Received: 30 October 2018 | Revised: 20 May 2019 | Accepted: 22 May 2019

DOI: 10.1111/idh.12409

ORIGINAL ARTICLE

Evaluation of the effects of different forms of periodontal

diseases on quality of life with OHIP‐14 and SF‐36
questionnaires: A cross‐sectional study

Gülbahar Ustaoğlu1 | Duygu Göller Bulut2 | Kerem Çağlar Gümüş1 | Handan Ankarali3

1
Department of Periodontology, Faculty
of Dentistry, Bolu Abant İzzet Baysal
University, Bolu, Turkey
2
Department of Dentomaxillofacial
Radiology, Faculty of Dentistry, Bolu Abant
İzzet Baysal University, Bolu, Turkey
3
Department of Biostatistics and Medical
Informatics, Faculty of Medicine, İstanbul
Medeniyet University, İstanbul, Turkey
Correspondence
Duygu Goller Bulut, Department of Oral and
Maxillofacial Radiology, Faculty of Dentistry,
Abant İzzet Baysal University, Bolu, Turkey.
Email: duygugoller@hotmail.com
Abstract
Objectives: To investigate the effect of generalized aggressive periodontitis (GAP),
generalized chronic periodontitis (GCP) and gingivitis (G) on oral health‐related qual‐
ity of life (OHRQoL) with Oral Health Impact Profile‐14 (OHIP‐14) and Short Form‐36
(SF‐36) questionnaires.
Methods: One hundred GAP patients, 114 GCP and 109 G patients were included
in the study. Age, gender, number of missing teeth, probing depth (PD), bleeding on
probing (BOP), plaque index (PI) and clinical attachment level (CAL) of patients were
recorded. The Turkish versions of OHIP‐14 and SF‐36 questionnaires were filled be‐
fore any medication and dental treatment were approved. The one‐way ANOVA test
was used to compare three groups.
Results: Generalized aggressive periodontitis and GCP groups were similar to each
other (P > 0.05) in most subscales except functional limitation and social disability of
the OHIP‐14 questionnaire (P = 0.034 and P = 0.018, respectively); conversely, there
was no statistically difference between GAP and G groups in functional limitation
and social disability subscales (P = 0.856 and P = 0.242, respectively). GAP group
gave higher scores than GCP group in all subscales of SF‐36 (P < 0.05). There was a
negative correlation between OHIP‐14 and SF‐36 subscale scores in all groups.
Conclusion: Study findings indicate that different forms of periodontal disease have
different effects on quality of life of patients when measured by OHIP‐14 and SF‐36.
Patients with GCP and GAP had poorer OHRQoL than G patients.

KEYWORDS
aggressive periodontitis, chronic periodontitis, gingivitis, quality of life

1 | I NTRO D U C TI O N
Dental plaque is a sticky, colourless, complex biofilm that accumu‐
lates on the tooth and the soft tissue. However, when plaque is not
removed on a daily care, oral infectious diseases such as gingivitis or
periodontitis frequently can occur. 1,2
Gingivitis is an inflammation as
the first stage in a chronic degenerative process and affects only the
gingiva that can be reversed by effective oral hygiene practices on
the part of the individual.3 Unless the process is prevented by treat‐
ment, the inflammatory process leads to the deeper periodontal
tissues and becomes apical migration of the epithelial attachment,
periodontal pocket and alveolar bone resorption and it is called as
periodontitis. Although periodontitis is preceded by gingivitis, not all
cases of gingivitis will progress to periodontitis.3,4
Chronic periodontitis, typically seen in adults, is the most com‐
mon form of periodontitis, which leads to loss of dental support

