Mean(SD) Effect size p-value FIS-12 15.7(9.2) 10.3(8.3) 5.4(8.3) 0.7 < 0.001* Parental/family Activity subscale (PA) 7.4(4.8) 4.7(4.5) 2.7(4.7) 0.6 < 0.001* Taken time off work 0.6(1.0) 0.3(0.7) 0.3(1.0) 0.3 Required more attention 2.8(1.3) 1.9(1.5) 0.8(1.5) 0.5 Had less time for yourself 1.5(1.4) 1.0(1.4) 0.5(1.6) 0.3 Sleep disrupted 1.5(1.3) 0.8(1.1) 0.7(1.2) 0.6 Family activity interrupted 1.0(1.3) 0.6(1.0) 0.4(1.3) 0.3 Parental Emotion subscale (PE) 6.1(3.8) 4.0(3.4) 2.1(3.2) 0.7 < 0.001* Been upset 1.3(1.2) 0.9(1.0) 0.4(1.1) 0.4 Felt guilty 1.8(1.3) 1.2(1.1) 0.6(1.1) 0.5 Worried about less opportunity 2.0(1.2) 1.3(1.2) 0.7(1.1) 0.6 Felt uncomfortable 1.0(1.3) 0.7(1.0) 0.3(1.3) 0.2 Family Conflict subscale (FC) 1.4(1.7) 1.0(1.2) 0.4(1.3) 0.3 0.004* Argued with child 0.8(1.1) 0.7(1.0) 0.1(1.0) 0.1 Caused conflict in the family 0.6(0.9) 0.3(0.6) 0.3(0.8) 0.4 Financial Burden subscale (FB) 0.8(1.1) 0.6(0.8) 0.2(1.0) 0.2 0.095 Cause financial difficulties 0.8(1.1) 0.6(0.8) 0.2(1.0) 0.2 Wilcoxon’s signed-rank test *Significant at α = 0.05 level Calculated using Cohen’s d (= difference / SD) on a 6-point Likert scale from “Very bad” to “Very between FIS score and global ratings. The Wilcoxon’s good”. rank-sum test was used to compare findings in patients with and without systemic disease and to compare indi- Statistical analysis viduals of different ages and genders. This test was also Statistical analysis of the survey responses was per- used to investigate effects of treatment variables, includ- formed using SPSS 21.0 (SPSS Inc., Chicago, IL, USA). ing number of decayed teeth, number of treated teeth The missing data was 4.39% of the total response. Before and pulp treatment. statistical analysis, the missing values of COHIP and FIS Finally, to understand the correlation between the items were replaced by the variables’ means to obtain utilized scales, a structural equation model was designed sum scores. Since there were no statistically significant using IBM SPSS Amos 23.0.0 to build a Multi-indicator differences in the number of decayed teeth and the model. The hypotheses for the structural equation model results of the OHRQoL questionnaire between general were as follows. First, the subscales of COHIP and FIS anesthesia and intravenous deep sedation, we have per- could have different explanatory power on COHIP and formed statistical analysis with the combined results. FIS, and COHIP would have a significant explanatory First, the Cronbach’s alpha coefficient was used to meas- power on FIS. The rationale for these hypotheses is that ure internal consistency. As the Kolmogorov−Smirnov a chronic illness such as dental caries in children can test indicated the COHIP-14 and FIS-12 scores did not affect the quality of life of the family, which is based on follow a normal distribution, the Wilcoxon’s signed-rank the family member’s recognition of chronic diseases in test was utilized to compare OHRQoL pre- and children [13]. Second, the magnitude of the explanatory post-treatment. Cohen’s d indicated the effect size and power in the structure equation model would be differ- was calculated by dividing the average difference in ent depending on the presence or absence of systemic OHRQoL scores between pre- and post-treatment by disease. Accordingly, the individual SEMs for patients the standard deviation. An effect size of 0.2 < d ≤ 0.5 was with and without systemic disease were constructed by considered small, 0.5 < d ≤ 0.8 was considered intermedi- confirmative factor analysis. This study included COHIP ate, and d > 0.8 was considered large. To assess conver- and FIS subscales as observed variables and COHIP-14 gent validity, the partial Spearman correlation was and FIS-12 per se as latent variables. To assess the fit- examined between the COHIP and global ratings and ness of the structural equation model, the chi-square Song et al. BMC Oral Health (2018) 18:92 Page 5 of 9 p-value, Goodness of Fit Index (GFI), and Normed Fit COHIP scores were higher and FIS scores were lower Index (NFI) were calculated. In general, if the GFI and post-treatment than pre-treatment. Therefore, the abso- NFI values are above 0.9, the suggested model is appro- lute value of the difference between pre- and priate and seems to have good explanatory power. post-treatment scores was used. Each of the item, pre- and post-treatment scores, as well as the difference in scores for COHIP-14 and FIS-12 are outlined in Tables Results 1 and 2. COHIP-14 and its subscale OH and FL scores Analysis was carried out on data from 93 pediatric were significantly and clinically improved at patients (46 males and 47 females) and their primary post-treatment (all p < 0.001 and effect size = 1.0, 1.0, caregivers. Among caregiver participants, 91 (97.8%) 0.5 respectively). Before dental treatment, the most fre- were parents (81 mothers and ten fathers) and two quent dental problem pointed out in OH was discolor- (2.2%) were grandmothers. A mean age of the 93 ation of the teeth (37.6%), while discomfort during pediatric patients was 5.0 ± 3.4 years. There were 43 pa- mastication (33.3%) was indicated for FL. tients without systemic diseases (21 male and 22 female) FIS-12 and its subscale PA and PE scores were all with a mean age of 4.0 ± 2.1 years, while the remaining significantly and clinically improved post-treatment 50 patients had systemic diseases (25 male and 25 (all p < 0.001 and effect size = 0.7, 0.6, 0.7). Before female), and a mean age of 5.9 ± 3.9 years. Patients with dental treatment, the most frequently reported con- systemic disease were significantly older than those with- cerninPA was “required more attention” (66.7%), out (p = 0.012). while that in PE was “worried about less opportunity The average dmft index and the average number of in future due to dental problems” (37.6%). In all the treated teeth due to dental caries were 10.8 ± 4.8 and 8.8 subcategories of FC and FB, more than half of the ± 4.4, respectively. There was no significant difference in responders reported “never” (57.0, 60.2, 55.9%), or “al- dmft index or number of treated teeth between the most never” (11.8, 20.4, 20.4%). groups with (10.6 ± 4.5, 8.7 ± 4.7) and without (11.0 ± As shown in Table 3, partial Spearman correlations indi- 5.1, 9.0 ± 4.0) systemic diseases (p = 0.648, 0.640). Dental cated statistically significant associations between the treatment included direct resin restoration, pulp treat- COHIP-14/FIS-12 scores and the global oral health status ment, prefabricated crown restoration and early extrac- and overall QoL both before and after dental treatment. For tion of carious teeth. The average number of teeth COHIP-14 before treatment, r(s) = 0.438, p <0.001 and according to type of dental treatment was as follows: 5.6 r(s) = 0.241, p = 0.02, respectively, and for FIS-12 before ± 3.3 for direct resin restoration, 2.6 ± 2.8 for pulp treat- treatment, r(s) = − 0.251, p =0.015, r(s)= − 0.391, p < 0.001, ment, 2.7 ± 2.9 for prefabricated crown restoration, and respectively. For COHIP-14 after treatment, r(s) = 0.429, p 0.5 ± 1.3 for early extraction. There was no statistically < 0.001 and r(s) = 0.287, p = 0.005, respectively, and for significant difference between the two groups according FIS-12 after treatment, r(s) = − 0.396, p < 0.001, r(s) = − to type of treatment. 0.372, p < 0.001, respectively. Correlations with the global In the 16 patients excluded from the analysis, the oral health status were of moderate magnitude, and correla- mean age, the average dmft index and the average num- tions with the overall QoL were of low magnitude. ber of treated teeth were 5.8 ± 3.5, 11.8 ± 5.8 and 8.8 ± As shown in Table 4, the presence of systemic disease 4.4, respectively. These results were not statistically dif- accompanied lower OHRQoL. Gender did not play a sig- ferent from the results of the 93 patients included in the nificant role in pre- and post-treatment scores of either analysis (p = 0.426, 0.409 and 0.943, respectively). the COHIP-14 or FIS-12 or in improvement level (p > Cronbach’s alpha coefficient, indicating internal 0.05). Age was not a significant factor for the FIS-12 consistency, for COHIP-14, OH, and FL were 0.737, score, but improvement in the COHIP-14 was signifi- 0.624, and 0.769, respectively. For FIS-12, PA, PE, and cantly greater in patients aged 1−6 years than in those FC, the values were 0.866, 0.810, 0.770, and 0.532, 7 years or older (8.8 ± 7.9, 3.6 ± 7.4, p = 0.012). And respectively. COHIP-14 and FIS-12 were not associated with number Table 3 Partial Spearman correlations between COHIP-14 and FIS-12 scores and global oral health status and overall quality of life Global oral health status Overall quality of life r(s) p-value r(s) p-value COHIP-14 before dental treatment 0.438 < 0.001 0.241 0.02 FIS-12 before dental treatment −0.251 0.015 −0.391 < 0.001 COHIP-14 after dental treatment 0.429 < 0.001 0.287 0.005 FIS-12 after dental treatment −0.396 < 0.001 − 0.372 < 0.001 Song et al. BMC Oral Health (2018) 18:92 Page 6 of 9 Table 4 COHIP and FIS scores according to gender, age, and medical condition of patients Gender Age Systemic Disease a b Male Female < 7 years ≥ 7 years Healthy Diseased Mean(SD) COHIP-14 B 38.0(7.7) 37.0(7.1) 36.9(7.8) 39.6(8.3) 40.2(6.1) 34.9(8.6)* A 45.6(7.2) 44.7(8.3) 45.7(7.4) 43.3(9.0) 47.2(6.7) 43.3(8.2)* D 