Cotnmunity Detit Oral Epidemiol 1997: 25: 284-90 Printed iti Denmark .

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Communify Dentistiy and Oral Epidemiology
ISSN 0301-5661

Derivation and validation of a shortform oral health impact profile
Slade GD; Derivation and validation of a short-fortn oral health impact profile. Comtnunity Dent Oral Epidetniol 1997; 25; 284-90. © Munksgaard, 1997 Abstract - Growing recognition that quality of life is an important outcome of dental care has created a need for a range of instrutnents to measure oral healthrelated quality of life. This study aimed to derive a subset of items from the Oral Health Impact Profile (OHIP-49) - a 49-itetn questionnaire that tneasures people's perceptions of the impact of oral conditions on their well-being. Secondary analysis was conducted using data from an epidemiologic study of 1217 people aged 60-1- years in South Austraha. Internal reliability analysis, factor analysis and regression analysis were undertaken to derive a subset (OHIP-14) questionnaire and its validity was evaluated by assessing associations with sociodetnographic and clinical oral status variables. Internal reliabihty of the OHIP-14 was evaluated using Cronbach's coefficient a. Regression analysis yielded an optimal set of 14 questions. The OHIP-14 accounted for 94% of variance in the OHIP49; had high reliability (a=0.88); contained questions from each ofthe seven conceptual dimensions of the OHIP-49; and had a good distribution of prevalence for individual questions. OHIP-14 scores and OHIP-49 scores displayed the same pattern of variation among sociodemographic groups of older adults. In a multivariate analysis of dentate people, eight oral status and sociodemographic variables were associated {P<0.05) with both the OHIP-49 and the OHIP-14. While it will be important to replicate these findings in other populations, the findings suggest that the OHIP-14 has good reliability, validity and precision.

Gary D, Slade
Department of Dental Ecology, University of North Carolina, USA

Key words: epidemiology; orai health: psychometrics; quality of life Gary D. Slade, Department of Dental Ecoiogy, University of North Caroiina, CB#7450, Chapei Hili, NC 27599-7450, USA Accepted for pubiication 4 August, t996

The extension of people's life span and the enhancement of their quality of life are two central goals of the Healthy People 2000 initiative (1). This emphasis on quality of life is consistent with the concept that health is a resource and not simply the absence of disease. Increasingly, quality-of-life assessment is being regarded as an essential component for as.sessing outcomes of health care, including outcomes for public health programs (2). Until a decade ago, there was a virtual absence of indices to measure quality of life as it relates to oral health. However, there is now an impressive range of instruments that assess the impact of oral conditions on well-being and quality of life (3). The Oral Health Impact Profile (OHIP) is one such instrument that measures people's perception of the so-

cial impact of oral disorders on their well-being. The development, reliability and validity of the OHIP have been described previously (4). The 49 questions in the OHIP capture seven conceptually formulated dimensions that are based on Locker's theoretical model of oral health (Fig. I) (5). The seven dimensions are: functional limitation, physieal pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. The hierarchy captures outcomes that have an increasingly disruptive itnpact on people's lives. For exatnple, the functional litnitation qttestions capture impacts that would be apparent primarily to the individual, such as; "Have you had difficulty chewing any foods because of problems with your teeth, tnouth or den-

tures?" Qtiestions in the disability dimension refer to itnpacts on everyday activities, such as; "Have you had to interrupt meals because of problems with your teeth, mouth or dentures?" while handicap represents the extent of disadvantage caused by oral health, such as; "Have you been unable to enjoy other people's company because of problems with your teeth, tnouth or dentures?" Separate subscales can be calculated for each dimension of the OHIP, while overall levels of social impact have been computed using all 49 questions. Epidemiological studies that have used the OHIP have found that missing teeth, untreated decay, periodontal attachment loss and barriers to dental care are associated with increasing levels of impact on well-being (6-

