Oral-health-related quality of life in adolescents: umbrella review

In the last years, the interest in associating Quality of Life and Oral Health increased potentially. Quality of life is an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. Oral health is the state of the mouth, teeth and orofacial structures that enables individuals to perform essential functions such as eating, breathing and speaking, and encompasses psychosocial dimensions such as self-confidence, well-being and the ability to socialize and work without pain, discomfort and embarrassment. Oral conditions and self-perception can impact the daily life and well-being of the individual [1‐3] and are not restricted to physical effects, but associate family, social, economic, psychological, spiritual and environmental issues, depending on the accumulated risk throughout life [4].

In this context, adolescence is a period of vulnerability and involves hormonal, behavioral and psychological changes. Studies indicate changes in eating habits and aesthetic perception [5, 6]. Adolescents have specific needs and concerns that can cause oral disease [6]. In this age group Malocclusion gingivitis and periodontal disease are very common problems. Such as dental caries and DMFT [6‐8].

The literature report worse oral health conditions impact school performance and socialization [5]. Impact on oral health-related quality of life (OHRQoL) increases proportionally with the severity of oral diseases [9, 10]. Fluorosis and dental caries impact on self-perception [11‐13]. Pain and aesthetic problems are associated with the worst OHRQoL reports and greatest impact on social and emotional domains [13, 14]. Socioeconomic and behavioral factors are reported to be strong predictors for the impact on OHRQoL. Maternal education level, family income and social support can significantly influence the adolescent's self-perception [15].

However, other studies observed that adolescents do not benefit from health care and attention, when compared to children and adults [15, 16]. Health practices, stress mechanisms, need for treatment, resistance to dental consultations, fear and anxiety about dental care are possible factors that impact health-related quality of life in teenagers, but they are rarely reported in the literature [11, 17‐19].

Systematic reviews carried out to observe the methodological quality of the studies, and thath encourage the realization of new, well-designed research on the subject [9, 10]. This because, many studies report general limitations in the papers included, which may compromise the quality of the evidence of the findings. Disagreements between authors on the method of evaluating predictive factors such as caries, frequency of dental visits and the outcome related to OHRQoL [9, 20], and the allocation of children and adolescents in the same group/assessment method may suggest biased data [9]. They also indicate the importance of using validated and tested socio-dental measures in different populations to analyze the impact on OHRQoL in adolescents [9, 10]. Untill now, only two instruments assess the impact of oral health on the oral health-related quality of life of adolescents between 11 and 18 years of age: the Caregiver Perceptions Questionnaire (CPQ 11–14), and the Child Oral Impacts on Daily Performances (Child OIDP [2, 19].

Therefore, the objective of this study is to review the literature who investigates the possible relationship of oral health conditions, demographic, socioeconomic and behavioral characteristics with OHRQoL in adolescents, through an umbrella systematic review.

The search strategy found 362 articles. Only 22 systematic reviews were included, as shown in Fig. 1.

Many systematic scientific reviews on this topic are found in the literatue, in the process of writing this article. However, it is essential to consider the methodological rigor of the studies in order to expand scientific knowledge. Thus, supporting decision-making and generating data for the implementation of health strategies and programs focused on specific and vulnerable populations. This is the first systematic umbrella review to provide an overview of factors that impact HRQoL in adolescentes between 10 and 19 years of age. The main findings show that dental caries, malocclusion [9, 26‐30], TMD [9], dental trauma (TDI) [32, 34, 35], poor brushing [36], toothache [26], periodontal disease [34] and edentulism [9] negatively affect the quality of life of adolescents. The need for orthodontic treatment [26, 34] and the completion of orthodontic treatment [40, 44‐46] also influence behavior and self-perception related to oral health in adolescents. This can be explained by the changes in adolescence and the increase in aesthetic perception, involving social, behavioral and psychological factors [5]. In addition, we can see that pain and aesthetics cause greater demand for dental care, causing financial expenses and impact on quality of life and parents tend to report the worst impact.

Another important finding is related to social determinants, such as demographic and socioeconomic factors. Being an only child, growing up in your nuclear family, housing area and security, level of maternal education, access to dental care and the performance of health promotion programs are directly proportional to OHRQoL in adolescents [36, 39, 43, 47]. This can be explained by the level of information and awareness, which favors similar behaviors. People with higher educational level tend to make better health choices.

As previous studies reported, low socioeconomic status, poor social support, negative oral health beliefs and lower levels of protective psychosocial factors were significantly associated with unhealthy behaviours and poor HRQoL in adolescentes [4]. Moreover, this indicators can be used to identify the risk of impaired OHRQoL already at the beginning of adolescence [48]. This systematic review observed that the place of origin of those responsible and use of services does not have sufficient scientific evidence. Parental occupation, marital status and the family provider being the mother or direct caregiver were not able to impact adolescents' self-perception on OHRQoL [43]. Perhaps, these findings can be explained by the adolescents' self-perception related to group acceptance and social support from the environment they live in. There are two theories that can explain the process: the psychosocial conceptual model and the lifetime risk accumulation model. Family or social groups tend to present the same health behaviors and this can have a negative or positive influence throughout life. The socio-environmental context and health choices throughout life can influence the development of diseases, including the socioeconomic level of the adult individual.

