Measuring Health: A Guide to Rating Scales and Questionnaires

Oral-health-related quality of life measures that exist are designed for adults. This study aimed to develop and evaluate the CPQ(11-14), a self-report measure of the impact of oral and oro-facial conditions on 11- to 14-year-old children. An item pool was generated with the use of a literature review and interviews with health professionals, parents, and child patients. The 36 items rated the most frequent and bothersome by 83 children were selected for the CPQ(11-14). Validity testing involved a new sample of 123 children. Test-retest reliability was assessed in a subgroup of these children (n = 65). Mean CPQ(11-14) scores were highest for oro-facial (31.4), lower for orthodontic (24.3), and lowest for pedodontic (23.3) patients. There were significant associations between the CPQ(11-14) score and global ratings of oral health (p < 0.05) and overall well-being (p < 0.01). The Cronbach's alpha and intraclass correlation coefficient for the CPQ(11-14) were 0.91 and 0.90, respectively. These results suggest that the CPQ(11-14) is valid and reliable.

Validity and Reliability of a Questionnaire for Measuring Child Oral-health-related Quality of Life

It is increasingly recognized that the impact of disease on quality of life should be taken into account when assessing health status. It is likely that tooth loss, in most cases being a consequence of oral diseases, affects Oral Health-Related Quality of Life (OHRQoL). The aim of the present study is to systematically review the literature and to analyse the relationship between the number and location of missing teeth and oral health-related quality of life (OHRQoL). It was hypothesized that tooth loss is associated with an impairment of OHRQoL. Secondly, it was hypothesized that location and distribution of remaining teeth play an important role in this. Relevant databases were searched for papers in English, published from 1990 to July 2009 following a broad search strategy. Relevant papers were selected by two independent readers using predefined exclusion criteria, firstly on the basis of abstracts, secondly by assessing full-text papers. Selected studies were grouped on the basis of OHRQoL instruments used and assessed for feasibility for quantitative synthesis. Comparable outcomes were subjected to meta-analysis; remaining outcomes were subjected to a qualitative synthesis only. From a total of 924 references, 35 were eligible for synthesis (inter-reader agreement abstracts κ = 0.84 ± 0.03; full-texts: κ = 0.68 ± 0.06). Meta-analysis was feasible for 10 studies reporting on 13 different samples, resulting in 6 separate analyses. All studies showed that tooth loss is associated with unfavourable OHRQoL scores, independent of study location and OHRQoL instrument used. Qualitative synthesis showed that all 9 studies investigating a possible relationship between number of occluding pairs of teeth present and OHRQoL reported significant positive correlations. Five studies presented separate data regarding OHRQoL and location of tooth loss (anterior tooth loss vs. posterior tooth loss). Four of these reported highest impact for anterior tooth loss; one study indicated a similar impact for both locations of tooth loss. This study provides fairly strong evidence that tooth loss is associated with impairment of OHRQoL and location and distribution of tooth loss affect the severity of the impairment. This association seems to be independent from the OHRQoL instrument used and context of the included samples.

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Tooth loss and oral health-related quality of life: a systematic review and meta-analysis

The terms 'health-related quality of life' and 'quality of life' are now in common use to describe the outcomes of oral health conditions and therapy for those conditions. In addition, there has been a proliferation of measures designed to quantify those outcomes. These measures, which were initially designated as socio-dental indicators or subjective oral health indicators are now more usually referred to as measures of oral health-related quality of life (OH-QoL). This is based on the assumption that the functional and psychosocial impacts they document must, of necessity, affect the quality of life. While this assumption has been subject to critical scrutiny in medicine, this is not the case with dentistry. Consequently, exactly what is being measured by indexes of OH-QoL is somewhat unclear. Based on the debate between Gill and Feinstein and Guyatt and Cook, we outline a number of criteria by means of which the construct addressed by measures of OH-QoL may be assessed. These are concerned with how the measures were developed and validated. These criteria are then used to appraise five of the many measures that have been developed over the past 20 years--the GOHAI, OHIP, OIDP, COHQoL and OH-QoL. The main conclusion is that while all document the frequency of the functional and psychosocial impacts that emanate from oral disorders they do not unequivocally establish the meaning and significance of those impacts. Consequently, the claim that oral disorders affect the quality of life has yet to be clearly demonstrated. Verifying this claim requires further qualitative studies of the outcomes of oral disorders as perceived by patients and persons, and the concurrent use of measures that more explicitly address the issue of quality of life.