Int J Dent Hygiene. 2019;00:1–7. wileyonlinelibrary.com/journal/idh © 2019 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 |
tissues and junctional epithelium, slow progressive destruction of the
5
alveolar bone, pocket formation or gingival extraction. Conversely,
aggressive periodontitis is a rapidly progressive periodontal disease
that affects the tooth‐supporting structures, leading to loss of bone
support and a tendency to aggregate in families and also generally
affects systemically healthy young individuals.4
Oral health‐related quality of life (OHRQoL) is a multi‐dimen‐
sional assessment of the individual's oral health and psycho‐social and
physical well‐being. It has an important place in health care, and it is
recommended to use definition of treatment‐needs assessments and
planning oral health. The Oral Health Impact Profile‐14 (OHIP‐14) is a
questionnaire to assess the OHRQoL.6 The questionnaire is separated
into seven subscales; participants were asked how frequently they had
experienced the impact of the subscales in the last 6 months, with val‐
ues.7 Medical outcomes Short Form health survey (SF‐36) measure is a
largely used, generic, self‐report measure of health status. The SF‐36
includes eight subscales that can also be summarized in two aggregate
8,9
scores, a physical component score and a mental component score.
In the studies performed up to date, the effect of clinical pa‐
rameters such as probing depth (PD) and clinical attachment level
(CAL) on quality of life (QoL) was investigated and it was observed
that OHRQoLs were developed by periodontal therapy. In contrast,
a previous study reported that periodontal disease did not have an
effect on OHRQoL.10 Despite the ever‐increasing importance of pa‐
tient‐centred assessments, only a narrow perspective of the impact
of periodontal diseases on QoL was investigated. For a better under‐
standing of the relationship, further studies with different question‐
naires are required in different patient groups.
The present study is aimed to evaluate the effect of generalized
aggressive periodontitis (GAP), generalized chronic periodontitis
(GCP) and gingivitis (G) on OHRQoL with two different question‐
naires OHIP‐14 and SF‐36.
2 | S T U DY P O PU L ATI O N A N D
M E TH O D O LO G Y
This cross‐sectional study was conducted during a period of six
months (between January 2018 and June 2018) at the Faculty of
Dentistry of Abant İzzet Baysal University after approval by the
Committee for Ethics in Human Research (protocol no: 2018/62).
The oral health profile of the patients who had GAP, GCP and G was
evaluated with the OHIP‐14 and SF‐36 questionnaires.
2.1 | Sample size determination
2.1.1 | Power analysis
The primary aim of the study was to investigate whether there is a
difference between GCP, GAP and G groups about the Oral Health
Impact Profile‐14 (OHIP‐14). For determining the minimum required
sample size, type‐I error probability was 5%, type‐II error probabil‐
ity was 20% (80% power) and effect size was taken as 5 ± 12 score
USTAOĞLU et al.
(the difference was taken as least 5 ± 12 score (clinical important
difference between the groups about total score of the OHIP‐14).11
According to this information, minimum required sample size for
each group was calculated as 100 subjects.
2.2 | Study population
The patients were recruited from the patient pool of the Department
of Periodontology at the University of Bolu Abant İzzet Baysal and
were diagnosed according the 1999 International Workshop for the
Classification of Periodontal Diseases and Conditions for GCP, GAP
and G. 100 GAP patients, 114 GCP and 109 G patients were included
and signed an informed consent form. The inclusion criteria used in
selecting patients were ability to understand verbal or written in‐
structions and no use of systemic medications (ie, muscle relaxants,
anti‐inflammatory medications, sedatives and narcotic analgesics)
within the past 3 months. Exclusion criteria were being pregnant or
lactating, age <18 years and having systemic diseases that influence
periodontal tissues of each participant.
2.3 | Clinical examination and diagnosis
The clinical periodontal investigation involved evaluating the plaque
index (PI),12 PD, CAL and bleeding on probing (BOP).13 PD was meas‐
ured as the distance between the deepest point of the pocket and
the gingival margin. CAL was measured as the distance between
the deepest point of the pocket and cementoenamel junction of
the tooth. After measuring the PD, full mouth bleeding scores were
recorded as the presence or absence of bleeding. All periodontal
measurements were taken on 6 surfaces per tooth for all teeth ex‐
cept third molars using a Williams periodontal probe (PCP‐12, Hu‐
Friedy). Periodontal examinations were performed by one previously
calibrated periodontist with 6 years of experience (GU). Examinations
were replicated in 30 subjects 2 weeks later to assess intraobserver
agreement. Intraobserver reproducibility of the clinical parameters
and indices was evaluated by Kappa statistics, and the value obtained
was 0.91 (excellent agreement). The data of these measurements
were used for diagnostic purposes, not included in statistical analysis.
To create groups, certain criteria were considered for the diagno‐
sis of each periodontal disease group:
Group G: cases with BOP at equal or more than 20% of the sites
and GI ≥1, with no sites with PD and CAL more than 3 mm or bone
loss were diagnosed as gingivitis.
Group GCP: cases who has 4 or more than 4 teeth in each jaw
with PD of ≥5 mm, CAL of ≥4 mm, BOP at more than 80% of the
proximal sites and radiographic evidence of interproximal bone loss
were diagnosed as generalized chronic periodontitis.
Group GAP: patients less than 35 years of age, with more than 20
teeth, have more than 8 teeth with a PD of more than 5 mm (three
of teeth must be other than first molar or incisor), with CAL of more
than 3 mm, and the cases where clinical diagnosis was confirmed by
the presence of interproximal bone loss on radiographic examination
were included.14
USTAOĞLU et al. | 3

