Microsoft Word - 2 Jenan J Bagh College Dentistry Vol. 32(3), September 2020 The impact of 8 The impact of caries experience on quality of life among dental students in Iraq Jenan O. Almaas(1), Ban S. Diab(2) Article DOI: https://doi.org/10.26477/jbcd.v32i3.2894 ABSTRACT Background: Dental caries is generally given the highest priority in national oral health services for adult populations. Yet, there is no study which has explored the impact on quality of life specifically related to dental caries in samples of dental students. The purpose of the current study was to assess the impact of caries experience on quality of life among dental students in three governorates in Iraq. Materials and Methods: This observational study included 1364 dental students aged 18–22 years old, from three governorates. Information on quality of life was obtained from a structured, self-administered questionnaire from the students who were willing to participate in the study. The data was collected, summarized and statistically analyzed. Caries experience in the present study was determined by the Decayed- Missing Filled Surfaces (DMFS) indexed by WHO in 1997 in which all teeth were examined and all the third molars were included. Results: Regarding dental caries and the four Quality of Life domains, in each domain scores, DS component had the highest contribution to the DMFS followed by the MS component while FS components had the lowest contribution to the index. On the other hand, DMFS showed the lowest mean among the good scores of all domains and it had the highest mean among the poor type. Conclusion: The quality of life among dental students is associated with caries severity as the DMFS and its components affected different domains regarding quality of life. Keywords: caries experience, dental students, quality of life. (Received: 3/6/2019; Accepted: 28/7/2019). INTRODUCTION Dental students constitute a special population group concerning their oral health status and behavior since they have the best access to information and motivation for the prevention and treatment of oral diseases (1). On the other hand, their caries experience was found to be similar to that of other university students. They explained this by the fact that DMFT index is irreversible while for caries initiation and development, a sufficiently long period of time is needed (2). Caries is a multifactorial disease, in addition to pH fluctuations in the bacterial plaque or biofilm which in turn may be influenced by many factors of oral hygiene, diet, fluoride and salivary flow, a number of other important factors such as social class, income, education, knowledge, attitudes and behavior may be involved in disease causes (3). Oral diseases such as dental caries are highly prevalent and their consequences are not only physical; they are also economic, social and psychological.They seriously impair quality of (1) Phd student, Department of Pedodontics and Preventive Dentistry, College of Dentistry University of Baghdad (2) Professor, Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad. life in a large number of individuals and can affect various aspects of life, including oral function, appearance, and interpersonal relationships (4). Quality of life is a ubiquitous concept that has different philosophical, political and health-related definitions. Health-related Quality of life is a patient-reported outcome usually measured with carefully designed and validated instruments such as questionnaires or semi-structured interview schedules which include the physical, functional, social and emotional well-being of an individual; its measurement was judged by a healthcare professional or similar (5). According to current knowledge, there is no previous Iraqi study concerning the effect of dental caries on quality of life assessment among dental students in Iraqi populations. This study was administered to a random sample at a public university with a caries experience profile. The aim of this study was to investigate how the oral health behavior and clinically-assessed dental caries are related to quality of life measured by WHOQOL-BREF Field Trial Version