Oral Health and Specific Impact of Caries on the Quality of Life of Middle-Aged People

Introduction. Dental caries is still an important social health problem in 
 many countries. The aim of this study was to determine the incidence and 
 impact of oral discomfort, particularly caused by dental caries on the 
 quality of life of middle-aged people as well as the association between oral 
 problems caused by caries and the current status of teeth. Material and 
 Methods. The study included 72 patients, age 25-45 years. Serbian version of 
 the questionnaire Oral Impacts on Daily Performance (OIDP) was used to 
 determine the overall impact of oral health as well as the specific effect of 
 caries (SP-OIDP) on the quality of life. To determine the status of teeth the 
 DMFT index was used. Results. The incidence of oral health impact on daily 
 activities was 68.1%. Carious teeth affected food intake (40.0%) and brushing 
 teeth (31.0%) but had no effect on showing teeth and maintaining normal 
 emotional state. Caries was the cause of oral discomfort in more than half of 
 the respondents. Of all clinical variables only DMFT>22 was associated with 
 the SP-OIDP score after inclusion of socio-demographic factors in the 
 analysis (rs=0.273). Conclusion. The results of this study indicate that the 
 incidence of the effect of oral conditions on the quality of life is high 
 with most respondents showing difficulties while eating. Using specific 
 questionnaire it was noted that dental caries had a significant effect on 
 oral functions of respondents. Also, there was a significant correlation 
 between dental status and the quality of life of middle-aged people.


INTRODUCTION
Oral health is traditionally assessed based on the presence of oral diseases and disorders, and verified by clinical examina tion and different dental indices.In the recent years, con siderable attention in epidemiological and clinical research has been devoted to negative effects of oral diseases, dental caries, periodontal diseases and traumas on the quality of life of individuals [1].Quality of life related to oral health is based on the fact that the consequences of diseases or con ditions cannot be determined by clinical examination only and it is a multidimensional concept that applies not just to "physical wellbeing" of an individual, but also to psycho logical and social dimensions of everyday life [2].To cover this area, in the recent years, standardized questionnaires that can assess the impact of oral health on the quality of life have been developed.They differ in area they cover, the total number and form of questions and the type of answers.
Clinical findings and subjective assessment of oral health are not always in agreement showing that object ive measures do not always represent the perception of an individual [3,4].Also, a little is known about individual factors that affect the quality of life related to oral health.In previous studies the association between the quality of life and clinical parameters that affect function and esthetics such as number of teeth, missing anterior teeth and the number of occluding teeth has been found [5 10].The impact of caries on the quality of life is clear but not completely understood.Some studies have indicated the association between the quality of life related to oral health and dental caries [8,9,11].However, Tsakos et al. [7,12], Srisilapanan and Sheiham [10] have not confirmed this association.Dental caries affects the quality of life because it is one of the most common causes of pain in the orofacial region [13], but also through other mechan isms such as dissatisfaction with teeth appearance, teeth loss or functional limitations due to teeth loss.
Caries prevalence is much higher in the studied age population in Republika Srpska [14] compared to other European countries [15,16].It is certain that poorer oral health status can significantly affect the quality of oral health as confirmed in the group of children and elderly people [7,10,12,17], however, this association has not been studied in middleaged population.In most studies, ques tionnaires used to examine the association between caries and the quality of life have been able to assess the impact of general oral conditions on the quality of life without analyz ing individual factors.In a small number of studies specific questionnaires that analyzed the effect of caries on the qual ity of life have been conducted in children [18,19,20].
The aim of this study was to determine the incidence and impact of oral discomforts especially caused by caries on the quality of life of middleaged population, i.e. the association of oral problems and carious teeth.

Oral Health and Specific Impact of Caries on the Quality of Life of Middle-Aged People MATERIAL AND METHODS
The cross sectional study was conducted at the Depart ment of Dental Medicine of the Faculty of Medicine, Foca, University of East Sarajevo in the period from July to October 2012.Seventy two respondents of both genders (30.6% male and 69.4% female) age 2545 years (mean age 32.78±5.11years) were included in the study.The tar get population was selected randomly from people who accompanied dental patients.All of them signed written consent after they were explained the objectives and the expected outcomes of the research.
Data were collected using questionnaires and by clinical examination.Each participant filled in an anonymous ques tionnaire that related to sociodemographic characteristics: age, gender, level of education (completed primary school, secondary school, high school, university college or more), employment (employed fulltime, employed parttime, unemployed).To determine the impact of oral health on the quality of life, Serbian version of the Oral Impacts on Daily Performance (OIDP) questionnaire was used.It was previously verified for the psychometric validity, reliability and sensitivity to change for the territory of Bosnia and Herzegovina [21].In addition to measuring the overall im pact of oral health on the quality of life using general OIDP questionnaire, the specific OIDP questionnaire (SPOIDP) was used to determine the impact of caries on the quality of life.Oral discomforts caused by toothache, sensitive teeth, cavities, fractured fillings and pain after filling placement were specific effects of caries on the quality of life [20].Each individual was asked about difficulties during eating, speak ing, cleaning teeth, sleeping, resting, showing teeth without embarrassment, emotional state, performing light physical activity, social contacts, or enjoy spending time with other people due to oral problems (OIDP) or problems with caries (SPOIDP) in the last six months.Respondents who gave positive answer to any of questions were asked about the frequency and severity of problems using a fivepoint scale.Respondents who had difficulties permanently provided answers from "less than once a month" (1) to "every day" (5), while respondents who had difficulties a certain period gave answers from "up to 5 days in total " (1) to "more than 3 months" (5).Using the scale from 0 to 5 the severity of the impact of oral problems on daily life was determined.SPOIDP and OIDP were expressed as a sum of scores that were obtained by multiplying the frequency and severity of the impact of oral problem for each activity, divided by the maximum possible score.Higher OIDP scores indicated worse quality of life.
