Archives of Oral Biology 86 (2018) 80–86

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Archives of Oral Biology

journal homepage: www.elsevier.com/locate/archoralbio

Impact of gingivitis treatment for diabetic patients on quality of life related T

to periodontal objective parameters: A randomized controlled clinical trial
⁎
Sheila C. Cortellia, , Fernando O. Costab, Antonio Gargioni-Filhoa, Davi R. Aquinoa,
⁎
Luis O.M. Cotab, Alexandre P. Schermaa, Taís B. Mirandaa, Jose R. Cortellia,
a
Nucleus of Periodontal Research, Dental School, University of Taubaté, Expedicionário Ernesto Pereira, 110 − Taubaté, São Paulo, Brazil
b
Periodontal Department, Dental School, Federal University of Minas Gerais, Avenida Presidente Antônio Carlos, 6627 − Belo Horizonte, Minas Gerais, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: Patients with diabetes have a poor oral health-related quality of life (OHRQoL). It is not clear if this
Gingivitis situation could be changed with effective periodontal treatment. This study examined both patients with dia-
Diabetes Mellitus betes and systemically healthy individuals to discover the impact of a gingivitis treatment protocol on OHRQoL
Quality of Life and its relation to objective periodontal parameters.
Therapeutics
Design: After ultrasonic debridement, patients were randomly assigned to an essential-oils (EO) or placebo
Bacteria
mouthwash group. At baseline and 3 months, OHRQoL was assessed with the Oral Health and Quality of Life-
United Kingdom questionnaire (OHQoL–UK) along with clinical, halitometric, microbiological and inflammatory
objective parameters. The primary outcome was a change in OHQoL–UK scores. A factor analysis was performed
and the impact of the extracted quality of life factor (QLF) and its interactions with diabetes, treatment, and time
on the objective parameters, were tested by multiple linear regression models (p < 0.05). Chi-Square test
compared questionnaire-answering profiles (p < 0.05).
Results: Combined treatment with EO provided OHQoL improvements in both systemic conditions. Positive
effect of oral health status on quality of life increased in EO groups but not in placebo groups. Question I (self-
confidence) showed the greatest factorial weight, while Question A (food intake) showed the lowest factorial
weight. All patients who showed OHRQoL improvements and used the EO rinse showed the lowest plaque and
gingival indices and lower levels of bacteria and volatile sulfur compounds.
Conclusions: OHRQoL positively changed overtime. Most effective treatment protocols would provide better
improvements in OHRQoL which is related to periodontal objective measures.

1. Introduction
Oral and periodontal statuses impact how individuals perceive their
quality of life. Although clinical conditions have improved, a significant
portion of the adult population (even in developed countries) fre-
quently suffers negative effects in their daily lives as a result of oral
health issues (White et al., 2012). The interaction among oral health,
general health and quality of life is only poorly understood. After
evaluating 1,007 adults Zucoloto, Maroco, Campos (2016) reported
that oral health, referred pain and presence of any chronic disease had
significant influence on health-related quality of life. In addition, when
poor oral health negatively impacts quality of life there is also an
association with poor general health (de Andrade, Lebrão, Santos, da
Cruz Teixeira, & de Oliveira Duarte, 2012). Most periodontal studies on
adults have focused on periodontitis, while the relationship between
gingivitis and quality of life has received less attention (Eltas, Uslu, &
Eltas, 2016; Mendez, Melchiors Angst, Stadler, Oppermann, & Gomes,
2017). Bleeding and bad breath are major complaints of gingivitis pa-
tients, although they are not always self-perceived (Kallio, Nordblad,
Croucher, & Ainamo, 1994; Eli, Baht, Koriat, & Rosenberg, 2001). Ha-
litosis is more likely to be detected in patients with gingivitis than in
periodontally healthy patients (Apatzidou et al., 2013). This is due to
volatile sulfur compound levels that are higher in inflamed gingiva than
in healthy gingiva (Yaegaki & Coil, 1999). In addition, an increase in

