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Original article

Assessment of changes in oral health-related quality of life among patients with complete denture before and 1 month post-insertion using Geriatric Oral Health Assessment Index
Kamal Shigli1 and Mamata Hebbal2
1

Department of Prosthodontics, Modern Dental College and Research Centre, Indore, Madhya Pradesh, India; 2Department of Preventive and Community Dentistry, K.L.E.V.K. Institute of Dental Sciences, Belgaum, Karnataka, India

doi:10.1111/j.1741-2358.2009.00323.x Assessment of changes in oral health-related quality of life among patients with complete denture before and 1 month post-insertion using Geriatric Oral Health Assessment Index Objective: Geriatric Oral Health Assessment Index (GOHAI) is a 12-item measure of patient-reported oral functional problems intended for use in the assessment of the effectiveness of dental treatment. Design and Setting: As there is scanty literature available on GOHAI in the Indian population, the present study was undertaken to assess the changes in GOHAI before and 1 month after placement of dentures in completely edentulous patients reporting to a dental hospital at Indore, India. Measurements: The GOHAI questionnaire was completed by the examiner who interviewed the patients (n = 35) before placement of complete dentures and 1 month later. Mean, median values were calculated and the data were analysed using Wilcoxon signed-rank test. Results: When overall mean was considered, the GOHAI scores increased from 27.48 to 30.19 (p = 0.002; highly signicant). Conclusion: Patients reported improvement in functional changes after placement of complete dentures. Keywords: complete denture, GOHAI, Functional changes. Accepted 16 March 2009

Introduction
Health has evolved over the centuries as a concept from an individual concern to a world-wide social goal and encompasses the whole quality of life. The widely accepted denition of health is that given by the World Health Organization (WHO) in the preamble to its constitution, which is: Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or inrmity1. The WHO denition of health introduces the concept of well-being. In point of fact, there is no satisfactory denition of the term well-being1. Recently, psychologists have pointed out that the well-being of an individual or group of individuals has objective and subjective components. The objective components relate to such concerns as are

generally known by the term standard of living or level of living. The subjective component of well-being (as expressed by each individual) is referred to as quality of life1. Quality of life was dened by WHO as: the condition of life resulting from the combination of the effects of the complete range of factors such as those determining health, happiness (including comfort in the physical environment and a satisfying occupation), education, social and intellectual attainments, freedom of action, justice and freedom of expression1. A recent denition of quality of life is: a composite measure of physical, mental and social well-being as perceived by each individual or by group of individuals that is to say, happiness, satisfaction and gratication as it is experienced in such life concerns as health, marriage, family work, nancial situation, educational opportunities,
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self-esteem, creativity, belongingness, and trust in others1. Thus, a distinction is drawn between the concept of level of living consisting of objective criteria and of quality of life comprising the individuals own subjective evaluation of these. The quality of life can be evaluated by assessing a persons subjective feelings of happiness or unhappiness about the various life concerns1. Now people are demanding a better quality of life. Therefore, governments all over the world are increasingly concerned about improving the quality of life of their people by reducing morbidity and mortality, providing primary healthcare and enhancing physical, mental and social well-being. It is conceded that a rise in the standard of living of the people is not enough to achieve satisfaction or happiness. Improvement of quality of life must also be added, and this means increased emphasis on social policy and on reformulation of societal goals to make life more liveable for all those who survive1. Health-related quality of life (HRQoL) captures not only clinical aspects but also the individuals perception of health which could be affected by a variety of factors; for example, the past experience of health or healthcare systems2. Oral health-related quality of life (OHRQoL) is a subset of (HRQoL)3. It is increasingly accepted that the measurement of oral health-related quality of life (OHRQoL) is an essential component of oral health surveys, clinical trials and other studies evaluating the outcomes of preventive and therapeutic programs intended to improve oral health. The assessment of OHRQoL also has an important role to play in clinical practice4. OHRQoL can be dened as the part of quality of life that is affected by a persons oral health. In particular, this term captures how oral health affects the persons ability to function (e.g. bite, chew, speak), psychological states (such as selfesteem, and satisfaction with ones appearance), social factors, and pain/discomfort related to oral health5. Prosthodontic research showed that patients OHRQoL is also affected by the type of treatment used, in particular whether implant retained dentures or conventional dentures were placed in an edentulous patient6. HRQoL can be measured by using different questionnaires; however, oral health, as a part of health, is not sufciently represented in measures of general HRQoL. Therefore, different questionnaires have been established for measuring, especially, the oral HRQoL (OHRQoL). Frequently used questionnaires are the Oral Health Impact Prole

