J Periodont Res 2017 © 2017 John Wiley & Sons A/S.

All rights reserved Published by John Wiley & Sons Ltd

JOURNAL OF PERIODONTAL RESEARCH

doi:10.1111/jre.12436
Review article
M. C. Ferreira1, A. C. Dias-Pereira1,
Impact of periodontal L. S. Branco-de-Almeida2,
C. C. Martins3, S. M. Paiva3

disease on quality of life: a

1
Master’s Program in Dentistry, Ceuma
University (UNICEUMA), Sa ~o Luıs, Maranha ~o,
Brazil, 2Department of Dentistry II, Federal
~o (UFMA), Sa ~o Luıs,

systematic review
University of Maranha
Maranha ~o, Brazil and 3Department of Pediatric
Dentistry and Orthodontics, School of Dentistry,
Federal University of Minas Gerais (UFMG),
Belo Horizonte, Minas Gerais, Brazil

Ferreira MC, Dias-Pereira AC, Branco-de-Almeida LS, Martins CC, Paiva SM.
Impact of periodontal disease on quality of life: a systematic review. J Periodont
Res 2017; doi: 10.1111/jre.12436. © 2017 John Wiley & Sons A/S. Published by
John Wiley & Sons Ltd.

The diagnosis of periodontal disease is commonly based on objective evalua-

tions of the patient’s medical/dental history as well as clinical and radiographic
examinations. However, periodontal disease should also be evaluated subjec-
tively through measures that quantify its impact on oral health-related quality
of life. The aim of this study was to evaluate the impact of periodontal disease
on quality of life among adolescents, adults and older adults. A systematic
search of the literature was performed for scientific articles published up to July
2015 using electronic databases and a manual search. Two independent review-
ers performed the selection of the studies, extracted the data and assessed the
methodological quality. Thirty-four cross-sectional studies involving any age
group, except children, and the use of questionnaires for the assessment of the
impact of periodontal disease on quality of life were included. Twenty-five stud-
ies demonstrated that periodontal disease was associated with a negative impact
on quality of life, with severe periodontitis exerting the most significant impact
by compromising aspects related to function and esthetics. Unlike periodontitis, Meire Coelho Ferreira, R. Perdizes, QD 35,
gingivitis was associated with pain as well as difficulties performing oral hygiene n. 27, Apto 805, Renascencßa II, 65075-340
~o Luıs, Maranha
Sa ~o, Brazil
and wearing dentures. Gingivitis was also negatively correlated with comfort. Tel/Fax: +55 XX 98 3214-4127
The results indicate that periodontal disease may exert an impact on quality of e-mail: meirecofe@hotmail.com
life of individuals, with greater severity of the disease related to greater impact. Key words: adolescents; adults; disease,
Longitudinal studies with representative samples are needed to ensure validity of periodontal; quality of life
the findings. Accepted for publication November 22, 2016

