THE IMPACT OF CARIES IN COMBINATION WITH PERIODONTITIS ON ORAL

HEALTH-RELATED QUALITY OF LIFE IN BAHIA, BRAZIL

Johelle de Santana Passos-Soares*†, Lília Paula de Souza Santos*, Simone Seixas da Cruz*‡,

Soraya Castro Trindade*, Eneida de Moraes Marcílio Cerqueira*, Kionna Oliveira Bernardes

Santos§, Izadora da Silva Campodonio Eloy Balinha*, Ivana Conceição Oliveira da Silva*,

Taciane Oliveira Bet Freitas*, Samilly Silva Miranda*, Gregory J Seymour, Isaac Suzart

Gomes-Filho*

Corresponding author: Isaac Suzart Gomes-Filho – Avenida Getúlio Vargas, 379, Centro,

Feira de Santana, Bahia, Brazil. Zip Code: 44025-010. Telephone number/fax: 55 75 3623-

0661; email: isuzart@gmail.com (fax number and e-mail can be published)

Word count: 3,493

Number of tables: 04

Running title: Oral condition and impact on quality of life.

Summary: The presence of dental caries combined with periodontitis is associated with a

significant negative impact on oral health-related quality of life.

*
Department of Health, Feira de Santana State University, Bahia, Brazil.
†
Department of Preventive Dentistry, Federal University of Bahia, Salvador, Bahia, Brazil.
‡
Department of Epidemiology, Federal University of Recôncavo of Bahia, Santo Antônio de Jesus,

Bahia, Brazil.
§
Department of Epidemiology, Health Sciences Institute, Federal University of Bahia, Bahia, Brazil.

School of Dentistry, The University of Queensland, Brisbane, Australia.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/JPER.18-0047.

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Abstract

Background: Both dental caries and periodontal disease, as isolated conditions, can generate
limitations and disabilities with negative repercussions on the individual's quality of life, but
the combination of both oral diseases has not been investigated yet. This study aimed to
evaluate the association between the combined exposure to dental caries and periodontitis and
the impact on oral health-related quality of life.
Methods: A cross-sectional study was conducted among 306 individuals seen in the public
health services in Feira de Santana, Bahia, Brazil. The individuals were divided into three
groups: individuals without caries and periodontitis (n=60), those with caries or periodontitis
separately (n=155) and those with both caries and periodontitis (n=91). Information regarding
sociodemographic, health conditions, behavioral aspects and health-care characteristics were
obtained through structured questionnaires. Oral clinical examination was performed to
evaluate dental caries (decayed, missing and filled teeth DMFT) and periodontal status
including bleeding upon probing, visible plaque index, probing depth and clinical attachment
level. The impact of oral health on quality of life was measured using the Brazilian version of
the Oral Health Impact Profile (OHIP-14).
Results: In terms of the OHIP-14, the mean±SD and median of the severity scores were
11.07±9.45 and 9, respectively, and mean±SD of the extension score: 1.78±2.27. The
adjusted association measurement showed that in individuals exposed simultaneously to
caries and periodontitis, the occurrence of the impact on quality of life was 63% greater than
among those without these diseases.
Conclusions: The results suggest that the combined occurrence of dental caries and
periodontitis is associated with a significant impact on oral health-related quality of life when
compared with absence of these oral diseases.

Keywords: quality of life; periodontitis; dental caries; oral health; epidemiology.

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Introduction

Dental caries and periodontal disease have varying prevalence rates in Brazil

compared, for example, with the United States of America1,2. In developing countries such as

Brazil, the decline of caries has not been as evident as in the developed countries of Western

Europe and the United States2,3. The mean DMFT varies between 16.75 and 27.03 among

adults and the elderly, and the percentage of untreated caries in the age group 35-44 years is

8.8% 2.

The variation in the reported prevalence of periodontal disease in different regions is

related not only to population characteristics, but also to the diversity of existing diagnostic

criteria4. In the United States, 46% of the population suffer from some degree of

periodontitis, being higher among the elderly (70%)5. In Brazil, this prevalence was 19.4%

and 3.3% in adults and the elderly, respectively2. The lower prevalence of the disease in the

Brazilian population, especially in the elderly, is a reflection, not only of the diagnostic

criterion adopted, but also of the large proportion of lost teeth, which in some way identifies

the precariousness of oral health in the aging Brazilian population 2.