1. For bier. and cotnputaSubjects in that study were a stratified tion of factor loadings for each quesrandotn satnple of cotntnunity-dwelling tioti to idetitify atiy that exceeded persons aged 60+ years living in Ade0. 285 IMPAIRMENT FUNCTIONAL LIMITATION DISCOMFORT &PAIN DISABILITY Physical Psychological Social I HANDICAP Eig. The Medical Outcomes Study (MOS) set of 116 core items was shortened to versions that contained 20 itetns (SF-20) and 36 itetns (SF-36) by selecting items that response was selected to identify questions that caused respotidents the greatest problems with interpretation or completion. which was used as a threshold laide. For this report. with the total OHIP score (obtaitied which were cotnpleted by 1217 interby summing the coded Likert-type viewed people. In addition. and frotn clinical oral responses from all questions) as the examinations that were conducted dependent variable and each quesamong 716 interviewed people who tion was an independent variable. responses. default stepwise procedure was used in which individual questions were For each of the 49 OHIP questions. and 3. Least-sc/uarcs regression was used administered OHIP questionnaires. some research settings do not pertnit use ofthe full battery of 49 questions in the instrutnent. This "controlled" regression a threshold of occasionally. the vahdity of the short form The first step in deriving a short (OHIP-14) was investigated by deterfortn begat! by elimitiating items that tnining whether its associations with applied only to denture wearers and sociodetnographic and clinical variables items where 5%) or more of responses were sitnilar to the associations between were left blank or marked "don't the full OHIP (OHIP-49) and those know". identified.were added sequenstatistics were created by computing the tially. the state capital. This was followed ondary analysis of data collected in by promax rotation of the factors 1991/92 during a cross-sectional study that accounted for the greatest of older adults in South Australia (6). fairly often procedure was also condueted until or very often was used to dichototnize 14 itetns. the General Health Questionnaire was shortened frotn 60 itetns to 28 itetns using factor analysis (12). amoutit of variation. a rural city in the south-east of the the factor analysis. considered sequentially for their people were asked how frequently they contribution to total R~. The data for this report come from self. Theti. For example. Prineipctl components factor analysis Methods was undertaken to identify a set of underlying factors contributing to This paper reports findings frotn a secOHIP responses. Some 1650 people took part in a were set to the variable's squared face-to-face interview that asked about multiple correlation with all other dental visits. atid the had experienced the impact in the prefirst 14 items tnaking the largest adceding 12 months. In other instances. thereby indicating people were selected. validity and precision). tnedical conditions and variables. who had experienced at least sotne itnpact. For example. 1. health services researchers frequently require a more succinct instrument to assess the perceived impact of oral health as one of several outcotnes of dental care. This is described below as the When the final set of questions was prevalence of each itetn. 3 = "fairly often". two from each ditnension. and Mt Gatnfor moderate to high loadings.Deriyalion attd yalidation of short-form OHIP DISEASE had the strongest associations with the long-form scales (13). 2 = over the stepwise procedure. for clinic settings. they should represent multiple health concepts and a range of health states pertaining to general functioning atid well-being. 2. A were dentate. again. The purpose of this report is to describe the derivation of a short-form OHIP questionnaire and to report initial findings concerning its reliability and validity.4. "occasionally". A second tnade on a Likert-type scale and coded procedure itnposed greater control 4="very often". Responses were dition to R. STEWART et al. except that no tnore than two mean of the coded response for each items frotn each coticeptuai dimenitetn which is described below as the sesion were pertnitted to enter the verity score for each itetn. 1. This percentage of non.3. sociodemographic characteristics. three statistical procedures were used with the intention of deriving a subset of approxitnately 1015 questions that could capture as much information as possible from the 49-item OHIP questionnaire. regression atialysis and factor analysis (11). they should have good psychometric properties (reliability. 2. including the frequency with which items were reported and experience with adtninistration of the instrutnent in research settings (14). l="hardly ever" and itetns making the greatest contribuO="nevcr". have described conceptual. cotntnunalities state. This was used to pro- . descriptive tion to total R. additional criteria were used.were selected. Locker's conceptual model of oral health. model. such as the final revision of the Sickness Itnpact Profile. Although there is a general psychometric principle that reliability of ati index decreases as the nutnber of items decreases (9) other criteria provide a rationale lor developitig short-fortn indices. While the OHIP is intended to provide comprehensive data about perceptions of impact on well-being. statistical and pragtnatic requirements for health status questiotinaires (10).same variables. Several statistical techniques have been used to identify short forms of health questionnaires including ititernal reliability analysis. Internal reliability attalysis used Cronbach's coefficient a to determine whether retnoval of individual questions would increase the instrutnent's reliability. they should be simple and easy to use.