Periodontal disease is a chronic
inflammatory infection that leads to
destruction of the supporting tissues
of the teeth, with the progressive loss
of connective tissue attachment and
bone resorption. The pathogenesis of
periodontal disease is characterized by
complex relationships between
microorganisms in dental biofilm (pla-
que) and the immuno-inflammatory
response of the host, which may be
influenced by genetic factors, environ-
mental and/or acquired conditions,
such as smoking and systemic diseases
(1). Importantly, periodontal disease
may also be a modifying factor of sys-
temic health (2) and its clinical conse-
quences can exert an impact on
quality of life in the form of emo-
tional, social and functional aspects
as well as symptoms in acute pro-
cesses (3–6).
Studies with representative samples
report prevalence rates of periodontal
disease ranging from 5.5% to 85.1%
among adults (7–9). These prevalence
findings depend on the diagnostic cri-
teria established and the severity of
the periodontal disease. The diagnosis
of periodontal disease is commonly
based on objective evaluations of the
patient’s medical/dental history as
well as clinical and radiographic
examinations. However, periodontal
disease should also be evaluated sub-
jectively though measures that quan-
tify its impact on oral health-related
quality of life (OHRQoL) (10). This
construct measures aspects of life that
2 Ferreira et al.
are compromised by adverse oral con-
ditions. It has been demonstrated that
a greater degree of clinical attachment
loss is related to greater complaints
on the part of patients (11–13).
The subjective evaluation of the
impact of adverse oral conditions
and/or their consequences on daily
living is performed with the use of
quality of life indicators. Such mea-
sures have emerged as a complement
to clinical indicators, providing a
broader assessment of the health of
individuals and populations (14). The
most widely used assessment tool is
the OHIP-14 (15), which measures the
social impact of problems that com-
promise oral health.
The negative impact of periodontal
disease on OHRQoL has been investi-
gated less than other oral problems,
such as dental caries and tooth loss.
Taking into consideration that a bet-
ter understanding of the perception of
individuals regarding the impact of
periodontal disease can help ensure
planning and treatment that fits the
needs and concerns of the patient, the
aim of the present study was to per-
form a systematic review of the litera-
ture to find more consistent evidence
regarding the negative impact of peri-
odontal disease on OHRQoL among
adolescents, adults and older adults.
The following was the PECO ques-
tion: Population (dentate individuals);
Exposure to risk factor (periodontal
disease); Comparison (individuals
without periodontal disease); and
Outcome (impact on OHRQoL).
Material and methods
The systematic review was conducted
in compliance with guidelines of the
Preferred Reporting Items for System-
atic Reviews and Meta-Analyses
(PRISMA) (16) (protocol number:
PROSPERO CRD42016038474).
Eligibility criteria
Only studies that met the following
inclusion criteria were considered eligi-
ble for the systematic review: (i) cross-
sectional studies; (ii) studies involving
any age group except children; (iii) use
of a quality of life assessment tool; (iv)
diagnosis of periodontal disease
regardless of the index or the evalua-
tion parameters employed; and (v)
studies published in English. Exclusion
criteria were: reviews; clinical trials;
cohort studies; case–control studies;
case report or case series; letters to the
editor; failure to employ a quality of
life assessment tool; self-reported peri-
odontal disease; studies in which indi-
viduals had a systemic disease that
could affect periodontal status; and a
lack of the description of the results of
traditional statistics that confirmed
whether the findings occurred by
chance or not. No restrictions were
imposed regarding the year of publica-
tion.
Search strategy
Electronic searches were performed of
the PubMed (http://www.ncbi.nlm.
nih.gov/pubmed), Web of Science
(http://www.isiknowledge.com) and
Lilacs (www.bireme.br) databases
with no restrictions regarding the date
of publication. Searches were per-
formed up to July 2015.
The following search strategies were
used in the PubMed database:
((((((Periodontal Disease) OR Disease,
Periodontal) OR Diseases, Periodon-
tal) OR Periodontal Diseases)) AND
(((Quality of life) OR Life Qualities)
OR Life Quality)) AND ((Adult)
OR Adults) (Search 1) and
(((((((((((((((((((((((((Cross Sectional
Studies) OR Cross-Sectional Study)
OR Studies, Cross-Sectional) OR
Study, Cross-Sectional) OR Cross-
Sectional Survey) OR Cross Sectional
Survey) OR Cross-Sectional Surveys)
OR Survey, Cross-Sectional) OR Sur-
veys, Cross-Sectional) AND Adult)
OR Adults) AND Quality of life)
AND Life Qualities) AND Life Qual-
ity) OR Disease, Periodontal) OR
Diseases, Periodontal) OR Periodon-
tal Disease) OR Periodontal Diseases)
AND OHRQoL)))))) (Search 2). The
following combination was used for
the Web of Science database: (Peri-
odontal disease*) AND Topic: (Qual-
ity* Life*) AND Topic: (Adult*). For
the Lilacs database, the strategy was
(tw:(Adults)) AND (tw:(Periodontal
Disease)) AND (tw:(OHRQoL)).
Selection of studies
A total of 849 potentially relevant
studies were identified from the elec-
tronic databases and 111 were identi-
fied through the manual search of the
reference lists of the studies evaluated
for eligibility (52 articles). Forty-one
studies were excluded for being dupli-
cates. Thus, 919 articles were ana-
lyzed, 860 of which were excluded
based on the analysis of the title and
abstract. Fifty-two were submitted to
full-text analysis, among which 18
were excluded and 34 were included
in the review. Failure to evaluate peri-
odontal status was the major reason
for the exclusion of studies after the
full-text analysis (Fig. 1).
Two reviewers underwent an exer-
cise for the determination of inter-
reviewer agreement with regard to the
inclusion criteria, origin and type of
sample using 20% of the retrieved
studies. Inter-reviewer agreement was
considered good (K = 0.68). The two
reviewers (M.C.F. and A.C.D.P.) per-
formed the analysis of the titles and
abstracts as well as the selection of
the studies independently. The full-
text analysis of potentially eligible
articles (n = 52) was then performed.
Disagreements between reviewers were
resolved by consensus. In cases for
which consensus was not reached, a
third reviewer (L.S.B.A.) was con-
sulted to decide the eligibility of the
study. Data extraction was also per-
formed independently by both review-
ers (M.C.F. and A.C.D.P.).
Risk of bias
For each study selected, the sam-
pling method, use of a control
group, determination of inter-exami-
ner and intra-examiner agreement
regarding the diagnosis of periodon-
tal disease, evaluation of the out-
come (masking or not) and
adjustment for confounding factors
for the outcome evaluated (impact
of periodontal disease on OHRQoL)
were evaluated.

Fig. 1. Study selection process: PRISMA flowchart of four phases of review showing number of studies identified, selected, eligible and
included.
Data extraction/data synthesis
The following data were extracted
from the selected studies: sample size;
sample origin; sampling method;
population characteristics; diagnosis
of periodontal disease; and affected
quality of life domains. Meta-analysis
was not possible. Thus, the data
from the studies were evaluated qual-
itatively.
Methodological quality assessment
Methodological quality was evaluated
using modified items recommended by
the Newcastle–Ottawa Scale (17) for
observational studies. As cross-sec-
tional studies were included in this
Periodontal disease and quality of life
review, a modified version of the
case–control and cohort study scales
was employed (Appendix S1). The fol-
lowing criteria were considered for
each study: representativeness of the
sample (evaluated by the sample gen-
eration methods and sample origin,
e.g., community, specific population
groups); comparability (evaluated by
the presence of a control group);
exposure (calibration for exposure);
outcome (outcome assessment tool;
concealment for evaluation of out-
come; adjustment for confounders
and non-response rate) (Appendix
S1). A percentage score was estab-
lished for each study in accordance
with the number of items present
(Appendix S2).
3
Results
Tables 1 and 2 describe the method-
ology and main findings of the stud-
ies. The articles involved samples
with adolescents, young adults, adults
and/or older adults. Twenty-three
studies involved a convenience sam-
ple. The age of the individuals ran-
ged from 15 to more than 75 years.
The sample size ranged from 24 to
6469 individuals. The largest samples
were in studies conducted in Aus-
tralia, the United Kingdom, Sudan
and India (Table 1).
The studies employed periodontal
indices or parameters. The community
periodontal index (CPI) was the most
commonly employed index for the
 4
Table 1. Summary of studies: country, type of sample, sampling method, sample size calculation, age, control group, intra-examiner and/or inter-examiner agreement for diagnosis of peri-
odontal disease, blinded evaluation of outcome and adjustment for confounding factors (n = 34)

Intra
and/or
inter-
examiner
Ferreira et al.

agreement
Sample for Blinded Adjustment
Type of size Sample Age Control diagnosis evaluation for confounding
Study Countrya sample Sampling method calculation size (years) group of PD of outcomeb factors