Abbreviations: CONSORT, consolidated standards of reporting trials; EO, essential oils; KMO, Kaiser-Myer-Olkin; OHQoL–UK, Oral Health and Quality of Life–United Kingdom
(questionnaire); OHRQoL, Oral Health-Related Quality of Life; ppm, parts per million; QLF, Quality of Life Factor
⁎
Corresponding author.
E-mail addresses: cavalcacortelli@uol.com.br (S.C. Cortelli), focperio@uol.com.br (F.O. Costa), tonygargioni@hotmail.com (A. Gargioni-Filho),
daviaquino@uol.com.br (D.R. Aquino), lot.cota@ig.com.br (L.O.M. Cota), scherma@uol.com.br (A.P. Scherma), taisbrowne@gmail.com (T.B. Miranda),
jrcortelli@uol.com.br (J.R. Cortelli).

https://doi.org/10.1016/j.archoralbio.2017.11.010
Received 3 February 2016; Received in revised form 20 November 2017; Accepted 26 November 2017
0003-9969/ © 2017 Published by Elsevier Ltd.
S.C. Cortelli et al. Archives of Oral Biology 86 (2018) 80–86

the levels of gingival bleeding can be observed when patients with

gingivitis are compared to those with good periodontal health (Pereira
et al., 2012). Although gingivitis is not always self-perceived, it can
affect quality of life, at least in children (Tomazoni et al., 2014).
In addition to behavioral factors, such as tobacco use (Bhat, Roberts-
Thomson, & Do, 2015) and alcohol consumption (Lages et al., 2015),
specific systemic diseases, such as cardiovascular disease and diabetes,
have been related to periodontal disorders (Kogawa et al., 2016; Xu
et al., 2017). Further, specific cytokine gene polymorphisms can in-
fluence individuals’ response against the bacterial challenge and
therefore host susceptibility to periodontal diseases (Cantore et al.,
2014). Interestingly, cytokine profiles can vary according to the pre-
sence of systemic diseases such as diabetes (Crincoli et al., 2016). Un-
fortunately, diabetic individuals have other risk factors for oral dis-
orders. Their reduced salivary flow and altered glycemic control are
related to halitosis (Negrato & Tarzia, 2010), gingival bleeding, and
higher dental biofilm levels (Ervasti, Knuuttila, Pohjamo, & Haukipuro,
1985; Gürsoy, Yildiz Çiftlikli, Könönen, Gürsoy, & Doğan, 2014). In
diabetic patients, good oral health is seldom. And this poor oral health
status can be related to a poorer quality of life (Nikbin, Bayani,
Jenabian, Khafri, & Motallebnejad, 2014).
Dental procedures can positively affect one’s quality of life. In
contrast to people who do not receive dental care on a regular basis,
those who do are found to have a better dental status and better quality
of life (Montero, Albaladejo, & Zalba, 2014). Conventional non-surgical
periodontal therapy for periodontitis patients can improve quality of
life (Sundaram, Narendar, Dineshkumar, Ramesh, & Gokulanathan,
2013; Jönsson & Öhrn, 2014; Santuchi et al., 2016). However, no clear
consensus has been achieved regarding how gingivitis treatment affects
the quality of life in patients either with or without diabetes. Moreover,
it is not completely understood how clinical and laboratory-monitored
parameters are related to self-reported quality of life. Recently, our Fig. 1. Study design from screening to completion of the trial according to consolidated
group verified that a protocol, which combines ultrasonic debridement standards of reporting trials (CONSORT).
with the regular use of a mouthwash that contains essential oils (EO),
was effective in treating gingivitis in patients with or without diabetes.
clinical response to a specific gingivitis treatment protocol (Raslan
Although promising results were observed in relation to traditional
et al., 2015). In comparison to Raslan’s study there were three addi-
objective parameters, other relevant patient-centered variables were
tional sample lost due to incomplete questionnaires (Fig. 1). Partici-
not evaluated (Raslan et al., 2015). Therefore, this manuscript reports
pants in this study were male and female plaque-related gingivitis pa-
quality of life data, which had not been previously reported in Raslan
tients who were in good general health (control group) or had
et al. (2015), and seeks to relate them to the other objective oral
controlled type II diabetes (diabetes group), who were between 20 and
parameters that have been previously reported.
45 years of age (32 ± 6 years) and who underwent gingivitis treat-
This study aims to verify the impact of this specific and previously-
ment between January and July, 2013. Data and personal information
tested (Raslan et al., 2015) gingivitis treatment protocol on the oral
regarding the medical and dental histories of the patients were obtained
health quality of life for patients with diabetes and systemically health
by interview. The initial sample size was determined based on efficacy
individuals. In addition, the relationship between quality of life and
of the tested treatment protocol (Raslan et al., 2015). In addition, it was
clinical, micro, immune, and halitometric parameters was evaluated. It
verified whether or not this sample size would be appropriate for a
was hypothesized that gingivitis treatment in diabetic patients would
factor analysis. Considering that the model has commonalities usable in
have a positive impact on the self-reported quality of life related to oral
the clinical situation according to (Mundfrom, Shaw, & Tian (2005), a
health status.
minimum of 18 individuals per group would be enough for 1 factor
(quality of life) with more than 7 variables (OHQoL–UK questions).
2. Methods
According to their systemic condition, two blocks of patients were
randomly allocated to one of two groups (Fig. 1). In brief, the EO group
The present 3-month, double-blind, single-centered, randomized,
underwent a one-stage ultrasonic debridement and a 90-day supply of
parallel group, placebo-controlled clinical trial was registered at
mouthwash (twice daily use; 20 ml/30 s) (Listerine Total Care, Johnson
ClinicalTrials.gov (NCT 02123563) and was approved by the
and Johnson, São José dos Campos, SP, Brazil) while after identical
Institutional Committee on Research of the University of Taubaté
mechanical procedures, the placebo group followed the same rinsing
(protocol #522/10), São Paulo, Brazil, in accordance with the Helsinki
regime with a placebo solution (Byofórmula, Taubaté, SP, Brazil).
Declaration of 1975, as revised in 2000. Prior to selection, oral and
written explanations regarding the research protocol were given to the
eligible participants. All patients provided written informed consent 2.2. Oral Health and Quality of Life–UK (OHQoL–UK)
before enrolling in the present study, which included baseline and 3-
month post-treatment appointments. The quality of life related to oral condition was evaluated at base-
line and 3 months after gingivitis treatment using the Portuguese ver-
2.1. Study population and gingivitis treatment sion of the OHQoL–UK questionnaire, validated by Dini, McGrath, and
Bedi (2003). This questionnaire covers 16 key issues that evaluate the
This study population had been previously described regarding their effect that the teeth, mouth, gums, and dentures can have in different

