|Year : 2019 | Volume
| Issue : 6 | Page : 817-823
Evaluation of the impact of early childhood caries, traumatic dental injury, and malocclusion on oral health–Related quality of life for Turkish preschool children and families
D Sakaryali1, M Bani2, C Cinar2, A Alacam2
1 Department of Pediatric Dentistry, Faculty of Dentistry, Baskent University, Bahcelievler-Cankaya, Ankara, Turkey
2 Department of Pediatric Dentistry, Faculty of Dentistry, Gazi University, Emek-Cankaya, Ankara, Turkey
|Date of Acceptance||13-Feb-2019|
|Date of Web Publication||12-Jun-2019|
Dr. D Sakaryali
Department of Pediatric Dentistry, Faculty of Dentistry, Baskent University, Bahcelievler-Cankaya, Ankara
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study was to assess the impact of the presence of early childhood caries (ECC), traumatic dental injury (TDI), and malocclusion, as well as severe conditions, on the oral health–related quality of life (OHRQoL) of preschool children and families. Materials and Methods: A cross-sectional survey was conducted in children aged 1 to 6 years old, who attended to the Department of Paediatric Dentistry, Gazi University. The questionnaires were adapted to Turkish, and OHRQoL was measured using the Turkish version of Early Childhood Oral Health Impact Scale (T-ECOHIS). Children were classified into four main groups, two subgroups in each group based on their severity conditions—Group 1: ECC group; Group 2: TDI group; Group 3: Malocclusion group; Group 4: Control group. Parents answered the questions about sociodemographic conditions and T-ECOHIS. The Kolmogorov–Smirnov test was used for non-normal distribution and Kruskal–Wallis and Mann–Whitney tests were used to compare T-ECOHIS score regarding ECC, TDI, and malocclusion. Results: Both simple and severe conditions of TDI showed a negative impact on the family and child based on T-ECOHIS scores (P < 0.05). The severe condition of ECC and malocclusion showed significantly negative impact on family (P > 0.05) but not on child (P > 0.0.5). Conclusion: The presence of ECC, TDI, and malocclusion has a negative effect on OHRQoL of Turkish preschool children and specially their families. So, public health programs should be carried out about oral health for raising parents' and children's awareness and increasing OHRQoL.
Keywords: Early childhood caries, ECOHIS, malocclusion, oral health–related quality of life, traumatic dental injuries
|How to cite this article:|
Sakaryali D, Bani M, Cinar C, Alacam A. Evaluation of the impact of early childhood caries, traumatic dental injury, and malocclusion on oral health–Related quality of life for Turkish preschool children and families. Niger J Clin Pract 2019;22:817-23
|How to cite this URL:|
Sakaryali D, Bani M, Cinar C, Alacam A. Evaluation of the impact of early childhood caries, traumatic dental injury, and malocclusion on oral health–Related quality of life for Turkish preschool children and families. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 15];22:817-23. Available from: http://www.njcponline.com/text.asp?2019/22/6/817/260043
| Introduction|| |
American Academy of Pediatrics defines child health as “the social, physical and emotional functioning of the child and when indicted his or her family”; therefore, measurement of health-related quality of life must be from the perspective of the child and family. Oral health is affiliated to general health, and it is important for the quality of children's and parent's lives. Therefore, in the field of oral health, questionnaires are preferred to clarify risk factors for numerous outcomes of oral conditions and it became necessary to investigate how highly prevalent were the oral problems related with the impact of the quality of life for children and families.,
Children younger than 6 years of age are especially vulnerable to oral health problems like temporary teething discomfort, traumatic injuries of teeth and supporting tissue, and early childhood caries (ECC). Caries, despite recent preventive regimes and advanced early diagnosis methods, remains a prevalent childhood disease around the world. In fact, dental caries is still the most common chronic disease in children.,
Traumatic dental injuries (TDI) are common among preschool children, who are likely to fall as they learn to crawl, stand, walk, and run during the development of motor skills. Moreover, TDI may result in pain and loss of function, and it could adversely affect the developing occlusion and aesthetics.