number of decayed surfaces (coronal and root). The high-loading questions ranged in preva- lence frotn 11. and maximum periodontal attachtnent loss.06 (Q48). both sutntnary seores varied consistently among subgroups of older adults in South Australia. fairly often or very often by each person.40 (Q34) to 0. perceived need for dental treattnent and financial hardship.30.286 SLADE vide evidence of discriminant validity (15). country of birth. educational attaintnent and household income.94) and could be improved only to the third decimal place by deletion of individual questions. This set of 14 questions was dominated by the two disability dimensions and the handicap dimension. the first seven questions selected (Q23. Although not shown in Table 1.66 to 0. The clinical variables were. (Q43) and severity scores ranged frotn 0.8% (Q34) to 1. usual reason for dental visits. Q18 and Q30) referred to denturerelated disorders. while seven other questions were left blank or marked "don't know" by at least 5% of respondents (Table 1). and it permitted calculation of standardized OHIP scores.0±1. The total R^ for this set of 14 questions was 0. Correlations between the sum of coded responses to all OHIP questiotis atid the individual coded responses were all statistically signifieant (P<0. soeial disability or handicap ditnensions (Table 1). After including the next seven questions.88.27 (Q12) to 0.91 (Q12) to 0. The prevalence of the 14 questiotis ranged from 34.1 that accounted for 69. and summed to produce a standardized score for each subject. Differences between subgroups of each sociodemographic variable were evaluated using analysis of variance. indicating that a mean of 1. Q2) had a total R. The sutn of the products within each ditnension represented subscale scores which were then standardized to a common mean and standard deviation (1. Q9. Models were constructed separately for each depetident variable by iticorporating all clinical and sociodetnographic variables used previously in this study.89) and could not be improved substantially by deletion of questions.64 or more) are presented in Table 1 (column headed "Factor loading").9.10 (Q43) (Table 1). Cronbach's a for this set of 14 questions was 0. Thirty-two of the OHIP questions had factor loadings that exceeded 0.5 to 1. sex. for subgroups defined by dentition status. number of missing teeth (anterior and posterior). Age group and sex differences in OHIP-14 scores were stnall and statistically tioti-significant. For the 14 items.6% (Q48) while severity ranged frotn 0. Q6. and the set of 14 questions included at least one from each dimension. The method has beeti described previously (4). in which the sutn of coded responses to all OHIP questions was the dependent variable. coded responses (ranging frotn 0 to 4) within each dimension were multiplied by previously developed weights. site of last dental visit. number of retained roots. P>0. maximutn periodontal recession. Coded responses to each question were multiplied by the weights and the products were added to produce seven subscale scores that were standardized (1. For the remaining 39 questions.64 questions were reported occasionally.97 to 0. fairly often or very often (Table 2). Furthermore.88. OHIP-14 scores differed by as mueh as a factor of two. Those diffetences were of a sitnilar magtiitude and were statistically significant using the OHIP-49 (Table 2). Results Three of the OHIP-49 questions (Q17. in which entry into the model was litnited to two questions frotn each ditnension. QI5. In bivariate analysis. Q35.7% (Q7) to 1. those 10 questions were excluded from the set for consideration in the short fortn.06 (Q48) (Table 1). Summary scores for the OHIP-14 and OHIP-49 were obtaining by counting the number of items reported occasionally. Eleven of the questions were identical to the questions obtained using the default method of selection. period since last dental visit. the total R-^ increased to 0. The weights reflected population judgments about the relative unpleasantness of each impact.2%. In the controlled stepwise regression procedure. obtained using Thurstone's method of paired comparisons.06 (Q48) (Table 1). least-squares regression to identify oral status and sociodemographic factors that were significantly related to both the OHIP-49 and the OHIP-14 scores for dentate persons. In the default stepwise regression