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situations related to the following four main aspects of quality of life:
functional limitations, pain or discomfort, and psychological, social,
and behavioral impacts. Response options ranged from “very bad”
(score 5), “bad” (score 4), “none” (score 3), “good” (score 2) to “very
good” (score 1). As a result, total scores varied between 16 (best quality
of life) to 80 (worst quality of life).
Two trained examiners administered the questionnaire in quiet and
private rooms before the dental procedures. In order to increase the
reliability of the results, the questionnaire was administered again to 20
subjects of the pilot study 7 days after the initial results. The test-retest
reliability was assessed using Spearman’s correlation coefficient (0.89,
p < 0.001). The quality of life data were obtained at baseline and at 3
months and the total number of completed questionnaires revealed a
Cronbach’s alpha of 0.97, indicating satisfactory consistency and in-
ternal validity of the OHQoL–UK instrument.
2.3. Objective oral parameters
As previously described (for details please see Raslan et al., 2015),
two calibrated examiners determined the diagnosis of plaque-related
gingivitis and monitored clinical outcomes of periodontal pocket depth,
plaque and gingival indices. Total bacteria load and the period-
ontopathogens Aggregatibacter actinomycetemcomitans, Porphyromonas
gingivalis, Treponema denticola and Tannerella forsythia were quantified
in biofilm samples by real-time quantitative polymerase chain reaction
in a 25 μL reaction volume using specific primers/probes and the
TaqMan® system. After collection, gingival crevicular fluid volume was
measured (Periotron®) and samples were assayed by an enzyme-linked
immunosorbent assay for interleukin 1-beta.
Volatile sulfur compound concentrations (not shown in Raslan et al.,
2015), in parts per million (ppm), were measured using a portable
sulfide monitor (Halimeter®, Interscan, Simi Valley, CA, USA) as pre-
viously done by our group (Dupim Souza et al., 2013). The participants
were instructed to keep their mouths closed and only breathe through
their noses for 3 minutes before measurement. Next, the pipe connected
to the disposable Halimeter® was inserted about 5 cm into the mouth of
the patient and placed on the back of the tongue. The subjects kept their
lips open, without breathing, while the unit was reading. The greatest
value from the display, in ppm, was noted on the clinical data sheet.
This measurement was taken three consecutive times in order to gen-
erate an average reading.
2.4. Statistical analysis
Answers to the OHQoL–UK were categorized on a Likert scale ran-
ging from 1 (best influence) to 5 (worst influence). To calculate the
OHQoL score, the points were summed from each of the 16 questions,
producing a total score ranging from 16 to 80. The primary outcome
was a change in quality of life scores. Also, questionnaire-answering
profiles in each group were analyzed by Chi-Square test. The “very bad”
and “bad” answers were summed creating a category that indicates a
negative impact of oral health on quality of life; while the sum of “very
good” and “good” answers indicated a positive impact of oral health on
quality of life. Finally, the third category (“none” answers) indicated no
impact by oral health on quality of life.
For analytical purposes, plaque and gingival indices were re-
classified as 0 (absence of plaque and bleeding) and 1 (presence of
plaque and bleeding). All periodontal measurements were averaged for
each subject. Intra-group comparisons between times regarding plaque
and gingival indices, volatile sulfur compounds, total bacterial load,
and OHRQoL were performed using Student’s t-tests, paired t-tests, and
Mann-Whitney tests.
A factor analysis was performed to reduce OHQoL–UK data to a
smaller set of key variables. Factorability-i.e., correlations among the
