Oral Health Related Quality of Life in Malnutrition

Introduction

Diet and nutrition play an important role in the normal growth and well-being of an individual from birth to death. The health of a growing child can also be affected by the diet of a pregnant woman. Nutrition is the science that studies food and its impact on health, focusing on the balance between nutrient and energy supply and the body's needs for growth, maintenance, and specific functions.

In present times, malnutrition is widespread in rural, tribal, and urban slum areas. It has also been seen to be prevalent in urban regions due to the consumption of processed food. The causes for undernourishment seen in children from regions of low socioeconomic status can be attributed to factors such as poverty, over-population, adverse cultural practices, poor maternal health, lack of education, gender inequality, and lack of sufficient access to medical care.¹

Based on the time of onset and duration of the condition, malnutrition can be classified as acute or chronic. Chronic malnutrition or growth delay is caused by a persistent deficit in nutrient intake, chronic disease, or prolonged acute disorders. In contrast, acute malnutrition occurs due to recent nutrient shortages or the sudden onset of a significant lesion that leads to high levels of catabolism.

Acute malnutrition mostly affects weight, while chronic nutrition has an impact on children's growth, which affects both weight and height. Infection and malnutrition are factors that adversely affect child growth and in most cases of childhood infections, the cause can be traced to insufficient food intake or absorption, which weakens the immune system thereby rendering the child vulnerable to infections. In India, the level of malnutrition among children under five years of age is high.¹ Malnourishment among growing children can result in them exhibiting behavioral changes such as irritability, apathy, decreased social responsiveness, anxiety, attention deficits, impaired growth, poor school performance and decreased intellectual achievement. Malnutrition is a related factor for the poor prognosis of many chronic diseases. Early detection of malnutrition and timely intervention can improve the health of the vast majority and reduce the incidence of chronic diseases, in turn improving the quality of life (QoL).

Dietary practices, nutritional status, oral health conditions and the general health status of an individual are inter-connected factors and all have effects on each other. While malnutrition negatively impacts the oral structures, proper nutrition fosters the development and maintenance of dental health. Literature has shown that malnutrition at early growth stages delays tooth eruption, affects structure of teeth, and cause increased dental caries due to a multitude of reasons.^2-4 Extreme cases of nutritional deficit can also lead to chronic malnutrition which does not only affect exfoliation of teeth but also renders the future permanent teeth susceptible to caries later in life.⁵ The presence of enamel hypoplasia may be a predisposing factor in initiating and progression of dental caries and a predictor of high caries susceptibility in these children.

The onset of caries, enamel development, tooth erosion, periodontal health, salivary features, and oral mucus in general are all conditioned by diet and have an impact on oral health. Oral lesions like fissured tongue, geographic tongue, aphthous ulcers, depapillated tongue and angular cheilitis are commonly associated with malnutrition. Untreated decay in infancy and early childhood has been shown to affect weight gain and overall growth and development of the child.⁶ Untreated dental caries in children can have a major adverse impact on their oral health related quality of life. As parents and caregivers are mainly responsible for the health and wellbeing of children, bad oral health can also affect them indirectly, by resulting in work-loss and they might have to endure financial impacts due to having to stay at home to take care of the child.^7,8

Despite its recent development, Oral Health Related Quality of Life (OHRQoL) has significant implications for dental research and clinical practice. It is regarded by the WHO as a crucial component of the Global Oral Health Program and is essential to overall health and wellbeing.⁹ OHRQoL evaluation “reflects people’s comfort when eating, sleeping, and engaging in social interaction. It also reflects their self-esteem and satisfaction with respect to their oral health”.¹⁰ This outcome is the result of interactions of different variables affecting oral health as well as environmental and social contexts alongside the rest of the body.^11,12 Researchers began to propose how oral health is related to health-related quality of life (HRQoL) in order to understand the relationships between and among conventional clinical parameters, data obtained via clinical examination, and patient-centered, self-reported health experience.¹³