It should also be said that the subject's condition of life is determined by the position he occupies in space in relation to the type of power or capital obtained. Thus, economic capital (income), while it can generate specific risks such as occupational ones, symbolizes greater access to care and living conditions, allowing better coping with the illness process; cultural capital (level of education) allows access to knowledge about the risks of becoming ill and prevention; symbolic capital (prestige, personal/professional recognition) is related to the subjective dimension of people's satisfaction with life, making them more normative in their environment; and social capital (social cohesion) concerns a set of elements of social organization, such as mutual trust, solidarity and civic engagement, which facilitate the coordination and cooperation of collective actions to achieve mutual benefits. Therefore, it can be said that exposure to different risks depends on how the individual places himself in different fields, as well as the relationships resulting from this position.

Biological data such as skin color and age have no concrete evidence about this impact in the OHRQoL. These factors could establish a strong correlation between demographic and socioeconomic factors. In the literature, this relationship is conflicting [48, 49]. There is great heterogeneity in age-related data collection. There is no standardized assessment. The cognitive understanding of a 5-year-old child is different from that of a 12-year-old, so it would be impossible to apply the same instrument to both age groups simultaneously. Thus, the questions are adapted and validated for the age group according to the cognitive needs of each one. It should be noted that self-perception and children's cognitive health are considered age-dependent and the result of continuous cognitive, emotional, social and language development. Therefore, it is important to obtain information from the child's parents or guardians in order to obtain complete information, thus obtaining an effective questionnaire, that is, capable of measuring the impact of oral conditions on the quality of life related to the oral health of children.

Another important aspect is the method of evaluating the OHRQoL outcome. Different measurement instruments were found in the 22 systematic reviews included in this study, which makes data analysis and results interpretation difficult. In this context, a large number of instruments that assess the impact of oral conditions on oral health-related quality of life have been produced and validated worldwide, with the aim of providing greater accuracy to individual and collective assessments. These instruments have become fundamental to complement clinical measures, but there is little guidance for the proper selection of these instruments, since there are principles to be followed.

In addition, the selected articles investigated different independente variable. Same variable presented different methods of observation and evaluation. Statistical approaches were also different, including univariate and multivariate regression. Therefore, the heterogeneity in the process of producing evidence and in the methodology proposed by the studies is highlighted. Likewise, differences were observed in the sampling according to age and gender. Age, developmental level and gender influence and affect the well-being of young people [34, 50]. Even the sample size of the different studies included in the systematic reviews demonstrate methodological flaws and limitations, which can lead the reader to misinterpret the results.

It was observed that only one article was considered of moderate/high quality [34] and one article of moderate Quality [39], ten had critically low Quality [9, 27‐30, 32, 35, 38‐40, 45], and ten others had low quality [29, 31, 33, 36‐38, 41‐44, 46], according to the AMSTAR 2-based method. This made it difficult to carry out the meta-analysis of this systematic review.

AMSTAR 2 was the instrument used in the present study, with the objective of critically qualifying the reviews. The tool has a robust and adequate method for evaluating sistematic reviews [21, 23, 24] and was deprecated from the RoB 2 (Cochrane risk-of-bias tool), as it focuses its analysis criteria on the field of randomized trials [24]. In addition, a trend towards the adoption of AMSTAR 2 as a methodological quality assessment tool was observed in the umbrella reviews published in the medical and dental field [35, 51‐54].

Three initially selected systematic reviews were later excluded due to lack of information, as the corresponding author did not respond to our contact to provide the necessary information. This fact can also be pointed out as a limiting factor, since the purpose of the umbrella review is to analyze the totality of sistematic reviews relevant to a given topic. It is impossible to ignore the fact that these studies could add new evidence, corroborate or refute the results obtained.

Umbrella systematic reviews are a recent modality of study, with no established conduction protocols. It is prudent to infer that this is a compilation of the above information organized in a concise manner. The search strategy was judicious, however there is a scarcity of studies with high quality on quality of life related to oral health. Important aspects such as tooth loss, agenesis, bruxism, TMD are neglected and little studied, despite the complaints of patients in the clinical routine.

The inclusion of gray literature was considered and a simple search strategy was even run in Opengrey and Google Scholar databases. As a result, an exorbitant number of works was obtained that did not meet the inclusion criteria, such as: theses, reports, annals and critical reviews. So, it was decided not to include the gray literature, despite not knowing the real harm in obtaining new evidence.

This systematic umbrella review found that dental caries, malocclusion, temporomandibular disorders, dental trauma, poor brushing, toothache, periodontal disease, and edentulism vahe a negative impact on oral health-related quality of life. In addition, social determinants, such as demographic and socioeconomic factors, like being an only child, growing up in your nuclear family, housing area and security, level of parental education, access to dental care and the performance of health promotion programs are directly proportional to OHRQoL and self-perception in adolescentes. Important aspects like gender and skin color did not have their level of impact clarified. These findings are important to clarify what context can cause negative impact in adolescents daily lives. Armed with this knowledge, strategies and public policies focused on this age group, will be assertive.