variables which allowed the identification of coherent factors-was ex-
amined via measures of sampling adequacy that require a Kaiser-Myer-
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Archives of Oral Biology 86 (2018) 80–86
Olkin (KMO) greater than 0.5 and a significant Bartlett’s test of
sphericity. The observed Bartlett’s test p value < 0.0001 confirmed
correlations among OHQoL–UK instrument variables, while the KMO
value of 0.935 demonstrated that a statistical factor analysis would be
appropriate for the present sample size population. A factor analysis
extracted one factor that was named the QLF or quality of life factor.
To investigate the impact of the QLF on clinical, microbial, immune,
and volatile sulfur compound parameters, multiple linear regression
models were used. The QLF’s isolated impact as well as the impact of its
interaction with diabetes (diabetes or non-diabetes), treatment (EO or
placebo), and time (baseline or 3 months) were investigated. In these
multiple linear regression models, the QLF and its interactions were the
independent variables. Dependent variables (clinical, microbial, im-
mune, and volatile sulfur compound parameters) were validated by
residual analysis (QQ-Plots); which showed acceptable values vali-
dating regression models. An analysis of oral bacterial levels took into
consideration the total bacterial load, isolated pathogenic species, and
the bacterial consortium of P. gingivalis, T. forsythia, and T. denticola
(red complex bacterial species).
All tests considered a significance level of 5% (p < 0.05) and were
carried out using Statistical Package for the Social Sciences 14.0 (SPSS
Inc., Chicago, IL, USA) for Windows.
3. Results
Gingival treatment provided a beneficial effect on quality of life as
demonstrated by OHQoL scores (Table 1). After treatment, both groups
who rinsed EO showed decrease in OHQoL mean scores. In addition,
individuals without diabetes who rinsed placebo after mechanical
procedures also showed improvements in their quality of life.
Fig. 2 shows three different categories of answers before (baseline)
and after treatment (3 months) according to presence of diabetes and
treatment group. Among individuals who rinsed EO there was a re-
duction in negative impact profile besides an increase in positive impact
profile. These findings indicate an overall positive effect of gingivitis
treatment on how patients perceived their quality of life, independently
of presence of diabetes. In the placebo groups different patterns were
observed. Patients without diabetes who rinsed placebo showed re-
duction of negative impact profile without changes in positive impact of
oral health on quality of life. Moreover, among patients with diabetes
who rinsed placebo the unique profile of answers that changed in-
dicated no influence by oral health on quality of life.
A factor analysis (Table 2) determined one factor—the quality of life
factor—related to underlying information (a latent unobserved vari-
able), interpreted as the effect of oral health on quality of life. Question
I (related to patients’ self-confidence) showed the greatest factorial
weight, while question A (related to patients’ food intake) showed the
lowest factorial weight. However, there were similarities among fac-
torial weights. The determination of one factor confirmed that all
questions in the instrument are measuring one outcome, here quality of
Table 1
OHQoL instrument scores according to systemic status and examination times.
Systemic condition Rinse OHQoL mean score values (range 16–80)
Baseline 3 months
Diabetes Essential oils 50.94 ± 10.55 * 34.33 ± 7.36
(n = 24)
Placebo 46.3 ± 12.16 43.1 ± 7.82
(n = 26)
Non-diabetes Essential-oils 40.23 ± 14.30 * 26.75 ± 5.77
(n = 28)
Placebo 39.73 ± 11.08* 32.38 ± 6.37
(n27)
* statistically significant differences (p < 0.05) between times (baseline vs. 3 months) by
Mann-Whitney test.
S.C. Cortelli et al. Archives of Oral Biology 86 (2018) 80–86