OHRQoL and HRQoL now include both positive and negative assessments of health outcomes and oral health outcomes as a result of health policy's growing emphasis on disease prevention and health promotion.¹⁴ In order to define acceptable treatment goals and outcomes, it is now possible to move away from standard medical/dental criteria and instead examine and care for a person's social, emotional, and physical functioning.¹⁵ Access to medical care is constrained in affluent nations by expensive pricing and occasionally by transportation issues.¹⁶ OHRQoL can be used to assess how differences in oral health affect general health and QoL.^9,14,17,-18

Other Populations among which OHRQoL is Affected by Malnutrition

Cancer patients

Malnutrition associated with cancer has a significant impact on patients' HRQoL because it reduces their ability to function socially, and worsens their general health.¹⁹ A group of patients were discovered to be either malnourished or at danger of malnutrition more than six months after the end of their treatment. This may be partially attributable to the fact that oropharyngeal and oral resections lead to decreased food intake and improper nutrition, which may last for some time.¹⁹ Also, radiotherapy and chemotherapy have a detrimental effect on nutrition, and it takes time to recover from damaging treatments such as this. The consequences of these therapies on the oral cavity result in the loss of natural teeth. Functional tooth units showed a strong correlation with nutritional status, which is consistent with earlier investigations.¹⁹

More than 95% of participants in a prior study on oral cancer patients felt that their treatment had a negative influence on their OHRQoL, demonstrating a relatively high incidence of oral consequences on day-to-day activities. Additionally, a study reported that there was a strong link between oral impacts and oral cancer.²⁰

Nutritional variables, among others, can affect HRQoL in oral cancer patients. A poor nutritional state can cause sadness, a decline in quality of life, and a change in how one feels about oneself. OHRQoL may also change as a result. After adjusting for potential confounding factors, a substantial correlation was discovered between dietary status and OHRQoL, but this was refuted by results of a study conducted by Jager Wittenaar et al. This mismatch could be the result of the two studies using different tools to measure diet and HRQoL.²¹

Geriatric population

For the general and oral health of elderly adults, proper and adequate nutrition is crucial. In order to keep elderly people healthy, diet is crucial. It has been demonstrated that social support, socioeconomic position, culture, and oral health, all influence general health and diet quality. Poor masticatory function and oral health are seen as risk factors for malnutrition. Common oral disorders in the elderly include poor oral hygiene, dental caries, periodontal disease, or improper dentures. The ability of patients to adopt the appropriate healthcare behaviors in order to raise indicators and maintain good health is referred to as ‘self-efficacy’. Enhancing self-efficacy can successfully raise oral health knowledge and encourage healthy oral hygiene behaviours.^22-24

Population with genetic disorders

With 4.8 cases per 100,000 people, X-linked hypophosphatemia (XLH) is the most prevalent type of vitamin D-resistant rickets.²⁵ The X-linked phosphate-regulating neutral endopeptidase (PHEX) gene, which is located on chromosome Xp22, is the gene responsible for XLH. By increasing the expression of fibroblast growth factor 23, they cause dysregulation that leads to phosphaturia, hypophosphatemia, and defective 25-hydroxyvitamin D activation to 1,25-dihydroxyvitamin D.²⁶ Although the clinical signs of XLH might vary, it is typically distinguished by bone malformations, a tiny body size, and dental anomalies. This is brought on by reduced renal phosphate reabsorption, which causes hypophosphatemia and decreased mineralization of the bones and teeth.²⁷

There are many different dental abnormalities in XLH cases, and the precise etiology is yet unknown. Recurrent abscesses and/or fistulas in caries-free teeth in both the primary and permanent dentition stages are the most typical oral abnormalities. Dentitiotarda (secondary late dentition) and radiographically evident, significantly enlarged pulp chambers are further signs.²⁸ A study that evaluated the QoL factors connected to oral health found that the condition had significantly decreased the patients' quality of life. The patient's quality of life will be significantly impacted by any genetic condition that affects the hard tissues of the mouth cavity.²⁹

Oral Health Related Quality of Life (OHRQoL)

The idea of well-being has recently been included to the dimension of oral health as a result of WHO expanding the definition of health to include social welfare. Since then, dental health has been understood to affect a person's entire wellbeing alongside presence or absence of disease.

