David Locker

Background: In Canada, national health surveys do not usually include questions pertaining to self-perceived oral health. Those that do use ad hoc sets of questions rather than standardized and validated measures of the functional and psychosocial impacts of oral disorders. Aims: To collect national data on the impacts of oral disorders from a representative sample of Canadian adults and to compare the results with similar national surveys conducted in the United Kingdom and Australia. Methods: Data were collected from adults by means of a telephone interview survey based on random-digit dialing. Oral health was measured with the short-form Oral Health Impact Profile (also known as the OHIP-14 questionnaire), which asks about the frequency of 14 functional and psychosocial impacts that people have experienced in the previous year as a result of problems with their teeth, mouth or dentures. Results: Of 3,033 interviews conducted, data were sufficient for analysis for 3,019 respondents. Just under one-fifth of the 3,019 respondents (19.5%) reported 1 or more of the 14 impacts "fairly often" or "very often" in the previous year. The prevalence was higher among edentulous respondents (30.7%) than among dentate respondents (18.6%), as were the extent and severity scores. The prevalence of impacts was lowest in Atlantic Canada (16.1%) and highest in the Prairies (23.3%), although the difference was not statistically significant. Prevalence rates and extent and severity scores were highest among those who wore dentures, recipients of public dental care and irregular dental visitors. Considerable income disparities were also observed, with 34.9% of those from the lowest-income households reporting impacts. The prevalence of effects and the extent and severity scores in Canada were similar to those reported from the United Kingdom and Australia. Conclusions: One in 5 Canadian adults experienced adverse impacts from oral disorders. Further work is needed to identify the material and psychological determinants of these impacts.

Objectives: This study aimed to investigate the referents and meanings that underlie self‐ratings of oral health and to determine whether they vary by participants' characteristics. Methods: Semistructured interviews were conducted with a convenience sample of 80 adults who were asked to rate their oral health and explain the reasons for their ratings. The interviews were tape‐recorded, transcribed in full, and subject to a content analysis that involved identification and coding of their frames of reference. These codes were collapsed to create a smaller number of categories to allow for comparisons of the proportions invoking each frame of reference. Results: There was considerable variation in the accounts offered to support the self‐ratings of oral health. The most common referents used were biomedical, involving current oral problems, treatment needs and treatment histories, and behavioral, which included oral self‐care practices, other health behaviors, and dental visiting patterns. Pain and tooth loss were also common. Most notable was the absence of functional and psychosocial referents that are prominent in contemporary definitions and measures of “oral‐health‐related quality of life.” There was some variation in the referents used according to sociodemographic characteristics, with age being the main source of variation. There was also variation according to the category of the self‐rating used; those with favorable ratings tended to use different frames of reference than those with unfavorable ratings. Conclusions: The biomedical model and professional ideologies and values provide the main frames of reference that give meaning to self‐ratings of oral health. Variations in the meanings of the self‐ratings have some implications for the use of this item in quantitative studies, which warrants further investigation.

To determine the influence of accessibility of dental services and other factors on the development of early childhood caries (ECC) among Toronto children 48 months of age or younger with at least one Portuguese-speaking immigrant parent. This population-based case-control study involved 52 ECC cases and 52 controls (i.e., without ECC) identified from community centres, churches and drop-in centres by a process of network sampling. Caries status (dmft/s) was assessed by clinical examination. Access to dental care and risk factors for ECC were determined through a structured interview with the Portuguese-speaking parent. Forty (77%) of the children with ECC but only 28 (54%) of controls had never visited a dentist. Thirty (58%) mothers of children with ECC but only 13 (25%) mothers of controls had not visited a dentist in the previous year. Bivariate analyses revealed that low family income, no family dentist, no dental insurance, breastfeeding, increased frequency of daily snacks and low parental knowledge about harmful child feeding habits were associated with ECC. Non-European-born parents and parents who had immigrated in their 20s or at an older age were 2 to 4 times more likely to have a child with ECC than European parents and those who had immigrated at a younger age. Lack of insurance, no family dentist and frequency of snacks were factors remaining in the final logistic regression model for ECC. The strongest predictors of ECC in this immigrant population, after adjustment for frequent snack consumption, were lack of dental care and lack of dental insurance. These findings support targeting resources to the prevention of ECC in children of new immigrants, who appear to experience barriers to accessing private dental care and who are exposed to many of the determinants of oral disease.

