1

Introduction

With global changes in life expectancy, there has been a growth in the population aged over 65 years, particularly in developed countries . Not only is the proportion of the population who fall into groups historically termed ‘the elderly’ (aged over 65 years) increasing, there is also an increase in the proportion who enter this age group who retain their health and functioning. This is true as much in oral health as it is in general health . The World Health Organisation has identified that this will bring new challenges in maintaining the dentition and oral health of those aged over 65 years . However little is known about how these trends will impact upon the lived experience of older people.

Oral Health-Related Quality of Life (OHRQoL) is a multidimensional construct that corresponds to the impact of oral health or diseases on an individual’s daily functioning, well-being or overall quality of life . Almost all measures of OHRQoL have ben founded on Locker’s conceptualization of the impact of oral disease based on the WHO model of health . This model states that there are five consequences of oral disease: impairment, functional limitation, pain/discomfort, disability, and handicap. Further the model proposes that these domains are sequentially related such that Impairment (structural abnormality e.g. caries) leads to functional limitation (restrictions in body functions, e.g., difficulty chewing) and pain/discomfort (self-reported physical and psychological symptoms), which, in turn, leads to disability (limitations in performing daily activities, such as an unsatisfactory diet) and disability may then lead to handicap (social disadvantage, such as social isolation). Impairment and functional limitation may also lead directly to handicap. Locker’s model has typically been viewed as a framework for understanding oral health rather than as a scientific model to be empirically validated but implicit in the model is the assumption that there is a relationship between poor oral health and impaired quality of life. This assumption has been questioned, and it would appear that any relationship is moderate , while Locker argued that the concept of quality of life is broader than clinical health and therefore such measures should not be expected to show high correlations . However, understanding which aspects of oral disease have the greatest impact on well bring may help to identify priorities for prevention and treatment. The aim of the present study is to explore the relationship between oral health status and oral health related quality of life in older adults in the United Kingdom.

2

Methods

Data from Adult Dental Health Survey (ADHS), United Kingdom 2009 was used in this study. The 2009 ADHS is the fifth in a series of national dental surveys that have been carried out every ten years since 1968. The 2009 survey covers the adult population in England, Wales and Northern Ireland, but excludes Scotland which decided not to participate in the 2009 survey. A two-stage cluster sample was used for the survey comprising of 253 primary sampling units (PSU) across England and Wales, and a further 15 PSUs in Northern Ireland. Each PSU consisted of two postcode sectors with 25 addresses sampled from each, giving a total sample of 13,400 addresses. Of these 12,054 were eligible for inclusion (1346 ineligibles were unoccupied households, business addresses, care homes etc.). Of the 12,054 eligible households, 7233 participated (60% household response rate), while the remaining 3895 households refused to participate or were non-contactable (n = 455) or other non-response (n = 471). Within the 7233 households there were 13,509 adults who were asked to participate in the survey – of these 11,382 participated (84%). A questionnaire based interview and clinical examination were used to get a picture of the dental health of the adult population. From these 13,509 interviewed participants, a clinical examination was completed for 6469 individuals for oral health and function including dental caries experience. Detailed information about the UK ADHS is available elsewhere . A subset of the 1277 elderly individuals aged 65 years or older was included in this study.

OHRQoL was measured using the 14-item Oral Health Impact Profile (OHIP-14). The OHIP-14 has good reliability, validity, and precision . The OHIP-14 measures the frequency of occurrence oral impacts in seven conceptual domain, two questions for each dimension namely; functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap . Ratings are made on a 5-point Likert scale: 0 = never; 1 = hardly ever; 2 = occasionally; 3 = fairly often; 4 = very often/every day. Summary OHIP-14 scores were calculated by summing ordinal values for 14 items. Higher OHIP-14 scores indicate worse and lower scores indicate better oral health-related quality of life.