Sanadhya et al. (45) India Convenience Randomized Yes 1200 20–79 Yes No Unclear Yes
Meusel et al. (9) Brazil Convenience Non-randomized No 100 30–58 No Yes Yes Yes
Carvalho et al. (31) Belgium Convenience Non-randomized Yes 611 16–32 Yes Yes Yes Yes
Fotedar et al. (7) India Convenience Non-randomized Yes 351 20–69 Yes No Unclear Yes
Batista et al. (44) Brazil Convenience Randomized Yes 248 20–64 Yes Yes Yes Yes
Lawal et al. (34) Nigeria Convenience Consecutive Yes 204 ≥ 18 Yes No Yes No
Batista et al. (33) Brazil Convenience Non-randomized Yes 386 20–64 Yes Yes No Yes
Rouxel et al. (29) England Convenience Randomized Yes 103 18–59 No Yes Yes No
Palma et al. (30) Brazil Convenience Non-randomized Yes 150 Adults No Yes Unclear Yes
Khalifa et al. (43) Sudan Convenience Consecutive Yes 1888 16–75+ Yes Yes Yes Yes
Jansson et al. (28) Sweden Community Randomized No 443 20–89 No Yes Yes No
Eltas & Uslu (8) Turkey Convenience Non-randomized No 53 21–48 No Yes Yes No
Borges et al. (6) Brazil Convenience Non-randomized Yes 24 23–76 Yes No Unclear No
White et al. (26) England, Community Randomizedc Yesd 6469 16–84 No Yese Unclear No
Wales and
North Ireland
Al Habashneh et al. (13) Jordan Convenience Systematically No 400 18–60 No Yes Yes No
randomized
Acharya & Pentapati (27) India Convenience Non-randomized No 134 25.97 ( 4.68) Yes Yes Yes Yes
Bandeca et al. (42) Brazil Convenience Non-randomized No 100 18–68 Yes No Yes Yes
Slade & Sanders (25) Australia Community Randomized Yes 3724 ≥ 15 Yes No Yes No
Zaitsu et al. (41) Japan Community Randomized No 459 40–55 No No Yes Yes
Andersson et al. (40) Sweden Convenience Consecutive No 204 20–86 Yes Yes Yes Yes
Ara ujo et al. (24) Brazil Convenience Randomized Yes 401 19–71 No No No No
Bernabe & Marcenes (23) United Kingdom Community Randomizedc Yes 3122 16–93 Yes No Yes Yes
Bianco et al. (22) Brazil Convenience Non-randomized No 224 ≥ 50 No Yes Yes Yes
Cohen-Carneiro et al. (21) Brazil Convenience Consecutive No 126 > 18 No Yes Yes No
Acharya (20) India Convenience Consecutive No 414 18–80 No Yes Yes Yes
Å slund et al. (19) Switzerland Convenience Non-randomized No 215 16–86 Yes No Yes No
Lacerda et al. (32) Brazil Community Randomized Yes 504 35–44 Yes Yes Yes Yes
Lawrence et al. (12) New Zealand Community Not described No 924 32 Yes No Yes Yes
Luo & McGrath (39) China Community Non-randomized No 147 21–75 No Yes Yes Yes
Brennan et al. (18) Australia Community Randomized No 879 45–54 No Yes Yes No
Ng & Leung (11) China Community Randomizedc No 727 25–64 Yes Yese Yes No
 Periodontal disease and quality of life 5

diagnosis of periodontal disease.

for confounding
Twenty studies addressed the impact

Adjustment
of periodontal disease on quality of

factors
life (4–6,12,13,18–32) and five studies

Yes
No

No
concluded that clinical attachment

Evaluation of impact masked when expressed in text, when quality of life assessment tool was administered before clinical examination, by other researcher or self-administered.
loss was associated with an impact on

of outcomeb
daily living (11,27,33–35) (Table 2).

evaluation
The quality assessment is summa-

Unclear
Unclear
Blinded rized in Appendix S2. According to

Yes
the modified Newcastle–Ottawa Scale,
the risk of bias was found to be mod-
agreement

erate for the majority of the studies

diagnosis
examiner
and/or

(55.5–77.7%) (Appendix S2).

of PD
inter-
Intra

Yesf

Nog
No
for

Discussion
Control
group

A broad search strategy was

Yes
Yes
No

employed in the present systematic

review, using all MeSH entry terms.
The exclusion of studies involving
children was because this age group
35–44

has much fewer cases of compromised

(years)

periodontal status. Studies involving

≥ 18

> 18
Age

individuals with any systemic disease

that could affect periodontal status
Sample

were also excluded, as periodontal

152
142
852
size

disease in patients with cardiovascular

disease and diabetes can increase the
calculation

risks stemming from the existing dis-

Sample

eases, thereby exerting a greater

Diagnosis of periodontal status performed by clinician who recommended patient for study.
Yesd
size

impact on quality of life (36). More-

No
No

over, diabetes is considered a risk fac-

tor for periodontal disease (37).
Sampling method

With regard to the measure of

Intra and/or inter-examiner agreement process was mentioned but not described.
Not described
Randomizedc
Consecutive

quality of life, it was determined that

studies employing different assessment
Intra and/or inter-examiner agreement described in previous publication.

tools would be included in the review.

The importance of health-related
quality of life assessment tools resides
Convenience

Convenience
Community

in the evaluation of the impacts on

Type of

physical functioning, and psychologi-

sample

cal and social aspects from the point

of view of the individual (38). Such
findings furnish valuable information
on different aspects of health in
Sample calculation in previous publication.
New Zealand

affected individuals, which assists in

Country in which study was conducted.
Countrya

the identification of effective treat-

Description in another publication.
Israel

ment (39). OHRQoL assessment tools

USA

specifically measure the impact of oral

problems on the daily lives of affected
individuals (40).
PD, periodontal disease.
Table 1. (continued)

Chen & Hunter (38)

Kushnir et al. (48)

Reisine et al. (17)

Evaluation of methodological quality

The validity of the findings of a study

resides in basic principles that should
Study

guide different study designs. Internal

validity is ensured when the planning
b

d
a

g
c

e
f
 6
Table 2. Results (periodontal disease/quality of life assessment tool) of studies included in systematic review (n = 34)

Indices, parameters or OHRQoL assessment tool Domains most

Study criteria for evaluation of PD (dependent variable) Main findings affected by PD

Sanadhya et al. (45) CPI OHIP-14 No significant difference in OHIP-14 (domains –

Sound or not sound Total score of measure and total score) between individuals with and
Ferreira et al.