procedure. The validation process was replicated by computing new summary scores that took advantage ofthe full range of coded responses to OHIP questions.4 for the first rotated factor. perceived need for dental treatment. difficulty paying a AUD 100 dental fee.1% (Q12) to 2. Q20. Consequently.74 (Q36).94. Sociodemographic variables were. maximutn periodontal probing depth. number of unreplaced spaces (anterior atid posterior). However.0\) and Pearson's correlation coefficients ranged from 0.92. the 14 itetns ranged in prevalence frotn 33.96 (Q7) to 0. age.0±1.05) were then eliminated from the model until a final model of significant first-order tertns was obtaitied. Factor atialysis revealed one principal cotnponent with an eigenvalue of 15. new weights were computed from the same data set of popvtlatioti judgments about the relative unpleasantness of impacts. The weights represented the proportion of people who judged the impact within each ditnension as more unpleasant than the other impact in that dimension.6% (Q48) and severity ranged from 0.6% (Q48) and the severity scores ranged frotn 1. number of teeth with occlusal attrition to dentin. Variables which were not statistically significant (F-test. For all 49 questions. Factor loadings for the questions with the 14 highest loadings (0. site of last dental visit.Ol). although they did not include questions from the physical disability.96. fairly often or very often) ranged from 73. the prevalence of reported impacts (at the threshold of occasionally. Cronbach's a for this set of 14 questions was 0. Internal reliability for the 39 questions was very high (a=0.0) and sumtned. and the differences were similarly small and nonsignificant using the OHIP-49. The corresponding mean for the OHIP-49 score was 7. reliability was moderate or high among questions within the seven conceptual dimensions (0.of 0. living alone. and an additional three principal components that had eigetivalues ratiging frotn 1. and the differences were statistically significant {P<O. The set of 14 questions from the controlled selection procedure was used to compute OHIP-14 scores. Additional assessment of validity used multivariate.0). .2"/i of variation.1%) (Q15) to 1.

007 0.7 10.6 12.1 12.55 0.76 0.0 23.19 0.6 6.65 0.18 0.80 0.10 0.4 33.34 1.8 1.74 0.19 0.06 0.7 10.8 2.for.10 0.5 34.6 27.2 1.3 0. factor analysis and regression analysis for 49 OHIP items Prevalence.8 16.64 0.48 0.91 0.024 * * 0.14 questions selected to maximize increase in total R^.032 * * * * 0.49 0.7 5.002 0.7 1.69 0.057 0.2 5.31 0.97 1.1 0.057 0.7 0. % reporting item % blank/ occasionally.8 1.39 0.3 32.2 13.2 1.6 0.5 1.5 2.73 0.0 1.70 0.3 6.7 18.71 0.004 0.087 0.Dcriyation and yalidatiott of short-Jorm OHIP Table 1.37 0.8 8.3 1.68 * 0.20 0.016 * * 0.7 0. Prevalence.7 1. Factor loading' Default selection- 287 Conceptual dimension and item Eiitictiotuil litititation Ql Difficulty chewing Q2 Trouble pronouncing words Q3 Noticed tooth that doesn't look right Q4 Appearance affected Q5 Breath stale Q6 Taste worse Q7 Food catching Q8 Digestion worse Q17 Dentures not fitting Physieal poiti Q9 Painful aching QIO Sore jaw Qll Headaches Ql2 Sensitive teeth Ql3 Toothache QI4 Painful gums Q15 Uncomfortable to cat Q16 Sore spots Q18 Discomfort (dentures) Psychological discotnfort Qi9 Worried ' Q20 Self-conscious Q21 Miserable Q22 Appearance Q23 Tense Physical disability Q24 Speech unclear Q25 Others misunderstood Q26 Less flavor in food Q27 Unable to brush teeth Q28 Avoid eating Q29 Diet unsatisfactory Q30 Unable to eat (dentures) Q31 Avoid smiling Q32 Interrupt meals Psychological disability Q33 Sleep interrupted Q34 Upset Q35 Difticult to relax Q36 Depressed Q37 Concentration affected Q38 Been embarrassed Soeial disability Q39 Avoid going out Q40 Less tolerant of others Q41 Trouble getting on with others Q42 Irritable with others Q43 Difficulty doing jobs Hatidleap Q44 Health worsened Q45 Financial loss Q46 Unable to enjoy people's company Q47 Life unsatisfying Q48 Unable to function Q49 Utiable to work Controlled selection-^ 1.4 4.0 8.16 0.75 0.8 1.4 2.2 11.78 0.005 0.18 0. .6 1.011 0.43 0.71 0.29 0.49 0.6 17.8 11.2 1.38 0.1 0. .2 4.1 2.5 3.88 0. means.14 0.82 0.007 0.33 0.56 * 0.12 0.004 0.6 15.8 3.7 11.77 0.2 0.60 0.1 44.3 4.003 * 0.4 1.001 ' 14 questions with highest factor loadings on first rotated factor.42 0.74 0.2 2.27 0.40 0.26 0.032 0.14 * 0.7 4.1 22.3 7.1 10.1 2.3 22. with no more than two items per dimension permitted to enter the model.016 * * * 0. ^ 14 questions selected to maximize increase in total R-.20 0.75 0.7 1.2 29.006 0.6 t.7 0.4 3.004 0.2 3.70 0.8 29.15 0.6 22.1 7.1 7.5 1.2 0.64 0.85 0.96 0.2 2.5 4.007 0.2 18.29 0.56 0.7 2.011 0.5 15.5 4.087 0. * Question excluded because it applies only to denture wearers or because of high non-response.8 Severity: item mean Sequential R.2 1. fairly often or very often don't know 1.5 73.71 0.2 24.1 0.09 0.2 14.8 8.5 0.7 9.29 0.31 0.44 0.03 0.50 0.7 2.8 7.17 0.8 2.6 7.024 0.6 1.6 1.3 9.7 0.7 4.7 4.008 0.7 2.58 0.