What do measures of ‘oral health-related quality of life’ measure?

In Dentistry, as in other branches of Medicine, it has been recognised that objective measures of disease provide little insight into the impact of oral disorders on daily living and quality of life. A significant body of development work has been undertaken to provide health status measures for use as outcome measures in dentistry. In descriptive population studies, poor oral health related quality of life is associated with tooth loss. There is a less extensive literature of longitudinal clinical trials, and measurement of change and interpretation of change scores continues to pose a challenge. This paper reviews the literature regarding the development and use of these oral health related QoL measures and includes an appraisal of future research needs in this area.

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Assessment of oral health related quality of life

Although clinical dental status has weak correlations with subjective impacts, some of them are significant. Those variables which had significant correlations could be used as a starting point to understand clinical and social characteristics of people who experience dental problems. This is indeed the basis for the current research. The study compares psychosocial impacts on the quality of people's life with their respective oral status. To that end, a socio-dental indicator, the 'Dental Impact of Daily Living' (DIDL), involving five dimensions, together with a scale which assesses dimension impacts, was developed. The resulting instrument was validated and the reliability tested. The instrument generates a total final score, in addition to scores for each dimension. The method was tested in Brazil on a sample of 662 people, aged from 35 to 44 years, of two social classes, both sexes, and with three different levels of dental caries status or with a full upper denture. To test whether DIDL discriminated...

Relation between Clinical Dental Status and Subjective Impacts on Daily Living

This study outlines the development of a socio-dental method which includes measures of the impacts of oral health status on the quality of daily living. The measure, the Dental Impact on Daily Living (DIDL), has five dimensions: Comfort, Appearance, Pain, Performance and Eating Restriction (CAPPER). DIDL differs from other socio-dental indicators in that it assesses the dental impacts on daily living, the relative importance respondents attribute to each impact dimension and their oral status. Weighting is assigned by every person through an easy to use scale using a sliding arrow that the subject moves. DIDL generates an impact score for each dimension. In addition, since impacts do not usually occur separately, a single total impact score is also estimated to assess total oral impacts. The instrument was tested using item-analysis, factor analysis, validation and reliability tests. The measure was tested in Brazil on a sample of 662 people, aged 35 to 44 years, of two social classes and both genders. Three different levels of oral status were used: high DMFT, medium DMFT and low DMFT. Estimating the relative importance people attributed to the different dimensions was important as shown by the fact that differences between sub-groups were found. DIDL attempts to assess how oral health is perceived by individuals and how the mouth and teeth affect people. Combined with clinical status measures, DIDL should prove a valuable tool to assess need.

The development of a socio-dental measure of dental impacts on daily living.

Objective: Clinical effects of periodontal treatment on biochemical and clinical markers of disease severity in rheumatoid arthritis (RA) patients with periodontal disease were evaluated.

Methods: Forty-two patients were assigned to two groups, G1 (n=16) and G2 (n=26). G1 patients were submitted to oral hygiene instruction and professional tooth cleaning and G2 patients additionally had full-mouth scaling and root planing (SRP). Clinical periodontal measurements were obtained at baseline and 3 months after periodontal treatment. A Health Assessment Questionnaire (HAQ) was used to evaluate their performance on daily living. Rheumatoid factor (RF), erythrocyte sedimentation rate (ESR) and drug therapy were assessed.

Results: Both groups presented a full-mouth improvement in all periodontal clinical parameters (p 6 mm for G1. G2 showed greater mean reductions on PPD >4 mm than G1 (p<0.001). HAQ analyses showed a reduction on the degree of disability of G2, but not statistically significant. ESR was significantly reduced for G2 after SRP although RF did not show statistical reductions.

Conclusion: The data suggest that periodontal treatment with SRP might have an effect on the ESR reduction.

