Acta Odontologica Scandinavica, 2013; 71: 547–552

ORIGINAL ARTICLE

Evaluation of oral health-related quality-of-life in patients withgeneralized aggressive periodontitis

ABUBEKIR ELTAS & MUSTAFA ÖZAY USLU

Department of Periodontology, Faculty of Dentistry, Inonu University, Malatya, Turkey

AbstractObjective. This study aimed to assess the association between the quality-of-life and clinical parameters in patients withgeneralized aggressive periodontitis. Materials and methods. The examination included assessing the number of missingteeth; the number of mobile teeth; and periodontal measures such as bleeding on probing (BoP), probing depth (PD), gingivalrecession (REC) and plaque index (PI). Patients were asked to rate the impact of their oral health on 16 key areas of oral health-related quality-of-life (OHQoL-UK�). Results. In this study, most of the subjects’ complaints were missing teeth (85%) andREC (75%), following by bleeding gums (62%), bad breath odor (58%), pain/sensitivity (53%) and mobility (53%). On theother hand all clinical parameters affected the OHQoL-UK� (p < 0.05) and the most affected parameters of QoL were missingteeth, BoP, mobility and REC (p < 0.05). Conclusions. The findings of the current study showed that aggresive periodontitishas a deep impact on patients’ oral health-related quality-of-life. When setting a treatment plan in aggressive periodontitispatients, clinicians must evaluate the patient perceptions and the effect of treatment options on a patient’s entire life.

Key Words: aggressive periodontitis, oral health-related quality-of-life, self-assessment

Introduction

Periodontitis is a complex inflammatory disease char-acterized by progressive destruction of the surroundingconnective tissue and supporting alveolar bone of theteeth [1]. As the most severe form of periodontitis,aggressive periodontitis (AgP) comprises a group ofrare, often severe, rapidly progressive forms of peri-odontitis characterized by the early onset of clinicalmanifestations and a distinctive tendency for cases toaggregate in families. This disease was characterized bya loss of collagen fibers in periodontal ligament andextensive bone resorption, deep periodontal pockets,gingival recession and tooth mobility and eventuallyteeth losses [2].Multidimensional assessments of oral functioning

and well-being, labeled as ‘oral quality-of-life’ (QoL)are increasingly used to provide assessments of health,healthcare needs and outcomes of care [3]. QoLassessments have an important place in healthcareand in recent years became an accepted end-pointin clinical research trials [4]. The effects of illness onQoL can be related to the impairment, disability and

handicap model of diseases [5]. Oral health-relatedquality-of-life (OHRQoL) focuses on aspects ofhuman life affected by oral health and dental care[6]. Oral health status is closely associated with QoL[7] and impaired OHRQoL could originate from poororal health status [8].The UK Oral Health-Related Quality-of-Life

(OHQoL-UK�) is among the most widely used instru-ments in studies evaluating oral health and QoL.OHQoL-UK� has recently been developed in theUK and is based on the World Health Organization’smodel of ‘structure–function–ability–participation’,which incorporates negative and positive influenceson health [9,10]. These measures had been previouslyvalidated with Turkish dental outpatients [11].Needleman et al. [12] explored the impact of oral

health on QoL in a group of referred periodontalpatients. Symptoms of generalized aggressive peri-odontitis (G-AgP) are highly relevant from thepatients’ point of view and often have considerableadverse effects on their daily QoL, but little is knownabout this issue. This is an area that deserves furtherstudy. So, the purpose of this study was investigating

Correspondence: Abubekir Eltas, PhD, Assistant professor, Inonu University, Dentistry Faculty, Department of Periodontology, 44280 Malatya, Turkey.Tel: +90 422 3411106. Fax: +90 422 3411108. E-mail: aeltas@yahoo.com

(Received 20 February 2012; revised 3 April 2012; accepted 13 April 2012)

ISSN 0001-6357 print/ISSN 1502-3850 online � 2013 Informa HealthcareDOI: 10.3109/00016357.2012.696698

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the impact on quality-of-life of the symptoms inG-AgP subjects and re-evaluating treatment protocolsfrom the view of patients.