TA B L E 1 Descriptive values of
Aggressive peri‐ Chronic periodonti‐ Gingivitis
demographic characteristics and clinical
odontitis (N = 100) tis (N = 114) (N = 109)
parameters of groups
Mean ± SD Mean ± SD Mean ± SD P
b a c
Age 28.88 ± 4.02 39.23 ± 11.32 23.71 ± 5.27 0.001
Missing teeth 0.69 ± 0.92b 1.49 ± 1.91a 0.21 ± 0.49c 0.001
a b c
PD 4.97 ± 0.50 4.56 ± 0.60 2.57 ± 0.30 0.001
a b c
CAL 5.31 ± 0.50 4.89 ± 0.50 2.48 ± 0.30 0.001
PI (%) 71 ± 23a 80 ± 21b 66 ± 15a 0.001
BOP (%) 58 ± 15 57 ± 18 56 ± 19 0.711
Smoking status (%) 32 45 30 0.114

Notes: If the any group mean carry superscript different letters (a, b, c) from the other group mean,
it indicates that the difference between them is statistically significant difference.
N, number of subjects; SD, standard deviation.
Bold values indicate statistical significance.

2.4 | Data collection
Each patient's age, gender, number of missing teeth and smoking
status were recorded. The Turkish versions of OHIP‐14 and SF‐36
questionnaires were filled in during a face‐to‐face interview at the
initial visit before dental treatment and before any medications were
prescribed. It was performed by only one investigator (KÇG) who
had no information about the periodontal status of the patients.
OHIP‐14 has seven subscales, each includes two items: functional
limitation, physical pain, psychological discomfort, physical dis‐
ability, psychological disability, social disability and social handicap.
Patients answered to the frequency of their negative experiences by
following a 5‐point Likert‐type scale: 0‐never, 1‐rarely, 2‐occasion‐
ally, 3‐quite often and 4‐very often. The total score ranges from 0
to 56, and the higher the number, the greater the patient's negative
experience. The SF‐36 is a self‐report generic health status survey
including eight subscales: physical functioning, role limitations due
to physical health, role limitations due to emotional problems, en‐
ergy/fatigue, emotional well‐being, social functioning, pain and gen‐
eral health. Scores range from 0 to 100 and lower scores show more
disability and higher scores show less disability.9
2.5 | Data analysis
Descriptive values of the obtained data were calculated as number,
frequencies, mean values and standard deviations. The one‐way
ANOVA model was used to compare three groups in terms of age,
number of missing teeth, number of caries teeth, SF36 subscales and
OHIP14 subscales and mean total score. The post hoc Bonferroni test
was used for the detection of the significant differences after one‐way
ANOVA. Gender distribution of the groups was examined by Pearson
chi‐square test. The Cronbach's alpha coefficient was used to evalu‐
ate the internal consistency of the scales. Relationships between sub‐
scale scores of OHIP‐14 and SF‐36 scales were examined by Spearman
rank correlation analysis. Statistical significance level was accepted as
P < 0.05, and SPSS (ver. 18) program was used in the analysis.
3 | R E S U LT S
A total of 323 patients participated in the study, with 100 GAP
group, 114 GCP group and 109 G group. Table 1 shows descriptive
values of the age, missing teeth, PD, CAL, PI, BOP values and smok‐
ing status. There was a significant difference between the mean age
of 3 groups (P = 0.001), and the highest average was in the GCP
group, the GAP group followed by and the lowest average group
was in the G group (all group differences were significant at 0.001
level). There was also a significant difference between the groups
in terms of the number of missing teeth, PD and CAL (P values for
each variables are 0.001), and the difference was similar to the av‐
erage age (all group differences were significant at 0.01 level). The
percentage of women in the GAP group was 32.4% (n = 57), in the
GCP group was 35.8% (n = 63) and in the G group was 31.8% (n = 56)
(P = 0.702).
The level of internal consistency among the 14 items of the
OHIP‐14 scale was quite high (Cronbach's alpha coefficient = 0.865).
Table 2 shows the internal consistency levels between the two items
in the 7 subscales. The general internal consistency of the SF‐36
scale was quite good (Cronbach's alpha coefficient = 0.879). Table 3
summarizes the correlations between the OHIP‐14 subscales and the
SF‐36 subscales. As the subscale scores of the OHIP‐14 increased,
subscale scores of the SF‐36 decreased.
Table 4 shows the comparison results of 3 diagnostic groups
in terms of the scores of the OHIP‐14 and SF‐36 subscales. GAP
and GCP were similar to each other in 5 subscales of the OHIP‐14
(P > 0.05) except the “functional limitation” and “social disability”
subscales (P = 0.034 and P = 0.018, respectively), and but GAP and
G groups were just similar in these 2 subscales, “functional limita‐
tion” and “social disability” (P = 0.856 and P = 0.242, respectively).
Also, total OHİP‐14 scores of GAP, GCP and G were 12.40 ± 6.42,
13.53 ± 9.38 and 7.06 ± 5.03, respectively.
In SF‐36 subscales, higher scores were obtained in GAP group
than in GCP group (p value for each subscale varies between 0.001
and 0.003). SF‐36 subscale results showed higher scores in the G
4 | USTAOĞLU et al.