among dental students in Iraq . Corresponding author, drban.sahib@codental.uobaghdad.edu.iq J Bagh College Dentistry Vol. 32(3), September 2020 The impact of 9 MATERIALS AND METHODS All the students participating in the study gave their verbal and written informed consent at the beginning. The participants were informed that they could withdraw from the study at any time. Ethical approval for this study was obtained by an official permission from Iraqi Universities/Colleges of Dentistry to facilitate conducting the research.This observational study was conducted at three universities (Basra, Anbar, Mosel), during the period between March 2018 to March 2019. Approximately 1364 dental students aged 18- 22 years old who attended the colleges of dentistry in the selected governorates in Iraq were examined. For convenience, students from the non-government colleges of dentistry were not included, as the study targeted Iraqi students from government universities only.The sample included both genders of the dental students (648 males and 716 females) with age range 18-22 years old. The participants should not had any chronic medical disease, not physically handicapped, and not exposed to psychological trauma during the last six months. The participants completed a questionnaire containing items regarding name, age, gender, year of study in the bachelor of dental surgery, geographical location and smoking status. All the answers of the questionnaire were confirmed by the researcher . Self-Administered WHOQOL-BREF (Field Trial Version) was used to evaluate the quality of life for the dental students into three groups: poor, fair and good scores (6-9). The applied cut- off level reflects public health perspectives and treatment needs, rather than detailed individual statements of symptoms. It was possible to derive four domain scores (physical, psychological, social and environmental domains). The four domain scores denote an individual's perception of quality of life in each particular domain. Domain scores are scaled in a positive direction (i.e. higher scores denote higher quality of life). Responses to the questions using a 5- point Likert scale. In the present sample, WHOQOL-BREF domain scores discriminated statistically highly significantly between contrasted groups of dental students at p-value ˂0.05 (n=736, df=734). The reliability index for the WHOQOL-BREF was assessed by using Cronbach’s alpha which was 0.98. As a result of that, the indicator stayed on its version without drop of any item. Caries experience in the present study was determined by the Decayed- Missing Filled surface (DMFS) index by the WHO in 1997(10) in which all the teeth were examined and all the third molars were included. The examination should adopt a systematic approach to the assessment of dentition status. Plain mouth mirror and CPI probe were used in the examination. Data were statistically analyzed using SPSS version 22 software. According to the central limit theorem, in large samples (˃30 or 40), the sampling distribution tends to be normal, regardless of the shape of the data. The collected data were grouped and illustrated in tables, and the following statistical tests were carried out: means, standard error. The Independent-Samples t- test procedure was used to compare means for two groups of cases. ANOVA (one way) was used to determine whether there are any significant differences between the means of more than two independent groups. When the p- values were less than or equal to 0.05, they were considered as statistically significant and if the p- values were more than 0.05 they were regarded as not significant. RESULTS A sample of 1364 students from dental colleges in the randomly selected governorates within the study age (18-22 years old) was examined. Table (1) shows the general description of the total samples. In this table the age in years categorized into five groups with the age group of 18 years of highly percentages than the others, females constituted 52.5% of the whole sample while the nonsmoking dental students form about 63.6%of both gender, however, 40.2% of the total sample was from the Basra University. Figure (1) illustrates that the percentage of dental students with low severity of dental caries was higher than that of dental students with high severity of dental caries. Table (2) demonstrates the Quality of life domains scores according to caries severity where the DMFS ≥ 12 was considered as high severity and the DMFS <12 was considered as low severity. In this table, the mean scores of the four WHOQOL-BREF domains were higher among caries free dental students with highly statistical significance (p˂0.001) among the three types of caries J Bagh College Dentistry Vol. 32(3), September 2020 The impact of 10 severity. However, among caries free dental students, the mean score of psychological domain was lowest. On the other hand, among the dental students with high caries severity, the mean score of physical domain was the lowest compared to other scores (34.91 ± 0.68) followed by mean scores of environment domain (35.97 ± 0.55) and then the mean score of both psychological and social domains were (42.91 ± 0.40, 40.64 ± 0.54 respectively). Regarding dental caries and the four WHOQOL-BREF domains, in each domain scores, DS component had the highest contribution to the DMFS followed by the MS component while FS components had the lowest contribution to the index. On the other hand, DMFS showed the lowest mean among the good scores of all the domains and it had the highest mean among the poor type. There were statistical highly significant differences (P˂0.001) among the three scores of four WHOQOL-BREF domains regarding the DMFS and its components, as illustrated in Table (3). Figure (1): The distribution of dental students according to caries severity 0 100 200 300 400 500 600 700 Caries freeLow severityHigh severity 295 626 443 21.60 %45.90 %32.50 % NO. % Table (1): The Distribution of the Total Sample according to the Sociodemographic Characteristics. Sociodemographic Characteristics No. % Governorate Anbar 464 34.0 % Mosel 352 25.8 % Basrah 548 40.2 % Age 18 years 295 21.6 % 19 years 270 19.8 % 20 years 274 20.1 % 21 years 265 19.4 % 22 years 260 19.1 % Gender Male 648 47.5 % Female 716 52.5 % Smoking status Smoking 497 36.4 % Non smoking 867 63.6 % J Bagh College Dentistry Vol. 32(3), September 2020 The impact of 11 *Highly significant P≤0.01 Table (3): Caries Experience DMFS and its Components (DS, MS, FS) according to Quality of Life Domains Scores. WHOQOL-BREF domains Caries experience (Mean ± SE) DS MS FS DMFS Physical health Poor N= 323 16.29 ± 0.33 10.90 ± 0.30 0.76 ± 0.05 28.86 ± 0.38 Fair N= 699 7.07 ± 0.18 4.50 ± 0.16 2.16 ± 0.09 12.25 ± 0.28 Good N= 342 1.73 ± 0.26 0.58 ± 0.14 0.18 ± 0.03 2.48 ± 0.40 ANOVA df= 2 F 697.25* 509.40* 225.02* 1137.81* Sig. 0.001 0.001 0.001 0.001 Psychological Poor N= 357 13.40 ± 0.38 8.54 ± 0.32 1.73 ± 0.09 23.34 ± 0.58 Fair N= 661 7.79 ± 0.22 5.18 ± 0.19 0.91 ± 0.05 13.74 ± 0.36 Good N=346 2.48 ± 0.30 1.13 ± 0.17 0.20 ± 0.03 3.81 ± 0.45 ANOVA df= 2 F 281.16* 202.75* 116.05* 371.51* Sig. 0.001 0.001 0.001 0.001 Social Poor N= 313 12.92 ± 0.39 8.71 ± 0.33 1.62 ± 0.09 22.95 ± 0.61 Fair N= 726 8.45 ± 0.23 5.35 ± 0.19 1.01 ± 0.06 14.64 ± 0.37 Good N= 325 1.90 ± 0.30 0.78 ± 0.16 0.14 ± 0.03 2.83 ± 0.44 ANOVA df= 2 F 260.40* 215.69* 96.80* 361.48* Sig. 0.001 0.001 0.001 0.001 Environment Poor N= 268 12.38 ± 0.45 7.91 ± 0.38 1.65 ± 0.10 21.62 ± 0.73 Fair N= 776 8.83 ± 0.23 5.82 ± 0.19 1.03 ± 0.05 15.52 ± 0.35 Good N= 320 1.95 ± 0.29 0.70 ± 0.15 0.15 ± 0.03 2.81 ± 0.43 ANOVA df= 2 F 218.07* 176.72* 92.27* 294.75* Sig. 0.001 0.001 0.001 0.001 *Highly significant P≤0.01. Table (2): Quality of Life Domains Score (mean and SE) according to Caries Severity. Caries severity WHOQOL-BREF domains (mean ± SE) Physical Psychological Social Environment Caries free N= 350 77.13 ± 0.34 63.88 ± 0.79 68.60 ± 0.93 65.27 ± 0.69 Low severity N= 633 59.12 ± 0.38 46.97 ± 0.39 46.13 ± 0.45 43.07 ± 0.57 High severity N= 381 34.91 ± 0.68 42.91 ± 0.40 40.64 ± 0.54 35.97 ± 0.55 ANOVA df= 2 F 1609.46* 393.44* 490.85* 507.28* Sig. 0.001 0.001 0.001 0.001 J Bagh College Dentistry Vol. 32(3), September 2020 The impact of 12 DISCUSSION Dental caries is a disease that is caused by many factors (11). In order