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Year : 2019  |  Volume : 22  |  Issue : 9  |  Page : 1213-1217

Oral health–related quality of life of patients undergoing different treatment of facial fractures: The OHIP-14 questionnaire

1 Clinic of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Montenegro, Podgorica, Montenegro
2 Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
3 Department of Neurotrauma, Emergency Center, Belgrade, Serbia
4 Department of Maxillofacial Surgery, Dental Clinic, Nis, Serbia

Date of Acceptance23-Apr-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Dr. B Vukcevic
Faculty of Medicine, University of Montenegro, Ljubljanska 1, Podgorica
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_124_19

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Background: The choice of surgical approach can affect the quality of life in patients with a facial fracture. Objective: The aim of this study was to assess the quality of life in surgically treated patients with facial fractures, and to determine the potential difference in the quality of life related to different surgical approaches. Materials and Methods: Ninety facial fracture cases were analyzed. They were divided into three groups: operated by skin incision, mucosal incision, and treated conservatively. To examine the quality of life of patients, a questionnaire on the quality of oral health Oral Health Impact Profile (OHIP)-14 questionnaire was used. Results: In the first days after the injury, patients with transcutaneous approach showed a poorer quality of life in comparison to patients with transmucosal and conservative treatment. The presence of severe posttraumatic pain is significantly more prevalent in patients with transcutaneous surgical approach than in other treatment types. Conclusion: During the immediate posttraumatic period, the quality of life is poorer in patients who have undergone transcutaneous approach. There are no differences in the quality of life 1 month or 3 months after the injury.Discussion: Assessment of complaints in the first days after the injury shows statistically significant differences across various therapeutical methods in variables such as pain, discomfort when eating certain foods, aesthetic appeal, nervousness, and relaxation. There is not sufficient evidence related to the differences in these outcomes regarding different surgical approaches for facial fractures.

Keywords: Facial fracture, quality of life, surgical approach, surgical treatment

How to cite this article:
Boljevic T, Vukcevic B, Pajic S, Pesic Z. Oral health–related quality of life of patients undergoing different treatment of facial fractures: The OHIP-14 questionnaire. Niger J Clin Pract 2019;22:1213-7

How to cite this URL:
Boljevic T, Vukcevic B, Pajic S, Pesic Z. Oral health–related quality of life of patients undergoing different treatment of facial fractures: The OHIP-14 questionnaire. Niger J Clin Pract [serial online] 2019 [cited 2020 Aug 14];22:1213-7. Available from:

   Introduction Top

Quality of life of the patients suffering from facial fractures has been widely researched.[1] Several psychosocial issues are related to undergoing maxillofacial surgery: depression, anxiety, changes in the perception of the appearance of their own body, low self-esteem, and poor social relationships.[2],[3] The surgical team treating facial fractures must pay attention to the psychosocial needs of the patient.[4],[5] About 30% of the patients express clear psychological morbidity (such as anxiety or depression) in the immediate posttraumatic and/or postoperative period.[2],[3],[6] Depressive symptoms may be present during the prolonged postoperative period.[6],[7] The incidence of the posttraumatic stress disorder is considered to be up to 27%–47% in maxillofacial injuries, with a risk of chronic persistency if not treated timely,[8],[9] thus increasing the need for adequate treatment and long-term psychological follow-up.[10],[11],[12],[13]

The quality of life is viewed through the context of personal beliefs and value systems, expectations, interests, as well as the cultural context.[5],[9],[11] There are four factors regarded as the pillars of the quality of life: health, functional ability, satisfaction with life, and self-esteem.[7] Poor quality of life during the first posttraumatic days predicts long-term depression.[1] Questionnaires and other screening tools might be useful in the prediction of psychological issues.[14],[15],[16],[17]

The aim of this article was to evaluate the quality of life of the patients undergoing surgery for facial fractures. Furthermore, different surgical approaches were compared to evaluate potential differences in the quality of life of the operated patients. Given the fact that there is not sufficient evidence regarding the differences in the quality of life of the patients undergoing different surgical approaches, the results of this study might spark interest for future research aimed at superior result – both on the surgical and the psychological level.

   Materials and Methods Top

Ninety patients of both sexes treated at the Department of Maxillofacial Surgery (Dental Clinic, Nis, Serbia) and the Clinic for Otorhinolaryngology and Maxillofacial Surgery (Clinical Centre of Montenegro, Podgorica, Montenegro) were analyzed. The age range was 18–65 years. Patients with mandibular, zygomatic, and maxillary fractures were included in the study. Exclusion criteria were diagnosed malignant disease, dementia, and other psychiatric disorders, as well as previous surgery for facial fracture. The diagnosis of facial fracture was based on anamnestic data, computerized tomography, and orthopantomography.