2 29. Table 4 presents the 14-OHIP questions obtained from the controlled se- lection procedure.28) (2.2 <0.12 <O.01 0. used in internal reliability analysis. High intercorrelation also appeared to be the teason that only Table 3. 10 explanatory variables were significant in a model using the standardized OHIP-49 score as the dependent variable.01 12. P=0. Multivariate least-squares regression models for 716 dentate persons aged 60-1. and all but one of thetn (financial hardship.01 1.20 <0. of missing anterior teeth No.01 14.44) (2.37) (8.77) (2.07).01) (9.05) when OHIP49 was the dependent variable.8 <0.12) were significant when the standardized OHIP-14 score was the dependent variable.01 <0.0 II.64 1.66) (6.44 2.51 0.4 P <O.37) (2.83) (7.34) (6.51) (2.05).64) (9. and conseqtiently high intercorrelations tneant that the OHIP had very high a values which could not be substantially itnproved by deletion of items.02 0.49) OHIP-14 mean 1.yrs Dependent variable.01) between other subgroups in Table 2.1 <0.01 12.24 6.01 <0.81) (10. difficulty paying AUD 100 dental fee Clinical and sociodemographic factors that were associated with OHIP-49 and OHIP-14 scores for dentate people are summarized in the multivariate regression analysis (Table 3). The same factors remained signifieant when the OHIP-14 was the dependent variable.8 <0.09 R'=0.7 11.09) (2.99) Sex Dentition Site of last dental visit Perceived need for dental treatment Finaticial hardship. of reported medical conditions Attended public dental clinic* Perceived need for dental treatment* Age (yrs) Born outside Australia *Dummy variables coded 0=no. Both indices yielded significant differences (P<0.01 2. Mean nuinber of OHIP-49 and QHIP-14 items for South Australians aged 60-1.89 8.02 0.O 5.12) (3. Discussion Of the three statistical methods that were explored in order to derive a subset of OHIP questions. along with the weights that refiect population judgments about the unpleasantness of each pair of items within ditnensions. is a sutnmary statistic which captures the extent of agreetnent between all possible subsets of questions. of items reported occasionally.01 (SD) (2. the results were generally comparable to the results obtained with the standardized OHIP-49. Cronbach's a. This can be attributed to the tnoderate or high correlation that each item had with the overall OHIP score.33). There were three clinical factors and four noticlinical factors that met the criteria for model building (P<0. sex differences were significant using standardized OHIP-49 (P=0.53) (2.30) (2.67 <0.0 9.60 0.33 1.7 <0.yrs P-value Male Female P-valuc Dentate Edentulous P-value Private dentist Public clinic P-value Yes No P-value None/hardly any A littlc/a lot P-value n 1217 576 473 168 646 571 905 312 962 245 325 850 808 390 mean 7. internal reliability analysis and factor analysis yielded the least satisfactory results.99 6.72) (6.96) (2.37 2.57 1.OI <0. of items reported occasionally.01 <0.17 31.36) (2.67 0.01 6.68 1. l=ycs.11) (1.60) (7.OI (SD) (7.8 5. For the multivariate analysis. In the bivariate analysis.04) in that model.04 R2= =0. When the weights were used to compute subscales and a standardized OHIP-14 score.68 1.74 6.IO) and the standardized OHIP-14 (P= 0. However.5 <0. fairly often or very often OHIP-49 OHIP-14 Explanatory variable No. and in addition country of birth was significant (^=0.0 0.0 <0.3 4.68) (7. there were non-significant differences amotig age groups using both the statidardized OHIP-49 {P=O.01 11.47 <O.47 9.75) (7.93 <0.01 3.19 .30 7. no. of missing unreplaced anterior teeth No.01 0.82 5.69 <0. although not significant usitig the standardized OHIP-14 {P= 0.87) (7.01 10.54 7.288 SLADE Table 2.75 L56 1. F P F 30.66) (7.01 15.23 <0.01 32.01 L39 2.43 10.OI 6.yrs No.16 7. of teeth with attrition No.23) (3.19 <0. fairly often or very often OHIP-49 Group All persons Age 60-69 yrs 70-79 yrs 80-t.