Since oral health affects daily activities like smiling, talking, eating, and making contributions to society, it is essential for the overall health and wellbeing. A paradigm change has taken place with regard to health, illness causation, and the availability of medical and dental care. The medical model of health has been replaced by the socio-environmental model, which based health on the ability to perform at one's optimal functioning as well as one's social and psychological well-being.^30,10

In comparison to the general HRQoL idea, which began to take shape in the late 1960s, the concept of OHRQoL did not appear in literature until the early 1980s. The lack of understanding of how oral diseases affect quality of life may be the cause of delay in the creation of oral health-related QoL. The term "OHRQoL" encapsulates the new perspective's aim, which is good oral health as the main objective of dental treatment. The US Surgeon General states that oral illnesses and diseases can "undermine self-image and self-esteem, discourage normal social interaction, and cause other health problems, leading to chronic stress and depression, as well as significant financial costs. They may also interfere with vital functions such as breathing, food selection, eating, swallowing, and speaking, as well as daily activities like work, school, and family interactions."

OHRQoLis defined as, “a multidimensional construct that reflects (among other things) people’s comfort when eating, sleeping, and engaging in social interaction; their self esteem; and their satisfaction with respect to their oral health.”1 Functional, psychological, social, and pain or discomfort-related aspects are all linked to OHRQoL (Figure 1).

Inspired by WHO's International Classification of Functioning, Disability and Health (ICIDH), David Locker developed a conceptual model to explain, for the first time, the mechanisms by which oral diseases and ailments affect quality of life.³¹

Locker’s concepts of health and quality of life are: 

• Difficult to define
• Multidimensional and complex
• Predominantly subjective
• Constantly evolving
• Differ depending on the political, social, cultural, and practical factors.

Quality of life was first used by British economist Pigou AC in 1920.³² After World War II, this phrase was further extended to include other domains, such as health, as the biological to the biopsychosocial model of health emerged.³³ In dentistry and medicine, practitioners and researchers began to acknowledge the presence of quality of life. An individuals’ view of their situation in life in respect to their own objectives, expectations, standards, and worries as well as the value systems and culture in which they live is referred to as ones QoL.³⁴

By combining the dominant biomedical notion with the new social concept, Wilson, and Cleary (1995) presented a complete yet straightforward model. Since the creation of the WHO International Classification of Functioning, Disability and Health (ICIDH) model, other models have been put forth by different scholars. This model was based on five abstract ideas: symptom status, general health, functional status, biological/ physiological, and quality of life, as well as referencing personal and environmental elements.³⁵

Different Indices Used to Measure OHRQoL

For public health purposes, oral health can be measured at the macro level using societal measurements of oral conditions, which show that oral disease creates a significant burden of sickness and is more prevalent in underprivileged groups in society.

The OHRQoL is a multidimensional term that measures how people perceive various aspects of their daily lives. The requirement for creating patient-centered measurements of oral health status was initially identified by Cohen and Jago. Slade claims that there are fundamentally three different kinds of OHRQoL measurements. These include multiple-item OHRQoL questionnaires, social indicators, and total OHRQoL self-ratings. In a nutshell, social indicators are used to assess the effects of oral health issues on the neighborhood. To estimate the impact of oral diseases on the general community, large-scale population surveys are frequently carried out utilizing social factors including days of restricted activity, lost work time, and missing school days. Despite being significant to policymakers, social variables have limitations for assessing OHRQoL. The most popular technique for evaluating OHRQoL is the use of questionnaires with several items.³⁶

To meet the demand for more specialized measures, researchers have created QOL instruments that are specifically focused on oral health, and their numbers are still expanding quickly. These tests can be divided into generic ones that assess oral health in general and specialized ones. Various OHRQoL measures that have been devised recently are shown below in Table 1.

Dental caries is one of the most common health problems affecting youngsters.

Oral diseases are more prevalent in developing countries compared to industrialized nations. This disparity is due to limited access to clean, fluoridated water, prevalent hunger, and unsanitary conditions, all of which are risk factors for both dental and general health. Furthermore, emergency and pain management are frequently the extent of therapy for many patients, and preventive or restorative dental care is not a top concern.