7.7(7.6) 7.7(8.6) 8.8(7.9) 3.6(7.4)* 7.0(6.9) 8.4(9.1) FIS-12 B 16.0(9.3) 15.4(9.2) 15.2(9.4) 17.5(8.2) 11.5(6.9) 19.4(9.4)* A 10.2(8.6) 10.4(8.1) 9.4(8.0) 13.5(8.9) 6.5(5.5) 13.7(8.9)* D 5.7(6.8) 5.0(9.5) 5.8(8.1) 4.0(8.8) 5.0(5.0) 5.7(10.3) Wilcoxon’s rank-sum test B: Before treatment A: After treatment D in COHIP-14: Difference between B and A (A - B) D in FIS-12: Difference between B and A (B - A) Healthy : Patients without systemic disease Diseased : Patients with systemic disease *: Significantly different between groups (p < 0.05) of decayed teeth, number of treated teeth, and pulp and the NFI score were 0.807, 0.972, and 0.937 in the treatment before and after dental treatment, respectively former model and were 0.060, 0.917, and 0.904 in the (all p > 0.05). But more than five treated teeth and pulp latter model, respectively. These results indicate excep- treatment resulted in greater improvement in the tional fitness and explanatory power of the models. COHIP-14 score (p = 0.016 and 0.024, respectively). Figures 1 and 2 shows the structure equation model Discussion flow-chart for pediatric patients without and with sys- This is the first study to examine the potential associ- temic disease respectively, as affected by COHIP and FIS ation between dental treatment and OHRQoL in variables. The coefficients estimated in this model repre- pediatric patients in Korea, using a Korean version of sent the degree of explanatory power of the independent the COHIP, which is the only questionnaire that has variable on the dependent variable, which indicates the undergone reliability and validity testing in Korean degree to which the increment of one unit in independ- pediatric patients [4]. OHRQoL is a subjective concept ent variable changes the dependent variable including that relies strongly on patient’s awareness. Particularly in the error term. If the value is large, it has stronger pediatric patients, teeth and facial development as well explanatory power. The COHIP-14 score negatively af- as psychological development vary markedly with age. fected the FIS-12 score, with explanatory power of 44.6 The age of 6 years marks the beginning of abstract and 65.3% respectively. The reason for the negative dir- thinking and self-concept [23], and the understanding of ection is that higher COHIP and lower FIS scores indi- even basic health concepts may be problematic in youn- cate better OHRQoL. The magnitude of the explanatory ger aged children, like the subjects of this study [24]. power between COHIP and COHIP subscales and be- And pediatric patients with systemic disease often tween FIS and FIS subscales was also greater in patients exhibit negative behavioral patterns during dental treat- with systemic disease compared to patients without sys- ment due to the previous experiences in the medical temic disease. The chi-square test p-value, the GFI score hospital. They may also exhibit cognitive impairment, Fig. 1 Structure Equation Model of COHIP and FIS in pediatric patients without systemic disease Song et al. BMC Oral Health (2018) 18:92 Page 7 of 9 Fig. 2 Structure Equation Model of COHIP and FIS in pediatric patients with systemic disease which makes it difficult to understand their cognitive malocclusion are not directly related to the caregiver’s processes and consequently results in unreliable meas- daily care. urement of QoL [7]. Therefore, studies on pediatric Among the items in the COHIP, the most evident im- patients’ OHRQoL often rely on the awareness of their provements were reported in the items of “discoloration primary caregivers [25]. Previous studies have shown of teeth” and “difficulty chewing firm food” before dental that there was greater agreement for observable oral treatment, which are easy-to-notice changes for primary conditions and lesser agreement for non-observable oral caregivers. This observation was slightly different from conditions between ratings of children’s OHRQoL made what was reported by Ahn et al. [4], where improvement by parents and the children themselves [25]. In this con- in discoloration was reported at a low frequency, while text, the COHIP-14 and FIS-12 questionnaires used in improvements in food sticking in the teeth, crooked this study were shortened from the original measure- teeth, spaces between teeth, and difficulty in maintaining ments for the primary caregiver to respond more appro- oral hygiene had high frequency. The age difference in priately. In order to supplement the modifications of the the patient cohorts, as well as the targets of the investi- items, internal consistency and convergent validity were gation, patients versus primary caregivers, could