to evaluate dental caries, DMFS index was used, which is an arithmetical index that measures the cumulative caries aggression of the individuals (12). However, it seemed that students' dental education affects DMFS components since it was noticed that a decrease in the number of carious lesions was accompanied by an increase in the number of fillings as the students progressed from one academic year to the next (2). This finding shows that as the dental students with low severity (DMFS ˂12) of dental caries in the present study showed the higher percentage (46.4%). This could be explained by many factors affecting the prevalence of dental caries such as the level of education, socioeconomic status or good oral hygiene measures. Evaluation of quality of life, including quality of life related to oral health, depends on an individual’s expectations and experiences, which vary according to the social, psychological, socioeconomic, demographic, and other cultural factors (4,13). Students with high DMFS had poor quality of life due to the psychological discomfort which is the biggest drivers of poor quality of life among dental students, which was in line with other studies (15-18). Therefore, one may assume a similar pattern of quality of life related to oral health exists in young adults in different countries. In the current investigation, a higher DMFS index was associated with low quality of life as the dental caries is multifactorial disease (19) and one of the most important factor that has an effect on it is the socioeconomic status (20,21) that includes social factor, low life style and behavior, low ability for utilization dental services (22,23). So, because of these difficulties and the bad environment, this could lead to less care for the oral hygiene (24). In contrast, Swedish and China studies did not find any differences in quality of life among young adults at high caries risk(17,25). Nevertheless, Japanese university students with a higher DMFS index had lower quality of life (18). At present, the mechanisms of the relationship between dental caries experience and quality of life are unclear. Given that physical pain was the most frequently reported, it is assumed that the dental caries experience among the dental students was likely associated with pain in their mouth. Public health measures, as well as dental practitioners, should focus on the prevention of dental diseases to decrease dental pain and DMFS index and improve quality of life among young Iraqis adults. CONCLUSION Clinically-assessed oral health (DMFS index) was found to be a significant predictor of low quality of life among dental students in Iraq. Public health measures should focus on the prevention of dental caries and the development of strategies to promote oral health specifically among dental students. REFERENCES 1. Kumar S, Motwani K, Dak N, Balasubramanyam G, Duraiswamy P, Kulkarni S. Dental health behaviour in relation to caries status among medical and dental undergraduate students of Udaipur district, India. Int J Dent Hyg. 2010; 8:86-94. 2. Simat S, Mostarcic K, Matijevic J, Simeon P, Grget KR, Jukic Krmek S. A comparison of oral status of the fourth-year students of various colleges at the University of Zagreb. Acta Stomatol Croat. 2011;45:177-83. 3. Kidd E. Essentials of Dental Caries: The Disease and Its Management. 3rd ed. Great Clarendon Street: Oxford University Press. 2005: 18-128. 4. Mariko N, Hidemichi Y, Yoshiaki N, Takeo N, Nobuyuki H and Nobuhiro H. Oral health status and health-related quality of life: a systematic review. J Oral Sci. 2006;48 (1):1-7. 5. Fallowfield L. What is quality of life? What is…? Series. Sanofi-Aventis and Hayward Medical Communications, Hyward group Ltd. UK. 2009. 6. WHOQOL Group. The development of the World Health Organization quality of life assessment instrument (the WHOQOL). In J. Orley and W. Kuyken (Eds) Quality of Life Assessment: International Perspectives. Heidelberg: Springer Verlag 1994b. 7. WHOQOL Group. The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med.1995;41(10):1403-1409. 8. WHOQOL Group. Development of the WHOQOL: Rationale and current status. Int. J Ment Health. 