ARTICLE
Auteur(s) : Pía
López-Jornet, Fabio Camacho-Alonso, Mayra Lucero Berdugo
Clínica Odontológica Universitaria. Medicina Bucal , Hospital
Morales Meseguer. Adv. Marques de los Velez s/n, Murcia 30008,
Spain
accepté le 30 Mai 2009
According to the World Health Organization (WHO), quality of
life (QOL) is defined as an individual’s perception of his position
in life in the context of the culture and value system in which he
lives and in relation to his goals, expectations and standards and
concerns [1]. While the ‘‘health-related quality of life’’ is
usually defined in relation to health and physical function,
emotional well-being, general health perception and social function
[2], oral health-related QOL (OHQoL) characterizes a person’s
perception of how oral health influences an individual’s quality of
life and overall well-being [3-6].
Patients with oral mucosa diseases suffer from severe and life
threatening symptoms, preventing them from eating and drinking, and
influencing daily life in many ways. The importance of embracing
patients’ views in assessing oral health needs and in treatment
planning has been widely advocated. To that end a number of
different patient-centered oral health status measures have been
developed over the last decade, to assess the physical, social and
psychological consequences of oral health, and thus the impact of
oral health status on quality of life. These measures are suggested
to complement traditional clinical oral health status, to improve
communication between patients and their clinical attendants, and
to provide greater understanding of the consequences of oral
disease upon day to day living and quality of life [7, 8].
The Short-Form Survey 36 (SF-36) is a validated instrument,
designed specifically to detect differences between individuals in
a general population [9, 10]. The Oral Health Impact Profile (OHIP)
questionnaire is designed to measure self-reported dysfunction,
discomfort and disability attributed to oral conditions, and is
based on a conceptual oral health model outlined by Locker [5, 6].
The original instrument has 49 items representing 7 domains
(functional limitation, physical pain, psychological discomfort,
physical disability, psychological disability, social disability,
and handicap) and has been shown to be reliable, sensitive to
changes, and to exhibit suitable cross-cultural consistency.
The Oral Health Impact Profile (OHIP-49) is one of the most
commonly used instruments for evaluating oral health-related
quality of life, and was developed for detailed measurement of the
levels of dysfunction, discomfort and disability associated with
oral disorders [11-13].
The concepts of general and oral health and QOL have become an
integral part of health care research. Oral mucosa disorders
include a vast group of dermatological diseases involving the mouth
as well as oral changes reflecting non-pathological conditions [14,
15]. Oral mucosa diseases can also be part of a disease involving
other sites. For example, lichen planus can remain limited to the
oral mucosa or involve other mucosal membranes and the skin.
The oral QOL measures are limited principally to dental disease,
hyposalivation, temporomandibular disorders and oral cancer
[16-19]. Very few studies are available on oral mucosal diseases
not related to the dental apparatus, such as oral lichen planus
[20].
The aim of this study was to evaluate the general quality of
life in patients with oral pathology using the Spanish validated
SF-36 questionnaire, and to measure the oral quality of life using
the OHIP-49 validated Spanish version.
Material and methods
Two hundred sixteen patients with pathologies of the oral mucosa
were studied consecutively at the Oral Medicine Service of the
University of Murcia between January 2006 and September 2008. This
was an observational transversal study to evaluate the
self-perceived Health-Related QOL in patients with oral mucosa
pathology. All patients in the study were Caucasian,
Spanish-speaking from the South-East of Spain.
The study was performed according to the principles of the
Helsinki Declaration and was approved by the local ethics
committee. The interviewer (previously trained) gave the patients
detailed information about the study, as well as the expected
length of the interview (30-40 minutes). The interview was carried
out after receiving informed consent from the patient. The
interview consisted of the SF-36 validated Spanish version [19] and
the OHIP-49 validated Spanish version, which contains 49 items
[11]. The subjects were asked about their symptoms in relation to
the last month.
Inclusion criteria to participate in the study were: patients
attending the Oral Medicine Service during the study period, aged
over 18 years, diagnosed with burning mouth syndrome, oral lichen
planus, recurrent aphthous stomatitis, and other mucosal diseases
including 6 pemphigus vulgaris, 1 cicatricial pemphigoid, and 8
oral discoid lupus erythematous. Exclusion criteria were: not
wishing to participate in the study, and patients with Behçet’s
disease or with cutaneous manifestations of the diseases studied.
To analyze the data, the diseases were grouped into different
categories. The lesions were classified in accordance with
established criteria and based on clinical examination,
complementary studies (biopsy and immunofluorescence) and etiology.
However, we are aware that the group denominated “others” includes
very different diseases, its creation being necessary due to the
small number of cases.
The SF-36 questionnaire is designed to evaluate the quality of
life during the 4 weeks prior to the interview. The standard
version of the Health Questionnaire SF-36 contains 8 areas [19].
