Age and Ageing Advance Access published November 25, 2013 Age and Ageing 2013; 0: 1–7 doi: 10.1093/ageing/aft183
© The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]
Do health provider–patient relationships matter? Exploring dentist-patient relationships and oral health-related quality of life in older people VANESSA ELAINE MUIRHEAD1, WAGNER MARCENES1, DESMOND WRIGHT2 1
Address correspondence to: V. E. Muirhead. Tel: 0207 882 8637; Fax: 0207 882 5842. Email: [email protected]
Abstract Background: patient experience is now a key parameter in health care. Yet, very little is known about the possible impact of dentist–patient relationships on patient-centred outcomes including older peoples’ oral health-related quality of life (OHRQoL). Objective: this study assessed the relationship between OHRQoL and dentist–patient relationships related to perceived unmet dental needs; shared decision-making; time spent discussing oral health problems; respect and confidence and trust. Participants: older people aged 65 years and over living in East London, UK in 2011. Methods: a cross-sectional study using stratified random sampling recruited a representative sample of older people (n = 772). Participants completed an oral examination and a structured questionnaire including the Oral Health Impact Profile-14 (OHIP-14) measuring OHRQoL and five dentist–patient relationship questions taken from the UK 2009 Adult Dental Health Survey. Multivariate Poisson regressions modelled the association between OHRQoL and dentist–patient factors adjusting for socio-demographic factors, clinical oral indicators, and dental attendance. Results: having a perceived unmet need for dental treatment (PRR = 1.84; 95% CI: 1.32, 2.56) and expressing a lack of trust and confidence in one’s dentist (PRR = 1.74; 95% CI: 1.01, 2.98) were significant predictors of poor OHRQoL among older people. Conclusions: these findings suggest that older people with unmet dental needs and those who expressed a lack of trust and confidence in their dentist were more likely to experience poor OHRQoL reinforcing the importance of the dental patient experience in healthy ageing and well-being. Keywords: oral health, dentists, quality of life, patient–provider relationships, older people
Introduction Dramatic improvements in oral health over the past 50 years in most industrialised countries now mean that more people retain their natural teeth into older age [1]. UK Adult Oral Health Surveys have shown a decline in the percentage of older people with no natural teeth from 78% in 1978 to only 24% in 2009 [2]. The preference for keeping teeth is socially entrenched even among older people. Eighty-five percent of people aged 55 years and over in the UK in 1998 expected to keep their teeth throughout their lifetime [3]. Maintaining one’s oral health is important for psychosocial well-being [4]. Holistic definitions of oral health now recognise the importance of patients’ perceptions of their own oral
health and not just clinical indicators of oral disease. Several validated oral health-related quality of life (OHRQoL) measures have captured older people’s patient-centred outcomes [5]. The Oral Health Impact Profile-14 (OHIP-14) [6] is a widely used OHRQoL measure based on Locker’s [7] adaptation of the WHO Classification of Impairment, Disability and Handicap [8]. The OHIP-14 incorporates five hierarchical psychosocial consequences of oral disease: impairment, functional limitation, pain/discomfort, disability and handicap [6]. Several studies have shown the negative impact of oral diseases on older peoples’ OHRQoL [9, 10]. However, OHRQoL is multifaceted and complex. While studies have found associations between OHRQoL and intrapersonal factors such as depression [11], we know very little about the
1
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Centre for Clinical and Diagnostic Oral Sciences, Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK 2 Public Health England, London Region, London, UK
V. E. Muirhead et al.
Methods
contained two items assessing functional limitations (difficulty pronouncing words and altered taste); physical pain (painful aching mouth and uncomfortable eating); psychological discomfort (self-consciousness about one’s dental appearance and feeling tense); physical disability (unsatisfactory diet and disrupted meals); psychological disability (difficulty relaxing and embarrassment); social disability (irritability and work difficulties) and handicap (life dissatisfaction and inability to function) [6]. All OHIP-14 items were scored on a 5-point scale (very often = 4, fairly often = 3, occasionally = 2, hardly ever = 1 and never = 0). Five dichotomous (yes/no) dentist–patient relationship questions were related to (i) their perceived need for treatment, (ii) time taken to discuss any problems; (iii) patient involvement in decision-making; (iv) respect and (v) confidence and trust. One dental attendance question asked about the time since their last dental visit with seven categories ranging from within the last 6 months to >10 years ago. Validated questions from the UK Census 2001 assessed socio-demographic factors including age, gender and ethnicity. Clinical examination
Participants also completed an oral examination carried out by calibrated dentists in their own home. Dentists followed the 2009 UK Adult Dental Health Survey protocol [18] and recorded the total number of teeth, denture use, the number of decayed teeth and pocket depths to assess patients’ periodontal (gum) conditions. Larger pockets depths indicated more severe periodontal disease.