Materials and methods

Sample

This clinical study was carried out in the Periodon-tology Department of the Faculty of Dentistry,Inonu University. Fifty-three patients with G-AgPwere investigated (female/male 25/28; age range 21–48; mean 31.3 ± 8.6). The study was approved bythe Local Ethics Committee of Inonu Universityand informed voluntary consent was obtained fromthe participants. Subjects were diagnosed in accor-dance with the clinical criteria for G-AgP agreed byconsensus at the World Workshop in Periodonticsin 1999 [13] as follows. Subjects who had more thaneight teeth with attachment loss of >5 mm andprobing depth of >6 mm and at least three affectedteeth that were not first molars or incisors werediagnosed as having aggressive periodontitis. Thebone loss estimation was radiographically per-formed in each patient for assessment of the extentand severity of alveolar bone loss.The criteria for exclusion were any systemic

diseases affecting the candidates’ oral health (dia-betes, etc.), psychiatric disorders or patients whohad received periodontal treatment in the past6 months.

Data collection

Each patient’s age, gender, date of birth and educa-tional status were recorded and a medical history wastaken. Clinical and radiographic examinations wereperformed. After an intra-oral examination, dentaloutpatients were asked to complete patient-centeredoutcomemeasures. The questionnaires were used in aface-to-face interview. The questionnaires wereadministered in a standard manner, with the initialexplanation given by the same clinician to all partici-pants (A.E.). All assessments were performed in themorning at the same clinic, free of extraneous noise,music or conversation.Each patient underwent a comprehensive peri-

odontal examination as part of his or her routineassessment. The examination included assessing thenumber of missing teeth; the number of mobileteeth; and periodontal measures such as bleedingon probing (BoP), probing depth (PD), gingivalrecession (REC) and plaque index (PI). Clinicalparameters were measured at six sites per tooth(mesio-buccal, buccal, disto-buccal, disto-lingual,lingual and mesio-lingual) in all teeth, exceptthird molars, using a Williams probe (PCP-12,Hu-Friedy, Chicago, IL).

Clinical recordings

. Plaque index [14]: Presence/absence of plaquescored by running a probe along the tooth surface.

. BOP [15]: Calculated as the percentage of sitesbleeding upon gentle probing.

. PD: The distance from the gingival margin to thebottom of the periodontal pocket.

. CAL: The distance between the cemento-enameljunction of the tooth and the deepest aspect of thepocket.

. REC: The distance between the cemento-enameljunction (CEJ) or the margin of a restoration andthe free gingival margin.

. Mobility [16]: The tooth is held firmly between twoinstruments and moved in the buccolingual direc-tion. Mobility is considered as any degree ofdetectable movement when force is applied.

Periodontal examinations were conducted maskedby one calibrated examiner (MOU). Before the startof the study, the examiner was trained to adequatelevels of accuracy and reproducibility in recording theclinical parameters and indices.The impact of oral health on the patients’ QoL was

assessed using the 16-item OHQoL-UK� measures.The questionnaires were translated into Turkish inaccordance with cross-cultural adaptation guidelines.Using the OHQoL-UK� measures, patients wereasked to rate the impact of their oral health on16 key areas of oral health-related quality-of-life:‘What effects do your teeth, gums and/or mouthhave on each of the 16 key areas of life quality (i.e.your comfort, your speech)?’Patients were also asked about a checklist of signs

and symptoms related to their periodontal health inthe past year: experiences of pain/sensitivity, bleedinggums, loose teeth, mobile teeth, gingival recessionand bad breath.

Data analysis

For the OHQoL-UK�, responses to the items wererecorded in a 5-point Likert scale: very bad effect,score 1; bad effect, score 2; no effect, score 3; goodeffect, score 4; and very good effect, score 5. As lowerscores indicate a poorer OHRQoL, a better OHRQoLwas indicated with higher scores in the OHQoL-UK�

questionnaires.Data was analyzed using the statistical package

SPSS 16.0 software program (Chicago, IL). Meanand standard deviations were calculated. T-test wasused for variations in mean OHQoL-UK� scores andself-reported periodontal health (symptoms of peri-odontal disease). The relation between OHQoL-UK�

scores and clinical periodontal measures was exam-ined through a Pearson correlation coefficient test.The level of significance was set at 0.05 for the tests.