Both caries and periodontal disease can trigger the loss of teeth and may have pain-

related impacts, limitations and disabilities in various dimensions, as well as implications for

a high demand for health services6-8. Possible limitations and generated disabilities have been

studied and the negative repercussion of these oral diseases on the individual's quality of life

identified8-12, including their psychological profile, social relationships, personal beliefs,

socio-environmental context and level of independence.

Studies that have evaluated the impact of oral conditions on the quality of life show

that not only the presence but also the severity of caries or periodontal disease are associated

with a worse oral health-related quality of life.6, 8, 13-17 The higher the caries experience or the

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severity level of periodontitis, the greater the impact on people's daily lives.16,17. However,

this research has traditionally analysed each disease separately. Assuming that individuals

with coexisting caries lesions and periodontitis can present an amplified oral self-perception,

and thus report the worst quality of life scores, the objective of this study was to evaluate the

impact of dental caries and periodontitis and their combined association with oral health-

related quality of life.

Materials and Methods

Study design and participants

A cross-sectional study was conducted in individuals attending public health services

in Feira de Santana-Bahia, Brazil, from December 2015 to February 2016. In order to

determine the impact of the oral condition on the oral health-related quality of life 306

individuals were divided into three groups: individuals without caries and without

periodontitis (n = 60), those with caries or periodontitis (n = 155) and those with both caries

and periodontitis (n = 91).

This study was approved by the Research Ethics Committee of the State University of

Feira de Santana, Bahia, Brazil (Register Number: 47927115.8.0000.0053). All participants

signed an informed consent for inclusion in this study.

Inclusion and exclusion criteria

Inclusion criteria consisted of individuals 18 years of age or older and who were able

to understand and answer the questionnarie. Pregnant individuals or those who had

undergone periodontal treatment in the last three months prior to the survey were excluded.

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Sample size

The sample size calculation was performed to detect differences in means, since the

outcome was obtained by the sum of the scores and it was presented in its continuous form.

The mean difference in the severity of the impact was obtained from the average of each

group: moderate periodontitis group equal to 12.55 (± 7.35 standard deviation - SD) and

without periodontitis group equal to 9.53 (± 7.12 SD)13. Considering 5% error and study

power of 80%, the minimum size of 182 individuals was determined, being 91 individuals for

each group.

Data collection

A structured interview was used to obtain socioeconomic and demographic data of the

participants, as well as information related to health conditions, life habits, oral care and use

of health services.

The main outcome of this study was measured by the OHIP-14, a validated Brazilian

version containing 14 items18, aggregated in seven dimensions: functional limitation, physical

pain, psychological discomfort, physical incapacity, psychological incapacity, social

incapacity and social disadvantage19. Each dimension is composed of two questions, each one

being classified on a Likert scale of 5 levels20: 4 (always), 3 (constantly), 2 (sometimes), 1

(rarely) and 0 (never). The final scores range from 0 to 56 points, with higher scores

representing greater impact on quality of life. This instrument was reapplied in 10% of the

individuals interviewed within a time interval of one week to evaluate its reliability, obtaining

a high general coefficient (α = 0.84).

After the interview, evaluation of the oral condition was performed by a dentist who

had been previously trained. All the teeth present were examined, using a Williams

periodontal probe (Hu-Friedy, Chicago, USA), and the following data recorded: number of

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decayed, lost and restored teeth, probing depth and recession measurements21, clinical

attachment level, visible plaque index and bleeding upon probing22. Periodontal

measurements were made at six sites per tooth (mesial buccal, mid- buccal, distobuccal,

distolingual, med-lingual and mesial lingual) of all teeth, except third molars.