Clinical examinations were performed at the dental clinic of the Faculty of Medicine in Foca using artificial light, mirror and dental probe according to the standards and criteria of the World Health Organization [22].Den tal radiography was not done due to practical and ethical reasons.The status of all teeth including third molars was determined; each surface of the teeth was examined.The prevalence of dental caries was determined using the DMFT index and its components (D -decayed, Mmissing, F -filled).Clinical examination was carried out by one dentist who was trained by another experienced dentist in this research field.The value of intraexaminer compliance was measured by kappa coefficient (0.83).
Statistical analysis was performed using SPSS 19.0 (IBM Corp., Armonk, NY, USA).Results were presented as mean and standard deviation for numerical data, or frequency for ordinal data.Due to the low frequency, independent variables with three or more groups were dichotomized: the level of education (completed primary and secondary school/ college, college or more), employ ment (employed fulltime and parttime employment/ unemployed).In addition, the DMFT index was dichot omized according to the value in the last quartile in the frequency of this index (DMFT>22).Correlation of clin ical variables with SPOIDP score was determined using Spearman's correlation analysis.Values of p<0.05 were considered statistically significant in all analyzes.

Sociodemographic characteristics of respondents are
shown in Table 1.More than half of the respondents were employed and had primary or secondary education.The mean value of DMFT index was 17.7, and the dominant component was filled (F) teeth (63.7%).The average num ber of present teeth was 27.7, while the average number of healthy teeth was 14.2.The average OIDP score was 5.4, while the value of SP OIDP score was 3.0.The overall incidence of oral impact on daily activities in the last six months was 68.1%.Oral problems were most pronounced during meals (50%), cleaning teeth (38.9%), showing teeth without discomfort (22.2%) and had an ef fect on maintaining normal emotional state (21%) (Table 2).In more than half of the respondents (54.2%) oral im pact was related to tooth pain, sensitivity, tooth cavity (decay), fractured restorations and pain after placement of restoration.Dental caries was the most common cause of discomfort during eating (40.3%) and cleaning teeth (30.6%) (Table 2).Comparison of the frequency of oral discomforts due to the different conditions in oral cavity with oral discomforts caused by tooth decay only suggest that decay had lower impact on daily activities than the overall condition of oral cavity (Table 2).
Table 3 shows the correlation between SPOIDP score and clinical variables.Poorer dental status (DMFT>22) and the existence of at least one carious tooth were as sociated with higher values of SPOIDP score.In con trast, respondents who had higher number of present teeth (r=0.248), and healthy teeth (r=0.238) had lower SPOIDP score.After inclusion of sociodemographic vari ables (gender, age, level of education and employment) in the analysis, a significant correlation was observed only between SPOIDP and DMFT>22 (Table 3).

DISCUSSION
This study highlights the impact of oral problems on individual's daily activities as well as the association be tween clinical status of teeth and the quality of life.Poorer dental status measured by the DMFT index is associated with higher SPOIDP score.This finding points to the importance of using questionnaire for the assessment of the quality of life indicators to complement clinical find ings.To assess the quality of life related to oral health several questionnaires were used.OIDP used in this study is multidimensional questionnaire that measures the fre quency and severity of oral impact on daily activities of patients.It is based on a theoretical model of the World Health Organization and it is related to the third level measurements [23], thus showing strong coherence and less chance of double scoring of oral impacts at different levels [24].It was proved valid and reliable in the number of studies in population o different cultures and age [9,10,25,26].Compared with others, this questionnaire allows determination of not only general but also the specific impact of oral disease on the quality of life.
About 68.1% of the respondents had at least one oral impact on daily activities.These results are similar to the results of the study of Dorri et al. [27] who found the value of OIDP score 64.9% in people age 2050 years.Higher values of OIDP were recorded in people aged 3544 years in Thailand (73.6%) [24] and Brazil (71.4%) [28].On the other hand, the lowest prevalence of oral impacts was observed in elderly in the UK (13%) [29] and Norway (18.3%) [6].These differences in results can be attributed to differences in oral health of patients as well as cultural differences and different measures applied for the assess ment of the quality of life.In some studies the intensity of individual effect was determined which may limit the comparison results.However, it was noted that intensity determination does not improve psychometric character istics for assessing the quality of life [30].In the current study, the most pronounced difficulties were associated with eating and cleaning teeth.Also, oral problems showed a significant impact on showing teeth and maintaining normal emotional state, while there was a little impact on social dimension of oral health.Ob tained results from the current study are in accordance with other studies that included people of different back ground, age and used different questionnaires to assess the quality of life [6,24,25].These findings suggest that the status of oral health plays an important and complex role in middle age population not only in terms of func tion, but also in psychological domain.
In addition to determining the overall impact, it is pos sible to link oral discomforts with specific oral status (SP OIDP).This is the first study where SPOIDP was used to determine specific effect of caries on the quality of life in adults.As found in our study, toothache, sensitive teeth, decayed teeth, fractured fillings and sensitivity after res toration placement are responsible for 80% of all recorded oral discomforts.This can be attributed to relatively high prevalence of caries in patients in the current study which was also found in the study that assessed oral health of middleage population in Republika Srpska [14].More than half of oral impacts are the result of caries in younger population, even in those cases where caries prevalence is relatively low [19,20].
Comparing the frequency of specific with general ef fects for each daily activity, it was found that caries had an impact on food intake and teeth cleaning, but did not affect showing teeth and maintaining normal emotional state.These findings suggest that discomforts caused by tooth decay in middle aged people affect their quality of life only due to functional limitations in daily activities without af fecting the psychosocial sphere.The problem of showing teeth was not always associated with caries, but also with discoloration and position of teeth in the arch [31].Also, toothache had lower impact on speech, smile and emo tional stability [32].Tooth sensitivity, toothache and caries had impact on almost all daily activities, but the least on those related to psychological and social aspects [33].