Fig. 2. Questionnaire-answering profiles observed in each group at baseline and 3 months. The profile designated as Negative impact indicates individuals whose oral heath had a
negative impact on their quality of life while the profile designated as Positive impact indicated individuals who reported a positive impact on quality of life by their oral health status. In
addition, there was a third category of individuals for which oral health had no impact on their quality of life.

Table 2 statistically significant impact related to quality of life.

Factor analysis of the OHQoL instrument and respective factorial weights. When microbiological parameters were investigated, the total bac-
terial load was significantly impacted by two interactions: 1) diabetes
Factor Question Factorial weight
and the QLF and 2) treatment and the QLF. Again, patients with dia-
QL factor A − eating 0.64 betes who showed improvements in quality of life showed lower sub-
B − appearance 0.83 gingival bacterial levels after treatment. In addition, patients who
C − speaking 0.72 rinsed with essential oils and experienced improvements in their quality
D − general health/well-being 0.88
E − sleeping/relaxing 0.81
of life related to oral status demonstrated a lower total bacterial load.
F − social life 0.87 Among immunological and halitometric parameters, the unique
G − love 0.88 significant impact was observed when treatment, the QLF, and volatile
H − smiling/laughing 0.89 sulfur compounds levels were considered. Both patients with diabetes
I − self-confidence 0.91
and those who were systemically healthy who rinsed with the EO and
J − worry 0.89
K − mood/happiness 0.85 experienced improvements in their quality of life showed better oral
L − work/daily activities 0.88 odor, revealed by lower volatile sulfur compound values (patients with
M − finance 0.83 [from 107.76 ppm to 51.42 ppm] or without diabetes [from 98.46 ppm
N − personality 0.88 at baseline to 37.53 ppm after 3 months] who rinsed with EO, and
O − comfort 0.85
P − oral odor 0.74
patients without diabetes [from 104.15 ppm to 67.38 ppm] who rinsed
Self-value 11.23 with placebo) (For changes in other variables please check Raslan et al.,
Variability % 70% 2015).
Cronbach alpha 0.971
Bartlett test (p-value) < 0.0001
KMO 0.935
4. Discussion
KMO − Kaiser-Myer-Olkin; QL factor − quality of life factor.
OHRQoL characterizes a person’s perception of how oral health
life related to oral health. Also, our results indicate a close relationship influences the quality of his or her life. Different authors applying many
among questions; thus, they can’t be properly interpreted one by one. questionnaires such as the Oral Health Impact Profile, General Oral
Total bacterial load, plaque index, gingival index and volatile sulfur Health Assessment Index, Oral Impact on Daily Performances Index,
compounds were related to quality of life when the multiple linear and the United Kingdom Oral Health and Quality of Life instrument
regression models were used. For the other variables no association have investigated this relationship (Aslund, Suvan, Moles, D’Aiuto, &
with quality of life was observed. Tonetti, 2008; de R. Castro, Portela, Leão, & de Vasconcellos, 2011;
Results from multiple linear regression models are shown in Table 3. Eltas et al., 2016; Mendez et al., 2017; Ozcelik, Haytac, & Seydaoglu,
Regarding clinical parameters, the interaction between the QLF and 2007; Tsakos et al., 2010). Most of these studies employed a cross-
diabetes on the plaque index had a statistically significant impact. sectional design. Unfortunately, patient-centered outcomes have not
Diabetic patients who experienced quality of life improvements after been properly investigated through randomized clinical trials, even
treatment showed lower plaque index values at 3 months. In addition, though the World Health Organization (1948) has for decades been
treatment and the QLF positively impacted the plaque index and gin- advocating an emphasis on the well-being of the patient, rather than
gival index. All patients who showed quality of life improvements and just an absence of disease, in its definition of health. In addition, the
who used the EO rinse showed the lowest reductions of plaque and quality of life factor could represent a relevant aspect when patients
gingival indices at 3 months. For pocket depth, there was no and clinicians are selecting treatment protocols, although it is not
completely understood how close or how far traditional outcomes are