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Results

Fifty-three patients with G-AgP (28 males,25 females) completed the OHQoL-UK� question-naires in this study. Their gender, age, educationalstatus and clinical characteristics are shown inTable I. Their mean age was 31.3 years, rangingfrom 21–48 years, and ~25% of the participantshad a university education.Themean clinical values of the patients in this study

were PI 53%; BoP 41%; REC 1.87 mm; number ofteeth PD >5 mm, 4.34; number of teeth PD >8 mm,2.86; number of mobile teeth, 6.27; and the numberof missing teeth, 5.83 (Table I).This study evaluated the association between

OHQoL-UK� and common complaints duringG-AgP (Table II). Most of the subjects’ complaintswere missing teeth (85%) and REC (75%), followingby bleeding gums (62%), bad breath odor (58%),pain/sensitivity (53%) and mobility (53%). The asso-ciation among these complaints and the OHQoL-UK� were evaluated by t-test and it was shown thatall complaints affected OHQoL-UK� with statisticalsignificance (p < 0.05).The mean OHQoL-UK� scores of subjects were

2.16. The mean scores of responses to OHQoL-UK� questions were between 1.41 (discomfort)and 2.88 (finance). The answers of subjects tendedtowards bad effects (score 2). The symptoms ofdiscomfort and breath odor had the lowest

Table I. Demographic characteristics and clinical measurements ofpatients with G-AgP.

Gender, n

Female 25

Male 28

Age (years), n

15–24 11

25–34 21

35–44 15

45+ 6

Education, n

Primary 15

High school 24

University 14

PI (% ± SD) 53 ± 37

BoP (% ± SD) 41 ± 29

PD >5 (n ± SD) 4.34 ± 3.17

PD >8(n ± SD) 2.86 ± 3.24

Mobility (n ± SD) 5.27 ± 3.07

REC (n ± SD) 5.83 ± 5.21

Missing teeth (n ± SD) 4.78 ± 4.11

PI, plaque index; BoP, bleeding on probing; PD, probing depth;REC, gingival recession.

Table II. The association between the OHQoL-UK� scores andcomplaints.

Complaint n (%) OHQoL-UK� p-value

Pain/sensitivity 0.006

Yes 28 (53%) 1.6

No 25 (47%) 2.8

Bleeding gums 0.023

Yes 33 (62%) 1.8

No 20 (38%) 2.7

Gingival recession 0.009

Yes 40 (75%) 1.7

No 13 (25%) 2.9

Missing teeth 0.014

Yes 45 (85%) 1.9

No 8 (15%) 2.9

Mobile teeth 0.032

Yes 28 (53%) 1.8

No 25 (47%) 2.6

Breath odor 0.016

Yes 31 (58%) 1.8

No 22 (42%) 2.8

t-test was used for examine of variations in mean OHQoL-UK�

scores and self-reported periodontal health.p < 0.05 statistical significance.OHQoL-UK�, UK oral health-related quality-of-life measures.

Table III. Mean score for the UK question of subjects.

UK question Mean scores

Symptoms

Comfort 1.41

Breath odor 1.67

Physical aspects

Eating enjoyment of food 1.49

Appearance 1.98

Speech 2.14

General health 2.35

Smiling/laughing 1.82

Psychological aspects

Ability to relax 2.61

Confidence 2.48

Carefree manner 2.34

Mood 2.18

Personality 2.51

Social aspects

Work/usual duties 2.64

Finances 2.88

Romance 2.29

Social life 1.76

Mean OHQoL-UK 2.16

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OHQoL-UK� scores and the physical, physicologi-cal and social aspects also had low scores. Whilethese lower scores were responses by patients aboutdiscomfort, eating enjoyment and breath odor, thehigher scores were related with relaxation, work andfinances (Table III).Table IV shows that all clinical parameters affected

the OHQoL-UK� in different ways. The OHQoL-UK� consists of 16 items. It was found that four itemson the questionnaires were related to PI, 13 items withBoP, six items with the number of teeth PD >5, sevenitems with the number of teeth PD >8, 11 items withREC, 12 items with the number of mobile teeth and13 items with the number of missing teeth.Themost affected parameters of QoL were missing

teeth, BoP, mobility and REC. These had statisticalassociations with ~75% of all of the questionnaires.Although the number of teeth PD >8 and PD>5 affected the sameOHQoL-UK� items, a statisticalcorrelation was evident between OHQoL-UK� itemsand PD >8 than for PD >5. In this study, theOHQoL-UK� items were affected the least by PI (25%)(Table IV).Eating enjoyment of food was affected by all clinical

parameters, except for PI. Physical aspects were alsoassociated with appearance and all parameters, exceptfor PD; however, speech and smiling/laughing did not

have a relationship with PD and mobile teeth. Inaddition, BoP, missing teeth and REC were morestatistical significant for smiling/laughing than forspeech (Table IV).There were statistically significant relationships

between psychological aspects and BoP, REC, mobil-ity and missing teeth. Subjects usually reported theirfears about their teeth’s condition in the futurebecause of the mobility threat; therefore, these sub-jects might have bad OHQoL-UK� scores associatedwith the psychological aspects (Table IV).In this study, the social aspects were the least

affected items in patients’ lives. The rate of affectedaspects was 50%. A statistically significant relation-ship between finance and clinical parameters was notfound, so this was the only question in questionnairethat was not correlated with any of the clinical para-meters in this study. Work was found associated withPD >8, mobility and missing teeth. Romance wasassociated with BoP, PD and missing teeth. Sociallife was affected by all of the clinical parameters,except for PI (Table IV).