TA B L E 2 The internal consistency levels of the OHIP‐14 scale

0.004
0.009

0.001
0.001

0.001
0.286
0.246
0.189
subscales within themselves

P
Cronbach’s alpha
Subdimensions coefficient

Handicap

−0.060
−0.065

−0.262
−0.073

−0.184
−0.217
−0.144

−0.160
Functional_limitation 0.659
Physical_pain 0.661

r
Psychological_discomfort 0.750

0.002
0.002

0.001
0.001
0.001
0.001
0.001
0.069
Physical_disability 0.777

Social disability

P
Psychological_disability 0.656
Social_disability 0.724

−0.264
−0.292

−0.211
−0.251
−0.189
−0.101
−0.169
−0.174
Handicap 0.523

0.000
0.003
0.060

0.035
0.255

0.016
0.261
group than in the GCP group for physical functioning and pain sub‐

0.551
scales (P < 0.001 and P = 0.001). Similar results were obtained for the

P
Psychological
other subscales (P > 0.05).

disability

−0.064
−0.063

−0.033

−0.164

−0.217
−0.134
−0.105

−0.118
4 | D I S CU S S I O N

0.000
0.001

0.001
0.001
0.029
0.318

0.014
0.421
Physical disability
This cross‐sectional study was conducted in a population of the

P
Western Black Sea region of Turkey on GAP, GCP and G patients.
Correlations between 7 subscales of OHIP‐14 scale and 8 subscales of SF‐36 quality of life scale

The effects of different forms of periodontal disease on QoL were

−0.045

−0.223
−0.056
−0.180

−0.121

−0.136
−0.191
−0.194
assessed by OHIP‐14 and SF‐36 questionnaires. So far, OHIP ques‐
tionnaire has been used to assess specific patient groups in the r
dental literature.11,15-19 However, in our comprehensive literature
review, no study was found comparing the effects of G, GAP and

0.001
0.001
0.049
0.468

0.035
0.011
0.139

0.076
GCP on the results of the OHIP‐14 and SF‐36 questionnaires and
P
Psychological

comparing the results of both questionnaires.