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Table 3
Multiple linear regression analysis regarding all monitored parameters.

Variable Periodontal pocket depth Plaque index Gingival index

Estimated parameter p value Estimated parameter p value Estimated parameter p value

Diabetes (presence) and QL factor -0.05 0.49 −0.28 0.03 −0.22 0.07
Treatment (EO) and QL factor -0.01 0.91 −0.23 0.02 −0.26 0.03
Time (baseline) and QL factor 0.11 0.13 −0.09 0.44 0.03 0.76
QL factor -0.08 0.26 −0.01 0.93 −0.04 0.70

Variable Total bacterial load Red complex bacterial species (P. gingivalis, T. forsythia and T. denticola) A. actinomycetemcomitans

Estimated parameter p value Estimated parameter p value Estimated parameter p value

Diabetes (presence) QL factor −0.98 0.03 -0.16 0.73 −1.14 0.19

Treatment (EO) and QL factor −0.76 0.02 -0.29 0.54 −0.83 0.34
Time (baseline) and QL factor 0.05 0.90 -0.39 0.36 −0.44 0.59
QL factor 0.57 0.15 0.59 0.16 1.41 0.08

Variable Interleukin 1 beta Gingival crevicular fluid Volatile sulfur compounds

Estimated parameter p value Estimated parameter p value Estimated parameter p value

Diabetes (presence) and QL factor 0.01 0.88 0.00 0.94 −0.20 0.05
Treatment (EO) and QL factor 0.05 0.47 0.10 0.06 −0.15 0.01
Time (baseline) and QL factor 0.04 0.50 -0.02 0.73 −0.01 0.89
QL factor -0.04 0.53 -0.06 0.23 −0.06 0.52

EO − essential-oils rinse; QL factor − quality of life factor.