(OHIP)7, the Oral Impacts on Daily Performance (OIDP)8 and the well-established Geriatric/General Oral Health Assessment Index (GOHAI)9 with translations into Chinese10, French11, Swedish12, Malay13, Japanese14, Arabic15, German2 and Turkish16. A variety of oral health-related quality-of-life instruments have been developed in the past 20 years as a result of increased concern about the impact of oral conditions on a persons quality of life17. The OHIP developed by Slade and Spencer7 is a rather long questionnaire with 49 items, can be time-consuming and difcult to administer. To overcome this shortcoming, a short form consisting of only 14 items extracted from the 49 items in the original questionnaire, OHIP-14, was derived by Slade18. It has been shown in several studies that the reliability and validity of this short-form OHIP14 is comparable to the long-form OHIP18 and that it may be a more practical instrument in a clinical setting. OHIP-EDENT was designed specically for edentulous populations with regard to prosthetic therapy19. The Geriatric Oral Health Assessment Index (GOHAI) is an example of a patient-based assessment of oral health problems commonly affecting elder adults9. More recently, it has been used with populations of younger adults. As the GOHAI appeared to have acceptable reliability and validity in all ages, it was recommended that the name of GOHAI be changed to the General Oral Health Assessment Index (GOHAI)20. The 12 items of the index assess oral healthrelated problems affecting people in three hypothesised dimensions: 1. Physical function, including eating, speech, and swallowing; 2. Psychosocial function, including worry or concern about oral health, dissatisfaction with appearance, self-consciousness about oral health, and avoidance of social contact because of oral problems; and 3. Pain or discomfort, including the use of medication to relieve pain or discomfort from the mouth21. The aim of this study was to assess the changes in GOHAI before and 1 month after insertion of dentures in completely edentulous patients (aged 6084 years) reporting to a dental hospital at Indore, India.

Materials and methods


A pilot study was conducted to assess the functional changes 1 month after placement of

2009 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2010; 27: 167173

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maxillary and mandibular complete dentures in geriatric patients. Approval from the Institution Review Board was obtained prior to the study. The patients who fullled the following inclusion criteria were considered for the study: adults who were free from any systemic diseases which affect oral functions and who did not have difculty in recollecting past history. Patients were excluded if they had poor residual ridge anatomy, single complete dentures and temporomandibular joint problems. The age of the patients ranged from 6084 years. Informed consent of patients was obtained regarding their voluntary participation in the study. Participants were asked about their sociodemographic characteristics including their age, gender, marital status, income, education and occupation. Kuppuswamys socioeconomic classication, which took into account the education level, monthly income and occupation, was used to classify the socioeconomic status of the patients. The socioeconomic status was divided from class I to class V, i.e. Upper (I), Upper Middle (II), Lower Middle (III), Upper Lower (IV) and Lower (V)22. Maxillary and mandibular complete dentures were fabricated by a single operator for 35 patients (26 men; 9 women) reporting to the Department of Prosthodontics, Modern Dental College and Research Centre, Indore during the period between January 2008 and April 2008 using standardised clinical and laboratory procedures. Conventional techniques were used to complete denture fabrication. According to the case requirement modication of the technique and material was carried out for the betterment of treatment. Anatomic acrylic resin denture teeth (Premadent; Super Dental Products, Delhi, India) were used to establish a balanced articulation. All of the dentures were processed in the same dental laboratory within the institution by compression moulding technique. Laboratory and clinical remount procedures, along with occlusal corrections were performed using a semi-adjustable articulator (Hanau Series H2; Teledyne Waterpik, Fort Collins, CO, USA). The GOHAI questionnaire was completed by the examiner who interviewed the patients on two different occasions. One questionnaire was recorded before denture insertion. When no further adjustment was required or indicated, patients were asked to return for a further review 1 month later and GOHAI was recorded by a single recorder. The 12th question which relates to dental sensitivity to heat and cold was not considered as all the patients in the present study

were completely edentulous. The study lasted at least 4 months. Although the items are usually scored on a 5-point scale, the GOHAI was administered using a three-point scale (always, sometimes, never)23. GOHAI scale scores at baseline and 1 month were calculated as a simple summation of the 11 items (response set is always, very often, often = 1, sometimes, seldom = 2, never = 3) after reversing the response set of three items (item 3: swallow comfortably; item 5: eat anything without feeling discomfort; item 7: happy with looks). A simple summative score ranging from 11 to 33 was calculated for each patient, with a higher score indicating better self-reported oral health. Means, median values, standard deviations and change scores were calculated for the GOHAI. Change in GOHAI score was calculated as the follow-up score minus the score at baseline. The data were analysed using Wilcoxon signedrank test. All the data analysis was carried out using Statistical Package for Social Sciences (Version 15.0) (SPSS Inc., Chicago, IL, USA). A probability value of less than 0.05 was considered statistically signicant.