In the current study, there was observed weak but sig nificant correlation between clinical indicators: dental caries, number of present and intact teeth, DMFT and quality of life.The highest coefficient value was 0.328; according to the psychometric standards it can be con sidered as low impact.This finding is probably not result of OIDP questionnaire limitations which has been shown to have excellent psychometric properties when applied in adult population in this region [5], but rather points to the conceptual and empirical distinction between health and disease.While clinical indicators determine a disease (bio logical concept) subjective indicators are more oriented towards health (a concept that is more oriented toward sociology and psychology) [8,34].In those cases where the disease has an impact it is caused by individual expecta tions, material, social and psychological resources, and even more importantly, social and cultural values [34].Studies that used SPOIDP found a strong correlation be tween untreated caries and oral impacts caused by caries [18,20], which has not been a case in the studies that used general questionnaire [35].Taking into account that in the current study group 80% of oral discomforts resulted from caries, and that specific questionnaire was used to examine the linkage between subjective and objective indicators, the weak correlation between quality of life and clinical variables or the absence of their association, except for the DMFT>22, indicate remarkable influence of sociodemographic factors on the quality of life.
According to the model of Chen and Hunter [36], a socioeconomic status, behavior related to oral health and oral status can affect the quality of life directly or indirectly, through oral health status.However, the worst clinical status had negative impact on daily life regardless of gender, age, employment and education level of the re spondents.On the other hand, if DMFT index was used to assess the presence of caries, a correlation between caries and quality of life has not been observed [26,37], except in cases where the caries prevalence was categorized based on disease severity [11,17] which was done in the current study.It is important to note that the DMFT index is a cumulative index that measures currently present and earlier caries, however, it is important to summarize the individual susceptibility to the disease over time.
This study has some limitations.The sample consisted of people who came with dental patients so we expected that they cared more about their oral health.However, observed prevalence of dental caries in this study group was similar to that obtained in other studies in this region [14].To obtain more representative data on the quality of life of middle aged population in this area, it is necessary to conduct extensive research with sample from general population.One of the shortcomings of this study is also the type of the study.Although this is a cross sectional study, there is no sufficient data about the specific impact of caries on the quality of life, especially in middle aged population.A prospective study could provide clearer pic ture of the association between the status of teeth and the quality of life as well as the relation between oral health and quality of life over time.Our research showed that quality of life depends on the status of teeth even after inclusion of sociodemographic factors in the analysis.For a more accurate determination of this bond and obtaining final conclusions it is important to include a number of factors in the multivariate analysis, not only sociodemographic, but also associated to the behavior related to own oral health.

CONCLUSION
Based on the results it can be concluded that there is high correlation between oral conditions and the qual ity of life.Discomforts caused by caries often lead to functional limitations in daily activities such as eating and cleaning teeth, but had no significant impact on the psychosocial domain.Poorer dental status, measured by DMFT index, was the only clinical variable that showed a significant correlation with the SPOIDP.

Oralno zdravlje i specifični uticaj karijesa na kvalitet života osoba srednje životne dobi
Dajana Nogo-Živanović 1 , Jelena Krunić 1 , Ljiljana Kulić 1 , Jelena Erić 2 , Nikola Stojanović 1 1 Katedra za bolesti zuba i endodonciju, Medicinski fakultet Foča, Univerzitet u Istočnom Sarajevu, Foča, Bosna i Hercegovina; 2 Katedra za stomatološku protetiku, Medicinski fakultet Foča, Univerzitet u Istočnom Sarajevu, Foča, Bosna i Hercegovina KRATAK SADRŽAJ Uvod Ka ri jes je i da lje u mno gim ze mlja ma zna ča jan so ci jal no-me di cin ski pro blem.Cilj ovog is tra ži va nja je bio da se utvr de in ciden ci ja i uti caj oral nih ne la god no sti, po seb no onih uzro ko va nih ka ri je som, na kva li tet ži vo ta oso ba sred nje ži vot ne do bi, od no sno da se utvr di po ve za nost oral nih pro ble ma uzro ko va nih ka ri je som sa sta njem zu ba.Ma te ri jal i me to de ra da U is tra ži va nje su uklju če ne 72 oso be sta ro sti 25-45 go di na.Srp ska ver zi ja upit ni ka Oral Im pacts on Daily Per for man ce (OIDP) ko ri šće na je za od re đi va nje op šteg uti ca ja oral nog zdra vlja i spe ci fič