satisfying because of problems with your teeth.51 0. This elbow represents a useful criterion for the selection of principal components for subsequent rotatioti (16). dentures? been a bit etiiborras. mouth or dentures? 0.92 could be obtained with only seven variables. closer inspection reveals that the controlled regressioti procedure yielded more questions that had low prevalence (six questions reported by lO'/o or less of people) cotnpared with the default procedure (three questions with prevalence of 10% or less). mouth or dentures? Have you had paltiful aching in your mouth? Have you found it uticottifortable to eat any foods because of problems with your teeth. some clinical populatiotis) (11).55 0.66 0.8% or less were selected with this method.45 0. Since it was deetned itnportant to capture multiple health concepts with a range of prevalences for the short-form OHIP. mouth or dentures? found it difftatlt to relax because of problems with your teeth. KESSLER & MROCZEK regard the triad of precision. This led .se because of problems with your teeth. Questions and weights for the OHIP-14* Dimension Functional limitation Question Weiaht 0. The subsets have 11 itetns in cotntnon. mouth or dentures? Have you felt that your seti.Deriyalion and yalidatiott of short-form OHIP Table 4. dentures? Psychological Have you disability mouth or Have you mouth or Social disability Have you been a bit irritable with other people because of problems with your teeth. the method of factor analysis was foutid to be unsatisfactory. While this result could be used as justification for the selection of the 14 highest-loading factors to represent a unidimensional index of social itnpact. mouth or dentures? Have you had difficulty doittg your usual jobs because of problems with your teeth. and indicate that there is one single construct underlying the responses to OHIP questions tnade by these older adults. Precision refers to the ability of an itidex to discritnitiate betweeti subgroups.41 Handicap * Responses are made on a 5-point scale.49 0.016 or greater) excluded the physical disability. However.40 289 Have you had trouble protiouticing any ^vords because of problems with your teeth.sed bec-dwx of problems with your teeth. discomfort and functional limitation itetns. they reject this substitution of "variation in frequency for variation in social itnportance" when developing health status indicators. mouth or dentures? Have you felt that life in general was le.62 0. motith or dentures? Have you been totally utiable tofittictioti because of problems wilh your teeth. l=haidly 0. R. KAPLAN ct al. coded responses can be multiplied by weights to yield a subscale score. This interpretation is based on the finding that there was a very rapid reduction in eigenvalues for the second and subsequent principal cotnponents. it failed to show further decrements in a satnple of hospital patients who scored at the lowest levels of health in sotne subscales (13). corresponding to the "elbow" in the scree plot of eigenvalues.59 0. However. The short Ibrtns of the MOS instrument illustrate this principle. coded O = ncvcr. mouth or dentures? discomfort Have you felt teii. there is little to distinguish between the subsets of 14 items obtaitied usitig the default selection procedure atid the controlled selection procedure. found that factors and items that contribute little to explaining variance in occurrence or frequency are considered unitnportant in factor analysis (15). pain. one principal component dominated the factor analysis. ATCHISON & DoLAN have reported a similar phenotnenon with the Geriatric Oral Health Assessment Index. with the pattern of responses indicating that little distitiction was tnade between ditnensions of oral ill-health that manifest as dysfunction. The results with the OHIP are consistent with that finding. that criterion was judged to be too arbitrary in this itistance. it was possible to retaiti two items frotn each ditnension with only a small reduction in of taste has worsened because of problems with your teeth. While some researchers advocate use of all principal components that have eigenvalues greater than one (four of which were found in this analysis).34 0. while the SF-20 had good reliability and validity.48 