account confirmed in this study. for the differences observed. The COHIP and FIS scores of pediatric patients were According to the study by Abanto et al. [5], dental car- significantly and clinically improved after dental treat- ies exhibited a negative impact on the total FIS score ments under general anesthesia or intravenous deep sed- and PA, PE and FB subscales. These are similar to our ation (Tables 1 and 2). These results were in agreement results except for the FB subscales. In our study, there with those of previous studies that reported reduced was little change observed in the FB subscale, with the OHRQoL due to a large number of dental caries [5, 6, 26] most frequent responses being “never” or “almost never” and assessed the OHRQoL of pediatric patients treated in items of the FB subscale. In cases where treatment is under general anesthesia [7–9, 16, 27–29]. These previous carried out under general anesthesia or intravenous deep studies showed statistical and clinical improvements in sedation at Seoul National University Hospital, there is a all subscales including oral symptoms and function. possibility that the primary caregivers could either bear And the effect size of FL was lower than that of OH, the financial burden for the treatment or received finan- this is probably because the caregivers might have diffi- cial support from outside organizations. Among the culties to recognize oral function objectively. This ten- items in the FIS, most evident improvements in this dency is also observed in previous studies in which the study were reported in the items of “required more caregivers responded to the questionnaire [7–9, 27, 29]. attention” and “worried about less opportunity”. These In contrast to these consistent results about dental car- results are also similar to those of Abanto et al.. ies on OHRQoL, the results of dental trauma and mal- The results of Table 4 indicate that OHRQoL is lower occlusion, which are also common oral disorders in in patients with systemic disease before and after dental young pediatric patients, exhibited somewhat conflict- treatment. These findings were in accordance with pre- ing results [26, 30–32]. Overall, dental caries seems to vious reports that found that patients with systemic dis- have a greater impact on OHRQoL than dental trauma eases, such as cerebral palsy [17, 33], autism [34, 35], or malocclusion in young pediatric patients. This is cancer [10, 36], and craniofacial anomalies [37], suffered likely because the OHRQoL questionnaires for young from a lower OHRQoL. children are mostly completed by their caregivers, and Gender was not an important factor in OHRQoL, in dental caries in children are strongly influenced by the agreement with reports by Broder et al. in 2007 and de caregiver’s daily oral hygiene care, but the trauma and Paula et al. in 2015 [22, 38]. Greater improvement in the Song et al. BMC Oral Health (2018) 18:92 Page 8 of 9 COHIP score in patients aged 6 years or younger may in patients with systemic diseases, and thus treating den- be related to the significantly higher average number of tal caries in these patients will greatly improve the OHR- treated teeth compared to patients aged 7 years or older QoL of the family members. (9.9 vs. 4.9, p < 0.001). And this is consistent with the results that a large number of treated teeth and pulp Abbreviations COHIP-14: Child oral health impact profile; FB: Financial burden subscale; treatments showed greater improvement in COHIP-14. FC: Family conflict subscale; FIS-12: Family impact Scale; FL: Functional A previous study reported that age is not an important limitation subscale; GFI: Goodness of fit index; NFI: Normed fit index; factor, but that study did not consider the number of OH: Oral Health subscale; OHRQoL: Oral health-related quality of life; PA: Parental/family activity subscale; PE: Parental emotion subscale treated teeth when considering the effect of age [6]. The COHIP-14 appears to have a greater impact on Funding the FIS-12 in patients with systemic disease (Figs. 1 and This research was supported by a grant of the Korea Health Technology R&D 2). Therefore, the diagnosis and understanding of oral Project through the Korea Health Industry Development Institute (KHIDI), health would exert a greater impact on the family’s funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI15C1503). OHRQoL for patients with systemic disease. In other words, dental treatment and improvement in oral health can result in an overall increase in the OHRQoL of fam- Availability of data and materials The datasets used and/or analyzed during the current study are available ilies of