Probing depth was recorded as the distance between the gingival margin and the most

apical depth of the pocket17. Recession measurement was defined as the distance between the

gingival margin and the cemento-enamel junction21. Clinical attachment level was defined as

the distance from the cemento-enamel junction to the base of the pocket21. Bleeding upon

probing, as the presence or absence of bleeding following removal of the probe during the

probing depth measurment22. The visible plaque index was defined by the presence of visible

biofilm deposits on the tooth surface, using the periodontal probe, at four sites per tooth:

buccal, lingual, mesial and distal22.

The reproducibility and agreement of clinical measures were calculated by index

kappa23 e intraclass correlation coefficients (ICC)24 A total of 10% of participants were

clinically reevaluated by two examiners (examiner 01 - principal, and examiner 02 -

specialist). Examiner 01 did the initial clinical measurements and one week later repeated

these measurements (intra-examiner evaluation) as recommended by the World Health

Organization25. Examiner 02 also performed these clinical measurements, which were then

compared with those of examiner 01 (inter-examiner assessment). The intraclass correlation

coefficients for recession and probing depth were, respectively, 0.71 (95%CI: 0.25-0.91, p =

0.004) and 0.91 (95%CI: 0.73-0.97, p <0.001), indicating a degree of concordance between

satisfactory and excellent. The Kappa test indicated a value of 0.84 for evaluation of caries,

suggesting a high degree of agreement. The stability and internal consistency of OHIP-14

were evaluated and presented a high coefficient (α = 0.84).

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Diagnosis of exposure - dental caries and periodontitis

The diagnosis of dental caries used the DMFT Index (decayed, missing and filled

teeth) 26. The participant was classified as having caries when they had at least one tooth with

a carious lesion.

The presence of periodontitis, was defined as at least four teeth with one or more sites

with probing depth greater than or equal to 4 mm, clinical attachment loss greater than or

equal to 3 mm in the same site and the presence of bleeding upon probing also at the same

site27,28.

Determination of outcome - Impact of oral condition on quality of life

The influence of the presence of caries and/or periodontal condition on participants’

oral health-related quality of life was evaluated by OHIP-14. The response patterns for the 7

domains of the above questionnaire were dichotomized for the purposes of analysis: with

impact (consistently l way) and no impact (never/rarely/sometimes). The prevalence, extent

and severity of the impact were established according to the system proposed by Slade et

al.29.

Prevalence was obtained based on the percentage of individuals who answered one or

more items with "constantly" or "always". Regarding the extent of the impact, the sum of the

number of items with impact was made, varying from 0 to 14, taking into consideration the

questions answered with following options "constantly" or "always". The severity

corresponded to the sum of all scores, ranging from 0 to 56.

Data Analysis

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 Descriptive analysis was performed with exposure variables (dental caries and

periodontitis), the outcome variable (impact of the oral condition on quality of life) and all

covariables evaluated. Simple frequency and central tendency measurements were obtained.

Bivariate analysis was performed using the chi-square or Fisher test for categorical variables

and Student's t-test for continuous variables to compare the proportions and means of the

covariables analyzed for the exposed and non-exposed groups, with a significance level of

5%. The cut-off points used to categorize the covariables were established according to their

distribution in the sample or in recognition of previous studies on the topic.

Stratified analysis was used to detect potential effect modifiers and confounders

among the covariables investigated. This identification was confirmed by Poisson regression

analysis with robust variance. The presence of effect modifiers was investigated using the

maximum likelihood ratio test (p <0.05), by comparing the models with and without the

product terms. For those covariables in which the presence of effect modification was not

identified, the role of the confounding covariables was evaluated by backward strategy, after

which the covariable produced a relative difference of 10% in the association measurement in

relation to the saturated model.

The association measurements between the two exposure groups (Exposed 1- caries or

periodontitis, Exposed 2 - caries combined with periodontitis) and impact on quality of life

were obtained by the Prevalence Ratio (PR) and their respective 95% confidence intervals,

both crude and adjusted. Certain covariables were maintained in the adjusted final model due

to the knowledge of their important epidemiological role in both the main exposure variable

and the outcome variable, despite the fact that statistical analysis did not identify any

confounders.

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 The Hosmer-Lemeshow test was used to verify the goodness of fit of the adjustments

of the logistic regression models obtained. Data analysis was performed using the statistical

software SPSS, version 21 (SPSS Inc., Chicago, IL, USA) and STATA Software v.12.0.