CAL without PD (CPI) (p > 0.05)

0–3 mm Score for psychological discomfort domain
4–5 mm significantly lower for adults with CAL in
6–8 mm comparison to those without loss (p = 0.04)
9–11 mm
≤ 12 mm
CAL = present
CAL = absent
Meusel et al. (9) BOP OHIP-14 Individuals with severe periodontitis experienced Functional
PPD Total score of measure greater impact on quality of life than those limitation,
CAL Prevalence of response scores with mild/moderate periodontitis (functional physical
Mild/moderate chronic limitation/p = 0.035; physical disability/p = 0.037; disability,
periodontitis (CAL = 1–4 mm) psychological disability/p = 0.032) psychological
Severe chronic periodontitis disability
(CAL ≥ 5 mm)
Carvalho et al. (31) BOP OHIP-14 Individuals with periodontal problems more –
PPD of at least 4 mm Severity of impact: Total score likely to experience impact on quality of life
CAL of at least 3 mm of measure (OR = 1.79; 95% IC = 1.14–2.81; p = 0.002)
Conditions observed in at least Prevalence of impact: No. of than those without periodontal problems
two sites of the same tooth individuals who reported at
were considered periodontal least one activity as “fairly
problems often” or “very often” affected
Dichotomized as low impact
(0–4) or high impact (≥ 5)
Fotedar et al. (7) CPI OHIP-14 PD was suggestive explanatory factor for impact Physical pain,
Scores of 3 and 4 indicative Severity of impact: Total score on quality of life (male sex: OR = 2.06; 95% psychological
of PD of measure; IC = 1.03–2.50; p = 0.012; female sex: OR = 2.43; discomfort,
Prevalence of impact: 95% IC = 1.51–2.21; p = 0.022). physical
No. of individuals who reported disability,
1 or more impacts as “fairly often” functional
or “very often”; limitation
Extent of impact: No. of OHIP-14
items on which “fairly often” or
“very often” were reported
Batista et al. (44) CAL ≥ 4 mm OHIP-14 PD suggestive explanatory factor for greater impact; –
Severity: Total score of measure Adults with CAL ≥ 4 mm had 1.49 greater
Prevalence of impact: likelihood (95% CI = 1.07–2.08; p = 0.02) of
No. of individuals who reported greater impact than adults without CAL ≥ 4 mm.
1 or more impacts as “fairly often”
or “very often”
Table 2. (continued)

Indices, parameters or OHRQoL assessment tool Domains most

Study criteria for evaluation of PD (dependent variable) Main findings affected by PD

Lawal et al. (34) CPI OHIP-14 CPI not associated with impact on OHRQoL –
Highest score in each sextant Dichotomized as impact (score ≥ 1) CAL significantly associated with prevalence
registered or no impact (score 0) of impact (p = 0.024)
0–2 = No pocket
3–4 = Pocket
CAL
CAL = 0
CAL > 0
Batista et al. (33) CPI OHIP-14 Prevalence and severity of impact not –
Code 3 = pocket 4–5 mm Dichotomized as high impact associated with CAL ≥ 4 mm (PR = 0.59/p = 0.59
Code 4 = pocket ≥ 6 mm (75th percentile) or low impact and PR = 1.21/p = 0.22, respectively)
CAL ≥ 4 mm
Present
Absent
Rouxel et al. (29) CPI OIDP Gingival bleeding more commonly related to impact –
Assessment of two sites per tooth on quality of life (difficulty cleaning teeth and/or
dentures)
Palma et al. (30) PSR OHIP-14 Total OHIP-14 score (p = 0.017), psychological Physical pain,
Gingivitis Dichotomized as impact (“fairly discomfort (p = 0.029) and physical disability psychological
Periodontitis often” or “very often”) or no domains (p = 0.029) score significantly higher discomfort and
impact (“occasionally”, “hardly among individuals with periodontitis than those physical
even” and “never”) with gingivitis disability
Khalifa et al. (43) CPI OHIP-14 Periodontal status not significantly associated with –
OHIP-14 (p = 0.818).
Jansson et al. (28) BOP OHIP-14 Pocket depth ≥ 6 mm and bleeding on probing Psychological
PPD ≥ 4 mm (evaluated at four Total score of measure ≥ 20% exerted significant negative influence on discomfort,
sites of all teeth) quality of life (p = 0.023). psychological
Bone loss (evaluated disability, social
radiographically): disability and
(i) bone loss < 1/3 of length of root handicap
(ii) bone loss 1/3 or more of length
of root in < 30% of teeth
(iii) bone loss 1/3 or more of length
of root in ≥ 30% of teeth
Eltas &Uslu (8) BOP OHQoL-UK BOP more strongly negatively correlated with All domains
PPD Total score of measure comfort and bad breath (r = 0.32 and r = 0.47); equally affected
GR probing depth > 5 and > 8 more negatively
Aggressive periodontitis correlated with bad breath (r = 0.29 and r = 0.33);
gingival recession more strongly negatively correlated
with appearance (r = 0.29)
Periodontal disease and quality of life
7
 8
Table 2. (continued)

Indices, parameters or OHRQoL assessment tool Domains most

Study criteria for evaluation of PD (dependent variable) Main findings affected by PD

Borges et al. (6) Alveolar bone length and tooth length OHIP-14 Loss of periodontal support structure had negative Physical pain,
ratio < 50%: moderate to severe Total score of measure effect on quality of life (physical pain/p = 0.003; psychological
Ferreira et al.