“Physical functioning”, “Role limitations physical”, “Bodily pain”,
“General medical health”, “Vitality”, “Social functioning”, “Role
limitations emotional” and “Mental health”. The scoring system is
designed in such a way that the higher scores indicate better
health; thus, 0 is the worst state of health and 100 the ideal
state of health.
The OHIP-49 focuses on measuring oral health. In this
instrument, each item is scored: “never”-score 0, “hardly
ever”-score 1, “occasionally”-score 2, “fairly often”-score 3,
“very often”-score 4. The OHIP-49 is divided into 7 different
domains, and the possible score range for each one is: “functional
limitation” (9 items) - from 0 to 36; “physical pain” (9 items) -
from 0 to 36; “psychological discomfort” (5 items) - from 0 to 20;
“physical disability” (9 items) - from 0 to 36; “psychological
disability” (6 items) - from 0 to 24; “social disability” (5 items)
- from 0 to 20; “Handicap” (6 items) - from 0 to 24; and finally
“Overall OHIP score” (49 items) - from 0 to 196. In this model, the
higher scores indicate a poorer state of health.
Statistical analysis
Data were analyzed using the SPSS 12.0 statistics program
(SPSS® Inc, Chicago, IL, USA). A descriptive study
was made of each variable. The one-way ANOVA test was used to
compare differences in the continuous variables. Probability for p
≤ 0.05 was accepted as significant.
Results
The study sample comprise 216 patients with a mean age of 56.63 ±
17.62, including 54 men (25%) and 162 women (75%). The patients
were classified according to the oral pathology presented. The
group with burning mouth syndrome (BMS) constituted 60 patients, 10
(6.7%) men and 50 (83.3%) women, mean age 64.10 ± 13.47, and minor
recurrent aphthous stomatitis 41 patients, 20 men (48.8%) and 21
women (51.2%), mean age 35.05 ± 15.57. There were 100 patients
diagnosed with oral lichen planus, 17 (17.0%) men and 83 (83.0%)
women, mean age 60.45 ± 13.13, and finally 15 patients formed the
group of other oral mucosa diseases, with a mean age of 60.20 ±
19.29, involving 7 (46.7%) men and 8 (53.3%) women.
With respect to the OHIP-49, we found significant differences
between the groups in the sub-scales: physical disability,
psychological disability, social disability and handicap, present
the OHIP-49 all item 58.35 ± 43.98 in burning mouth syndrome (table 1). In the group formed by other
mucosal diseases, the worst scores were obtained in the domains
“physical pain” and “social disability”.
Regarding quality of life, table 2
illustrates the results for the SF-36 questionnaire between the
different study groups, showing the significant differences found
between the groups in each domain, except in the bodily pain.
Patients with BMS had in general the lowest scores in the
sub-scales of physical functioning, bodily pain, vitality, social
functioning, emotional and mental health when compared with the
other groups. The group formed by other mucosal lesions presented
the lowest scores in the domains physical and general health.
Table 1 Oral health impact profile (OHIP-49) sub-scale
and all items, by group (One-way ANOVA test)
|
OHIP-49 Dimensions
|
Burning mouth syndrome (n = 60)
|
Recurrent aphthous stomatitis (n = 41)
|
Oral lichen planus (n = 100)
|
Othter vesicular and bullous disorders* (n = 15)
|
p-value
|
|
Functional limitation
|
12.77 ± 8.11
|
8.63 ± 7.78
|
11.83 ± 7.65
|
11.73 ± 7.98
|
0.067
|
|
Physical pain
|
11.53 ± 8.92
|
8.83 ± 7.83
|
11.15 ± 7.39
|
11.93 ± 8.05
|
0.324
|
|
Psychological discomfort
|
6.22 ± 5.74
|
4.44 ± 6.48
|
4.62 ± 5.76
|
4.53 ± 3.50
|
0.315
|
|
Physical disability
|
11.62 ± 9.09
|
7.29 ± 7.74
|
9.12 ± 7.16
|
11.00 ± 7.48
|
0.043
|
|
Psychological disability
|
5.18 ± 5.96
|
1.66 ± 3.51
|
2.16 ± 3.51
|
4.20 ± 3.50
|
< 0.001
|
|
Social disability
|
3.75 ± 5.04
|
1.83 ± 5.43
|
1.65 ± 3.71
|
3.87 ± 4.79
|
0.018
|
|
Handicap
|
7.32 ± 6.21
|
2.68 ± 5.88
|
2.16 ± 4.24
|
4.33 ± 5.17
|
< 0.001
|
|
OHIP-49 (all items)
|
58.35 ± 43.98
|
35.05 ± 38.28
|
42.20 ± 32.61
|
51.60 ± 36.25
|
0.011
|
Table 2 Medical outcomes short form Health Survey
Questionnaire (SF-36), by group (One-way ANOVA test)
|
SF-36 Dimensions
|
Burning mouth syndrome (n = 60)
|
Recurrent aphthous stomatitis (n = 41)
|
Oral lichen planus (n = 100)
|
Othter vesicular and bullous disorders* (n = 15)
|
p-value
|
|
Physical functioning
|
47.08 ± 36.91
|
96.17 ± 11.34
|