Results

Of the 306 participants involved in the study, 155 individuals with caries or

periodontitis (50.7%) were in exposed group 01, 91 individuals with combined caries and

periodontitis (29.7%) were in exposed group 02 and 60 individuals (19.6%) were not exposed

to either disease. Further, 225 (73.5%) were women and 81 (26.5%) were men, with a mean

age ± standard deviation of 45 years ± 14.8 years, with a minimum of 18 years and a

maximum of 80 years.

Characterization of the study sample is presented in Tables 1 and 2. In general, the

exposed and non-exposed groups are homogeneous for the great majority of demographic,

socioeconomic, general and lifestyle characteristics (Table 1). The proportions of skin color

not white and the presence of smoking habit in the exposed group 02, and number of children

more than three in the exposed group 01 were statistically higher than in the non-exposed

group (p ≤0.05).

The distribution of oral clinical covariables (Table 2) was statistically significantly

different in both exposed group 01 and exposed group 02 with respect to: caries component

(p <0.01), filled/restored component (p = 0.02 / p <0.01), probing depth (p = 0.04 / p <0.01),

bleeding upon probing (p <0.01), visible plaque index (p <0.01) and percentage of teeth with

clinical attachment level ≥ 5 mm (p = 0.02 / p <0.01). With the exception of the

filled/restored component, these clinical parameters were higher in exposed group 02.

In exposed group 02 there was also a statistically significant difference for the

covariables clinical attachment level (p <0.01), percentage of teeth with clinical attachment

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level 1 or 2 mm (p <0.01) and percentage of teeth with clinical attachment level 3 or 4 mm (p

<0.01).

Regarding the scores and dimensions of OHIP-14 (Table 3), the group of

individuals with caries or periodontitis (exposed 01) presented a statistically significant

difference for the psychological incapacity dimension (p = 0.03) and for the severity score ( p

= 0.03). On the other hand, the group of individuals with caries and periodontitis combined

(exposed 02) showed a statistically significant difference for the dimensions of psychological

discomfort (p = 0.03) and psychological incapacity (p = 0.02) and for the extent (p = 0.03)

and severity (p <0.01) scores, with the highest mean of these scores being 2.16 ± 0.27 and

13.15 ± 1.11, respectively.

The crude and adjusted association measurements are presented in Table 4. There was

no association between caries or periodontitis and the impact on quality of life (PRcrude =

1.35, 95%CI: [0.88- 2.07], p = 0.17). However, the crude association between caries and

periodontitis combined and the impact on quality of life (PRcrude = 1.56, 95% CI: 1.01-2.45, p

= 0.05) was statistically significant.

Effect-modifying and confounding covariables were not identified in the statistical

analysis. However, in view of the epidemiological relevance of the following covariables in

the associations under study: age, sex, schooling level and smoking habit were maintained in

both models obtained for adjustment. Only the exposed group 02 maintained statistical

significance (PRadjusted = 1.63, 95%CI [1.03 - 2.59], p = 0.04) after adjustment, with an

increase in the magnitude of the association being observed as caries and periodontitis events

overlap. In contrast, after adjustment, the exposed group 01 lost statistical significance and

did not show an association (PRadjusted = 1.34, 95% CI [0.87 - 2.05], p = 0.19).

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 The Hosmer-Lemeshow statistical test indicated the absence of a significant

difference in the distribution of effective and predicted dependent values, suggesting a good

adjustment of the final regression models. The p value ranged from 0.74 to 0.87.

Discussion

The results of this study showed that the combined occurrence of dental caries and

periodontitis is associated with a negative impact on the oral health-related quality of life.

Previous studies have generally analyzed only one of these oral conditions6,8,13, 15-17, and to

our best knowledge, the present investigation is the first to evaluate the coexisting effect of

caries and periodontitis, as well as employing a control group without either disease.