The patients were divided into three groups:

  1. The first group consisted of 30 patients treated with transcutaneous approach for internal fixation.
  2. The second group consisted of 30 patients treated with transmucosal approach for internal fixation. The first and the second groups showed a complete bone fracture with facial dislocation.
  3. The third (control) group) consisting of 30 patients treated conservatively for incomplete or complete facial fractures without dislocation.

The treatment type was chosen based on the clinical and radiological criteria (the degree of dislocation, diplopia, deformity, the presence of a comminuted fracture, and the absence of teeth). The quality of life was assessed using Oral Health Impact Profile (OHIP) questionnaire, measuring the perception of the influence of oral health on the social sphere and the overall quality of life.[17] It was designed by Adulyanon and Sheiham, with the original version consisting of 49 questions (OHIP-49), and an abbreviated version with 14 questions (OHIP-14). The questionnaire addresses oral functioning (basic functions such as chewing, speaking, pain, food choice), psychological response, and social consequences. The score for each answer ranges from 0 to 4, depending on the extent to which a patient estimates the degree of disability.[18] Informed consent was signed by all the patients included in the study. The research was conducted in accordance with the Declaration of Helsinki in 1975 as revised in 2000.

The standard protocol for descriptive statistics was used, as well as χ2 test for categorical data with a confidence interval of 95%. A P value below 0.05 was considered statistically significant. The results are laid out in tables.

   Results Top

The sample consisted of 76 (84.4%) men and 14 (15.6%) women. [Table 1] shows the numerical values and the percentage distribution of patients by age for all the three groups. In the first group, a majority of patients were in the third decade of life (13 patients, 46.7%), followed by the fourth decade (8 patients, 26.7%). In the second group, a majority of the patients were in the fourth decade (12 patients, 40%), followed by 11 patients in the third decade (36.7%). In the control group, a majority of the patients were in the third decade (12 patients, 40%), followed by the fourth decade (10 patients, 33.4%). The age structure among the groups tested did not differ significantly.
Table 1: Age distribution among the examined groups

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[Table 2] contains the responses to the OHIP-14 questionnaire. A statistically significant difference was found in the answers to the question regarding severe pain (χ2 = 32.605; P < 0.001) between the groups. A significantly higher number of patients undergoing conservative treatment (χ2 = 29.243; P < 0.001) and transmucosal treatment (χ2 = 7.233; P < 0.001) answered “not at all” compared with patients with transcutaneous access. The “often” response is significantly more prevalent in patients with transcutaneous surgery versus conservative treatment (χ2 = 6.405; P = 0.011).
Table 2: OHIP-14 questionnaire on the quality of life

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For the question regarding discomfort while eating certain foods, there was a significant difference in the answers given by the three groups (χ2 = 34,041; P < 0.001). A significant number of patients in the control group answered “not at all” in comparison to patients who underwent transcutaneous surgery (χ2 = 21.172; P < 0.001). On the other hand, the patients in the first group responded “rarely” more often than the patients undergoing conservative treatment (χ2 = 21.172; P < 0.001).

The answers to the question regarding general discomfort after the treatment yielded a statistically significant difference between the three groups (χ2 = 34,041; P < 0.001). The first group answered “not at all” significantly more seldom than the second (χ2 = 9.319; P = 0.002) and the control group (χ2 = 35.605; P < 0.001). Furthermore, the answer “rarely” was more frequent in the first group in comparison to the second (χ2 = 8.864; P = 0.002) and the third groups (χ2 = 13.548; P < 0.001).

A majority of the patients undergoing conservative treatment did not change their diet after the fracture – significantly more than the first (χ2 = 28.708; P < 0.001) and the second groups (χ2 = 9.600; P = 0.001). The patients from the first group answered “rarely” to this question more frequently than the patients in the control group (χ2 = 18.467; P < 0.001). Also, the question addressing meal stopping showed the first group answering “rarely” more often than the control group (χ2 = 7.431; P = 0.006).

The control group dominantly stated that they do not have problems relaxing after the injury. This answer was more common in this group in comparison to patients who underwent transcutaneous surgery (χ2 = 10.416; P = 0.001) and transmucosal approach (χ2 = 10.416; P = 0.001). A similar conclusion was reached when analyzing the answers to the question regarding the embarrassment after the injury, with the control group giving the answer “not at all” more commonly than the first (χ2 = 10.416; P < 0.001) and the second groups (χ2 = 20.000; P = 0.006).