Periodontal infection as a possible severity factor for rheumatoid arthritis

Background: Oral disorders can have a negative impact on the functional, social and psychological wellbeing of young children and their families and cause pain/discomfort for the child. Oral health-related quality of life (OHRQoL) has emerged as an important health outcome in clinical trials and healthcare research. The Early Childhood Oral Health Impact Scale (ECOHIS) is a proxy measure of children’s OHRQoL designed to assess the negative impact of oral disorders on the quality of life of preschool children. The objective of this study was to evaluate the psychometric properties of the Brazilian version of the ECOHIS (B-ECOHIS). Methods: This investigation was carried out in preliminary and field studies. The preliminary study comprised a cross-sectional study carried out in the city of Petropolis, Brazil. A sample of 150 children from two to five years of age was recruited at a public hospital. In the field study, an epidemiological survey was carried out in public and private preschools of Belo Horizonte, Brazil. The B-ECOHIS was answered by 1643 parents/caregivers of five-year-old male and female preschool children. In both phases, oral examinations were performed by a single previously calibrated dentist. Reliability was determined through test-retest reliability and internal consistency. Validity was determined through convergent and discriminant validities. The correlation between the scores obtained on the child and family impact sections was assessed. Results: In the preliminary (P) and field (F) study, test-retest reliability correlation values were 0.98 and 0.99 for the child impact section and 0.97 and 0.99 for the family impact section, respectively. The B-ECOHIS demonstrated internal consistency: child impact section (P: a = 0.74; F: a = 0.80) and family impact section (P: a = 0.59; F: a = 0.76). The correlation between the scores obtained on the child and family impact sections was statistically significant (P: rs = 0.54; F: rs = 0.62; p ≤ 0.001). In both phases of the study, B-ECOHIS scores were significantly associated with the decayed, missing and filled teeth index, decayed teeth and discolored upper anterior teeth (p < 0.05). Conclusion: The B-ECOHIS proved reliable and valid for assessing the negative impact of oral disorders on the quality of life of preschool children.

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Psychometric properties of the Brazilian version of the Early Childhood Oral Health Impact Scale (B-ECOHIS)

Aim: This case–control study investigates the relationship of stress and anxiety with periodontal clinical characteristics. Method: Seventy-nine selected patients (mean age 46.878 years) were assigned to three groups in accordance with their levels of probing pocket depth (PPD): control group (PPDr3 mm, n 5 22), test group 1 (at least four sites with PPD X4 mm and r6 mm, n 5 27) and test group 2 (at least four sites with PPD 46 mm, n 5 30). An inclusion criterion of the study required that patients presented a plaque index (PI) with a value equal to or larger than 2 in at least 50% of dental surfaces. All subjects were submitted to stress and anxiety evaluations. Stress was measured by the Stress Symptom Inventory (SSI) and the Social Readjustment Rating Scale (SRRS), while the State–Trait Anxiety Inventory (STAI) was used to assess anxiety. Clinical measures such as PI, gingival index (GI), PPD and clinical attachment level (CAL) were collected. Patient’s medical history and socioeconomic data were also recorded. Results: The mean clinical measures (PI, GI, PPD and CAL) obtained for the three groups, were: control group, 1.5670.32, 0.6870.49, 1.7270.54 and 2.0470.64 mm; group 1, 1.5670.39, 1.1370.58, 2.6770.67 and 3.1070.76 mm, group 2, 1.6570.37, 1.5470.46, 4.1471.23 and 5.0171.60 mm. The three groups did not differ with respect to percentage of clinical stress, scores of the SRRS, trait and state anxiety. Frequency of moderate CAL (4–6 mm) and moderate PPD (4–6 mm) were found to be significantly associated with higher trait anxiety scores after adjusting for socioeconomic data and cigarette consumption (po0.05). Conclusions: Based on the obtained results, individuals with high levels of trait anxiety appeared to be more prone to periodontal disease.

Anna Thereza Thomé Leão

Papers

Relation between Clinical Dental Status and Subjective Impacts on Daily Living

The development of a socio-dental measure of dental impacts on daily living.

Periodontal infection as a possible severity factor for rheumatoid arthritis

Psychometric properties of the Brazilian version of the Early Childhood Oral Health Impact Scale (B-ECOHIS)

The relationship of stress and anxiety with chronic periodontitis