from quality of life outcomes. A systematic review indicated that pa-
tient-centered outcomes are more relevant to patients’ daily lives be-
cause, as opposed to objective measurements (which use surrogate
markers such as periodontal pocket depth), they capture patients’ per-
spectives (Shanbhag, Dahiya, & Croucher, 2012).
Therefore, based on the clinical, microbial, and immune improve-
ments observed in patients with and without diabetes after a mechan-
ical-chemical gingivitis treatment (Raslan et al., 2015), this study ver-
ified this protocol’s ability to positively impact one’s OHRQoL in the
same study population. In addition, this study investigated how ob-
jective parameters (such as gingival index and total bacterial load)
correlate to self-reported quality of life.
Although initially developed to evaluate quality of life in the United
Kingdom, OHQoL–UK has been widely used in other populations and
was validated for use in Brazil (Dini, McGrath, & Bedi, 2003). In
comparison to other instruments, OHQoL–UK focuses on quality of life
related to health or disease statuses (based on the structure-function-
activity-participation model of health) and not just on sickness (based
on the disease-disability-impairment model of health).
Overall, diabetes has a negative impact on quality of life that, sys-
temically, can be associated with higher levels of glycated hemoglobin
(Kuznetsov et al., 2014). It is important to keep in mind that in the
present study, only well-controlled diabetic patients were selected.
Unfortunately, patients with diabetes in the placebo group did not ex-
perience improvements in OHRQoL. On the other hand, the improved
OHRQoL found in groups who rinsed with EO after mechanical treat-
ment indicated that, in addition to traditional outcomes, an applied
therapeutic protocol could profoundly benefit patients. In systemically
healthy individuals mechanical treatment of periodontitis improve
OHRQoL (Nagarajan & Chandra, 2012; Santuchi et al., 2016). However,
there is reduced information about the impact of gingivitis treatment on
OHRQoL and also about protocols with adjunctive use of mouthwash.
Recently, Mendez et al. (2017) evaluated the impact of periodontal
treatment on OHRQoL in participants diagnosed with gingivitis or
periodontitis. Similarly to the present study, they also observed im-
provements in OHRQoL but using a different questionnaire they failed
to demonstrate any association with clinical variables.
In regards to oral parameters, bleeding gums and bad breath are
associated with the worst quality of life scores (Castro et al., 2011). This
relationship makes sense when considering systemically healthy in-
dividuals; however, gingival bleeding was found to negatively impact
quality of life scores even in patients with severe medical conditions
such as Alzheimer’s disease (Cicciù et al., 2013). In addition, hemo-
dialysis patients showed poorer gingivitis indices, plaque indices, and
OHQoL scores (Pakpour, Kumar, Fridlund, & Zimmer, 2014). In the
present study, prior to gingivitis treatment, well-controlled diabetic
patients showed mean OHQoL scores of 50.94 (EO group) and 46.3
(placebo group) in comparison to scores of 40.23 (EO group) and 39.73
(placebo group) in the non-diabetes group. Based on the lowest possible
score (16 = best quality of life), these observed baseline values in-
dicated a negative impact of gingivitis status on quality of life for both
patients with and without diabetes. However, Sadeghi, Taleghani, and
Farhadi (2014) did not find that diabetes had an influence on quality of
life. Fortunately, the final values of the present study revealed a posi-
tive effect of gingivitis treatment on quality of life in both systemic
conditions. Moreover, in the presence of diabetes, these improvements
were dependent on the type of mouthwash. Similarly, Aslund et al.
(2008) reported that OHQoL scores improved from an initially negative
effect on quality of life to a level of no effect in a group with a worse
periodontal condition, according to periodontitis diagnosis. In the
present study, a similar pattern of changing was observed in the non-
diabetes placebo group. On the other hand, most importantly changes
were observed in the EO groups for both patients with or without
diabetes. These groups experienced an increase in the profile that re-
veals a positive effect on quality of life. These observations suggested a
relation between improvements in oral health status and quality of life,
which was confirmed by the described linear regression models. In fact,
if gingivitis is clinically evident it is able to impair OHRQoL (Buset
et al., 2016) being this negative effect comparable to that caused by
periodontitis (Eltas et al., 2016).
Tsakos et al. (2010) assessed the minimally important difference
regarding quality of life related to oral status, again in periodontitis
treatment. They used Oral Impact on Daily Performance in addition to
two subjective global transition scales, one in relation to periodontal
health and the other covering oral health in general. A five-point Likert
scale ranging from “worsened a lot” to “improved a lot” was used.