0. mouth or dentures? Have you had to interrupt ttieols because of problems with your teeth. social disability and handicap ditnensions. In addition. disability or handicap. Within each dimension.60 0. including all of the pain. an R.88). Regression analysis resulted in selection of itetns that had a greater range in prevalence atid severity compared with the range obtained with factor analysis. mouth or dentures? Physical pain Psychological Have you been self-cotiscious because of your teeth.96. the factor loadings in Table 1 indicated that a large nutnber of conceptually itnportant items would be eliminated. With the default regression procedure. reliability and validity as critical psychometric properties for health status tneasures and they argue that it is itnportant to retain less frequently reported items in order to diseritninate between subgroups frotn populations with high levels of disease or disability (for exatnple. although those itetns (Table 2. when 14 variables were selected by the default tnethod. at least one item from each conceptual dimension was included.of 0.value of . These litnitations of factor analysis as a tool for developing indices of health status have been observed by others. The prevalence of items within a battery of questions becotnes a critical factor when the precision of the index is evaluated within different 0. where only one principal component emerged frotn their analysis of the 12 questions in that index (17). only items with relatively low prevalences of 11. By controllitig the process. both account for more than 9O'Mi of variation in total OHIP scores. However. mouth or dentures? Physical disability Has your diet been unsatisfactory because of problems with your teeth. with a small increase of R. The construct could be interpreted to represent "oral ill-health". 4=very often. and both have excellent internal reliability (a=0. 2 = occasionally 3 = fairly often. At first appearance.94.38 0.52 0.

Spencer AJ. Furthertnore. 7. and health-related quality of life. Boston. Locker D. Med Cate 1995. 1978. Slade GD. Nonetheless. Social impact of oral disease among older aldults. 77. Nunnally JC. with the obvious benefit that the data could be collected with less fieldwork effort and respondent burden. 109: 665-72. when standardized scores were computed the satne conclusion was reached . 17. In the current study. types of validity and the index of well-being. Measuring health-related quality of life for public health stirveillancc. not all research settings will be concerned with cross-sectional associations. since the 14 items were selected specifically because they accounted for most of the variance in the summed OHIP responses. 5: 5-13. Gorkic E. Carter WB.the 14 questions were effective in detecting the same associations with clinical and sociodemographie factors that were observed using the 49 questions. Aust Detit J 1994. Coatcs E. Measuring the effects of medical interventions. 55: 205-9. Jones and Bartlett. 9. 33: NS57-77. The findings frotn the OHIP-14 indicate that the items obtained from the controlled selection method were as effective as the OHIP-49 items in detecting differences among subgroups of older South Australians. 8. Standardized scores also utilize the weights refiecting lay judgments about the severity of impacts. McGraw-Hill. prevalence and severity scores have been derived from a sample of independently living older adults who generally are free of severe oral disease. Psyehotttetrie theory. and therefore it will be necessary to evaluate the perfortnance of the OHIP-14 using other research designs. Atchison KA. Spencer AJ. 26: llA-'il. Consequently. 41: 33-6. Mazel RM. 12. Acknowledgtnents . Bush JW. questions with low prevalence in this population would be reported more frequently in subgroups of people with more severe oral disease. An important caveat in this study relates to the use of a single source of data for both derivation of a subset and validation of that subset of questions. Health Serv Res 1976. Plenum Press. Racial variations in social impact among older community-dwelling adults.290 SLADE to the development of the SF-36 which included questions about more severe levels of disability. 33: AS 109-19.O. However. Bcrgner M. of Health and Human Services.3-I1. 14. 