nog uti ca ja ka ri je sa (SP-OIDP) na kva li tet ži vo ta is pi ta ni ka.Za od re đi va nje sta nja zu ba ko ri šćen je in deks KEP.Re zul ta ti Ukup na in ci den ci ja oral nog uti ca ja na dnev ne ak tiv no sti bi la je 68,1%.Po re đe njem uče sta lo sti spe ci fič nih sa op štim uti ca ji ma za sva ku dnev nu ak tiv nost uoča va se da je ka ri jes uti cao na jedenje (40,0%) i pra nje zu ba (31,0%), ali ne i na po ka zi va nje zu ba i odr ža va nje uobi ča je nog emo ci o nal nog sta nja.Ka ri jes je bio uzrok oral nih ne la god no sti kod vi še od po lo vi ne is pi ta ni ka.Od svih is pi ti va nih kli nič kih va ri ja bli sa mo je vred nost in dek sa KEP ve ća od 22 bi la po ve za na sa SP-OIDP sko rom po sle uklju či va nja so ci o de mo graf skih fak to ra u ana li zu (r s =0,273).Za klju čak Re zul ta ti ovog is tra ži va nja po ka zu ju da je in ci den ci ja uti ca ja oral nih sta nja na kva li tet ži vo ta vi so ka, pri če mu su is pi ta ni ci ima li naj vi še po te ško ća tokom je la.Ko ri ste ći spe ci fič ni upit nik uoče no je da ka ri jes zu ba ima zna ča jan uti caj na oral no funk ci o ni sa nje is pi ta ni ka, te da po sto ji zna čaj na ko re la ci ja iz me đu sta nja zu ba i kva li te ta ži vo ta oso ba sred nje ži vot ne do bi.Ključ ne re či: in deks KEP; kva li tet ži vo ta u ve zi s oral nim zdra vljem; OIDP; pre va len ci ja ka ri je sa

UVOD
Oral no zdra vlje tra di ci o nal no se pro ce nju je na osno vu za stu plje no sti obo lje nja i po re me ća ja usta i zu ba, a po tvr đu je kli nič kim pre gle dom i pri me nom raz li či tih sto ma to lo ških in dek sa.U po sled nje vre me zna čaj na pa žnja u epi de mi o lo škim i kli nič kim is tra ži va nji ma po sve ću je se lo šim uti ca ji ma oral nih bo le sti, ka ri je sa, pa ro don to pa ti je i tra u mat skih ošte će nja na kva li tet ži vo ta po je din ca [1].Kva li tet ži vo ta u ve zi s oral nim zdra vljem za sno van je na či nje ni ci da se po sle di ce bo le sti ili sta nja ne mo gu pot pu no utvr di ti kli nič kim pre gle dom i on za pra vo pred sta vlja mul ti di men zi o nal ni kon cept ko ji se ne od no si sa mo na "fi zič ko bla go sta nje" po je din ca, već i na nje go vu psi ho lo šku i so ci jal nu di men zi ju sva ko dnev nog ži vo ta [2].S tim u ve zi po sled njih de ce ni ja su raz vi je ni stan dar di zo va ni upit ni ci ko ji mo gu pro ce ni ti uti caj oral nog zdra vlja na kva li tet ži vo ta.Ovi upit ni ci se me đu sob no raz li ku ju u po gle du ši ri ne ko je po je di ni upit nik obuhva ta, ukup nog bro ja pi ta nja, for mu la ci je pi ta nja, ali i vrste po nu đe nih od go vo ra.
Is pi ti va nja o me đu sob noj po ve za no sti kli nič kih me re nja oral nih bo le sti i su bjek tiv ne pro ce ne oral nog zdra vlja po ka zu ju da objek tiv ne me re ni su uvek u sa gla sno sti s per cep ci jom po je din ca [3,4].Ta ko đe, ma lo se zna o in di vi du al nim fak to ri ma ko ji uti ču na kva li tet ži vo ta u ve zi s oral nim zdra vljem.U pret hod nim is tra ži va nji ma uoče na je po ve za nost kva li te ta ži vo ta i kli nič kih po ka za te lja ko ji u ve li koj me ri uti ču na funk ci o nal nu i estet sku kom po nen tu, kao što su broj zu ba, ne do sta tak zu ba in ter ka ni nog sek to ra i broj oklu di ra ju ćih pa ro va [510].Uti caj ka ri je sa na kva li tet ži vo ta je ja san, ali ne pot pu no raz ja šnjen.Ne ke stu di je uka za le su na po ve za nost kva li te ta ži vo ta u ve zi s oral nim zdra vljem i ka ri je sa [8,9,11], dok s dru ge stra ne, Ca kos (Tsa kos) i sa rad ni ci [7,12] i Sri si la pa nan (Sri si la pa nan) i Ša jam (She i ham) [10] ni su za pa zi li tu ve zu.Ka ri jes uti če na kva li tet ži vo ta lju di jer je naj če šći uzrok bol nih sta nja u oro fa ci jal noj re gi ji [13], ali i pre ko dru gih me ha ni za ma kao što su ne za do volj stvo iz gle dom zu ba, gu bit kom zu ba ili funk ci o nal nim ogra ni če njem zbog gu bit ka ve ćeg ili ma njeg bro ja zu ba.
Pre va len ci ja ka ri je sa je mno go ve ća u is pi ti va noj sta ro snoj po pu la ci ji na pod ruč ju Re pu bli ke Srp ske [14] u po re đe nju s re zul ta ti ma stu di ja iz dru gih evrop skih ze ma lja [15,16].Si gur no je i da ovaj lo ši ji oral no zdrav stve ni sta tus is pi ta ni ka mo že zna čaj no da uti če na kva li tet oral nog zdra vlja, pri če mu je uti caj ka ri je sa na kva li tet ži vo ta pro ce nji van kod de ce ili kod sta rih oso ba [7,10,12,17], dok je vr lo ma lo po da ta ka o oso ba ma sred nje ži vot ne do bi.Za is pi ti va nje po ve za no sti ka ri je sa i kva li te ta ži vo ta uglav nom su ko ri šće ni ge ne rič ki upit ni ci, ta ko da do bi je ni re zul ta ti pred sta vlja ju, u stva ri, uti caj op šteg oral nog sta nja na kva li tet ži vo ta, bez ana li ze po je di nač nih.U ma lom bro ju is tra ži va nja pri me nji va ni su spe ci fič ni upit ni ci za od re đi va nje uti ca ja ka ri je sa na kva li tet ži vo ta, a ona su ura đe na u deč joj po pu la ci ji [18,19,20].
Cilj ovog is tra ži va nja je bio da se utvr de in ci den ci ja i uti caj oral nih ne la god no sti, po seb no onih uzro ko va nih ka ri je som, na kva li tet ži vo ta oso ba sred nje ži vot ne do bi, od no sno da se utvr di po ve za nost oral nih pro ble ma uzro ko va nih ka ri je som sa sta njem zu ba.