Maxillary central incisors are the most frequently affected teeth by trauma, possibly because of their position in mouth or being less protected than other teeth.,, The presence of an increased incisal overjet and anterior open bite are physical features that have been reported as predisposing factors of TDI. Moreover, the presence of these anterior malocclusions traits may cause loss of function and aesthetics problems by themselves.
Early Childhood Oral Health Impact Scale (ECOHIS) has been developed to evaluate the impact of oral health–related quality of life (OHRQoL) of preschool children and their families. This scale can provide public health programs about oral health care for preschool children and their families and also inform evidence-based dental practice.
Several studies have demonstrated the impacts of different oral health problems on quality of life, and most of these studies have used the ECOHIS to assess OHRQoL of preschool children.,,,, The ECOHIS was developed in English and it was subsequently translated and adapted to several languages. The questionnaire consists of a parental proxy report with acceptable internal consistency and reliability, as well as validity, in varying populations, for example, B-ECOHIS for Brazilian children.,,,,,
There are few studies assessing the impact of ECC, TDI, and malocclusion on the OHRQoL of preschool children and their families at the same time. Therefore, the aim of this study was to assess the impact of the presence and severity of ECC, TDI, and malocclusions on the OHRQoL of Turkish preschool children and their families using T-ECOHIS. The hypothesis of this study was that the presence of ECC, TDI, and malocclusion have a negative effect on OHRQoL for both children and their parents.
| Materials and Methods|| |
A cross-sectional survey was conducted in children aged 1 to 6 years old, who attended to the Department of Paediatric Dentistry, Gazi University. The patients who referred to the Department of Pediatric Dentistry for dental examination were asked to participate in the study with own willing and written consents were taken from the patients' mother or father. Healthy children with no physical or psychological disorder, age lower than 6 years old, and preschool children who were accompanied by their mother or father were included in the study. The exclusion criteria were parents of children with special health care needs who refused to give written informed consent for enrolment in the study.
A power analysis was undertaken by Sample Power 2.0 (SPSS Inc., Chicago, IL, USA). A total of 120 participants, which meant to be 30 mothers or fathers as participants, were required in each group to have 80% statistical power for identifying a significant difference in ECOHIS scores. Children were classified into four major groups based on their dental conditions and every major group was separated into two subgroups by its severity condition according to the clinical and radiographical examination. Major groups were as follows; Group 1: ECC, Group 2: Traumatic Dental Injury (TDI), Group 3: Malocclusion (M), and Group 4: Control group. Subgroups were separated as simple and severe conditions of these groups.
All participant children received comprehensive clinical examination during routine dental examination or emergency reference due to the TDI. The examinations were blind to parental assessments. The clinical oral examination took place in a dental chair under normal lighting and a mouth mirror by one pediatric dentist. The simple and severe conditions of ECC, TDI, and malocclusion were recorded based on WHO criteria, IADT Guideline for Traumatic Dental Injuries for Primary Dentition, and also previous studies.,,,,,,,, However, a patient might have more than one of these conditions but the patient was included to the group because of the primary reason for referring the hospital.
Group 1A: Presence of one or more decayed, missing, or filled surfaces in any primary tooth of a child which can be defined as simple type of ECC.,,
Group 1B: Smooth-surface caries in children younger than 3 years of age or with one or more cavitated, missing, or filled smooth surfaces in primary anterior teeth for children aged between 3 and 5, or a decayed, missing, or filled surface score of ≥4 at age 3, ≥5 at age 4, ≥6 at age 5, and ≥7 at age 6 which can be defined as severe type of ECC.,,
Group 2A: Those in which the pulpal tissue was not exposed or/and the tooth was not dislocated can be defined as uncomplicated traumatic injuries such as concussion, subluxation, enamel fracture, and enamel dentin fracture.,,,,,,,
Group 2B: Those involving exposure of the pulpal tissue and/or tooth dislocation can be defined as complicated traumatic injury such as intrusive luxation, extrusive luxation, avulsion, crown root fracture, and root fracture.,,,,,,,
Group 3A: Malocclusions such as overjet, overbite, deep bite, open bite, diastema, crowding, misplaced midline, asymmetry, cross bite, and protrusion,,
Group 3B: Patients with more than one of these malocclusions,,
Group 4: Children without ECC, TDI, and malocclusion
Sociodemographic data and questionnaires
The Turkish version of the ECOHIS (T-ECOHIS) was used to assess the OHRQoL of the children by interview with the families. T-ECOHIS was translated by two native English translators and validated. T-ECOHIS was distributed to families at the same time with clinical examination, and all families of the children were asked to complete the questionnaires by face to face with a pediatric dentist.