discomfort

OHRQol is defined as a result of the interaction between oral

−0.082

−0.099
−0.041

−0.242
−0.186
−0.116

−0.117
−0.141
health situations and social and related factors and the other parts
r

of the body. Questionnaires measuring OHRQoL attempt to define

the effects of oral health on overall health and well‐being after treat‐
0.304

0.001

0.001
0.833
0.085

0.298

0.026
0.618
ment. OHRQoL provides important information both in theory and
practice.6 OHIP‐14 is a simplified QoL questionnaire based on the
P
Physical pain

disease‐impairment‐disability‐handicap model developed by the

−0.058
−0.028
−0.012
−0.057
−0.096

−0.180

WHO. 20 Regarding the OHIP‐14 results in the present study, in the

−0.124
−0.196

GCP group, all of the subscale scores were significantly higher than
r

the G group. Conversely, in the study of Eltas et al,11 only the phys‐
Functional limitation

ical disability subscale had higher scores in GCP than in G group.

0.000
0.004

0.005
0.001
0.001
0.007
0.095
0.018

These differences might be related to the socio‐economic status and

P

Bold values indicate statistical significance.

lifestyle of the population. In our study, the total OHIP‐14 score was
found to be 10.37 for G and GCP groups. Mendez et al21 reported
−0.209
−0.093

−0.157
−0.177
−0.132

−0.198
−0.151
−0.161

a total score of 17.3 of both groups. The difference between total

scores may be related to population size and methodology.
r

In our data, GAP and GCP were similar to each other in 5 of the
Emotional well‐being

7 OHIP‐14 subscales; however, functional limitation and social dis‐

Physical functioning

Social functioning

ability subscale scores were higher in GCP group than GAP group.
Role limitations/

Role limitations/
emotional role
Energy/fatigue

General health
physical role

Higher scores of the GCP group could be related to the higher av‐
TA B L E 3

erage age of the patients and the higher percentage of the smok‐
ers in this group. Conversely, Llanos et al22 reported no significant
Pain

differences in functional limitation and social disability subscale in

 USTAOĞLU et al.

TA B L E 4 The comparison results of diagnostic groups in terms of subscale scores of OHIP‐14 and SF‐36 scales

Generalized aggressive Generalized chronic

periodontitis (GAP) periodontitis (GCP) Gingivitis (G)
(N = 100) (N = 114) (N = 109)
P value for GAP— P value for G—GAP P value for G—
Questionnaires Subscales Mean SD Mean SD Mean SD GCP groups groups GCP groups

OHIP‐14 Functional limitation 1.16 1.14 1.65 1.63 1.06 1.42 0.034 0.856 0.006
Physical pain 2.83 1.68 2.68 1.82 1.58 1.48 0.777 <0.001 <0.001
Psychological discomfort 2.25 1.94 2.18 2.03 1.13 1.35 0.951 <0.001 <0.001
Physical disability 1.67 1.44 1.97 1.92 0.94 1.20 0.331 0.002 <0.001
Psychological disability 2.33 1.71 2.42 2.12 1.12 1.22 0.922 <0.001 <0.001
Social disability 0.97 1.30 1.47 1.66 0.67 0.97 0.018 0.242 <0.001
Handicap 1.19 1.27 1.17 1.48 0.58 0.87 0.990 0.001 0.001
Mean total score 1.77 0.91 1.93 1.34 1.01 0.72 0.760 <0.001 <0.001
SF‐36 Physical functioning 95.12 12.1 83.60 14.41 88.26 13.67 <0.001 0.182 <0.001
Role limitations/physical 90.95 27.2 82.51 32.35 75.91 30.69 0.001 0.004 0.852
role
Role limitations/emotional 85.67 26.06 69.59 36.99 69.42 35.75 0.002 0.002 0.999
role
Energy/fatigue 67.85 10.45 60.39 17.83 63.99 17.45 0.002 0.182 0.206
Emotional well‐being 75.48 10.45 66.46 17.16 68.92 17.39 <0.001 0.007 0.462
Social functioning 94.50 10.26 75.00 23.16 75.92 22.42 <0.001 <0.001 0.936
Pain 86.10 14.37 76.36 21.40 84.77 15.34 <0.001 0.847 0.001
General health 70.90 8.42 64.65 15.88 67.61 15.39 0.003 0.200 0.246

Notes: Statistically significant level is P < 0.05.