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These authors concluded that the minimally important difference was
around five scale points and corresponded to a moderate effect size. In
the present study, except for patients with diabetes who rinsed placebo
(= 4.2) the other groups reached reductions of more than five scale
points. In fact, greater numerical reductions were observed when EO
was part of the treatment (diabetes EO group = 16.61; non-diabetes EO
group = 13.48) in comparison to placebo (diabetes placebo = 4.2;
non-diabetes placebo = 7.35).
Interestingly, the type of periodontal treatment influences how in-
dividuals perceive OHQoL. In comparison to surgical procedures, non-
surgical treatment—such as that tested in the present study—had a
better influence on patients’ perceptions during the immediate post-
operative period (Ozcelik et al., 2007). Further, in the treatment of
gingivitis and periodontitis, less invasive supragingival procedures had
a greater impact on OHRQoL then subgingival procedures (Mendez
et al., 2017).
Although patients from different geographic areas, ethnic back-
grounds, and socio-economic status might perceive OHQoL questions
differently, consistency of this instrument has not been investigated in
periodontics research. In the present study, factor analysis has not
yielded conflicting results for the OHQoL–UK questionnaire, since only
one factor was identified. However, we are not sure that this would not
happen, for example, in other periodontal statuses or in different lo-
cations. John, Feuerstahler, et al. (2014) performed an exploratory
factor analysis of the Oral Health Impact Profile after detecting con-
flicting results in the literature and reported four correlated dimensions.
Later, a confirmatory factor analysis of the Oral Health Impact Profile
conducted by these same authors (John, Reissmann, et al., 2014) sug-
gested that OHQoL could be sufficiently identified with one score.
Multiple linear regression models were used to evaluate the isolated
impact of the QLF as well as the impact of its interaction with objective
measured parameters. In the present study, plaque index, gingival
index, total bacterial load, and volatile sulfur compounds showed sig-
nificant improvements. Patients with diabetes have large amounts of
dental biofilm (Gürsoy et al., 2014) but in the present study, those who
experienced improvement in quality of life showed a decrease in plaque
index and in subgingival bacterial levels.
Patients with or without diabetes who showed quality of life im-
provements and rinsed with the EO as part of the gingivitis treatment
showed reductions in the amount of plaque and gingival inflammation
in addition to improvements in oral odor. The literature shows EO’
beneficial effects on plaque index, gingival index (Van Leeuwen, Slot, &
Van der Weijden, 2011; Cortelli, Cortelli, Wu, Simmons, & Charles,
2012), and bacteria which produce volatile sulfur compounds (Fine
et al., 2005); however, the findings of the present study show, for the
first time, that EO-related improvements positively impact self-per-
ceived quality of life in gingivitis patients with diabetes or systemically
healthy. Interestingly, Pakpour et al. (2014), based on a case-control
study, suggested that self-reported measures can be used to predict
treatment need since, in their study, clinical variables were related to
quality of life.
Why not all variables were associated with quality of life should be
addressed in further studies.
5. Conclusions
OHRQoL improved over time, confirming that quality of life could
be changed by the treatment of oral diseases such as gingivitis, even in
systemically compromised patients. Since self-reported quality of life
was related to traditional objective parameters, treatment protocols
that are clinically more effective would provide better improvements in
quality of life.
The impact of gingivitis treatment on OHRQoL is an additional as-
pect to be considered when patients and clinicians are discussing
therapeutic options. These observations emphasize the relevance of
periodontal care for individuals’ daily life.
85
Archives of Oral Biology 86 (2018) 80–86
Funding Sources
This work was supported by the São Paulo Research Foundation
(FAPESP), São Paulo State, Brazil—research grant 2010/20424-1 and
scholarship 2015/02995-5. It was also assisted by Productivity
Research fellows (PQ) from the National Council of Scientific and
Technological Development (CNPq), Brasília. Funding sources had no
influence in study design; in the collection, analysis and interpretation
of data; in the writing of the report; or in the decision to submit the
article for publication.
Disclosure
All authors have read and approved the revised article. Also, authors
declare that they have no conflict of interests related to the present
work.
Acknowledgments
The authors are grateful to periodontics Ph.D. student Suzane A.
Raslan for her clinical assistance and for laboratory assistance from the
University of Taubaté team.
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