Sociodemographic data and characteristics of the families were recorded as age (12-72 months) and gender (boy or girl) of the child, family structure (living with mother or father or both of them), age of mother or father (<30 or ≥30 years), number of siblings (none, one, two, or more), education status of mother or father (<8 or ≥8 years), and monthly family income (
T-ECOHIS consists of 13 questions divided into child impact section and family impact section. ECOHIS is scored using a simple 5-point Likert scale: 0 = never, 1 = once/twice, 2 = sometimes, 3 = often, 4 = always. ECOHIS subgroups and scores for child are symptoms (one item, range = 0-4), function (four items, range = 0-16), psychology (two items, range = 0-8), and self-image/social interaction (two items, range = 0-8). ECOHIS subgroups and scores for families are distress (two items, range = 0-8) and family function (two items, range = 0-8). The total score ranges from 0 to 52: from 0 to 36 in the child section and 0 to 16 in the family section. A higher ECOHIS data scores indicate greater impact and/or more problems for OHRQoL. Participants that responded “don't know” to two or more items in the domains related to the child, or one or more items in the domains related to the family, were excluded from the study.
Data analysis was performed using SPSS V. 20.0 (SPSS Inc., Chicago, USA) and included frequency distribution and descriptive analysis for overall mean T-ECOHIS scores. The Kolmogorov–Smirnov test was used to for non-normal distribution, and Kruskal–Wallis and Mann–Whitney tests were used to compare T-ECOHIS scores regarding ECC, TDI, and malocclusion. Mann–Whitney and Kruskal–Wallis tests were used to evaluate non-parametric values like gender and age of child, family structure, age of mother or father, number of siblings, educational level of mother or father, and family income. The level of significance was set at 0.05.
| Results|| |
A total of 107 children and their parents participated in the study. The mean age of the children was 55.14 months and 44.8% were female. Most of the questionnaires were answered by mothers (76.6%). The majority of the participating parents (66.35%) had more than 8 years as educational level. The majority of participants (99.06%) were living with both mother and father and about half of the participant families (45.79%) had two children. Family income was less than two Turkish minimum wages among 51.40% of the families [Table 1].
|Table 1: Sociodemographic data of the participated children and their families|
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All the parents interviewed in this study completed the T-ECOHIS questionnaire. [Table 2] displays the distribution of responses to the T-ECOHIS according to each question. The items related to pain, difficulty during eating, irritation, difficulty on drinking, and trouble of sleeping were the most frequently reported in the child impact section. Items related to the family about feeling guilty and being upset were frequently reported on the family impact section of the T-ECOHIS. However, only one participant (0.93%) of the total participants reported no impacts, which means a score of “0” on T-ECOHIS. Four participants (3.73%) whose common point was having severe ECC had the highest score of T-ECOHIS which was “23.” Mean values of 0.61 and 1.41 were reported on the child impact section and family impact section, respectively. The mean overall score of the T-ECOHIS was 1.01. [Table 3] shows the mean difference between severe and simple conditions of ECC, TDI, malocclusion, and control groups for the overall T-ECOHIS. Compared with the effect on child and family, there was significant difference between both simple and severity of ECC, TDI, malocclusion, and control group (P < 0.05).
|Table 3: Median and standard deviation scores of T-ECOHIS for simple and severe conditions of ECC, TDI and malocclusion|
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All groups were compared with the Group 4. There was a significant difference between the both severe and simple conditions of ECC, TDI, and malocclusion for OHRQoL on child and family (P < 0.05). Group 1A had negative effect on families with statistically significant difference (P < 0.05) but not on child (P > 0.05). However, only Group 1B had significantly negative impact on children (P < 0.05). Both Group 2A and Group 2B showed significantly negative impact on the families and children (P < 0.05). Group 3B showed significantly negative impact on family and child impact, but Group 3A showed significantly negative impact only on family (P < 0.05).
| Discussion|| |
ECC, TDI, and malocclusion have physical, psychological, functional, and social impacts on quality of life in preschool children and on their families as well., ECOHIS considers the child's lifetime experience of dental diseases through parental proxy reports. So, T-ECOHIS which was an adapted form of ECOHIS was preferred to assess the emotional, functional, and psychological effects on both children's and parents' OHRQoL. Although there are some studies with T-ECOHIS, this is the first study evaluating presence and severity of ECC, TDI, and malocclusion for Turkish preschool children.