Caries is an infectious disease that compromises dental structures30 and periodontitis is

a chronic inflammation of the periodontal tissues that can lead to tooth loss when left
31
untreated. They are disorders that usually affect individuals at a young age and also

throughout life and can progress in the absence of adequate dental care and effective control

measurements. 30, 31 The cumulative effect of these life-long disorders and their association

with some systemic diseases, such as cardiovascular diseases, asthma, and diabetes32-25,

further complicates this public health scenario, contributing to an increase in the global

burden of diseases and a reduction of healthy life years.

The hypothesis that the coexistence of oral diseases can potentiate a negative quality

of life perception is confirmed in this study. In addition, individuals with comorbidities,

generally, comprise groups of greater vulnerability and present common socioeconomic

determinants and life habits.

In the present study of individuals from the Bahia region of northern Brazil, the

association was not statistically significant in individuals who presented with only one of the

oral conditions (caries or periodontitis). This is in contrast to investigations in other countries

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and regions that evaluated the impact of these oral conditions on quality of life separately8,13-
17, 36
. In these studies, individuals with severe periodontitis reported a greater negative impact

on quality of life related to oral health8,13, 15, 17. So too with dental caries, in that the greater its

severity, the greater the impact perception14,16,36. Furthermore, in the abovementioned

investigations, the selection process used did not guarantee that the concomitant effect of the

other oral problem under analysis (caries or periodontitis) did not interfere with the

perception of the impact, with the exception of the study carried out on Jordanian adults13.

When the oral clinical parameters were analyzed in detail, statistically significant

differences were observed between the two exposed and the non-exposed groups. Higher

average decayed teeth, probing depths, bleeding upon probing index, clinical attachment

levels and visible plaque index were observed in the group of individuals with combined

caries and periodontitis compared with those that had only one disease.

When analyzing the perception of the impact of these oral clinical conditions on the

OHIP-14, there was a greater impact on the psychological discomfort and psychological

incapacity dimensions, with statistically significant differences, thus corroborating other

studies8,12,13,36,37. Besides the known physical and functional limitations, the results of the

present study also suggest that oral problems have psychological repercussions reflected in

attitudes such as difficulty to relax, embarrassment, stress and preoccupation with one’s oral

situation, all of which can interfere in the field of social relationships. Other investigations

have also shown that the greater the progression of the disease and its oral involvement, the

greater the repercussion in the psychological domain7,12,38. Again, in the present study the

highest means of OHIP-14 extent and severity were observed in the group with the worst oral

conditions (individuals with combined caries and periodontitis). In the group with caries or

periodontitis alone, only the mean scores of OHIP-14 severity were statistically significant,

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showing a clear distinction between individuals exposed to caries and / or periodontitis and

those without these oral problems.

The present study however, has some limitations. Due to the cross-sectional design, it

is not possible to establish the temporal antecedence of the independent variables on the

outcome studied. This type of design is subject to recall bias, since most of the information

obtained from the questionnaires was self-referred. In addition, by involving a non-random

sample within a specific population, it may have its external validity compromised for future

comparisons.

Furthermore, the high values of visible plaque index, caries, and periodontal clinical

parameters seen in the population being investigated in the present study are in accordance

with those seen in the adult Brazilian population39,40 . Hence, a limitation of the current study

is that a sufficient number of individuals with the same socioeconomic demographic

characteristics, life style and health conditions, with no history of caries and periodontitis, i.e.

truely a non-exposed group, were unable to be selected and compared with those with either

disease and with those with both diseases. This limitation means that the non-exposed group

has many individuals with a history of disease, now treated, and they may have some quality

of life issues related to the past history of oral disease that were not able to be considered.

The effect of variations in the diagnosis of both caries and periodontitis, is widely

known in the literature26,28. In this context, the use of specific diagnostic criteria that

minimize misclassification is necessary to avoid possible distortions in the association

mesurements. In the present study, the presence of caries was defined by untreated caries

lesions and not by the dental caries experience, in order to avoid a reduction in the sensitivity

of OHIP-14. In order to minimize false positives, the criterion for diagnosing periodontitis

was chosen due to its robustness and high specificity28, application of a full oral examination,

and use in previous epidemiological studies41,42,. In contrast, many studies employed a

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variety of diagnostic criteria, with partial oral examinations, and the selection of only one

periodontal clinical parameter to detect disease11,12,43,44.