Even though oral health issues are rarely life threatening, they continue to be a significant public health issue due to their great frequency and the fact that oral health issues can have an impact on social, economic, and psychological outcomes. In other words, a person's quality of life may be impacted by their oral health.

The WHO's Global Oral Health Program includes oral health as a vital component since it recognized oral health as being essential to overall health and wellness. Dental problems can make it difficult for someone to carry out social obligations, cause pain and discomfort, and obstruct basic body activities like chewing, talking, and smiling. Public health initiatives and dental procedures can enhance OHRQoL, according to the findings of numerous clinical and interventional studies. The increasing significance of patient-reported outcome assessments in clinical practice, public health, and research has been recognized by the medical profession. But there are very few publications in the dental literature about patient reported outcome assessment. Therefore there is potential in this area, and future research on oral health services will concentrate on self-reported quality of life as a secondary or possibly a key outcome measure in assessing interventions or community health initiatives.³⁵

Measurement of OHRQoL

There are two commonly used, pertinent general measures that can be used to assess OHRQoL. The 14 elements in the Oral Health Impact Profile (OHIP-14) examine seven aspects of impact: psychological discomfort, physical impairment, physical pain, functional restriction, psychological impairment, social impairment, and handicap. The response of participants is recorded on a five-point Likert scale (ranging from 0 to 4) based on impact and frequency -very often, often, occasionally, hardly ever, never. The dimensions and overall score of the simple count (OHIP-SC) scoring technique were determined by adding the number of impacts that were described as occurring infrequently, pretty frequently, or very frequently.³⁷

The Oral Impacts on Daily Performances (OIDP) index measures how oral health issues affect eight different daily activities: eating, speaking, brushing teeth, performing important tasks or roles, interacting with others, unwinding/sleeping, smiling, and emotional state. Through the use of Likert scales, it assesses both the frequency and the impact of these effects. The frequency and severity scores are multiplied to create a score for each performance. To calculate the percentage overall score, the sum of these performance scores is multiplied by 100, then divided by the highest possible score. Additionally, the number of performances impacted by effects, which ranged from 0 to 8 was used to compute the OIDP extent. Higher scores on the OHIP-14 and OIDP suggest lower OHRQoL.^38-39

The link between OHRQoL and the likelihood of malnutrition may have significant therapeutic ramifications. After therapy is finished, patients should have a nutritional assessment to identify any potential malnutrition. This will improve their OHRQoL and help to manage the rising economic costs of malnutrition.²⁰

Measurement of Nutritional Status

The European Society for Clinical Nutrition and Metabolism recommends the Mini Nutritional Assessment for assessing nutritional status (MNA).⁴⁰ The short form (screening questionnaire) and the complete version of the MNA can be taken separately. The brief version consists of six questions about body mass index, mobility, cognitive issues, psychological stress or recent illness, and weight loss or recent appetite. It is not required to proceed with the second portion of MNA if the score falls between 12 and 14 (the maximum score), which denotes satisfactory nutritional status. A screening score of 11 or less indicates the possibility of malnutrition and the requirement to complete the full MNA. The total possible MNA score is 30, and there are 12 more questions in this second section with a maximum score of 16 points. Three groups can be identified using the MNA score: those who have appropriate nutrition (score 24), or who simply required to fill out the screening questionnaire; those who are at risk of malnutrition (scores between 17 and 23.5); and those who are malnourished (scores under 17).^41,42

Uses of OHRQoL⁴³

The subjective perception of oral health-related quality of life symptoms that have an impact on a person's wellbeing is represented by OHRQoL. The OHRQoL examines patient-centered outcomes to determine how oral health affects social, psychological, and functional elements of daily living. Hence it has a wide array of uses in both individual as well as community settings:

1. It can be used to assess the OHRQoL of individual patients to help avoid deficiency related dental problems.
2. It can be used to assess the nutrition related oral health of a group of people who consume the same type of food to help in filling any gaps in nutrition.
3. It can be used to assess the OHRQoL of pregnant women which could have possible effects on the delivered infant.
4. It can have widespread uses in schools to ascertain the nutritional status of growing children and ensure optimal growth.