Objective.  The aim of this study was to assess the validity of single‐item parental ratings of child oral heath.Methods.  Data were collected during a study to assess the impacts of dental injury. Clinical examinations of children aged 11–14 years were undertaken that included measures of trauma, decay, treatment needs, and fluorosis. Children with trauma and a group of trauma‐free children were followed‐up. Parents were mailed a questionnaire along with a questionnaire for the child that contained a short form of the Child Perceptions Questionnaire 11–14 (CPQ11–14). Bivariate analyses examined associations between parents’ ratings of their child's oral health, measures of dental disease, clinically defined treatment needs, and scores on the CPQ11–14. Logistic regression was used to see if the associations observed remained after controlling for access to dental care variables.Results.  Complete data were collected from 370 children and their parents. Parental ratings showed significant associations with most of the clinical indicators used and CPQ11–14 scores. Similar results were obtained when the data were analysed for subgroups defined by household income and mother's education. These associations remained after controlling for access to dental services.Conclusion.  The data suggest that single‐item parental ratings of child oral health have adequate construct validity.

The terms ‘health‐related quality of life’ and ‘quality of life’ are now in common use to describe the outcomes of oral health conditions and therapy for those conditions. In addition, there has been a proliferation of measures designed to quantify those outcomes. These measures, which were initially designated as socio‐dental indicators or subjective oral health indicators are now more usually referred to as measures of oral health‐related quality of life (OH‐QoL). This is based on the assumption that the functional and psychosocial impacts they document must, of necessity, affect the quality of life. While this assumption has been subject to critical scrutiny in medicine, this is not the case with dentistry. Consequently, exactly what is being measured by indexes of OH‐QoL is somewhat unclear. Based on the debate between Gill and Feinstein and Guyatt and Cook, we outline a number of criteria by means of which the construct addressed by measures of OH‐QoL may be assessed. These are concerned with how the measures were developed and validated. These criteria are then used to appraise five of the many measures that have been developed over the past 20 years – the GOHAI, OHIP, OIDP, COHQoL and OH‐QoL. The main conclusion is that while all document the frequency of the functional and psychosocial impacts that emanate from oral disorders they do not unequivocally establish the meaning and significance of those impacts. Consequently, the claim that oral disorders affect the quality of life has yet to be clearly demonstrated. Verifying this claim requires further qualitative studies of the outcomes of oral disorders as perceived by patients and persons, and the concurrent use of measures that more explicitly address the issue of quality of life.

To investigate the frequency of use of mouthguards among a representative sample of Ontario schoolchildren, the type of mouthguard most commonly used and reasons for noncompliance during sporting activities. A population-based, matched case-control study was undertaken in a total of 30 schools in 2 suburban Ontario communities. Dental hygienists trained in the use of the Dental Trauma Index screened 2,422 children 12 to 14 years of age. Of 810 children identified as potential cases (with evidence of dental trauma) and controls (no dental trauma), 270 responded to a mail survey (135 cases and 135 age- and sex-matched controls). The children with dental injuries provided information such as the age at which the injury occurred and the setting and causes of the injury. Children from both case and control groups answered questions concerning use of mouthguards during sports. Parents provided demographic and other information. Only 5.5% of children wore mouthguards for school sports, and 20.2% wore protection in league sports. Of those who wore mouth protection, 48.2% wore boil-and-bite mouthguards and 21.4% wore stock-type mouthguards; only 30.4% wore professionally made, custom mouthguards. This high proportion of ill-fitting mouthguards was the major contributor to the commonly perceived problems of speech, breathing discomfort and poor appearance associated with mouthguard use. Boys were 1.52 times more likely to wear mouthguards than girls. Data on history of dental trauma and regularly visiting a dentist were not related to mouthguard use. The single most important predictor of mouthguard use was parents who had private dental insurance (p = 0.02), followed by having a family dentist (p = 0.16). Mouthguard use was very low in both school and league sports in this sample of Ontario schoolchildren, and the largest proportion of those who wore mouth protection used generic products rather than custom-fitted mouthguards. Lack of parental or coaching advice on mouthguard usage and peer beliefs about esthetics and function were the main reasons for noncompliance.