72.70 ± 30.55
|
66.00 ± 33.01
|
< 0.001
|
|
Role physical
|
29.33 ± 43.61
|
78.65 ± 40.91
|
46.50 ± 49.74
|
13.33± 35.18
|
< 0.001
|
|
Bodily pain
|
55.05 ± 27.47
|
72.50 ± 21.85
|
62.97 ± 24.66
|
58.83 ± 25.35
|
0.008
|
|
General health
|
37.49 ± 26.52
|
72.84 ± 18.44
|
52.02 ± 27.54
|
36.66± 31.07
|
< 0.001
|
|
Vitality
|
42.58 ± 24.93
|
65.31 ± 15.31
|
51.20 ± 20.89
|
48.66 ± 17.67
|
< 0.001
|
|
Social functioning
|
58.75 ± 27.55
|
88.71 ± 16.00
|
71.65 ± 22.23
|
63.33 ± 25.20
|
<0.001
|
|
Role emotional
|
42.77 ± 47.17
|
86.99 ± 31.51
|
51.99 ± 49.30
|
60.00 ± 50.70
|
< 0.001
|
|
Mental health
|
53.03 ± 26.05
|
74.79 ± 15.77
|
55.37 ± 18.31
|
57.60 ± 10.56
|
< 0.001
|
Discussion
Based on the existing literature, oral health problems can result
in pain and discomfort and can lead to problems in eating,
interpersonal relationships, appearance and an individual’s
positive self-image [21, 22].
This study investigated the impact of oral mucosa disease on
patients’ quality of life. The measures employed in this study were
chosen because they have been widely used internationally, and both
are validated Spanish versions. This study demonstrates that
routine evaluation during clinical activity is feasible, and
provides relevant and useful information for the clinical
management of patients with oral mucosa pathology. Although until
recently the use of measurement instruments has been limited to
clinical trials and other research programs, their use is now
recommended for the clinical diagnosis and follow-up of the
patients. These instruments must be simple and practical enough for
clinicians and patients to use and interpret [11-13, 21].
Using the SF-36 and OHIP-49 health-related quality of life
instruments, aiming to compare with other conditions and with the
general population, showed that the impact of burning mouth
syndrome on quality of life is surprising, there is a drastic
reduction in quality of life. Llewellyn and Warnakulasuriya [20]
evaluated stomatological diseases (keratosis, ulcers, lichen
planus, candidiasis, dry mouth, burning mouth, temporomandibular
disorders and pain) using the OHIP-14, finding that diseases of the
oral mucosa can have a serious impact on the patients’ oral quality
of life.
Hegarthy et al. [2] found that increase in pain evaluated
by VAS score was associated with poor oral health-related quality
of life in patients with lichen planus. Pain is an important factor
in limiting oral and other everyday functions in patients. Tambolli
S et al. in 2009 [10] studied the quality of life and
psychological problems in patients with oral mucosa disease,
finding that oral mucosal conditions radically affected HRQoL and
were accompanied by a very high frequency of psychological
problems.
Mumcu et al. [23] observed worse oral health-related
quality of life in patients with Behçet’s disease and recurrent
aphthous stomatitis, and in patients with active oral ulcers
compared with ulcer-free ones. In the present study, some disparate
values were found in the SF-36 for the group recurrent aphthous
stomatitis (RAS) in the domains physical functioning and general
health, this disparity may be explained in part by the difference
in mean age between the groups, being lower in the study group.
In recent years, there has been a growing interest in the
assessment of quality of life (QoL), particularly in chronic
disabling conditions [24, 25]. It is increasingly accepted that
physical indicators of oral morbidity and the patient’s perception
of oral conditions contribute to the description of oral health
status. Both the objective part, which is accessible to the
healthcare professional, and the subjective part, which is
experienced by the patient, are complementary, not antagonistic.
Like the two sides of a coin, they belong together and cannot be
separated in clinical practice or research [8, 20].
The observation in one single time point during the course of
these diseases is a substantial limitation of the study; being a
transversal design, it is impossible to establish an unequivocal
cause-effect relationship in the association between two factors.
The next stage is to evaluate patients longitudinally for
effectiveness of mucosal disease management and quality of life,
and to evaluate the effectiveness of the incorporation of patient
centered outcome measures into the clinical decision-making
process.