MATERIJAL I METODE RADA
Stu di ja pre se ka ura đe na je na Kli ni ci za sto ma to lo gi ju Me di cin skog fa kul te ta u Fo či, Uni ver zi te ta u Is toč nom Sa ra je vu, od ju la do ok to bra 2012.go di ne.Uzo rak su či ni la 72 is pi ta ni ka oba po la (30,6% mu škaraca i 69,4% žena) sta ro sti 25-45 go di na (pro seč na sta rost bi la je 32,78±5,11 go di na).Cilj na po pu la ci ja oda bra na je me to dom slu čaj nog iz bo ra od oso ba ko je su do šle u prat nji sto ma to lo ških pa ci je na ta.Svi is pi ta ni ci su na kon pi sa nog upo zna va nja s ci lje vi ma i oče ki va nim is ho di ma is tra ži va nja pot pi sa li pri sta nak za uče šće u is tra ži va nju.
Po da ci su pri ku plje ni po mo ću upit ni ka i na osno vu kli nič kog pre gle da.Sva ki is pi ta nik je po pu nja vao ano nim ni upit nik ko ji se od no sio na so ci o de mo graf ske od li ke: sta rost, pol, ni vo obra zo va nja (za vr še na osnov na ško la, za vr še na sred nja ško la, za vr še na vi ša ško la, za vr šen fa kul tet i vi še) i za po sle nje (za po slen s pu nim rad nim vre me nom, za po slen s ne pu nim rad nim vre me nom, ne za po slen).Za od re đi va nje uti ca ja oral nog zdra vlja na kva li tet ži vo ta ko ri šće na je srp ska ver zi ja upit ni ka Oral Im pacts on Daily Per for man ce (OIDP), ko ja je pret hod no ve ri fi ko va na u po gle du psi ho me trij ske va lid no sti, po u zda no sti i ose tlji vo sti na pro me nu za pod ruč je Bo sne i Her ce go vi ne [21].Po red me re nja ukup nog uti ca ja oral nog zdra vlja na kva li tet ži vo ta op štim OIDP upit ni kom u is tra ži va nju je ko ri šćen i spe ci fič ni OIDP upit nik (SPOIDP) ra di od re đi va nja uti ca ja ka ri je sa na kva li tet ži vo ta.Oral ne ne la god no sti na sta le zbog zu bo bo lje, ose tlji vo sti zu ba, ka vi te ta u zu bu, frak tu ri sa nog is pu na i bo la po sle po sta vlja nja is pu na pred sta vlja le su spe ci fi čan uti caj ka ri je sa na kva li tet ži vo ta [20].Sva kom po je din cu je po sta vlje no pi ta nje o po te ško ća ma to kom je de nja, go vo re nja, pra nja zu ba, spa va nja i od ma ra nja, po ka zi va nja zu ba bez ne la god no sti, emo ci o nal nog sta nja, iz vr ša va nja la ga nih fi zič kih ak tiv no sti, so ci jal nih kon ta ka ta ili uži va nja u dru že nju sa dru gim lju di ma u po sled njih šest me se ci zbog oral nih pro ble ma (OIDP) ili pro ble ma s ka ri je som (SPOIDP).Is pi ta ni ci ma ko ji su od go vo ri li po tvrd no na bi lo ko ju stav ku po sta vlje no je do dat no pi ta nje o uče sta lo sti i te ži ni ko ri ste ći pe to ste pe nu ska lu.Za is pi ta ni kod ko jih su te ško će bi le re dov ne od go vo ri su va ri ra li od "re đe od jed nom me seč no" (1) do "da, sva ki dan" (5), a za pa ci jen te kod ko jih su te ško će po sto ja le kroz od re đe no raz do blje od go vo ri su va ri ra li od "do pet da na ukup no" (1) do "vi še od tri me se ca" (5).Ska lom od 0 do 5 utvr đe na je te ži na oral nog uti ca ja na sva ko dnev ni ži vot.OIDP i SPOIDP iz ra že ni su kao su me sko ro va ko ji su re zul tat mno že nja fre kven ci je i te ži ne oral nog uti ca ja za sva ku ak tiv nost po de lje ne s naj ve ćim mo gu ćim sko rom.Ve ći OIDP skor je uka zi vao na lo ši ji kva li tet ži vo ta.
Kli nič ki pre gle di su oba vlje ni na sto ma to lo škoj kli ni ci Me di cin skog fa kul te ta u Fo či uz pri me nu ve štač kog osve tlje nja, sto ma to lo škog ogle dal ce ta i sto ma to lo ške son de pre ma stan dar di ma i kri te ri ju mi ma Svet ske zdrav stve ne or ga ni za ci je [22].Ra di o gra fi sa nje zu ba ni je oba vlje no iz prak tič nih i etič kih raz lo ga.Od re đen je sta tus svih zu ba, uklju ču ju ći i tre će mo la re, a pri li kom pre gle da is pi ti va na je sva ka po vr ši na zu ba.Ras pro stra nje nost ka ri je sa od re đe na je po mo ću in dek sa KEP i nje go vih kom po nen ti (K -ka ri jes, E -eks tra ho van zub, P -plom bi ran zub).Kli nič ke pre gle de oba vio je ob u če ni sto ma to log.Vred nost unu tar po sma trač ke sa gla sno sti, me re ne ko e fi ci jen tom ka pa, bi la je 0,83.