Discussion

The findings of this study indicate that G-AgP leads tothe deepest impact on discomfort, eating enjoyment

Table IV. Evaluation of statistical the relationship between the OHQoL-UK� question and clinical measurements associated with G-AgP.

UK question PI BoP PD > 5 PD > 8 REC Mobility Missing teeth

Symptoms

Comfort �0.15* �0.32** �0.17* �0.14* �0.21* �0.21* �0.39**

Breath odor �0.07 �0.47*** �0.29** �0.33** �0.01 �0.12* �0.08

Physical aspects

Eating, enjoyment of food �0.01 �0.11* �0.16* �0.15* �0.20* �0.22* �0.37**

Appearance �0.15* �0.17* �0.02 �0.04 �0.29** �0.13* �0.21*

Speech �0.13* �0.16* �0.03 �0.06 �0.22* �0.10 �0.17*

General health �0.11 �0.09 �0.12* �0.15* �0.20* �0.35** �0.49***

Smiling/laughing �0.17* �0.18* �0.06 �0.08 �0.21* �0.10 �0.35**

Psychological aspects

Ability to relax �0.02 �0.12* �0.03 �0.03 �0.06 �0.19* �0.09

Confidence �0.01 �0.14* �0.01 �0.01 �0.13* �0.17* �0.23**

Carefree manner �0.02 �0.17* �0.03 �0.02 �0.41*** �0.22* �0.18*

Mood �0.05 �0.11* �0.03 �0.05 �0.15* �0.14* �0.13*

Personality �0.01 �0.17* �0.02 �0.02 �0.18* �0.18* �0.14*

Social aspects

Work/usual duties �0.01 �0.07 �0.09 �0.11* �0.10 �0.17* �0.43***

Finances �0.01 �0.03 �0.01 �0.01 �0.08 �0.06 �0.06

Romance �0.05 �0.20* �0.14* �0.15* �0.08 �0.09 �0.37**

Social life �0.02 �0.15* �0.11* �0.11* �0.17* �0.12* �0.21*

PI, plaque index; BoP, bleeding on probing; PD, probing depth; REC, gingival recession.Statistical analysis was performed by a Pearson correlation coefficient test.*p < 0.05; **p < 0.01; ***p < 0.001.

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and breath odor on patients’ life, however, it leads tothe least impact related to relaxation, work andfinances. OHRQoL assessments may play an impor-tant role in clinical practice in terms of identifyingneeds, selecting therapies and monitoring patients’progress [17–20]. A greater understanding of theconsequences of periodontal disease and the effectsof therapy are important on many fronts: in under-standing and embracing patients’ perceptions of theimpact of their oral health on their lives, in planningperiodontal care that addresses patients’ needs andkey concerns, in evaluating outcomes from periodon-tal treatment from the patients’ perspective and indrawing attention to the importance of periodontalcare in society [21].OHQoL-UK� is a self-completed questionnaire

consisting of 16 items sub-divided into eight domains:functional limitation, physical discomfort, psycholog-ical discomfort, physical disability, psychological dis-ability, social disability and handicap. The impact oforal health on patients’ QoL was assessed using theTurkish version of OHQoL-UK�. The instrument’spsychometric properties, validity and reliability havebeen assessed and Cronbach’s alpha coefficient of theOHQoL-UK� (0.96) was found high [11]. For thesereasons, the present study was assessed using theQHQoL-UK� impact of oral health on patients’QoL.Although there is not enough research about the

impacts of periodontal clinical parameters on OHR-QoL, limited previous studies have reported on gin-gival bleeding, CAL and PD affecting various degreesof OHRQoL [12,22,23]. Therefore, we evaluated thecomprehensive perspective that the periodontal para-meters of G-AgP patients affect their OHRQoL. Ourresults determined that the OHRQoL was closelyassociated with BoP, mobility, missing teeth andREC in G-AgP subjects.A study by Ng and Leung [23] attempted to explore

the differences in QoL in patients with variousperiodontal conditions. Ng and Leung assessed theimpact of periodontal health status on QoL andinvestigated the association between psychologicalfactors and CAL, as well as the patients complaintsrelated to periodontal problems. They reported asignificant association between OHRQoL and CALand the self-reported periodontal symptoms, asswollen gums, sore gums, receding gums, loose teeth,bad breath and toothache. The present study resultsare consistent with the Ng et al. [23] study whichshows impact on patients OHRQoL by CAL. Ourresults supported the relationship between OHRQoLand amount of periodontal tissue breakdown.There has not yet been a study of patients with