ECC can be used to describe dental caries occurring in the primary dentition of preschool children. Severe ECC is a term used to refer atypical, progressive, or rampant patterns of decay. Both simple and severe conditions of ECC cause aesthetic and functional problems in children, and also compromise the daily life of parents., ECC causes pain in a significant number of children, and also can interfere with the growth of the body, with adverse effects on body weight and height, and can result in developmental failures.,
Evidence also indicates that ECC results in loss of the workdays for parents to take care of their child or spending time and money in accessing dental care.,, Parents or caregivers are responsible for the health of children and, generally, they have to decide about their health. Therefore, assessing parents' perceptions about how oral health problems, including symptoms, disease, and treatments, influence their children's quality of life is important, and ECOHIS is a type of life quality questionnaire that was preferred to assess OHRQoL for both children and their parents. According to the results of this study, ECC, TDI, and malocclusion had a negative effect on both children's and parents' OHRQoL. This result was not surprising for us due to the high level of caries risk in our country. This study was planned with a total of 120 participants which meant 30 mothers or fathers for each group—ECC, TDI, malocclusion, and control group. But, during the 6-month period for this study, healthy patients without ECC, TDI, or malocclusion did not refer to the pediatric dentistry clinic; so, we had to finalize the study with 17 patients for control group.
Peker et al. applied T-ECOHIS on 121 patients aged 5 to 6 years to measure the impact of dental caries, and according to the results reported, T-ECOHIS is a reliable and valid instrument for assessing the OHRQoL. Cantekin et al. used T-ECOHIS for children aged 4 to 6 before and after dental treatments under general anesthesia and reported that both children and family impact scores decreased significantly. Both studies had shown that ECC has an important effect on OHRQoL for both children and their families., According to the results of this study, both simple and severe conditions of ECC had negative impact on children's and families' OHRQoL. But simple condition of ECC did not have statistically significant impact on children's OHRQoL different from the parents' OHRQoL. This result can be concluded to the fact that children's pain sensitivity might be higher in severe condition than simple condition and parents' may have higher aesthetic expectations than children.
OHRQoL was evaluated with ECOHIS many times due to the presence or severity of ECC, TDI, and malocclusion. But, Vollú et al. evaluated the impact of ECC before and after dental treatments on OHRQoL with B-ECOHIS in their study and concluded that dental treatments under general anesthesia could be favorable to decrease the negative impact of ECC. The authors have paid attention to a new point that we know ECC have negative effect on both patients and families but what we do not know is if we might decrease or eliminate this negative effect after the treatments. So, as a new perspective, we should evaluate OHRQoL before and after the dental treatments for further studies to have more reliable evidence about OHRQoL.
TDI is known to be a serious problem in preschool children due to its pain, aesthetic, emotional, and functional impact on daily lives.,, According to a systematic review and meta-analysis, TDI had negative impact on OHRQoL for preschool children based on the overall ECOHIS studies. Bani et al. evaluated the impact of TDI on children aged 7 to 15 by using Turkish version of Family Impact Scale, and according to the results, parental emotions, parental activity, financial burden, and family conflict have negative impact on parents' quality of life. The results of this study supported that results about parental symptoms and functions, but this study also assessed the impact of TDI for children. According to the results of this study, we might conclude that ECC, TDI, and also malocclusion have negative impact on OHRQoL of both parents and children. Also, we should emphasize that both simple and severe conditions of TDI have statistically significant negative impact on both parents' and children's OHRQoL.