Results
In the present study, 35 patients (9 females and 26 males) (Table 1) completed a baseline interview and complete dentures were inserted for all the 35 patients. The age of the patients ranged from 6084 years. Eight patients did not return back and were considered as drop-outs. Twenty-seven patients completed the GOHAI questionnaire on both occasions, so statistical analysis was performed considering 27 as the sample size. The highest mean GOHAI score at baseline was 2.85 (SD = 0.36) for ability to swallow comfortably followed by 2.70 (SD = 0.54) for being pleased or happy with the look of teeth and gums or dentures (Table 2). The highest mean GOHAI score 1 month after denture insertion was 3.00 for limiting contacts with people because of the condition of teeth or dentures, being pleased or happy with the looks of

Table 1 Distribution of patients according to sex. Number Male Female Total 26 9 35 Mean age 69.07 63.55 67.65 SD 7.12 3.81 6.83

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Table 2 Change in mean GOHAI score i.e. pre-insertion and post-insertion. Change in Score (PostPre) 0.34 Percentage change (%) 15.42

Pre-insertion 1. How often did you limit the kinds or amounts of food you eat because of problems with your teeth or dentures? 2. How often did you have difculty biting or chewing any kinds of food, such as rm meat or apples? 3. How often were you able to swallow comfortably? 4. How often have your teeth or dentures prevented you from speaking the way you wanted? 5. How often were you able to eat anything without feeling discomfort? 6. How often did you limit contacts with people because of the condition of your teeth or dentures? 7. How often were you pleased or happy with the looks of your teeth and gums, or dentures? 8. How often did you use medication to relieve pain or discomfort from around your mouth? 9. How often were you worried or concerned about the problems with your teeth, gums or dentures? 10. How often did you feel nervous or self-conscious because of problems with your teeth, gums or dentures? 11. How often did you feel uncomfortable eating in front of people because of problems with your teeth or dentures? Q1Q11 (mean for 11 questions) 2.14 0.53

Post-insertion 2.48 0.64

2.00 0.55

2.30 0.61

0.3

15.00

2.85 0.36 2.67 0.55

2.89 0.32 2.63 0.49

0.04 )0.04

1.40 )1.50

2.63 0.56 2.67 0.68

2.63 0.63 3.00 0.00

0 0.33

0.00 12.36

2.70 0.54

3.00 0.00

0.3

11.11

2.52 0.58

3.00 0.00

0.48

19.05

2.41 0.69

2.89 0.32

0.48

19.92

2.48 0.75

2.89 0.32

0.41

16.53

2.41 0.63

2.48 0.64

0.07

2.90

27.48 3.75

30.19 2.29

2.71

9.86

teeth and gums, or dentures and use of medication to relieve pain or discomfort from around the mouth followed by 2.89 (SD = 0.32) for ability to swallow comfortably, worried or concerned and feeling nervous or self-conscious because of problems with teeth, gums or dentures (Table 2). Statistically signicant difference was observed for medication used to relieve pain or discomfort from around the mouth, being worried or concerned about the problems with teeth, gums or dentures and for limiting the kinds or amounts of food because of problems with teeth or dentures. Factors such as difculty biting or chewing food, limiting contacts with people, being pleased or happy with the looks of their teeth and gums or dentures and feeling nervous or self-conscious because of problems with teeth, gums or dentures also showed a statistically signicant difference. Regarding dentures preventing speech, there was a

decrease in the mean GOHAI score after denture insertion with a percentage difference of 1.5% which was not signicant. When the overall mean was considered, the difference between pre- and post-denture insertion scores was statistically highly signicant. The highest change between pre- and post-insertion scores was 19.92% for being worried or concerned about the problems with their teeth, gums or dentures (Tables 2 and 3).

Discussion
In India, data on assessment of functional changes after placement of maxillary and mandibular complete dentures in geriatric patients is limited. Therefore, the present study was designed to assess the opinion of the prostheses worn by patients reporting to the Modern Dental College and

2009 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2010; 27: 167173

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Table 3 Change in GOHAI score before and after insertion tested using Wilcoxon signed-rank test (n = 27 excluding drop outs). Pre-insertion Median 1. How often did you limit the kinds or amounts of food you eat because of problems with your teeth or dentures? 2. How often did you have difculty biting or chewing any kinds of food, such as rm meat or apples? 3. How often were you able to swallow comfortably? 4. How often have your teeth or dentures prevented you from speaking the way you wanted? 5. How often were you able to eat anything without feeling discomfort? 6. How often did you limit contacts with people because of the condition of your teeth or dentures? 7. How often were you pleased or happy with the looks of your teeth and gums, or dentures? 8. How often did you use medication to relieve pain or discomfort from around your mouth? 9. How often were you worried or concerned about the problems with your teeth, gums or dentures? 10. How often did you feel nervous or self-conscious because of problems with your teeth, gums or dentures? 11. How often did you feel uncomfortable eating in front of people because of problems with your teeth or dentures? Q1Q11 (mean FOR 11 questions) 2 Inter quartile range 0 Post-insertion Median 3 Inter quartile range 1 p Value 0.020 Inference S

0.033

3 3

0 1

3 3

0 1

0.655 0.763

NS NS

1.00

NS

0.024

0.011

0.001

HS

0.005

HS

0.017

0.674

NS

29

31

0.002

HS

NS, non-signicant; S, signicant; HS, highly signicant.