periodontitis psychological discomfort/p = 0.008; physical discomfort and

incapacity/p = 0.033; total score/p = 0.001) physical
disability
White et al. (26) CPI OHIP-14 used to measure Individuals with severe periodontitis (pocket depth –
frequency of impact ≥ 6 mm) and attachment loss ≥ 9 mm reported
OIDP used to measure severity of greater frequency and severity of impact on quality
impact of life (p < 0.0001; p < 0.0001).
Al Habashneh et al. (13) PPD, CAL, GI, PI OHIP-14 23% of patients with gingivitis, 31.6% with mild Physical pain,
Gingivitis Response of “fairly often” and periodontitis, 53.8% with moderate periodontitis psychological
Periodontitis: 4 or more teeth with one “very often” considered impact and 63.9% with severe periodontitis reported impact discomfort and
or more sites with PPD ≥ 4 mm and on one or more OHIP-14 items. psychological
CAL ≥ 3 mm Total OHIP-14 score significantly higher among disability
Mild periodontitis (CAL 1–2 mm) individuals with severe periodontitis in comparison
Moderate periodontitis (CAL 3–4 mm) to those with mild periodontitis (p < 0.05) and
Severe periodontitis gingivitis (p < 0.05)
(CAL ≥ 5 mm)
Acharya & Pentapati (27) CPITN OIDP Individuals who reported impact on daily performance –
Score of 3 and 4 = periodontal disease Total score of measure had significantly higher CPITN scores; PD (CPITN
Impact: with and without impact score of 3 or 4) predictor of impact on daily
performance (OR = 10.05; 95% CI = 1.92–52.4;
p = 0.006).
Bandeca et al. (42) CPI OHIP-14 PD not predictor of total OHIP-14 score (p = 0.20) –
Total score of measure
Slade & Sanders (25) PPD, CAL OHIP-14 Severity OHIP-14 score significantly higher for –
Recorded at three sites of all teeth Total score of measure individuals with moderate/severe periodontitis in
Moderate/severe periodontitis comparison to those without disease (p < 0.001)
Without disease
Zaitsu et al. (41) PPD GOHAI Mean probing depth not significantly different between Not satisfied with
Deepest pocket recorded based on Total score of measure individuals with GOHAI score < 54 and ≥ 54 appearance of
probing of all sites around each tooth; (p = 0.053) teeth (item)
Pocket depth ≥ 4 mm = periodontitis
Andersson et al. (40) CPITN OIDP No significant association between pocket depth ≥ 6 mm –
Pocket depth: Severity of impact: Total score and one or more impacts on quality of life (OR = 1.43;
Pocket ≥ 6 mm of measure 95% CI = 0.77–2.65)
No pocket ≥ 6 mm Prevalence of impact:
Radiographic exam Proportion of individuals who
Alveolar bone loss (measured from reported at least one daily
cementum–enamel junction to alveolar activity affected
ridge): ≥ 4 mm
No alveolar bone loss
Table 2. (continued)

Indices, parameters or OHRQoL assessment tool Domains most

Study criteria for evaluation of PD (dependent variable) Main findings affected by PD

Bone loss < 30% at all sites; bone

loss > 30% at all sites
Ara
ujo et al. (24) PSR OHIP-14 PD associated with total OHIP-14 score (p < 0.001) Functional
Gum disease (gingivitis and hyperplasia) Dichotomized as category 1 limitation,
PD (aggressive periodontitis and chronic (never, hardly ever, sometimes) physical pain
periodontitis) and category 2 (fairly often, very and
Acquired conditions (recession and often); total score dichotomized psychological
bone defects) as 0–33 and 36–56 discomfort
Bernabe & Marcenes (23) PPD, CAL OHIP-14 PD was suggestive explanatory factor for total –
At least two proximal sites with CAL Total score of measure OHIP-14 score. Adults with PD had 1.26-fold
≥ 4 mm and at least one proximal site greater probability (95% CI = 1.16–1.38) of
with probing depth ≥ 4 mm (not more impact (total OHIP-14 score) than adults
necessarily the same tooth) without disease.
PD: Yes or No
Bianco et al. (22) CPI and PALI OHIP-49 Mean CPI score significantly associated with Functional
Total score of measure functional limitation, physical pain and limitation,
handicap (p = 0.005, 0.011 and 0.038, physical pain
respectively) and handicap
Cohen-Carneiro et al. (21) CPI OHIP-14 Significant but weak positive correlation –
Total score of measure between total OHIP-14 and CPI score
(p = 0.031)
Acharya (20) GI OHIP-14 Physical pain domain positively correlated with Physical pain
Gingivitis Total score of measure gingivitis (r = 0.17; p < 0.05);
Gingivitis with negative influence on quality
of life (p = 0.051).
Aslund et al. (19) Not reported OHQoL-GE (OHQoL-UK/ Oral health-related quality of life moderately –
original tool) correlated with mean score of basic periodontal
Total score of measure exam (rs = 0.295; p < 0.01)
Lacerda et al. (32) CPI and PALI OIDP 20.7% (95% CI = 17.2–24.6) of individuals Eating, chewing
Low interference of oral status reported some interference of oral health status foods well and
on daily performance (≤ 3) on performance of daily activities in previous cleaning teeth/
High interference (≥ 10) 6 mo. Mean OIDP score of 14.17 (SD = 14.6) mouth (items)
among affected individuals; Most affected
activities – eating, chewing foods well (16.8%)
and cleaning teeth/mouth (13.2%); High
interference of oral status on daily performance
reported by 11.4% (95% CI = 8.7–14.6) of
individuals; Periodontal attachment loss was
explanatory factor for high interference of oral
status on daily performance (OR = 3.22; 95%
CI = 1.55–6.69).
Periodontal disease and quality of life
9
 10

Table 2. (continued)

Indices, parameters or OHRQoL assessment tool Domains most

Study criteria for evaluation of PD (dependent variable) Main findings affected by PD
Ferreira et al.

