Measuring the impact of oral mucosa disease on quality of life

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

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

Results

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)

Discussion

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

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