   Discussion Top

The age structure of the patients included in the study showed that nearly three-quarters of the injured individuals were in the third and the fourth decades of life. The gender structure showed a predominance of male sex (with the male: female ratio being 5.4:1). These results are in accordance with a majority of the literature data on the epidemiology of facial fractures.[1],[6],[10]

The group of patients who underwent transcutaneous surgery was recognized as the most prominent regarding severe pain. Posttraumatic pain arises from the presence of edema, trismus, and tissue damage.[6] The extent of surgical trauma delivered to the skin and the subcutaneous soft tissue through the skin incision increases the inflammatory response, leading to an increased amount of pain. The findings of this study indicate that the patients from the first group are more susceptible to general discomfort than the other two groups – a result that is in accordance with the greater amount of pain and dietary changes in this group, given the fact that the onset of pain significantly reduces the quality of life of patients with a facial fracture.[7],[12] From a sample of 42 patients with injuries to the lower face, Lewandowski et al. showed that the immediate posttraumatic period was characterized by a high prevalence of complaints such as pain and dissatisfaction due to food consumption issues (changes in diet and difficulties in chewing or swallowing).[11] A similar conclusion was reached by Omejje et al., who showed that the nutrition-related issues are the most frequent problems during the early recovery period after mandibular fracture surgery.[16] The study on the health-related quality of life in patients with zygomatic fractures conducted by Kaukola et al. showed that the sensory complications related to the bone fracture may also significantly influence the quality of life.[12]

After the injury, the presence of edema, hematoma, and wound sutures may induce speech impediment.[2] There were no significant differences regarding eventual posttraumatic (or posttreatment) speech or taste changes across the three groups. However, a significantly larger number of patients who underwent transcutaneous surgery reported a higher incidence ofanxiety, embarrassment, and difficulty to relax related to the injury. Despite the lack of statistical significance, a slightly higher prevalence of general dissatisfaction with life was also seen in the first group. These results indicate that the problems associated with the transcutaneous approach affect the overall quality of life. Tebble et al. showed that facial scar size is significantly related to self-consciousness and anxiety levels in patients suffering even minor facial lacerations.[19] The results published by Snell et al. indicate that the patients who suffered complex maxillofacial fracture exhibit personality changes and lack of ability to socialize. These changes influenced the lives of 50% of the patients' relatives, while only 30% of the patients realized that their relatives' lives were changed.[13] From a sample of 50 patients suffering from maxillofacial trauma, Gandjalikhan-Nassab et al. reported an eight-fold increase in the risk of depression and a two-fold increase in the risk of anxiety in this group of patients compared with the control group.[20] The authors of these studies unanimously conclude that it is necessary to provide psychological support to the patients suffering from facial trauma because of the proven risk of psychiatric morbidity and social dysfunction.

Our study has several limitations. The sample was relatively small. Furthermore, the type of injury and surgery, the length of hospital stay, and patient comorbidities were not analyzed. These variables should be taken into account in a repeated, possibly follow-up larger-scale study with matched controls and psychometric testing to illustrate the extent of the described differences in the oral health–related quality of life.

The results of this study show that certain aspects of life in facial fracture patients are affected differently by various treatment methods. Even though the therapeutical decision depends mainly on the type of the fracture and patient characteristics, these differences should inspire the clinicians to provide emotional support to the patient. There is not yet enough published evidence on the impact of different therapeutic strategies on the psychological outcome. The knowledge of psychological consequences which may ensue after certain therapeutic methods provides fertile ground for preventive intervention. Despite the fact that there is no ideal instrument for examining the quality of life of the patients undergoing treatment for facial fractures, it is necessary to analyze the psychological burden of every individual patient. Adequate communication between the surgeon and the patient is absolutely crucial to achieve a satisfying outcome – both medically and emotionally.