Acknowledgements
Financial support: none. Conflict of interest: none.
References
1 Koller M, Klinkhammer-Schalke M, Lorenz W. Outcome
and quality of life in medicine: a conceptual framework to put
quality of life research into practice. Urologic Oncology 2005; 23:
186-92.
2 Hegarty AM, McGrath C, Hodgson TA, et al.
Patient centered outcome measures in oral medicine: Are they valid
and reliable? Int J Oral Maxillofacial Surg 2002; 31: 670-4.
3 Slade GD, Spencer A. Development and evaluation of
the Oral Health Impact Profile. Community Dental Health 1994; 11:
3-11.
4 Slade GD. Assessing change in quality of life using the
Oral Health Impact Profile. Community Dent Oral Epidemiol 1998; 26:
52-61.
5 Locker D. Measuring oral health: a conceptual framework.
Community Dent Health 1988; 5: 3-18.
6 Locker D, Jokovic A, Clarke M. Assessing the
responsiveness of measures of oral health-related quality of life.
Community Dent Oral Epidemiol 2004; 32: 10-8.
7 Chren MM, Lasek RJ, Quinn LM, et al.
Skindex, a quality-of-life measure for patients with skin disease:
reliability, validity, and responsiveness. J Invest Dermatol 1996;
107: 707-13.
8 McGrath C, Hegarty AM, Hodgson TA, et al.
Patient-centered outcome measures for oral mucosal disease are
sensitive to treatment. Int J Oral Maxillofac Surg 2003; 32:
334-6.
9 Alonso J, Prieto L, Anto JM. The Spanish
version of the SF-36 Health Survey (the SF-36 health
questionnaire): an instrument for measuring clinical results. Med
Clin (Barc) 1995; 104: 771-6.
10 Tabolli S, Bergamo F, Alessandroni L, et al. Quality of
Life and Psychological Problems of Patients with Oral Mucosal
Disease in Dermatological Practice. Dermatology. 2009 Jan 28. Epub
ahead of print
11 Lopez R, Baelum V. Spanish version of the Oral
Health Impact Profile (OHIP-Sp). BMC Oral Health 2006; 6: 1-8.
12 Kieffer JM, Hoogstraten J. Item-order effects in
the Oral Health Impact Profile (OHIP). Eur J Oral Sci 2008; 116:
245-9.
13 Kieffer JM, Hoogstraten J. Linking oral health,
general health, and quality of life. Eur J Oral Sci 2008; 116:
445-50.
14 Tabolli S, Mozzetta A, Antinone V, et al.
The health impact of pemphigus vulgaris and pemphigus foliaceus
assessed using the Medical Outcomes Study 36-item short form health
survey questionnaire. Br J Dermatol 2008; 158: 1029-34.
15 Tabolli S, Baliva G, Lombardo GA, et al.
Health related quality of life assessment in the routine clinical
practice of a dermatology unit. Eur J Dermatol 2006; 16:
409-15.
16 Lee S, McGrath C, Samman N. Quality of life in
patients with dentofacial deformity: a comparison of measurement
approaches. Int J Oral Maxillofac Surg 2007; 36: 488-92.
17 John MT, Reissmann DR, Schierz O, et al.
Oral health-related quality of life in patients with
temporomandibular disorders. J Orofac Pain 2007; 21: 46-54.
18 Baker SR, Pankhurst CL, Robinson PG. Utility
of two oral health-related quality-of-life measures in patients
with xerostomia. Community Dent Oral Epidemiol 2006; 34:
351-62.
19 Ikebe K, Matsuda K, Morii K, et al.
Impact of dry mouth and hyposalivation on oral health-related
quality of life of elderly Japanese. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2007; 103: 216-22.
20 Llewellyn CD, Warnakulasuriya S. The impact of
stomatological disease on oral health-related quality of life. Eur
J Oral Sci 2003; 111: 297-304.
21 López-Jornet P, Camacho-Alonso F,
Lucero-Berdugo M. Quality of life in patients with burning
mouth syndrome. J Oral Pathol Med 2008; 37: 389-94.
22 Soto Araya M, Rojas Alcayaga G, Esguep A.
Association between psychological disorders and the presence of
Oral lichen planus, Burning mouth syndrome and Recurrent aphthous
stomatitis. Med Oral 2004; 9: 1-7.
23 Mumcu G, Inanc N, Ergun TI, et al. H.
Oral health related quality of life is affected by disease activity
in Behçet’s disease. Oral Dis 2006; 12: 145-51.
24 Tabolli S, Baliva G, Lombardo GA, et al.
Health related quality of life assessment in the routine clinical
practice of a dermatology unit. Eur J Dermatol 2006; 16:
409-15.
25 Gieler U. Psychodermatology. Eur J Dermatol 2007; 17:
106-7.
|
Printable version
Version PDF