Sociodemographic factors (Age, gender and marital status) socioeconomic status (education level, occupation and index for multiple deprivation), oral health status (active caries, periodontal pocket, number of missing teeth, gingival bleeding, root caries, anterior tooth wear), smoking status and general health (having any systemic problem, self-reported general health) were used as explanatory variables for the prediction of OHIP-14 and its domains. Sociodemographic factors, socioeconomic status, smoking status and general health variables were measured through self-report in the questionnaire. Education level was coded as “no qualification, below degree, and degree/above degree”. Occupation was measured using National Statistics Socio-economic Classification (NSSEC) and categorised as “professionals, intermediate, manual and unemployed”. Index of multiple deprivation (IMD), measures the relative deprivation of the people on a docile scale, it was recoded into quintiles with the lowest quintile representing the wealthiest participants and the highest quintile for the poorest. Clinical examination was performed in order to determine the oral health status. Findings from the examination were dichotomized into “no or yes” for the oral health status variables; having active caries, at least one pocket ≥4 mm, at least one bleeding site, at least one PUFA score, pain related to teeth, active root caries and anterior tooth wear. The number of missing teeth was categorised into five categories “0-5, 6–11, 12–17, 18–23 and 24–32. Smoking status was measured as ‘never, past and current smoker’. Self-reported general health measures the self-perception towards their general health and was measured as “very good/good, fair and poor/very poor”. The presence of a systemic health problem was dichotomised as “no or yes”.

All statistical analyses for this study were performed using R- project statistical software. The ADHS 2009 examination survey weights were used to account for the unequal probability sampling and geographical clustering of the data. The mean and standard error (se) of the Oral Health Impact Profile-14 (OHIP-14) were explored. Total OHIP-14 was a continuous count variable (ranging from 0 to 56) with a high prevalence of zero values. Therefore, Zero-inflated Poisson was used in bivariate and multi-variable regression models for analysing OHIP-14 as an outcome variable. A series of sequential bivariate and multivariate Zero Inflated Poisson (ZIP) models were used to estimate the associations between explanatory variables and OHRQoL, by calculating incidence rate ratios (IRR) for the non-zero OHIP-14 scores and odds ratios (OR) of having no event (score of zero in the outcome). Bivariate models were used to measure the association between OHIP-14 and explanatory variables. Multivariate ZIP models were used to measure the association of each explanatory variable with OHIP-14 after adjusting other variables. Domain scores were ranged from 0 to 8, however, there were relatively few non-zero values in the domain variables. Therefore, values on these domains were dichotomised into (0 for 0 values, 1 for all non-zero values). Logistic regression analysis was used to measure the association of these domains with the explanatory variables. Missing data occurred at very low frequency in the variables included in this study and occurred randomly. Multiple imputation was tested and the results showed little difference with and without imputation. Therefore, to keep the maximum number of the observations in the analysis, missing data was imputed using the simple random imputation method .

3

Results

A total of 1277 elderly participants were included in this study. Table 1 shows the unweighted frequency distribution and weighted percentage of the population for different sociodemographic factors, socioeconomic status and oral health status. No significant difference in mean OHIP-14 score was found for age, gender, marital status, education level, occupation and IMD. Having active caries, a PUFA score, pain related to teeth, active root caries, number of missing teeth and current smokers was associated with significantly higher mean OHIP-14 scores. Mean scores for OHIP-14 and its domains are presented in Table 2 . The mean(SE) weighted total OHIP-14 score was 2.95 (0.17). Among the domains, pain had the highest and social disability the lowest mean score.

The results from the multivariate Zero-inflated Poisson regression analysis are presented in Table 3 . People with higher age and higher education level (degree and above) were significantly associated with lower OHIP-14 score. Gender was not significantly associated with OHIP-14. People with intermediate and manual occupations had significantly higher OHIP-14 score than professionals, however; unemployed people did not have significantly higher OHIP-14 than professionals. IMD was significantly associated with OHIP-14, where more deprived people had higher OHIP-14 scores than less deprived people (except quintile 3). People with an active dental caries or a PUFA score or pain related to teeth had significantly higher OHIP-14 scores than people with no active caries or PUFA score or pain related to teeth. Number of missing teeth or having an active root caries was negatively associated with OHIP-14 score. Wearing a denture was associated with higher OHIP-14 scores. “Current smokers” had significantly higher OHIP-14 scores compared with “never smokers”, while “past smokers” had similar OHIP-14 scores as “never smokers”. Self-reported general health was positively associated with OHIP-14, participants with poor/very poor self-reported general health had higher OHIP-14 score. Having a periodontal pocket, a bleeding site, anterior tooth wear and having systemic diseases were not associated with OHIP-14.