   Conclusion Top

The group of patients who underwent transcutaneous surgery in the treatment of facial fracture had a higher incidence of severe pain and discomfort, an increased need for dietary changes, as well as anxiety, embarrassment, and overall dissatisfaction levels. These results indicate that there is a need for psychological intervention in injured patients undergoing surgery for facial fractures. Furthermore, future studies on this subject should provide additional evidence which may prove useful in providing emotional support to the patients suffering from facial trauma.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Ologunde R, Mc Leod NMH. Use of patient-reported outcome measures in oral and maxillofacial trauma surgery: A review. Br J Oral Maxillofac Surg 2018;56:371-9.  Back to cited text no. 1
De Sousa A. Psychological issues in oral and maxillofacial reconstructive surgery. Br J Oral Maxillofac Surg 2008;46:661-4.  Back to cited text no. 2
Auerbach SM, Laskin DM, Kiesler DJ, Wilson M, Rajab B, Campbell TA. Psychological factors associated with response to maxillofacial injury and its treatment. J Oral Maxillofac Surg 2008;66:755-61.  Back to cited text no. 3
Hermes D, Matthes M, Saka B. Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-centre trial. J Craniomaxillofac Surg 2007;35:316-21.  Back to cited text no. 4
Samieirad S, TohidiE, Shahidi-Payam A, Hashemipour MA, Abedini A. Retrospective study maxillofacial fractures epidemiology and treatment plans in Southeast of Iran. Med Oral Patol Oral Cir Bucal 2015;20:e729-36.  Back to cited text no. 5
Conforte JJ, Alves CP, Sanchez M del PR, Ponzoni D. Impact of trauma and surgical treatment on the quality of life of patients with facial fractures. Int J Oral Maxillofac Surg 2016;45:575-81.  Back to cited text no. 6
Gironda MW, Der-Martirosian C, Belin TR, Black EE, Atchison KA. Predictors of depressive symptoms following mandibular fracture repair. J Oral Maxillofac Surg 2009;67:328-34.  Back to cited text no. 7
De Silva MJ, Lee L, Fuhr DC, Rathod S, Chisholm D, Schellenberg J, et al. Estimating the coverage of mental health programmes: A systematic review. Int J Epidemiol 2014;43:341-53.  Back to cited text no. 8
Glynn SM, Shetty V. The long-term psychological sequelae of orofacial injury. Oral Maxillofac Surg Clin North Am 2010;22:217-24.  Back to cited text no. 9
Beogo R, Dakoure P, Savadogo LB, Coulibaly AT, Ouoba K. Associated injuries in patients with facial fractures: A review of 604 patients. Pan Afr Med J 2013;16:119.  Back to cited text no. 10
Lewandowski B, Szeliga E, Czenczek-Lewandowska E, Ozga D, Kontek A, Migut M, et al. Comparison of oral-health-related quality of life in patients in the short- and long-term period following lower-facial injury and fractures – Preliminary report. Dent Med Probl 2018;55:57-62.  Back to cited text no. 11
Kaukola L, Snäll J, Roine R, Sintonen H, Thorén H. Health-related quality of life of patients with zygomatic fracture. Med Oral Patol Oral Cir Bucal 2017;22:e636-42.  Back to cited text no. 12
Snell BJ, Roberts RM, Anderson P, David DJ. Neuropsychologic outcomes in patients treated for complex maxillofacial trauma. J Craniofac Surg 2014;25:1164-7.  Back to cited text no. 13
Islam S, Ahmed M, Walton GM, Dinan TG, Hoffman GR. The prevalence of psychological distress in a sample of facial trauma victims. A comparative cross-sectional study between UK and Australia. J Craniomaxillofac Surg 2012;40:82-5.  Back to cited text no. 14
Kaukola L, Snall J, Lindqvist C, Roine R, Sintonen H, Tornwall J, et al. Health-related quality of life after surgical treatment of mandibular fracture. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:402-7.  Back to cited text no. 15
Omeje KU, Adebola AR, Efunkoya AA, Osunde OD, Bamgbose BO, Akhiwu BI, et al. Prospective study of the quality of life after treatment of mandibular fractures. Br J Oral Maxillofac Surg 2015;53:342-6.  Back to cited text no. 16
Stančić I, Tišanček Šojić Lj, Jelenković A. Adaptation of oral health impact profile (OHIP-14) index for measuring impact of oral health on quality of life in elderly to Serbian language. Vojnosanit Pregl 2009;66:511-5.  Back to cited text no. 17
Rustemeyer J, Gregersen J. Quality of life in orthognathic surgery patients: Post-surgical improvements in aesthetics and self-confidence. J Craniomaxillofac Surg2012;40:400-4.  Back to cited text no. 18
Tebble NJ, Thomas DW, Price P. Anxiety and self-consciousness in patients with minor facial lacerations. J Adv Nurs 2004;47:417-26.  Back to cited text no. 19
Gandjalikhan-Nassab SA, Samieirad S, Vakil-Zadeh M, Habib-Aghahi R, Alsadat-Hashemipour M. Depression and anxiety disorders in a sample of facial trauma: A study from Iran. Med Oral Patol Oral Cir Bucal 2016;21:e477-82.  Back to cited text no. 20


  [Table 1], [Table 2]

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