Lawrence et al. (12) PPD, GR, CAL OHIP-14 Significant association between prevalence of impact –
Cases of PD: two or more sites with Prevalence of impact: and cases of PD [2 or more sites with CAL
CAL ≥ 4 mm No. of individuals who reported ≥ 4 mm (p = 0.04)]
Less than two sites with CAL ≥ 4 mm 1 or more impacts as “fairly No significant association between mean no. of
often” or “very often” OHIP-14 items with responses of “fairly often” or
Extent of impact: No. of OHIP-14 “very often” and cases of PD (IRR = 1.14; 95%
items for which “fairly often” or CI = 0.86–1.52; p = 0.349)
“very often” were reported Significant association between total OHIP-14
Severity of impact: Total score score and cases of PD [2 or more sites with
of measure. CAL ≥ 4 mm (IRR = 1.14; 95% CI = 1.05–1.23;
p = 0.002)]
Luo & McGrath (39) CPI OHIP-14 No reports of impact of PD on OHRQoL –
Prevalence of impact:
No. of individuals who reported
1 or more impacts as “fairly often”
or “very often”
Severity of impact: Total score of
measure.
Brennan et al. (18) BOP EuroQoL Gingivitis associated with low prevalence of Pain/discomfort,
GR Response categories: problems (6.1%) for pain/discomfort domain; anxiety/
PPD 1 = no problems Gingival recession associated with low prevalence depression
CAL: GR + PPD 2 = some/moderate problems of problems (11.1%) for pain/discomfort and
Gingivitis: One or more sites with 3 = extreme problems anxiety/depression domains;
CAL ≤ 4 mm Probing depth associated with low prevalence of
GR: One or more sites with recession problems for “usual activities” (3.2%) and anxiety/
≥ 6 mm depression (9.7%), but associated with high
PPD: One or more sites with pocket prevalence of problems for pain/discomfort
≥ 6 mm (25.8%). Attachment loss associated with low
CAL ≥ 6 mm prevalence of problems for “usual activities”
(2%) and anxiety/depression (10.2%), but
associated with high prevalence of problems for
pain/discomfort (22.5%) (similar to probing depth)
Ng & Leung (11) CAL, REC, PPD OHIP-14 Individual with CAL > 3 mm had significantly Functional
CAL dichotomized as ≤ 2 mm (sound/ Total score of measure higher total OHIP-14 score and scores for all limitation
mild attachment loss) or CAL > 3 mm domains (p < 0.05), except social disability and
(high/severe attachment loss) handicap
Table 2. (continued)

Indices, parameters or OHRQoL assessment tool Domains most

Study criteria for evaluation of PD (dependent variable) Main findings affected by PD

Kushnir et al. (48) CPI OHIP-14
Severity of impact: Total score
of measure.
Prevalence of impact:
Proportion of individuals who
reported 1 or more impacts as
“fairly often” or “very often”
Chen & Hunter (38) CPITN No specific namea
Reisine et al. (17) Mean PPD of 5 mm (periodontal patients) Gill’s Wellbeing Scale and anxiety
scales: Evaluation of wellbeing
McGill Pain Questionnaire and
West Haven–Yale Multidimensional
Pain Inventory: Evaluation of
physical symptoms (problems with
oral function and pain)
Disease Impact Profile: Evaluation
of social function directly related
to oral health status
No association between higher CPI score and total –
OHIP-14 score (p-value not described)
Periodontal status non-significant predictor of –
dental symptoms (p-value not described)
Periodontal patients (one of groups studied) Speech/
had greater discomfort upon chewing; 12% of communication
patients had considerable discomfort with (Disease Impact
appearance of teeth and 27% reported pain in Profile), pain in
the previous week; Patients reported at least previous week
one impact on function/most common and pain
problem – speech/communication severity (pain
scales)