The cutoff point for classifying the greatest impact of OHIP-14 has also varied in the

literature. In the present study, the impact of the oral condition on quality of life was

evaluated for its prevalence, extent and severity in order to increase the validity of the

findings10,14,29,45. On the other hand, the majority of other studies only make use of the mean

scores that do not adequately discriminate the differences.

In addition, the final association measurements were adjusted for age, sex, schooling

level and smoking habits, thus taking into consideration the conceptual framework and the

epidemiological relevance of these covariables in relation to the outcome and the exposures.

Thus the present study on this Brazilian population corroborates the few previous studies on

the topic10,13,38,46,47. The occurrence of periodontitis is higher in older age groups36, whereas

individuals with low income, low schooling level8 and smoking habit38 are more exposed to

both oral health problems. Factors, such as sex, age, family income, schooling level and

smoking habits are also associated with the severity of the impact on quality of life related to

oral health49,50.

Conclusion

Finally, the findings of the present study show that the coexistence of dental caries

and periodontitis is associated with worse oral health-related quality of life scores, when

compared to those without these diseases, especially in the areas of psychological incapacity

and psychological discomfort. Self-perception of the oral condition should be considered in

the clinical follow-up of the individuals, in order to take into account aspects that normative

diagnosis methods cannot capture and, thus, promote an integral approach to health care. In

view of the need for advances in this topic, further studies are required to evaluate both the

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combined and isolated effects of these oral conditions longitudinally, such that both the past

and current level of exposure to caries and periodontal disease can be assessed.

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Table 01 - Number (N) and percentage (%) of demographic, socioeconomic, general/oral
health and life style covariables among non-exposed (without caries and without
periodontitis), exposed 1 (with caries or periodontitis) and exposed 2 (with combined caries
and periodontitis) groups. (n = 306)
With caries OR With combined caries
Characteristics Non-exposed (n=60) periodontitis AND periodontitis
(n=155) (n=91)
n (%) n (%) P* n (%) P*
Sex
Female 48 (29.45) 115 (70.55) 62 (56.36)
Male 12 (23.08) 40 (76.90) 0.37 29 (70.73) 0.11
Age
18 to 45 years 31 (28.70) 77 (71.30) 46 (59.74)
46 to 80 years 29 (27.10) 78 (72.90) 0.79 45 (60.81) 0.89
Skin color*
White 8 (40.00) 12 (60.00) 03 (27.27)
Not White 51 (27.87) 132 (72.13) 0.26 85 (62.50) 0.02
Employment
status†
Paid 30 (34.09) 58 (65.91) 37 (55.22)
Unpaid 27 (24.11) 85 (75.89) 0.12 45 (62.50) 0.38
Schooling level †
> 4 years of study 45 (30.82) 101 (69.18) 60 (57.14)
≤ 4 years of study 15 (21.74) 54 (78.26) 0.17 31 (67.39) 0.24
Marital status†
With partner 32 (34.02) 62 (65.96) 39 (54.93)
Without partner 28 (23.93) 89 (76.07) 0.11 50 (64.10) 0.25
Family income -
monthly‡
(minimum wage)
≥1 49 (31.82) 105 (68.18) 70 (58.82)
<1 11 (20.00) 44 (80.00) 0.10 18 (62.07) 0.75
Household density
< 4 people 35 (31.53) 76 (68.47) 46 (56.79)
≥ 4 people 25 (24.04) 79 (75.96) 0.22 45 (64.29) 0.35
Number of
children†