Malocclusion can cause both aesthetic and functional problems, and increased over-jet and anterior open-bite have been also reported as predisposing factors of TDI. According to the results of this study, malocclusion had negative effect on both children's and parents' OHRQoL. Only severe condition of malocclusion had statistically significant effect on children but both simple and severe conditions had significantly negative effect on parents. So, according to these results, the hypothesis might be accepted because of the statistically significant effects of ECC, TDI, and malocclusion on both children's and parents' OHRQoL.
Sousa et al. and Carvalho et al. assessed the impact of malocclusion of OHRQoL among preschool children and families, and reported that malocclusion was not associated with a negative impact on OHRQoL. Corrêa-Faria et al. reported a cross-sectional study about the impact of dental caries, malocclusion, and developmental defects of enamel on the OHRQoL for preschool children and parents. According to their findings, dental caries was associated with a negative impact on the quality of life of children similarly with the findings of this study. But, malocclusion and developmental defects of enamel did not have a negative impact on the children's quality of life, and they also mentioned that older children had higher frequency of negative impact on OHRQoL. Also, Yetkiner et al. mentioned a study about relationship between orthodontic treatment need determined by an orthodontist and OHRQoL defined by aesthetic score given by adolescent patients. Due to the results of the study, there was no statistically significant difference, but the authors concluded a possible disassociation between clinical norms and perceptions of children. This result might show similarities with our results about the impact of malocclusion since according to our findings, children were not affected from simple condition of ECC and both conditions of malocclusion but parents did. So, this result can be concluded as there is higher aesthetic expectations of parents than the children.
Gomes et al. reported a cross-sectional study evaluating the impact of dental caries, TDI, and malocclusion on preschool children and their parents or caregivers. Authors concluded that caries lesions and TDI had exerted an impact on OHRQoL of the preschool children and their families, and also, parents' or caregivers' perception of their child's oral health as low economic status and the birth order of the child were predictors of a greater impact on OHRQoL. Also, Díaz et al. evaluated the impact of dental caries, TDI, and dental malocclusion on OHRQoL with Colombian ECOHIS. According to the results of the study, the authors reported that all demographic data have an impact on OHRQoL but specially concluded that family structure has an important role for providing better OHRQoL. According to our results, the overall T-ECOHIS was high; so, it might be concluded that more than half of the participant families' monthly income was less than two minimum wage which would be a predictor for OHRQoL for this study as well. But, the birth order or family structure or education levels of participant families were not showing an impact on OHRQoL in this study. Most of participants had more than 8 years of education level; so, low OHRQoL might be related to low socio-economic status but not with the education level of parents.
Gomes et al. reported that ECC and TDI had a negative impact on OHRQoL of both children's and their parent's or caregiver's life but only malocclusion did not have an impact on OHRQoL for children or their parents. The results of this study showed that both conditions of ECC, TDI, and malocclusion had a significantly negative impact on families' OHRQoL but simple condition of ECC and malocclusion did not have significant impact on children's OHRQoL. The results about simple condition of ECC and malocclusion might be related to higher aesthetic expectations of families than their children. It can be concluded that severe condition of ECC or malocclusion or both conditions of TDI show an impact on OHRQoL for both children and families due to the discomfort or pain, and this condition would not change from person to person or within different populations. It is also important to mention that, if the study had been conducted on schoolchildren, the results might have been different due to the social interactions and increased awareness of children as well as their families.
In our study, T-ECOHIS scores showed that Turkish parents of preschool children had been affected more than their children in the presence of ECC, TDI, and malocclusion. As a conclusion, raising parental awareness by public health programs to improve oral health as early as possible will help to decrease T-ECOHIS scores which will be the sign of better life quality for parents and children.
| Conclusions|| |
- The presence of ECC, TDI, and malocclusion have negative impact on the OHRQoL for Turkish preschool children and families
- The severe conditions of ECC, TDI, and malocclusion have a negative impact on OHRQoL for preschool children and families due to the discomfort or pain for children and aesthetic awareness of families
- The T-ECOHIS data supposing as predictors for Turkish population showed low life quality; so, further public health studies and programs should be carried out for raising awareness to parents and children about oral health and also OHRQoL.
The study was presented as poster presentation at 22nd Congress of Turkish Society of Paediatric Dentistry.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]