patients with systemic disease. from the corresponding author on reasonable request. General anesthesia or intravenous deep sedation was performed by a single anesthesiologist. However, dental Authors’ contributions treatment was performed by five professors in pediatric JS and YK conceived the ideas, TS is the anesthesiologist who performed dentistry working at Seoul National University Dental general anesthesia and intravenous deep sedation in this study, and contributed to collect anesthesia related data. JS and HH contributed to statistical analysis of Hospital. Therefore, the follow-up period varied among the collected data and led the writing. All authors have revised the manuscript, the dentists, resulting in inconsistent time-lapses be- and have approved the final manuscript prior to its submission. tween pre- and post-treatment surveys. To minimize the effect of the inconsistencies, only cases in which the dur- Authors’ information ation between surveys was less than 6 months were Dr. Ji-Soo Song is a specialist of pediatric dentistry and a clinical professor in included for analysis. In addition, we removed several the department of pediatric dentistry, Seoul National University Dental Hospital. items from original COHIP and FIS questionnaires to Dr. Hong-Keun Hyun is a specialist of pediatric dentistry and an associate compensate the differences of patient age and respon- professor in the department of pediatric Dentistry, dental research institute, dents to the questionnaire. Despite of the validity and school of dentistry, Seoul National University, Seoul National University Dental Hospital. reliability tests conducted in this study, the COHIP-14 Dr. Teo Jeon Shin is an anesthesiologist and an associate professor in the and FIS-12 were not fully validated. And the magnitude department of pediatric Dentistry, dental research institute, school of dentistry, of correlations between the COHIP-14/FIS-12 and the Seoul National University, Seoul National University Dental Hospital. Dr. Young-Jae Kim is a specialist of pediatric dentistry, a professor and the overall QoL were low. This is probably because more chairman in the department of pediatric Dentistry, dental research institute, than half of the patients had systemic disease, and sys- school of dentistry, Seoul National University, Seoul National University temic disease itself, apart from oral health status, could Dental Hospital. have a negative impact on the overall QoL. Therefore, further research to confirm the overall reliability and val- Ethics approval and consent to participate The study was performed with the approval of the Seoul National University idity of COHIP-14 and FIS-12 are required. A difference Dental Hospital Research Ethics Board (IRB Number: CRI12006), and we fully in the mean age of patients with and without systemic explained the study to the primary caregivers only if they were the legal disease and the fact that there was no equivalent cohort guardians of the patients and only included participants with written consent on the day of treatment. of children with similar systemic condition who were treated without general anesthesia or intravenous deep Competing interests sedation may be other confounders. The authors declare that they have no competing interests. Conclusion Dental treatment under either general anesthesia or Publisher’sNote intravenous deep sedation can improve the OHRQoL in Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Korean pediatric patients, which can be recognized by their primary caregivers. Systemic disease results in re- Author details duced OHRQoL, and the COHIP-14 appears to have a Department of Pediatric Dentistry, Seoul National University Dental Hospital, 101, Daehakno, Jongno-gu, 03080 Seoul, Republic of Korea. Department of greater impact on the FIS-12 in patients with systemic Pediatric Dentistry, Dental Research Institute, School of Dentistry, Seoul disease than on patients without. In other words, the im- National University, Seoul National University Dental Hospital, 101, Daehakno, pact on the OHRQoL of the family is more pronounced Jongno-gu, 03080 Seoul, Republic of Korea. Song et al. BMC Oral Health (2018) 18:92 Page 9 of 9 Received: 29 September 2017 Accepted: 18 May 2018 24. Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson LM. Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5). Health Qual Life Outcomes. 2012;10:62. 25. Eiser C, Morse R. Can parents rate their child's health-related quality of life? 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BMC Oral HealthSpringer Journals

Published: May 29, 2018

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