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≤3 50 (33.11) 101 (66.89) 71 (58.68)
>3 09 (16.67) 45 (83.33) 0.02 16 (64.00) 0.62
Hypertension
No 30 (25.86) 86 (74.14) 42 (58.83)
Yes 30 (30.30) 69 (69.70) 0.46 49 (62.03) 0.64
Diabetes
No 44 (27.50) 116 (72.50) 61 (58.10)
Yes 16 (29.09) 39 (70.91) 0.82 30 (65.22) 0.41
Cardiovascular
disease†
No 56 (27.45) 148 (72.55) 88 (61.11)
Yes 04 (36.36) 07 (63.64) 0.52 02 (33.33) 0.17
Smoking Habit
No 50 (28.90) 123 (71.10) 57 (53.27)
<0.0
Yes 10 (23.81) 32 (76.19) 0.51 34 (77.27)
1
Alcoholic
beverage
consumption
No 48 (29.63) 114 (70.37) 65 (57.52)
Yes 12 (22.64) 41 (77.36) 0.33 26 (68.42) 0.24
Last visit to the
dentist†
≤1 year 39 (28.06) 100 (71.94) 59 (60.20)
> 1 year 20 (27.03) 54 (72.97) 0.87 32 (61.54) 0.87
Last visit to the
doctor†
≤1 year 51 (27.87) 132 (72.13) 82 (61.65)
> 1 year 08 (26.67) 22 (73.33) 0.89 09 (52.94) 0.49

Reason for consulting the dentist†

14
Prevention 30 (68.18) 25 (64.10)
(31.82)
44
Treatament 122 (73.49) 0.48 63 (58.88) 0.57
(26.51)
Gingival treatment†
41
No 109 (72.67) 63 (60.58)
(27.33)
18
Yes 37 (67.27) 0.45 27 (60.00) 0.95
(32.73)

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Frequency of brushing †
2 or more times a day 06
12 (66.67) 06 (50.0)
(33.33)
52
Once 140 (72.92) 0.57 82 (61.19) 0.45
(27.08)
Flossing usage
36
Yes 75 (67.57) 48 (57.14)
(32.43)
24
No 80 (76.92) 0.13 43 (64.18) 0.38
(23.08)

* p value: significance level ≤ 0.05 – boldface;

† Loss information;
‡ Minimum wage value at the time of data collection: R$ 788,00 (equivalent to US $ 271.60 in the year 2016).

Table 2 – Number (N) and percentage (%) of oral clinical covariables among non-exposed
(without caries and without periodontitis), exposed 1 (with caries or periodontitis) and
exposed 2 (with combined caries and periodontitis) groups. (n = 306)

With
With caries
Non- combined
OR
Oral clinical parameters exposed P* caries AND P*
periodontitis
(n=60) periodontitis
(n=155)
(n=91)
Number of teeth present
Mean (±SD) 20.70 ±8.57 20.21 ±7.28 0.67 21.91 ±5.76 0.34
Median 24.00 21.00 22.00
Minimum-Maximum 4 a 32 4 a 32 7 a 32
DMFT (n)
Mean (±SD) 15.27±7.08 17.11 ±6.66 0.07 14.60 ±6.39 0.55
Median 16.00 18.00 14.00
Minimum-Maximum 0.00-28.00 0.00-30.00 3.00-28.00
Decayed teeth (n)
Mean (±SD) 0.00 2.93 ±3.24 <0.01 3.89 ±3.14 <0.01
Median 0.00 2.00 3.00
Minimum-Maximum 0.00 0.00-16.00 1.00-19.00
Filled/restored teeth (n)
Mean (±SD) 6.42±4.91 4.77 ±4.51 0.02 3.45 ±3.79 <0.01
Median 6.50 4.00 2.00
Minimum-Maximum 0.00-18.00 0.00-18.00 0.00-20.00
Missing teeth (n)
Mean (±SD) 8.85±8.18 9.41 ±7.15 0.62 7.26 ±5.29 0.19

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Median 6.00 8.00 6
Minimum-Maximum 0.00-28.00 0-27.00 0.00-21.00
Probing depth (mm)
Mean (±SD) 2.09±0.49 2.29 ±0.66 0.04 2.94±0.61 <0.01
Median 2.02 2.24 2.87
Minimum-Maximum 1.08-3.69 1.07-4.38 1.54-5.40
Bleeding upon probing index
(%)
Mean (±SD) 18.52±15.47 31.62 ±21.45 <0.01 53.09 ±20.57 <0.01
Median 14.70 27.78 54.8
Minimum-Maximum 0.00-70.00 0.00-100.00 11.33-100.00
Clinical attachment level
(mm)
Mean (±SD) 2.66±0.99 2.95 ±1.29 0.07 3.64 ±1.12 <0.01
Median 2.40 2.54 3.35
Minimum-Maximum 1.23-6.15 1.18-8.10 2.00-7.83
Visible plaque index (%)
Mean (±SD) 24.67±25.00 42.02 ±30.10 <0.01 56.38 ±29.01 <0.01
Median 17.07 38.46 60.00
Minimum-Maximum 0.00-100.00 0.00-100.00 0.00-100.00
Teeth with clinical attachment level = 1 or 2 mm (%)