Table 4 shows the results of the multivariate logistic regression analysis for OHIP-14 domains. People who wear a denture have 2.5 times greater functional limitation than people who don’t wear a denture. Self-reported general health was also significantly associated with functional limitation. People with poor/very poor self-reported general health had 2.3 times higher oral health functional limitation than the participants with very good/good self-reported general health. The pain domain was associated with pain related to teeth, systemic problems and self-reported health issues. People with systemic problems had a 44% greater chance of experiencing psychological discomfort than people with no systemic problem. More deprived people had significantly higher discomfort scores compared to less deprived people, however most deprived people didn’t have significantly higher odds for discomfort. However, having pain related to teeth, active root caries and systemic problems were associated with higher odds of discomfort. People wearing a denture have double the chances of experiencing discomfort.

Table 4

Multivariate linear regression analysis of determinants of domains of OHIP-14 in UK elderly population.

	Functional Limitation	Pain	Psychological Discomfort	Physical Disability	Psychological Disability	Social Disability	Handicap
Age
65–75	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
75 and above	0.89(0.54;1.20)	0.79(0.61;1.03)	0.54(0.38;0.75) *	0.93(0.61;1.42)	0.72(0.45;1.05)	0.56(0.29;1.07)	0.89(0.52;1.49)
Gender
Male	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Female	0.71(0.48;1.04)	1.09(0.84;1.41)	1.33(0.97;1.82)	0.73(0.48;1.10)	1.22(0.85;1.75)	1.16(0.65;2.09)	0.65(0.39;1.08)
Marital Status
Never married	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Married	1.18(0.55;2.86)	1.06(0.63;1.79)	0.71(0.39;1.34)	0.91(0.43;2.10)	1.03(0.50;2.16)	0.59(0.29;1.26)	0.78(0.33;2.08)
Previously married	1.06(0.47;2.65)	1.12(0.65;1.93)	1.07(0.58;2.05)	0.99(0.45;2.33)	1.40(0.69;3.08)	0.55(0.20;1.73)	1.11(0.45;3.03)
Education
No qualification	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Below degree	0.98(0.63;1.46)	1.18(0.90;1.57)	0.94(0.67;1.33)	1.25(0.81;1.93)	0.95(0.65;1.40)	0.75(0.39;1.41)	1.42(0.82;2.42)
Degree or above	0.70(0.35;1.33)	0.95(0.63;1.43)	1.54(0.94;2.51)	1.24(0.61;2.45)	1.09(0.60;1.95)	0.82(0.31;1.98)	1.45(0.62;3.25)
NSSEC
Professional	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Intermediate	0.89(0.51;1.51)	1.20(0.86;1.67)	1.28(0.85;1.94)	1.84(1.04;3.25) *	1.16(0.71;1.88)	1.56(0.73;3.40)	2.52(1.28;5.08) *
Manual	1.07(0.66;1.75)	0.92(0.66;1.28)	1.42(0.95;2.13)	2.11(1.25;3.65) *	1.45(0.92;2.31)	1.10(0.50;2.44)	2.09(1.07;4.20) *
Unemployed	1.01(0.47;2.05)	0.77(0.47;1.22)	0.84(0.44;1.52)	1.87(0.84;3.94)	1.17(0.59;2.23)	1.72(0.61;447)	1.19(0.36;3.25)
IMD
Quintile 1	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Quintile 2	1.93(0.92;4.19)	1.52(0.93;2.51)	1.85(1.01;3.45) *	1.99(0.94;4.38)	1.53(0.81;2.95)	1.68(0.48;6.77)	1.37(0.56;3.47)
Quintile 3	1.63(0.81;3.46)	1.24(0.77;1.97)	1.65(0.93;2.97)	1.75(0.86;3.70)	1.08(0.57;2.04)	2.62(0.89;9.64)	1.39(0.62;3.35)