OHRQoL Across the Globe

By the turn of the previous century, the topic of measuring OHRQoL in children had somewhat inevitably come to the forefront of discussion. It was not that it had been avoided; rather, it was more difficult for kids to self-report on their oral health. Since very young children are prone to provide incorrect information, it seemed probable that different measures would be required for various ages due to their ongoing social and cognitive development.⁴⁴

Researchers may reliably place children on the misery continuum using their OHRQoL scores, and then track their treatment-related progress towards the less severe end of that continuum. Pre- and post-intervention studies have been the norm up to this point, with the same kids being evaluated both before and after treatment.⁴⁴

Various studies have been conducted across the globe to assess the OHRQoL of patients affected by different types of ailments such as OHRQoL in patients before and after treatment under general anesthesia (GA),^45-56 children who have undergone orthodontic treatment, children with cleft lip or/and palate, children suffering from chronic respiratory diseases, to name a few.⁵

These studies have shown varied levels of improvement in the OHRQoL with studies involving GA showing large effect sizes. Studies including adolescents undergoing orthodontic treatment showed scarce levels of improvement.^58,59 However, one country wide study conducted in New Zealand for a duration of four years showed improvement in OHRQoL with a moderate to large effect size.⁶⁰ With regard to patients who had undergone cleft-related surgery, children reported poorer self-rated and caregiver-rated OHRQoL over time than children who did not have surgery.⁶¹

OHRQoL was also used to assess the effectiveness of Silver Diamine Fluoride treatment on uncooperative children and was proven to significantly improve the OHRQoL of the patients.⁶²

Studies conducted to assess association of oral health and social status concluded that across all social categories, dental caries has also been found to be strongly related with poor child and family experiences and lower OHRQoL. However, families that are more disadvantaged may perceive less of an impact on quality of life at the same degree of disease experience. Therefore, subjective quality-of-life measurements may change depending on the socioeconomic environment, which could have an impact on how often people use services, how well oral health interventions work, or how much disease morbidity there is among low-socio-economic status populations.⁶³

OHRQoL Studies Conducted in India

Multiple studies assessing OHRQoL have been conducted in the Indian subcontinent for a multitude of objectives.

• A study was conducted to compare the OHRQoL among preschool children residing in urban and rural areas of Bangalore city. The results showed that OHRQoL status was better among the children living in urban areas than those in rural areas.⁶⁴ Similar result was obtained in a study conducted among children in Rangareddy District of Telangana state.⁶⁵
• Studies were conducted to assess the effect of hearing and visual impairments on the OHRQoL of children and the results obtained pointed towards unfavorable OHRQoL.^66-68
• Children suffering from autism and cerebral palsy were also found to have low OHRQoL.^69-71 Low level of OHRQoL was also seen among children suffering from oral diseases such as early childhood caries, gingivitis, as well as anomalies such as cleft formation.^72-75
• A striking finding emerged from the study on the relationship between children's OHRQoL, dental anxiety (DA), and intelligence quotient (IQ). Children with higher IQs reported lower OHRQoL status, and there was a negative correlation between DA and OHRQoL.⁷⁶
• A study conducted by Raghu R et al. to assess OHRQoL changes among Early Childhood Caries patients showed that the oral health-related quality of life significantly improved after complete oral rehabilitation under GA and the improvement persisted beyond the immediate post-treatment period.⁷⁷

Conclusion

Nutrition and oral health are interrelated. Nutrition and diet can affect overall health and well-being as well as the development and integrity of the oral cavity and the progression of oral diseases. This is more important in children as any malnutrition problems during the growth phase can have long standing effects later in life. The use of scales like the OHRQoL can help in assessing the status of individuals or groups of people so that they can be assisted to receive the necessary treatment and be free from any ailment related to the oral cavity. The normal growth of children can be ensured by making sure that children who are in danger of nutritional deficiencies can be given the necessary help and supplementations.

Conflict of Interest

The authors report there are no competing interests to declare

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Data statement

The data that support the findings of this study are available from the corresponding author upon request.