Mean (±SD) 23.20±22.40 18.71±23.27 0.20 5.46 ±8.82 <0.01

Median 20.42 7.69 0
Minimum-Maximum 0.00-92.86 0.00-100.00 0.00-40.00
Teeth with clinical attachment level = 3 or 4
mm (%)

Mean (±SD) 53.63±23.55 46.53 ±26.12 0.07 39.89 ±23.35 <0.01

Median 56.94 45.45 40.9
Minimum-Maximum 3.57-100.00 0.00-96.43 0.00-100.00
Teeth with clinical attachment level ≥ 5 mm
(%)

Mean (±SD) 19.20±25.94 29.49 ±32.10 0.02 48.96 ±26.58 <0.01

Median 8.33 17.24 42.86
Minimum-Maximum 0.00-87.50 0.00-100.00 0.00-100.00
* p value: significance level ≤ 0.05 – boldface;

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Table 3 – Number (N) and percentage (%) of overall OHIP-14 and OHIP-14 scores among
non-exposed (without caries and without periodontitis), exposed 1 (with caries or
periodontitis) and exposed 2 (with combined caries and periodontitis) groups. (n = 306)

With combined
With caries OR
Non- exposed caries AND
periodontitis
OHIP-14 (n=60) periodontitis
(n=155)
(n=91)
n (%) n (%) P* n (%) P*
Fuctional limitation
No 53 (27.18) 142 (72.82) 80 (60.15)
Yes 07 (35.00) 13 (65.00) 0.46 11 (61.11) 0.94
Physical pain
No 45 (43.69) 101 (69.18) 58 (56.31)
Yes 15 (31.25) 54 (78.26) 0.17 33 (68.75) 0.15
Psychological discomfort
No 42 (29.79) 99 (70.21) 48 (53.33)
Yes 18 (24.32) 56 (75.68) 0.4 43 (70.49) 0.03
Physical disability
No 53 (29.28) 128 (70.72) 69 (56.56)
Yes 7 (20.59) 27 (79.41) 0.3 22 (75.86) 0.06
Psychological disability
No 51 (45.13) 109 (68.13) 62 (54.87)
Yes 9 (23.68) 46 (83.64) 0.03 29 (76.32) 0.02
Social disability
No 58 (28.57) 145 (71.43) 84 (59.15)
Yes 2 (16.67) 10 (83.33) 0.37 7 (77.78) 0.27
Handicap -Social disadvantage
No 56 (42.42) 76 (57.58) 134 (70.53)
Yes 4 (21.05) 15 (78.95) 0.08 21 (84.00) 0.16
Extent score
Mean ±standard deviation 1.27 ±0.26 1.75 ±0.17 0.14† 2.16 ±0.27 0.03†
Severity score
Mean ± standard deviation 7.97 ±1.03 11.04 ±0.72 0.03† 13.15±1.11 <0.01†
*p value: significance level ≤ 0.05 – boldface;
†Mann-Whitney U Test.

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Table 4 – Prevalence ratio (PR), crude and adjusted, and 95% confidence interval (95%CI),
between exposure to caries/periodontitis and their impact on quality of life related to oral
health. (n = 306).

Models PR 95%CI P*

Exposed to caries OR periodontitis x Impact on

quality of life
Crude 1.35 0.88 - 2.07 0.17
Adjusted† 1.34 0.87 - 2.05 0.19
Exposed to caries AND periodontitis combined x
Impact on quality of life
Crude 1.56 1.01 - 2.45 0.05
Adjusted† 1.63 1.03 - 2.59 0.04
* p value: significance level ≤ 0.05 – boldface;
†Adjusted for age, sex, schooling level and smoking habit.

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