Quintile 4	1.86(0.92;3.94)	1.15(0.72;1.84)	2.01(1.14;3.62) *	1.68(0.82;3.60)	1.34(0.73;2.53)	2.29(0.77;8.50)	1.16(0.49;2.87)
Quintile 5	1.50(0.73;3.25)	1.18(0.74;1.89)	1.56(0.87;2.87)	1.48(0.70;3.25)	1.01(0.54;1.94)	193(0.62;7.43)	0.91(0.37;2.34)
Active caries
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	1.37(0.85;2.17)	1.00(0.72;1.39)	1.05(0.70;1.55)	1.05(0.70;1.55)	1.32(0.84;2.03)	2.21(1.16;4.12) *	1.60(0.83;2.84)
At least one pocket ≥4 mm
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	1.16(0.79;1.73)	1.01(0.78;1.30)	1.13(0.82;1.54)	1.13(0.82;1.54)	1.06(0.74;1.52)	1.21(0.68;2.21)	0.92(0.56;1.52)
At least one PUFA
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	1.56(0.80;2.93)	1.17(1.05;1.31)	1.20(0.68;2.08)	0.92(0.42;1.90)	1.06(0.53;1.92)	1.09(0.40;2.63)	1.07(0.44;2.35)
Pain related to teeth
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	2.01(0.99;3.89)	5.75(3.11;11.35)*	1.95(1.08;3.47) *	2.26(1.08;4.48) *	2.41(1.28;4.40) *	3.26(1.37;7.21) *	4.01(1.84;8.33) *
Active root caries
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	0.87(0.47;1.59)	0.87(0.78;1.98)	1.71(1.04;2.83) *	0.68(0.34;1.33)	1.47(0.85;2.54)	0.50(0.18;1.23)	0.86(0.40;1.80)
Anterior tooth wear
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	0.82(0.44;1.60)	0.99(0.87;1.12)	1.43(0.81;2.64)	1.07(0.54;2.24)	1.02(0.56;2.01)	1.25(0.46;4.46)	0.92(0.41;2.38)
At least one bleeding site
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	0.78(0.53;1.15)	1.07(0.83;1.38)	0.95(0.70;1.30)	1.05(0.70;1.58)	1.20(0.84;1.70)	0.99(0.56;1.77)	0.93(0.57;1.53)
Number of missing teeth
0–5	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
6–11	1.04(0.53;2.14)	0.75(0.52;1.09)	1.04(0.63;1.73)	0.57(0.29;1.12)	0.64(0.37;1.15)	0.50(0.10;1.65)	1.26(0.78;0.97)
12–17	1.25(0.57;2.85)	0.81(0.51;1.29)	1.33(0.74;2.41)	0.58(0.26;1.31)	0.93(0.48;1.81)	0.74(0.32;2.15)	0.82(0.03;1.29)
18–23	1.11(0.45;2.78)	1.01(0.57;1.77)	1.06(0.52;2.13)	0.88(0.36;2.17)	0.71(0.32;1.56)	1.07(0.30;3.75)	1.60(0.16;1.48)
24–32	1.52(0.60;3.90)	1.13(0.61;2.07)	0.98(0.46;2.07)	0.97(0.38;2.45)	0.77(0.33;1.76)	1.31(0.33;4.93)	2.00(0.39;1.75)
Wearing Denture
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	2.56(1.50;4.40) *	1.31(0.92;1.85)	2.25(1.50;3.42) *	2.79(1.57;5.03) *	2.03(1.26;3.29) *	1.23(0.54;2.80)	1.72(0.85;3.52)
Smoking status
Never	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Past	1.18(0.79;1.77)	1.06(0.82;1.37)	1.08(0.78;1.48)	1.01(0.66;1.55)	1.04(0.72;1.50)	0.80(0.44;1.48)	0.83(0.50;1.40)
Current	0.97(0.47;1.92)	1.13(0.69;1.85)	1.44(1.83;2.45) *	2.12(1.11;3.99) *	1.48(0.80;2.66)	1.84(0.74;4.30)	0.81(0.32;1.83)
Systemic Problem
No	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Yes	0.95(0.62;1.45)	1.44(1.11;1.87)*	1.28(0.92;1.78)	1.47(0.94;2.31)	1.54(1.05;2.26) *	1.62(0.88;3.20)	1.30(0.76;2.26)
Self-reported general health
Very good/good	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)	1.00 (Reference)
Fair	1.74(1.11;2.72) *	1.45(1.06;1.98) *	1.72(1.19;2.48) *	1.84(1.17;2.90) *	1.45(0.96;1.15)	1.20(0.61;2.27)	1.57(0.88;2.76)
Poor/very poor	2.32(1.18;4.41) *	1.16(0.69;1.41)	1.97(1.11;3.47) *	3.10(1.62;5.84) *	1.37(0.71;2.55)	0.50(0.10;1.65)	1.90(0.78;4.34)

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