Periodontal indices: CPI, community periodontal index; CPITN, community periodontal index of treatment needs; GI, gingival index; PALI, periodontal attachment loss index; PI, plaque
index; PSR, periodontal screening and recording.
CPI: 0 = sound; 1 = gingival bleeding (gingivitis); 2 = calculus; 3 = pocket 4–5 mm (shallow); 4 = pocket ≥ 6 mm (deep); X = sextant excluded (< 2 teeth).
Periodontal parameters: BOP, bleeding on probing; CAL, clinical attachment loss; GR, gingival recession; PPD, probing pocket depth; REC, measurement of recession.
Oral health-related quality of life assessment tools: OHIP-14, oral health impact profile: 14 items distributed among seven domains (functional limitation, physical pain, psychological discom-
fort, physical disability, psychological disability, social disability and handicap); GOHAI, general oral health assessment index: 12 items (oral function, anxiety and pain/discomfort); OIDP,
oral impacts on daily performances: nine items related to physical, psychological and social aspects to determine difficulties with eating/enjoying foods, speaking/pronouncing clearly, going
out (going to mall or visiting someone), cleaning teeth or dentures, sleeping/relaxing, smiling/laughing/showing teeth without embarrassment, maintaining emotional state (easily upset), exe-
cuting work/social roles and enjoying contact with others. Severity and frequency of difficulty also evaluated; OHQoL-UK, oral health related quality of life – United Kingdom: 16 items dis-
tributed among four domains (symptoms, physical, psychological and social aspects) to measure positive and negative effects of oral status (score 1: very bad effect; 2: bad effect; 3: no effect;
4: good effect; and 5: very good effect); score: 16 (worse impact) to 80 (better impact); EuroQoL (generic health-related quality of life assessment tool) – this tool contains six dimensions (mo-
bility, e.g., walking about; self-care, e.g., washing dressing; usual activities, e.g., work, study, housework, family or leisure; pain/discomfort; anxiety/depression; and cognition, e.g., memory,
concentration, coherence, IQ).aAssessment tool with no specific name: three domains (dental symptoms [eight items], perceived oral wellbeing and perceived dental appearance [two items] and
problems with social/physical function [two and three items, respectively]).
CI, confidence interval; IRR, ratio of geometric mean values; OR, odds ratio; p, p-value; PD, periodontal disease; PR, prevalence ratio; r, correlation coefficient; SD, standard deviation.
Periodontal disease and quality of life
11
12 Ferreira et al.
of the study involves attention to pos-
sible biases and confounding factors
such as to eliminate or control these
aspects. Confounding factors can
mask an association or even falsely
indicate a causal relationship between
a risk factor and outcome (41), which
justifies the adjustment for con-
founders of the outcome by means of
multivariate statistics. Several studies
included in the present review
included confounding factors in the
multivariate analyses, such as demo-
graphic and socio-economic character-
istics, clinical conditions (teeth with
caries, missing teeth, maximum verti-
cal mandibular movement, treatment
needs, tooth sensitivity, dry mouth,
toothache, orofacial pain and func-
tional dentition), the use of services,
oral hygiene habits, smoking, dietary
habits, self-rated oral health, difficulty
speaking, systemic diseases and work-
related stress (4,6,12,21,23,24,28,31–
34,42–49).
Tendentiousness can exert an influ-
ence on how a researcher executes a
study. To avoid this in studies involv-
ing a quality of life questionnaire
administered in interview format, the
evaluator should be unaware of
important information regarding the
characteristics of the participants,
such as the clinical oral condition;
this impedes the interviewer from sug-
gesting responses to the respondent,
which would lead to the risk of evalu-
ation bias. Thus, when a question-
naire and the clinical examination are
administered by the same researcher,
the questionnaire should precede the
examination. Another solution would
be for a second researcher to
administer the questionnaire or the
participants themselves could self-
administer the questionnaire. These
aspects should be clarified in the
methodology, whether by describing
the blinding of the evaluator, report-
ing the previous administration of
the questionnaire, delegating another
researcher to administer the question-
naire or asking the participants to
self-administer the questionnaire. In
some of the studies included in the
present review, it was not clear when
the quality of life measure was
administered (3,4,27,31,42,49). In
other studies, the risk of evaluation
bias was found (18,25,34).
The risk of memory bias is inherent
to studies that evaluate impacts per-
ceived by individuals stemming from
their oral condition. Those with few
problems may not recall certain
events. In contrast, those with greater
problems tend to concern themselves
more with why an event occurred. A
longer period of time considered in
the evaluation of the impact increases
the risk of this type of bias. Most
studies in the present review employed
the OHIP-14 for the evaluation of
OHRQoL and the time evaluated was
the previous 12 mo.
The characteristics common to the
participants of a study should be simi-
lar among groups to avoid estimation
errors. For this to be possible, it is
necessary to avoid the risk of selec-
tion bias. In cross-sectional studies,
the risk of this type of bias is greater
when non-randomized sampling is
performed. With randomized sam-
pling, it is possible to distribute the
baseline aspects of individuals in
groups in a cross-sectional study in a
more balanced fashion. This means
that the confounding variables that
can contribute to the results are
equally distributed among the groups.
It should be stressed, however, that
the principle of randomization does
not always work when the sample size
is small. Fourteen of the studies ana-
lyzed performed randomized sampling
(11,13,19,24–27,29,30,33,42,45,48,49)
to avoid selection bias and the distor-
tion of estimates of a population
parameter, thereby lending representa-
tiveness to the sample. Among these
studies, one failed to explain how the
sampling process was conducted (29);
for four others, the methodology had
been described in a previous publica-
tion (11,24,27,42).
A convenience sample does not
allow the generalization of the conclu-
sion, as this type of sample has poten-
tial selection bias and normally
exhibits the particular characteristics
of a group (source population) that is
distinguished from other individuals
in the target population. This means
that the study produces estimates that
do not correspond to actual
frequencies in the population or may
even produce erroneous estimates
stemming from the lack of a balanced
distribution of the baseline character-
istics of the individuals in different
groups. Given the transitory nature of
individuals who visit healthcare ser-
vices, it is not always possible to
obtain a complete list of people who
have passed through a service in a
particular period of time to act as an
appropriate sample structure from
which a randomized sample of indi-
viduals can be selected. In two studies
involving a convenience sample, the
authors report a randomized sampling
process, but failed to mention the size
of the source population (25,48).
Eleven of the studies analyzed
investigated periodontal disease as the
main explanatory factor for the
impact on OHRQoL (3,5,6,11,13,-
19,20,24,25,29,31). Among these stud-
ies, only two had a population-based
sample and a control group (without
periodontal disease) (11,24). For the
majority of studies with convenience
samples, the comparison groups were
not strictly free of periodontal disease
(5,6,13,18,20,21,25,29–31,44). Among
the studies that evaluated the impact
of oral problems, including periodon-
tal disease, on quality of life, nine did
not have a control group (18,21–
23,27,30,43–45). The lack of a control
group weakens the validity of the
findings. Studies should clarify the
differences between a control group
and a group with a disease/condition
to test whether such differences
account for the disease/condition
under evaluation (50). If the compar-
ison groups have different degrees of
a disease, it may not be possible to
determine clearly what exposure
factors are truly responsible for the
disease.
The risk of observer bias was
detected in 12 of the 34 articles
reviewed (3,4,12,18,20,25,26,35,42,45,
46,49). This reinforces the importance
to use measures aimed at improving
diagnostic capacity before and
throughout a study. The training per-
iod for diagnostic criteria followed by
repeated examinations allows the
memorization of the criteria of the
index or parameter used for