Abstract –  Few population‐based studies of traumatic dental injury in adults have been undertaken. The objective of this study was to assess the prevalence and severity of injuries to the mouth and teeth among adults aged 18–50 years living in the Canadian province of Ontario. A telephone survey was undertaken based on random digit dialling and 2001 adults in the target age range were interviewed. Overall, 15.5% reported a history of injury to the mouth and teeth. Of these, one‐third reported two or more episodes of injury. Males were more likely than females to report injury and to have experienced more than one injury. There was no association with age but a U‐shaped relationship with education. When asked about the nature of the worst injury experienced, 85% with a history of trauma reported damage to the teeth and of these, 38.5% reported one or more teeth were chipped and 26.0% broke one or more teeth. One quarter (25.4%) reported avulsions and 6.5% reported luxations. Other types of injury were reported by 3.5%. Two‐thirds of the injuries reported occurred before the age of 18 years and one‐third after this age. One‐fifth of those with tooth injuries had not been treated by a health professional. This was not associated with the nature of the damage that occurred; rather subjects from the lower educational groups were less likely than those from higher educational groups to have received treatment. There was a significant association between injuries to the mouth and teeth and injuries in other body locations. One‐third of those reporting two or more episodes of the latter reported having experienced injuries to the mouth and teeth. The results of this self‐report study indicate that dental trauma constitutes a significant health issue among adults and that a minority may be injury prone. Health promotion programmes to reduce the incidence of injury among lower socioeconomic groups are needed since these have high rates of injury and the lowest rate of receipt of treatment.

Abstract –  Objectives:  To assess socioeconomic disparities in the oral health‐related quality of life in a group of Canadian children.Methods:  Data were obtained as part of a study designed to assess the functional and psychosocial impact of traumatic dental injury. Clinical data were collected on a random sample of children during a school‐based dental screening program that included measures of dental decay experience, treatment needs, dental trauma, fluorosis, and malocclusion. Children with dental trauma and a comparison group of trauma‐free children were selected for follow‐up. Their parents were mailed a questionnaire concerning the child's personal and family characteristics. Also enclosed was a questionnaire for the child that contained a short form of the Child Perceptions Questionnaire (CPQ) 11–14. Bivariate and multivariate analyses were undertaken to determine whether there were disparities in oral health‐related quality of life according to household income.Results:  Complete data were collected from 370 children. Mean CPQ11–14 scores showed a gradient across income categories with children from low income households having poorer oral health‐related quality of life. Children from households containing only one adult also had higher scores than children living with two or more adults. In both linear and logistic regression analyses household income and family structure remained significant predictors of CPQ11–14 scores after controlling for oral disease variables. Further analyses suggested that oral disorders had little impact on the health‐related quality of life of higher income children but a marked impact on lower income children. The highest mean CPQ11–14 scores were observed among low income children with the more severe levels of oral disease.Conclusion:  The data indicate that in this group of children there were socioeconomic disparities in oral health‐related quality of life. A potential explanation may be differences in psychological assets and psychosocial resources.