Sta ti stič ka ob ra da po da ta ka ura đe na je u pro gra mu SPSS 19.0 (IBM Corp., Ar monk, NY).Po da ci su pri ka za ni kao sred nje vred no sti i stan dard ne de vi ja ci je za nu me rič ka, od no sno uče sta lo sti za atri bu tiv na obe lež ja.Zbog ma le uče sta lo sti, ne za vi sne va ri ja ble sa tri ili vi še gru pa su di ho to mi zi ra ne: ni vo obra zo va nja (za vr še na osnov na ško la i sred nja ško la/za vr še na vi ša ško la, fa kul tet i vi še) i za po sle nje (za po slen s pu nim i ne pu nim rad nim vre me nom/ne za po slen).Ta ko đe, in deks KEP je di ho to mi zi ran pre ma vred no sti po sled njeg kvar ti la u uče sta lo sti in dek sa (KEP>22).Po ve za nost kli nič kih va ri ja bli sa SPOIDP sko rom od re đe na je pri me nom Spir ma no ve (Spe ar man) ko re la ci o ne ana li ze.Vred no sti p ma nje od 0,05 sma tra ne su sta ti stič ki zna čaj nim u svim ana li za ma.

REZULTATI
So ci o de mo graf ske od li ke is pi ta ni ka pri ka za ne su u ta be li 1. Vi še od po lo vi ne is pi ta ni ka bi li su za po sle ni i ima li su osnov no ili sred nje obra zo va nje.Sred nja vred nost in dek sa KEP bi la je 17,7, a do mi nant nu kom po nen tu či ni li su re sta u ri sa ni zu bi (63,7%).Pro se čan broj pri sut nih zu ba bio je 27,7, dok je pro se čan broj zdra vih zu ba bio 14,2.Sred nji OIDP skor bio je 5,4, a vred nost SPOIDP sko ra bi la je 3,0.
Ukup na in ci den ci ja oral nog uti ca ja na dnev ne ak tiv no sti u po sled njih šest me se ci bi la je 68,1%.Te go be su naj vi še bi le iz ra že ne to kom obe do va nja (50,0%), pra nja zu ba (38,9%), po ka zi va nja zu ba bez ose ća ja ne la god no sti (22,2%) i uti ca le su na odr ža va nje uobi ča je nog emo ci o nal nog sta nja (21%) (Ta be la 2).Kod vi še od po lo vi ne is pi ta ni ka (54,2%) oral ni uti caj je bio ve zan za bol zu ba, ose tlji vost zu ba, ka vi tet (šu plji nu) u zu bu, frak tu ri sa ni is pun i bol na kon po sta vlja nja is pu na.Ka ri jes zu ba je naj če šće uzro ko vao ne la god no sti to kom je la (40,3%) i pra nja zu ba (30,6%) (Ta be la 2).Upo re đu ju ći uče sta lost oral nih ne la god no sti ko je su se ja vlja le zbog raz li či tih sta nja u usnoj du plji s oral nim ne la god no sti ma ko je su uzro ko va ne ka ri je som, mo že se uoči ti da je ka ri jes imao ma nji uti caj na raz li či te dnev ne ak tiv no sti is pi ta ni ka u od no su na sve u kup no sta nje usne du plje (Ta be la 2).
U ta be li 3 pri ka za na je ko re la ci ja iz me đu SPOIDP sko ra i kli nič kih va ri ja bli.Lo ši ji sta tus zu ba (KEP>22) i po sto ja nje naj ma nje jed nog ka ri je snog zu ba bi li su po ve za ni s ve ćim vred no sti ma SPOIDP sko ra.Na su prot to me, is pi ta ni ci ko ji su ima li ve ći broj zu ba u usti ma (r=0,248) i ve ći broj zdra vih zu ba (r= 0,238) ima li su ma nji SPOIDP skor.Po sle uklju či va nja so ci o de mo graf skih va ri ja bli (pol, sta rost, ni vo obra zo va nja i za po sle nje) u ana li zu, zna čaj na po ve za nost je za be le že na sa mo iz me đu SP OIDP i vred no sti in dek sa KEP ve ćih od 22 (Ta be la 3).

DISKUSIJA
Ova stu di ja po ka zu je uti caj oral nih pro ble ma na dnev ne ak tiv no sti po je din ca, kao i da je kli nič ko sta nje zu ba po ve za no s kva li te tom ži vo ta.Lo ši ji sta tus zu ba, me ren in dek som KEP, po ve zan je s ve ćim SPOIDP sko rom.Ovaj na laz uka zu je na zna čaj pri me ne upit ni ka za pro ce nu kva li te ta ži vo ta kao do pu ne kli nič kim po ka za te lji ma u is tra ži va nji ma oral nog zdra vlja.Za pro ce nu kva li te ta ži vo ta u ve zi s oral nim zdra vljem ko ri šće no je ne ko li ko upit ni ka.OIDP, ko ji je pri me njen u ovom is tra ži va nju, je ste vi še di men zij ski upit nik ko jim se me re uče sta lost i te ži na oral nih uti ca ja na dnev ne ak tiv no sti is pi ta ni ka.Za sno van je na te o ret skom mo de lu Svet ske zdrav stve ne or ga ni za ci je i od no si se na tre ći ni vo me re nja [23], čime pokazuju snažnu ko he rent nost i ma nju mo guć nost dvo stru kog bo do va nja istih oral nih uti ca ja na raz li či tim ni vo i ma [24].Po ka zao se va lid nim i po u zda nim u ve li kom bro ju stu di ja u ko ji ma su uzo rak či ni le oso be raz li či tih kul tu ra i sta ro snih do ba [9,10,25,26].U po re đe nju sa dru gim, ovaj upit nik omo gu ća va od re đi va nje ne sa mo op šteg, već i spe ci fič nog uti ca ja oral nih obo lje nja na kva li tet ži vo ta po je din ca.Naj ma nje je dan oral ni uti caj na sva ko dnev ne ak tiv no sti ima lo je oko 68,1% is pi ta ni ka.Ovi re zul ta ti su slič ni re zul ta ti ma stu di je Do ri ja (Dor ri) i sa rad ni ka [27], u ko joj je kod oso ba sta ro sti iz me đu 20 i 50 go di na vred nost OIDP sko ra bi la 64,9%.Ve će vred no sti OIDP su za be le že ne kod oso ba sta ro sti 35-44 go di ne na Taj lan du (73,6%) [24] i u Bra zi lu (71,4%) [28].S dru ge stra ne, naj ni ža pre va len ci ja oral nih uti ca ja uoče na je kod sta ri jih oso ba u Ve li koj Bri ta ni ji (13%) [29] i Nor ve škoj (18,3%) [6].Ove raz li ke u re zul ta ti ma mo gu se pri pi sa ti raz li ka ma u oral nom zdra vlju is pi ta ni ka, kul tu ro lo škim i raz li ka ma u pri me nje nim me ra ma pro ce ne kva li te ta ži vo ta.U po je di nim is tra ži va nji ma od re đi van je i in ten zi tet po je di nač nog uti ca ja, što mo že ogra ni či ti po re đe nje re zul ta ta.Me đu tim, uoče no je da od re đi va nje in ten zi te ta ne uti če na po bolj ša nje psi ho me trij skih ka rak te ri sti ka za pro ce nu kva li te ta ži vo ta is pi ta ni ka [30].