AgP, but Lopez and Baelum [24] investigated theimpact on OHRQoL of necrotizing ulcerative gingi-vitis and destructive periodontal disease. Theseresearchers showed that both attachment loss andnecrotizing ulcerative gingivitis were significantly

associated with a higher impact on the OHRQoLamong adolescents. This study observed that theseverity and progress of G-AgP such as PD, CAL,BoP and REC clearly affected OHRQoL. In thisregard, our results consistent with theirs. Accordingto our results, REC was one of the most influentialfactors on OHRQoL. REC, which leads to foodimpaction, sensitivity on exposed root surfaces andesthetic fears, may cause a decrease of OHRQoL.Increasing PD has usually been seen as depending

on the rapid progressive of AgP. It is well known thatmicrobial plaque accumulation caused by increasingPD leads to both poor oral health maintenance andbad breath odor. Based on similar causations, wefound a correlation among the scores of question-naires and number of teeth with PD >5 mm andPD >8 mm. The increased PD was seen in the lowscores of OHRQoL associated with comfort, breathodor and eating. A study by Needleman et al. [12]attempted to explore the impact of oral health on QoLin periodontal patients. Accordingly, OHQoL-UK�

scores were correlated with the number of teeth withprobing depths of 5 mm or more. Our findings weresimilar to these results, so PD was found to have asignificant impact on QoL.Due to the speed of tissue loss in AgP if left

untreated, irreversible tissue damage can occur inthe bone and soft tissue surrounding the teeth, leadingto tooth mobility and, ultimately, to the loss of teeth. Inthe present study, we found that missing teeth affectedcomfort and physical aspects more than they affectedphysiological and social aspects. Cunha-Cruz et al.[22] assessed the OHRQoL of patients by means ofPD and missing teeth. They reported that the missingteeth and periodontal pockets were problems and thesenegatively affected patients’ quality-of-life. Previousstudies reported a close relationship between missingteeth and OHRQoL [23,25,26]. This study alsoshowed that social aspects were the items most affectedby missing teeth. We did not find any research thatevaluated the effect on OHRQoL of mobile teeth. Inour study, mobile teeth affected the OHRQoL. Thereason for this situation is the greater importance ofappearances to patients than physical factors.The present study used BoP because gingival

inflammation has an impact on QoL [27]. Therewas a statistical relationship between BoP and 12items on the OHQoL-UK� questionnaires, exclud-ing finances, work, general health and personality.Previous studies investigated the affects of periodon-tal disease on OHRQoL and CAL and PD weretypically used, but bleeding gums, which are the firstclinical signs of periodontal disease, were ignored. Inthe literature, only D’Avila et al. [27] reportedbleeding on probing as correlated significantly withoral health impacts. However, at the end of presentstudy, a strong correlation was seen between BoPand QoL in AgP patients with widespread

Quality-of-life in aggressive periodontitis 551

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inflammation. Although this severely affected OHR-QoL, unfortunately the relationship between someOHQoL-UK� items and bleeding gums was notfound because of the lack of oral health awarenessin society.Our study has some limitations. First, this study did

not evaluate which QoL factors will affect other intra-oral factors such as decay and denture wear. Second,Eres et al. [28] reported that the prevalence of localizeAgP was 0.6% in the Turkish population. Therefore,this study did not evaluate the effect of individualfeature such as educational levels, household situationor marital status, because our study did includeenough patients with AgP. Further research in thisarea is needed with a larger patient population andwith comparisons of post-treatment results.

Conclusion

Finally, symptoms and signs of AgP such as gumbleeding, deep periodontal pocket, attachment loss,mobility and teeth loss has a deep impact on patients’OHRQoL. Therefore, we recommend that, whensetting a treatment plan in AgP patients, cliniciansmust evaluate the patient perceptions and the effect oftreatment options on a patient’s entire life.

Declaration of interest: The authors have no finan-cial relationship with the organization that sponsoredthe research.

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nly.