– Objectives: In order to minimize acquiescence response set bias, it is often recommended that questionnaires measuring attitudes, behaviours or health states contain items worded positively and negatively. It has also been suggested that when measuring health status this approach means that both the negative and positive dimensions of health can be assessed. This study aimed at assessing the performance of negatively and positively worded items in questionnaires to measure child and parent perceptions of child oral health-related quality of life. Methods: Both the child and parent questionnaire included four pairs of items, one negatively worded and one positively worded, that assessed eating, appearance, oral self-care and self-confidence. The response format was a five-point Likert frequency scale with a ‘Don't know’ option. Prior to analysis, the positive items were reverse coded. The relative performance of the two sets of items was assessed by means of comparisons of the proportions with ‘Don't know’ responses or missing values, mean item scores and proportions with the two highest frequency codes. Kappa statistics and intraclass correlation coefficients were used to assess the agreement between the negative and reverse-coded positive items and scores and the agreement between child and parent pairs. Factor analysis was used to determine if the two sets of items were measuring the same underlying construct. Results: The study was completed by 91 Canadian children and 100 parents (91 child–parent pairs) recruited from clinics treating paediatric, orthodontic and oro-facial conditions. The positively worded items elicited substantially more ‘Don't know’ responses or missing values than the negatively worded items and failed to discriminate between groups. In addition, mean item scores and proportions with the highest frequency codes were substantially larger for reverse-coded positive than negative items. Agreement between pairs of items was slight. Child–parent agreement was substantial for a scale constructed from the negative items but only moderate for the positive items. Factor analysis revealed that the two sets of items loaded onto different factors. Conclusions: The performance of the positively worded items was unsatisfactory and their use in oral health-related quality of life indexes, either to reduce response set or assess positive oral health, is at best questionable.

Abstract –  Objectives:  To assess the association between scores on the Child Perceptions Questionnaire for 11–14 year olds (CPQ11–14) and clinical and self‐perceived measures of malocclusion.Methods:  Children were recruited from an orthodontic clinic just prior to starting orthodontic treatment. They completed a copy of the CPQ11–14 and a short questionnaire concerning their feelings about the condition of their teeth. Study models were taken and rated according to the Dental Aesthetic Index (DAI) and the Peer Assessment Rating (PAR) index by two sets of three examiners. Intra and inter‐rater reliabilities for the two sets of examiners ranged from 0.80 to 0.99. CPQ11–14 scores were calculated for the full 35‐item version and for 16 and 8‐item short forms by summing the item response codes. The association between these scores, the DAI and PAR ratings and self‐perceived measures of malocclusion were examined using appropriate parametric and nonparametric tests.Results:  Complete data were collected for 141 children, 63 boys and 78 girls. The mean age was 12.5 (SD = 1.0). DAI scores ranged from 17.0 to 58.0 with a mean of 35.0 (SD = 8.0). The distribution of subjects across the four severity categories was minor/none – 6.6%, definite – 35.2%, severe – 15.6% and handicapping 42.6%. PAR scores ranged from 8.0 to 66.0 with a mean of 31.4 (SD = 11.1). Eight percent had scores of 50 or above indicating marked deviation from an ideal occlusion. Both the long and the short forms of the CPQ11–14 identified substantial variability in the impacts of malocclusion. Correlations between CPQ11–14 scores and the orthodontic indices ranged from 0.26 to 0.31 (P < 0.01). There was a clear gradient in CPQ11–14 scores across four categories of the PAR based on quartiles. The gradient across the DAI categories was less clear. There were significant associations between all CPQ11–14 scores and the children's self‐ratings of oral health, ratings of the extent to which the condition of the teeth affected life overall and expressions of happiness with the appearance and arrangement of the teeth.Conclusion:  The results provide some evidence of the validity of the CPQ11–14 when used with children needing orthodontic treatment. However, because clinical samples are biased the study needs to be repeated in different treatment settings in order to confirm the utility of the measure.