U ovom is tra ži va nju naj če šće iz ra že ne te ško će bi le su u ve zi sa je lom i pra njem zu ba.Ta ko đe, oral ne te ško će su po ka za le zna tan uti caj na po ka zi va nje zu ba i odr ža va nje uobi ča je nog emo ci o nal nog sta nja, dok je po sto jao ma li uti caj te ško ća na so ci jal nu di men zi ju oral nog zdra vlja.Do bi je ni re zul ta ti o uče sta lo sti te ško ća u na šem uzor ku su u skla du s re zul ta ti ma dru gih is tra ži va nja ko ja su uklju či va la oso be raz li či tog po re kla i sta ro sti i u ko ji ma su ko ri šće ni raz li či ti upit ni ci za pro ce nu kva li te ta ži vo ta [6,24,25].Ovi na la zi po ka zu ju da usna du plja ima va žnu i vi še stru ku ulo gu kod oso ba sred nje do bi, ne sa mo u po gle du funk ci o nal ne ak tiv no sti, već i u psi hič kom do me nu.
Po red od re đi va nja op šteg uti ca ja, mo gu će je i po ve za ti oral ne ne la god no sti sa spe ci fič nim oral nim sta njem (SPOIDP).Ovo je pr va stu di ja u ko joj je ko ri šćen SPOIDP ra di od re đi va nja spe ci fič nog uti ca ja ka ri je sa na kva li tet ži vo ta od ra slih oso ba.Pre ma na la zi ma ove stu di je, zu bo bo lja, ose tlji vo sti zu ba, ka vi tet u zu bu, frak tu ri sa ni is pu ni i bol po sle po sta vlja nja is pu na su od go vor ni za 80% svih za be le že nih oral nih ne la god no sti.To se mo že pri pi sa ti re la tiv no vi so koj pre va len ci ji ka ri je sa is pi ta ni ka u ovom is tra ži va nju, na šta su uka za la i is tra ži va nja oral nog zdra vlja oso ba sred nje ži vot ne do bi u Re pu bli ci Srp skoj [14].Vi še od po lo vi ne oral nih uti ca ja su po sle di ca ka ri je sa kod mla đe po pu la ci je, čak i u onim slu ča je vi ma ka da je pre va len ci ja ka ri je sa re la tiv no ni ska [19,20].
Po re đe njem uče sta lo sti spe ci fič nih s op štim uti ca ji ma za sva ku dnev nu ak tiv nost uoča va se da je ka ri jes imao uti ca ja na jedenje i pra nje zu ba, ali ne i na po ka zi va nje zu ba i odr ža va nje uobi ča je nog emo ci o nal nog sta nja.Ovi na la zi ot kri va ju da ne la god no sti uzro ko va ne ka ri je som kod oso ba sred nje ži vot ne do bi uti ču na kva li tet ži vo ta do vo de ći do ogra ni če nja u sva ko dnev nim funk ci o nal nim ak tiv no sti ma, ali bez uti ca ja na psi ho so ci jal ne sfe re.Uti caj na po ka zi va nje osme ha ni je uvek po ve zan s ka ri je som, već sa dis ko lo ra ci jom i po zi ci jom zu ba u zub nom lu ku [31].Ta ko đe, zu bo bo lja ima ma nji uti caj na go vor, smeh i emo ci o nal nu sta bil nost [32].Ose tlji vost zu ba, zu bo bo lja ili ka ri je sna šu plji na ima ju uti caj na sko ro sve sva ko dnev ne ak tiv no sti, ali naj ma nje na one ko ji se od no se na psi ho lo ške i so ci jal ne aspek te [33].