the diagnosis as well as the correct
diagnosis of the conditions evaluated.
It should be noted that diagnostic
precision measured using a concor-
dance statistic does not mean diagnos-
tic accuracy, as the examiner may be
repeatedly committing a diagnostic
error.
Main findings
The present systematic review
demonstrates that periodontal disease
can exert a negative impact on
OHRQoL. Moreover, severe peri-
odontitis has a significantly greater
impact than mild to moderate peri-
odontitis (6,12,13,27). Some studies
demonstrated the strength of the
association between periodontal dis-
ease and OHRQoL (4,24,28,32). Gin-
givitis also exerted an impact, albeit
less than periodontitis, and was asso-
ciated with pain as well as difficulties
involving tooth brushing and wearing
dentures, demonstrating a negative
correlation with comfort (5,21,30,31).
These findings underscore the impor-
tance of a periodontal treatment plan
based on both the needs diagnosed
by the clinician as well as those per-
ceived by the patient, which allows a
different view for the resolution of
the pathological process and the
understanding of the clinical conse-
quences that compromise dental
function and esthetics.
The studies analyzed generally
found similar results with regard to
impact, although the parameters and
indices employed for the diagnosis of
periodontal disease differed. This
requires caution when interpreting the
findings, as different measures can
generate different information with
regard to the prevalence of the dis-
ease. The variation among the studies
for the definition of cases of peri-
odontal disease can exert an influence
on the evaluation of the impact of
this disease on OHRQoL, while the
perception of an affected individual is
unique (51). The groups formed con-
stitute another factor that hinders
comparisons among studies, as differ-
ent criteria and, consequently, differ-
ent types and degrees of severity were
compared in the studies.
Periodontal disease and quality of life
Although the use of the CPI is con-
secrated in the literature as an impor-
tant tool for the diagnosis of
periodontal disease in epidemiological
studies, this index classifies individuals
based on the worst sextant, regardless
of the minimum number of teeth
affected, as well as the tooth with the
worst condition, which leads to an
overestimation of periodontal disease.
This may explain the lack of an
impact of periodontal disease on the
OHRQoL of patients with diabetes
when the CPI was employed (51).
According to the authors cited, the
occurrence of a single site with a
probing depth ≥ 4 mm for the diag-
nosis of periodontal disease explains
the lack of an association. Among the
13 studies reviewed that employed the
CPI, six reported the lack of an asso-
ciation between periodontal status
and quality of life (33,35,43,46,47,-
49,52), one study found a significant
positive but weak correlation between
the CPI and OHIP-14 (22) and a
study involving homeless Chinese
individuals failed to report an evalua-
tion of the association between peri-
odontal disease and the OHIP-14
(43). The five remaining studies found
that poor periodontal status exerted
an impact on quality of life
(4,23,27,30,34).
In studies conducted with Chinese,
Indian and Brazilian individuals, clini-
cal attachment loss was significantly
associated with a greater impact on
OHRQoL (6,11,27,33–35).
The samples in the studies analyzed
had different and wide age ranges,
which may have exerted an influence
on the findings. The prevalence of
periodontal disease tends to diminish
with the advance in age, which is due
to tooth loss among older adults (53).
Besides the lower number of teeth,
the increase in age alone makes indi-
viduals perceive their oral problems
as less harmful. Indeed, many older
adults have a positive view of their
oral health and see tooth loss as a
normal consequence of the aging pro-
cess (26).
Individuals affected by periodontal
disease do not easily perceive the
problem because the disease is often
asymptomatic. Moreover, in the
13
chronic state, clinical attachment loss
is slow and gradual, allowing an
affected individual to adapt progres-
sively to the new condition, which
makes the perception of impact more
difficult. Thus, it is easier for an indi-
vidual with no awareness regarding
periodontal disease only to perceive
dental caries due to pain in the pulp.
Physical pain was the most affected
domain in four studies (4,13,19,31). In
three of these studies, the finding may
have been influenced by confounding
factors, such as dental caries, which
tends to exert an impact on the daily
lives of individuals through the occur-
rence of pain. Although caries experi-
ence was measured in these studies,
the percentage of teeth with caries
was not reported (13,19,31). In the
adjusted multiple analysis performed
by Palma et al. (31) and Al Habash-
neh et al. (13), the authors failed to
mention whether dental caries was
incorporated into the model.
Besides physical pain, the other
domains most affected by periodontal
disease were functional limitation,
psychological discomfort, physical dis-
ability and psychological disability.
The domains related to pain as well
as functional and emotional aspects
were also those that benefited most
from periodontal therapy according
to a systematic review on the impact
of periodontal intervention on OHR-
QoL (36). Some studies demonstrated
that the severity of impact (total score
on a quality of life measure) and the
prevalence of impact (frequency of
response items that denote impact) on
quality of life were explained by peri-
odontal disease as well as other clini-
cal variables, such as dental caries
and tooth loss (4,12,24,28,32).
Strong points and limitations
The present systematic review was
conducted in compliance with the
PRISMA guidelines (16). Thus, expli-
cit systematic methods were used to
identify, select and critically evaluate
relevant studies as well as to offer
greater clarity of the information,
thereby allowing a more informed dis-
cussion of the available evidence.
However, the limitations of the
14 Ferreira et al.
present study should be recognized. A
convenience sample was employed in
23 studies, which limits the extrapola-
tion of the findings to the general
public. The cross-sectional design low-
ers the level of evidence, as the cause-
and-effect relationship cannot be
determined in this type of study
design. Moreover, observational stud-
ies generally have a greater risk of
bias and confounding variables, which
can compromise the internal and
external validity of the findings. How-
ever, when the examiners undergo a
training/calibration process and cer-
tain factors are controlled, it is
respectively possible to diminish the
risk of measurement bias and isolate
confounders that can exert an influ-
ence on the outcome. In 21 of the
studies included in the present review,
the examiners underwent a training
and calibration process for the diag-
nosis of periodontal disease and other
oral health problems, which mini-
mizes the occurrence of measurement
bias. Moreover, the examiners were
blinded to the clinical situation of the
individuals during the evaluation of
the outcome (impact on quality of
life) in 25 studies and adjustments
were made for confounding factors in
19 studies. Such conduct confers relia-
bility to the findings.
The results indicate that periodon-
tal disease may exert a negative
impact on the oral health-related
quality of life of adults, with greater
severity of the disease leading to a
greater negative impact. Longitudinal
studies with community-based sam-
ples are needed to confirm the validity
of the findings. Having greater knowl-
edge regarding the impact of this
pathology will allow periodontists to
clarify to patients the importance of
periodontal treatment to overcome
this impact.
Acknowledgements
The authors are grateful to the State
of Maranh~ao Assistance to Research
and Scientific and Technological
Development (FAPEMA; process no.
01762/13), Brazil. The authors have
stated explicitly that there are no
conflicts of interest in connection with 10. Locker D, Allen F. What do measures of
this article. ‘oral health-related quality of life’ measure?
Community Dent Oral Epidemiol 2007;
35:401–411.
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