1994a;23(3): 24-56. 9. WHOQOL Group. Development of the World Health organization WHOQOL-BREF quality of life assessment. The WHOQOL group. Psychol Med. 1998;28(3):551-558. 10. World Health Organization (WHO). Oral health surveys: basic methods. 4 ed. Geneva: ORH/EPID, 1997. 11. Shaffer JR, Wang X, Desensi RS, Wendell S et al. Genetic susceptibility to dental caries on pit and fissure and smooth surfaces. Caries Res. 2012; 46(1):38-46. 12. Hiremath SS. Textbook of preventive and community dentistry, 2 nd ed. India: Elsevier 2011. 13. Carr AJ, Gibson B, Robinson PG. Is quality of life determined by expectations or experience? Br Med J. 2001;322:1240-1243. 14. Mohammed SM, Diab BS. The impact of depression status on dental caries severity among internally displaced people in Baghdad/ Iraq. J Bagh Coll Dent. 2019; 31(1):9-13 J Bagh College Dentistry Vol. 32(3), September 2020 The impact of 13 15. Acharya S, Sangam DK. Oral health-related quality of life and its relationship with health locus of control among Indian dental university students. Eur J Dent Educ. 2008; 12:208-212. 16. Gonzales-Sullcahuaman JA, Ferreira FM, de Menezes JV, Paiva SM, Fraiz FC. Oral health-related quality of life among Brazilian dental students. Acta Odontol Latinoam. 2013;26:76-83. 17. Lu HX, Wong M, Lo E, McGrath C. Oral health related quality of life among young adults. Appl Res Qual Life. 2015; 10:37-47. 18. Yamane-Takeuchi M, Ekuni D, Mizutani S, Kataoka K, Taniguchi-Tabata A, Azuma T, Furuta M, Tomofuji T, Iwasaki Y, Morita M. Associations among oral health-related quality of life, subjective symptoms, clinical status, and self-rated oral health in Japanese university students: A cross-sectional study. BMC Oral Health. 2016;16: 127. 19. Aas JA, Griffen AL, Dardis SR, Lee AM, Olsen I, Dewhirst FE, Paster B.J. Bacteria of Dental Caries in Primary and Permanent Teeth in Children and Young Adults. J Clin Microbiol. 2008; 46(4):1407-17. 20. Al-Azawi LA. Oral health status and treatment among Iraqi five year old kindergarten children and fifteen years old students (A national survey). PhD thesis, university of Baghdad, Collage of Dentistry. 2000. 21. Abdul-Razzaq QR. Oral health status among 15 years old School students in Suilimania city – Iraq. Master thesis, College of Dentistry, University of Baghdad. 2007. 22. Pitts N, Amaechi B, Niederman R, Acevedo A, Vianna R, Ganss C, Honkala E. Global oral health inequalities: Dental caries task Group—Research agenda. Adv Dent Res. 2011;23(2): 211-220. 23. Olusile AO, Adeniyi AA, Orebanjo O. Self-rated oral health status, oral health service utilization, and oral hygiene practices among adult nigerians. BMC Oral Health. 2014;14:140. 24. World Health Organization. International Statistical Classification of Diseases and Health Related Problems. Geneva: Author; 2016 25. Oscarson N, Kallestal C, Lindholm L. A pilot study of the use of oral health-related quality of life measures as an outcome for analysing the impact of caries disease among Swedish 19-year-olds. Caries Res. 2007;41:85-92. :مستخلصال يأخذ تسوس األسنان األولوية القصوى في خدمات صحة الفم التي تخص الفئة الشبابية. لغاية اآلن التوجد دراسة محلية الخلفية: تكشف تأثير جودة الحياة وعالقتها بتسوس األسنان بين طالب طب األسنان.الهدف من الدراسة الحالية :هو لقياس تأثير تسوس األسنان في ثالث محافظات في العراق. األسنان على جودة الحياة بين طالب طب سنة من ثالث محافظات. تم الحصول على معلومات عن 22- 18طالب طب أسنان بعمر 1364: شملت العينة المواد والطرق جودة الحياة من الطالب بواسطة أستبيان خاص. تم جمع البيانات وتلخيصها وتحليلها أحصائيا. تم قياس تسوس األسنان في الدراسة من منظمة الصحة العالمية. DMFSالحالية بأستخدام مقياس : فيما يخص تسوس األسنان واألنماط األربعة لجودة الحياة فأنه في كل نمط تكون القيمة المتوسطة لالسطح المسوسة اعلى النتيجة قياس تسوس األسنان يظهر أقل معدل قيمة في المقياس تليها القيمة المتوسطة لالسطح المفقودة ثم الممتلئة. من ناحية أخرى فأن م له بين مجموعة جودة الحياة المرتفعة في كل أنماط جودة الحياة ويكون أكبر معدل لتسوس األسنان بين مجموعة جودة الحياة المنخفضة. التسوس. كان لجودة الحياة بين طالب طب األسنان تأثيرعلى تسوس األسنان كما أنها ترتبط أرتباط وثيق مع شدة الخالصة: الكلمات المفتاحية: تجربة نخر االسنان, طالب طب األسنان, جودة الحياة