U ovom is tra ži va nju za be le že na je sla ba, ali ipak zna čaj na po ve za nost kli nič kih pokazatelja: ka ri je snih zu ba, bro ja pri sut nih, in takt nih zu ba, in dek sa KEP i kva li te ta ži vo ta.Naj ve ća vred nost ko e fi ci jen ta je iz no si la 0,328, što se, pre ma psi ho me trij skim stan dar di ma, mo že sma tra ti sla bim uti ca jem.Ovaj na laz ve ro vat no ni je po sle di ca ogra ni če nja OIDP upit ni ka, za ko ji je po ka za no da ima od lič ne psi ho me trij ske ka rak te ri sti ke ka da se pri me nju je kod od ra sle po pu la ci je na na šim pro sto ri ma [5], već na pro tiv, uka zu je na kon cep tu al nu i em pi rij sku raz li ku iz me đu zdra vlja i bo le sti.Na i me, dok se kli nič kim po ka za te lji ma od re đu je obo lje nje (što je bi o lo ški kon cept), su bjek tiv ni po ka za te lji su vi še ori jen ti sa ni ka zdra vlju (kon cept ko ji je vi še okre nut ka so ci o lo gi ji i psi ho lo gi ji) [8,34].U onim slu ča je vi ma ka da obo lje nje i ima uti ca ja, ono je uslo vlje no oče ki va nji ma po je din ca, ma te ri jal nim, so ci jal nim i psi ho lo škim re sur si ma, ali još zna čaj ni je i so ci jal nim i kul tu ro lo škim vred no sti ma [34].U is tra ži va nji ma gde je ko ri šćen SPOIDP upit nik uoče na je ja ka ve za iz me đu ne sa ni ra nog ka ri je sa i oral nih uti ca ja ko ji su po sle di ca ka ri je sa [18,20], što se ne be le ži ka da se u is tra ži va nji ma ko ri sti ge ne rič ki upit nik [35].Uzi ma ju ći u ob zir či nje ni cu da je 80% oral nih ne la god no sti po sle di ca ka ri je sa u ovoj is pi ti va noj gru pi, kao i da je za is pi ti va nje po ve za no sti su bjek tiv nih i objek tiv nih po ka za te lja ko ri šćen spe ci fič ni upit nik, sla ba ko re la ci ja kva li te ta ži vo ta i kli nič kih va ri ja bli i iz o sta nak nji ho ve po ve za no sti, osim za vred no sti in dek sa KEP ve će od 22, uka zu ju na iz ra žen uti caj so ci o de mo graf skih fak to ra na kva li tet ži vo ta.
Pre ma mo de lu Če na (Chen) i Han te ra (Hun ter) [36], so ci o e ko nom ski sta tus, po na ša nja u ve zi s oral nim zdra vljem i oral ni sta tus mo gu da uti ču na kva li tet ži vo ta di rekt no ili in di rekt no, pre ko sta nja oral nog zdra vlja.Ipak, naj go re kli nič ko sta nje ima lo je loš uti caj na sva ko dnev ni ži vot is pi ta ni ka, ko ji je ne za vi san od po la, go di na sta ro sti, za po sle nja i ste pe na obra zo va nja is pi ta ni ka.S dru ge stra ne, u stu di ja ma gde je ko ri šćen in deks KEP za pro ce nu po sto ja nja ka ri je sa, ni je za be le že na po ve za nost s kva li te tom ži vo ta [26,37], osim ka da je pre va len ci ja ka ri je sa ka te go ri sa na na osno vu te ži ne obo lje nja [11,17], kao i u ovom is tra ži va nju.Va žno je na po me nu ti da je in deks KEP, kao ku mu la ti van in deks ko jim se me ri i sa da šnje i pri ja šnje po sto ja nje ka ri je sa, zna ča jan za su mi ra nje in di vi du al ne ose tlji vo sti ka bo le sti to kom vre me na.
Ovo is tra ži va nje ima i od re đe na ogra ni če nja.Na i me, uzo rak su či ni le oso be ko je su do šle kao prat nja sto ma to lo škim pa ci jen ti ma, pa se mo že oče ki va ti da ove oso be vi še bri nu o svom oral nom zdra vlju.Me đu tim, za be le že na pre va len ci ja ka ri je sa u ovoj is pi ti va noj gru pi je slič na kao i u dru gim is tra ži va nji ma u ovom re gi o nu [14].Za do bi ja nje re pre zen ta tiv ni jih po da ta ka o kva li te tu ži vo ta is pi ta ni ka sred nje ži vot ne do bi na ovim pro sto ri ma po treb no je ura di ti obim ni je is tra ži va nje s uzor kom ko ji či ne oso be iz op šte po pu la ci je.Ne do sta ci ovog is tra ži va nja le že i u vr sti stu di je.Iako je ovo stu di ja pre se ka, ov de ne po sto ji do volj no po da ta ka o spe ci fič nom uti ca ju ka ri je sa na kva li tet ži vo ta, po seb no ka da je reč o oso ba ma sred nje ži vot ne do bi.Pro spek tiv na is tra ži va nja mo gla bi da ti ja sni ju sli ku o po ve za no sti sta nja zu ba s kva li te tom ži vo ta u ve zi s oral nim zdra vljem, kao i nje go vom uti ca ju na kva li tet ži vo ta u funk ci ji vre me na.Ovo is tra ži va nje je po ka za lo da je kva li tet ži vo ta za vi san od sta nja zu ba i po red uklju či va nja so ci o de mo graf skih fak to ra u ana li zu.Za pre ci zni je od re đi va nje po ve za no sti i do bi ja nja ko nač nih za klju ča ka po treb no je u mul ti va ri jant nu ana li zu uklju či ti ve ći broj ne sa mo so ci o de mo graf skih, već i fak to ra ve za nih za po na ša nje u ve zi sa sop stve nim oral nim zdra vljem.

ZAKLJUČAK
Na osno vu do bi je nih re zul ta ta mo že se za klju či ti da je in ci den ci ja uti ca ja oral nih sta nja na kva li tet ži vo ta lju di vi so ka.Ne la god no sti iza zva ne ka ri je som naj če šće do vo de do ogra ni če nja u sva ko dnev nim funk ci o nal nim ak tiv no sti ma, kao što su obe do va nje i pra nje zu ba, ali su bez znat nog uti ca ja na psi ho so ci jal ne do me ne.Lo ši je sta nje zu ba, me re no in dek som KEP, je di na je kli nič ka va ri ja bla ko ja je po ka za la zna čaj nu po ve za nost sa SPOIDP.

Table 2 .
Frequency of OIDP and SP-OIDP and their impact on daily activities in the study population Tabela 2. Učestalost OIDP i SP-OIDP i njihov uticaj na svakodnevne aktivnosti u ispitivanoj populaciji