Research Centre, Indore. This would enable patients to indicate their opinion regarding the prostheses and perhaps serve as a guideline for the prosthodontist to pay increased attention to the factors of patient concern. This study presents the results of a pilot study of a self-reported geriatric oral health assessment instrument. As the name implies, this is an assessment tool, not an objective measure of the

patients oral health status. The GOHAI should not be used in place of a clinical oral examination or dental radiographs, which provide objective measures of disease. As an assessment instrument, it is designed to assess oral health status on two levels: the patient level and the population level9. On the patient level, the GOHAI could be used to indicate when a comprehensive oral examination

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K. Shigli, M. Hebbal

or dental referral is necessary. It provides valuable information about oral symptoms, and psychosocial and functional problems that are bothersome to the patient. For the non-dental provider, such as a geriatrician, it could serve as a means of systematically collecting information about a patients oral complaints to assist in deciding when a dental referral was appropriate9. On the population level, for epidemiological purposes, this instrument could be a cost-effective means of gathering information about peoples oral health problems. The GOHAI could facilitate patient outcome evaluations needed to capture the effect of treatment on patient populations9. Veyrune et al.24 showed that patients with the lowest initial GOHAI score derived greatest benet from placement of new dentures indicating that the decision to make them should not be based only on a clinical evaluation. It is necessary to take into account their quality of life and subjective perceived needs. In the present study, the highest mean GOHAI score 1 month after denture insertion was for limiting contacts with people because of the condition of teeth or dentures, being pleased or happy with the looks of teeth and gums, or dentures and use of medication to relieve pain or discomfort from around the mouth. This may be as they learn to accept the functional limitations of their dentures25. There was a decrease in the mean GOHAI score for dentures preventing speech after denture insertion. As we know speaking normally with dentures requires practice26. This result may have been obtained as a result of the short follow-up period of the study. There was an overall increase in the mean GOHAI scores 1 month after placement of complete dentures which was highly signicant. In a similar study, Veyrune et al.24 reported no difference in GOHAI scores 6 weeks after placement of the new dentures and a signicant increase in the GOHAI scores 12 weeks after placement. These results emphasise the importance of a follow-up of patients during the period of adaptation that is essential for the psychological and functional integration of the new prostheses. The limitations of this study were its small sample size and the short follow-up period. History of previous denture wearing was not taken into account. The study could also have been supplemented with a clinical examination. Though socioeconomic status was taken into consideration, it could not be classied further because of the sample size; hence further elaboration was not carried out on results. Sensitivity

of the GOHAI to particular demographic differences (e.g., age, marital status, education and income) could not be assessed in the present study.

Conclusion
A statistically signicant difference was observed for medication used to relieve pain or discomfort, being worried or concerned and for limiting the kinds or amounts of food because of problems with their teeth or dentures. Factors such as difculty with biting or chewing, limiting contacts with people, being pleased or happy with the looks and feeling nervous or self-conscious because of problems with teeth, gums or dentures also showed a statistically signicant difference. When an overall mean was considered, the difference between preand post-denture insertion scores was highly signicant. Further studies with a larger sample size and a longer duration of follow-up are essential before generalising the results.

Acknowledgements
The authors would like to acknowledge Dr Ravi Shiratti, Lecturer, Department of Preventive and Community Dentistry, Dr D.Y. Patil Dental College, Pune, for guidance in developing this instrument; Dr Gangadhar Shivappa Angadi, Professor and Head, Department of Prosthodontics, Rural Dental College, Loni, Maharastra, for suggestions in the manuscript and Dr Puneet Gupta, Research Consultant, http://www.shodh.co.in for carrying out the statistical analysis.

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Correspondence to: Dr Kamal Shigli, B-205, Staff Quarters, Modern Dental College and Research Centre, Opposite Gandhi Nagar, Nainod Gram, Airport Road, Indore-453112, Madhya Pradesh, India. Fax: 91-731-2882700 E-mail: kamalshigli@yahoo.co.in Presented at the 36th Indian Prosthodontic Society Conference on 79th November, 2008 at Bangalore, Karnataka, India.

2009 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2010; 27: 167173

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