18. While this measure is simple to compute and interpret.The author acknowledges with gratitude the comments provided by Dr Ronald Hunt and Dr Dan Shugars during the preparation of this manuscript. Sutnmary scores based on the OHIP-14 displayed the satne pattern of variation among sociodemographic groups that was observed using the OHIP-49. Furthermore. References 1. For these reasons. Brackbill R.88. New York. and those questions have a good distribution of prevalences. 1967. Shcrbournc CD. Hays RD. Healthy people 2000. Slade GD. when the OHIP-49 was administered to a sample of dental patients aged 21-49 years with HIV infection. In some respects. and therefore those questions diseritninate tnore effectively within those subgroups. Gilson BS. Hunt RJ.• 478-507. Atchison KA. Gerodcmtology 1994. 16. Kessler RC. J Pttblic Health Dent 1995. Med Care 1995. their levels of social impact were more than twice as high as the levels reported by general dental patients (19). Psyehol Med 1979. Kaplan RM. a conceptual framework. Locker D. Original data for this analysis were collected with financial assistance from the Australian National Health and Medical Research Council and the US National Institute of Dental Research (Grant No. Gift HC. Med Care 1981. 15.• 108-14. 3. 5. both the OHIP-14 and OHIP-49 (Tables 2 and 3) were computed by counting the number of items reported oecasionally. health. Cottitnutiity Detit Health 1994. Mroczek DK. 1992. 9: 139-45. Slade GD. Moriarty DG. and therefore experience impacts on qualitatively different aspects of their lives (18). Aust Detit J 1996. Scherr PA. R0I-DE09588). Health Eeon 1993. this should not be surprising. Oral health.i. In conclusion. For example. //. development and final revision of a health status measure. Berry CC. 19. / Public Health Dent 1994. Evaluation of subjective oral health status indicators. Goss AN. Hays RD. Health status. it fails to take advantage of the full range of responses to each question. Cotntiiutiity Detit Health 1988. Development of the geriatric oral health assessment index. Goldberg DP Hillicr VF A scaled version of the general health questionnaire. The MOS short-form general health survey Med Care 1988. The sickness impact profile. Cattell RB. fairly often or very often. 54: 680-7. it will be important to investigate the reliability and validity of the OHIP-14 in other populations. New York. Measuring oral health. an impact that is rare. the use of this threshold probably contributes to "false positive" reports (for example. 11. 192-3' 10. standardized scores are a preferred method for examining associations betweeti explanatory factors and reported impact. Publie Health Rep 1994. and therefore they rely on a threshold of reported itnpact. / Dent Edite 1990. Ware JD. Hennessy CH. Oral conditions and their social impact among HIV dental patients. //. The RAND 36-item health survey I.' . Precision has also been cited as an important requirement for oral health indices. Slade G. 39: 358-64. suggesting the instrument should be useful for quantifying levels of impact on wellbeing in settings where only a limited number of questions can be administered. a controlled regression procedure permitted identificatioti of a subset of 14 questions about the social itnpact of oral disease that accounted for 94% of variation in total OHIP scores and which had an internal reliability coefficient (a) of 0. but which is incorrectly reported at the "occasional threshold"). suggesting that the OHIP14 has good statistical properties and validity. 4. Slade GD. Bobhitt RA. Strauss R. Development and evaluation of the oral health impact profile. Stewart AL. The OHIP-14 contains questions that retain the original conceptual ditnensions contained in the OHIP. 19: 787-805. Dolan TA. these cross-sectional findings provide encouraging results. 2: 217-27. Association between clinical and subjective indicators of oral health in an older adult population. Locker D. 13. //. Miller Y. Natiotial health protitotioti atid disease prevetitioti objectives. 2. and both the OHIP-14 and the OHIP-49 resulted in sitnilar tnultivariate models relating oral status and sociodetnographic variables to social impact. 54: 167-76. Zack MM. since different subgroups may have vastly different oral conditions. Nonetheless. 6. such as longitudinal studies and experimental trials.scieittifie use of faetor analysis in behavioral and life sciences. However. . US Dept.

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