N, number of subjects; SD, standard deviation.
|
5
6 |
GAP and GCP patients. In their study, only psychological discom‐
fort subscale score was higher in GCP patients than in GAP patients.
Furthermore, Llanos et al22 reported that patient with GCP or GAP
showed poorer OHRQoL than those with localized aggressive peri‐
odontitis (AP). This may be due to the fact that the localized form of
AP is less disturbing for patients because it affects a more limited
area than the generalized form.
Levin et al23 reported that AP patients had a worse OHIP‐14
global score than the control group. Eltas and Uslu24 also found a
significant association between OHRQoL and disease severity in pa‐
tients with AP disease. Al Habashnneh et al25 likewise reported that
severe and moderate periodontal diseases have a negative effect on
QoL. The control group was not included in the present study, and
the severity of periodontal diseases groups was not graded, because
the aim of this study was to compare three different groups of peri‐
odontal diseases among themselves. Therefore, the present study
could not be compared with these previous studies but, in accor‐
dance with the previous study outcomes, it was seen that G, GAP
and GCP diseases had negative effects on QoL. Conversely, some
researchers found poor correlations between gingival status of pa‐
tients and OHRQoL. 26-28
SF‐36 is a research tool that enables measuring health status
and QoL used in medical outcome studies. The survey addresses
two main components: mental health and physical functioning.
The reliability of the SF‐36 has been rigorously tested and veri‐
fied in Sheffield, England. 29
Heydecke et al 30
found that functional
limitations, physical pain, physical limitations and mental disability
dimensions in SF‐36 were important variables for OHRQoL and
oral health effects in elderly patients receiving implant therapy
and prosthetic treatment. Mumcu et al31 found a significant as‐
sociation between OHIP‐14, SF36 and OHRQoL‐UK scores. In
accordance with these studies, the present study results showed
a significant correlation between SF‐36 subscale scores and
OHIP‐14 subscale scores. Bodily pain, general health and vitality
subscale scores were similar for GAP and G groups. In the GAP and
GCP groups, the physical role subscale score was similar, but the
other SF‐36 subscale scores were higher in the GAP group than in
the GCP group.
The most authors noted that OHRQoL correlated with patient
well‐being and general QoL and recommended to clinicians and
healthcare providers to assess oral health and QoL tools to deter‐
mine individual's treatment plans and new approaches to improve
oral health of patients.6,21,25,32,33 In fact, the results of periodontal
disease such as redness, bleeding while brushing, gum extraction,
mobility of teeth and loss of teeth affect the chewing, swallowing
and smile aesthetics, and as a result self‐esteem and QoL were af‐
fected by negative. 23 All periodontal diseases included in the pres‐
ent study affect the QoL in a negative way.
In conclusion, as regards the SF‐36 results, GCP group showed
higher disability compared to GAP, while GCP group scored
higher scores in the functional limitation and social disability
subgroups according to OHIP‐14. On the other hand, G group
showed more positive experience than the other two groups
USTAOĞLU et al.
according to the results of both questionnaires. The present study
is a cross‐sectional study and does not include long‐term follow‐
up. Longitudinal studies are needed, so that the effect of improve‐
ment and change in periodontal tissues on QoL can be evaluated
more comprehensively.
5 | C LI N I C A L R E LE VA N C E
5.1 | Scientific rationale
Different forms of periodontal diseases affect the QoL adversely.
There is a lack of information in the literature on the evaluation of
the correlation between the SF‐36 and the OHIP‐14 questionnaires
for different forms of periodontal diseases.
5.2 | Principal findings
Generalized aggressive periodontitis, GCP and G diseases affect ad‐
versely the OoL in different degrees. The results of the OHIP‐14 and
SF‐36 questionnaires are consistent.
5.3 | Practical implications
The negative effects of different forms of periodontal diseases on
oral health as well as on quality of life should be considered in diag‐
nosis and treatment planning.
C O N FL I C T O F I N T E R E S T
The authors declare that they have no conflict of interest.
ORCID
Duygu Göller Bulut https://orcid.org/0000-0003-4260-2520
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How to cite this article: Ustaoğlu G, Göller Bulut D, Gümüş
KÇ, Ankarali H. Evaluation of the effects of different forms of
periodontal diseases on quality of life with OHIP‐14 and
SF‐36 questionnaires: A cross‐sectional study. Int J Dent
Hygiene. 2019;00:1–7. https://doi.org/10.1111/idh.12409