Study design
This cross-sectional survey included older people aged 65 years and over living in three inner city London boroughs in 2011. Our sample size calculation estimated a minimum sample of 731 older people based on a 5% margin of error, a 95% confidence interval, a design effect (DEFF = 4), an 80% power and an estimated 37% prevalence of older people reporting at least one oral health impact derived from the 2009 UK Adult Oral Health Survey [17]. Stratified random sampling selected a representative sample from 80 electoral wards (strata). After excluding commercial addresses and vacant premises, the final sampling frame consisted of 1,270 households. At least one older person aged 65 years and over residing in valid addresses received a postal invitation to participate and complete an interviewer-administered questionnaire and an oral examination. Data collection Interviewer-administered structured questionnaire
Trained interviewers administered the questionnaire in participants’ own homes. The questionnaire included the OHIP-14 and validated questions taken from the 2009 Adult Dental Health Survey about their relationship with their dentist at their most recent visit [18]. The OHIP-14 assesses the impact of dental conditions on participants’ daily functioning over the past 12 months related to seven domains [6]. Each domain
2
Data analysis
Data were analysed using STATA/IC 11 taking into account survey weights and the complex survey design. The main outcomes were the total OHIP-14 score and the seven domain (subscale) scores reflecting the severity of oral health impacts. Subscale scores ranged from 0 to 4 and total OHIP-14 scores ranged from 0 to 56; higher scores indicated worse OHRQoL. The prevalence of negative oral health impacts was also calculated as the percentage of participants reporting one of more OHIP-14 items ‘fairly often’ or ‘very often’. The main explanatory variables were the five dentist–patient variables related to perceived need for treatment, time taken to discuss problems, patient involvement in decision-making, respect and dignity and confidence and trust. Other explanatory variables included ethnicity (i.e. White, Black, Asian and mixed/other), age, gender, oral health status and dental attendance. Four dichotomised oral health status variables assessed untreated decayed teeth (i.e. no decayed teeth/one or more untreated decayed tooth), periodontal (gum) disease (no teeth with pockets depths/one or more teeth with pocket depths ≥4 mm), denture usage (no dentures/dentures) and the number of teeth with a cut-off of 21 or more teeth to indicate a functional dentition. Research has shown that people can function adequately with a minimum of 21 teeth [19]. One dichotomised dental attendance variable assessed the time since their last visit (last visit within the past year/last dental visit >1 year ago).
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effect of interpersonal relationships on OHRQoL beyond one’s immediate social network. What effect the relationship between a dentist and a patient has on a patient’s OHRQoL is an underexplored research area. Although few OHRQoL studies have explored patient–provider dynamics, studies involving other health conditions infer that positive patient experiences such as patient communication, trust, empathy and respect can affect patient outcomes and quality of life [12]. For example, Lee et al.’s longitudinal study of diabetic patients found that patient autonomy and trust in their physician improved patients’ physical and mental health-related quality of life when combined with high information provision [13]. Ong et al.’s cancer study found that patient communication related to asking questions was negatively associated with global quality of life scores [14]. Slade et al. [15] also studied quality of life and unmet need for community mental health services and found that patients’ quality of life decreased with increasing unmet physical health needs. This raises the possibility that older peoples’ perceptions about their need for dental care may also be an important dentist–patient correlate of OHRQoL. Older people have more contact with dental providers than younger patients [2]. Dentist and older-patients’ relationships may also be more problematic with ill health, increasing disability and co-existing systemic diseases in older age [16]. This study addressed this knowledge gap by assessing the relationship between dentist–patient relationship factors and OHRQoL in older people living in East London, UK.
Do health provider–patient relationships matter? Hierarchical Poisson regression models tested the relationship between total OHIP-14 scores and dentist–patient factors. This involved incrementally adding explanatory variables into four regression models to produce adjusted prevalence rate ratios (PRR). Model 1 included socio-demographic factors (i.e. age, gender and ethnicity); Model 2 adjusted for the socio-demographic factors and oral health status confounders: untreated decayed teeth, gum pocketing ≥4 mm, denture use and functional dentition (i.e. >21 natural teeth). Model 3 added dental attendance to Models 1 and 2. The final fully adjusted Model 4 included Model 3 variables and the five dentist–patient relationship variables. The level of statistical significance for all tests was set at P < 0.05. The NHS East London Research Ethics Committee (REC) approved the study.
Table 1. Severity and prevalence of oral health impacts by OHIP-14 subscale and total scores for the sample of older people living in East London in 2011 (n = 772)
Results
scores (mean OHIP-14 = 8.97) than older people with no perceived unmet dental needs (mean OHIP-14 = 3.41) (P < 0.001) (Table 2). Similarly, older people who lacked trust or confidence in their dentist (mean OHIP-14 = 12.32) had higher scores than those who expressed confidence and trust in their dentist (mean OHIP-14 = 5.74) (P = 0.005) (Table 2). We tested the relationship between OHIP-14 score and dentist–patient relationship adjusting for other explanatory variables in the hierarchical Poisson regression models (Table 3). The significant associations between OHRQoL and perceived need for treatment and OHRQoL and older people’ trust and confidence in their dentist attenuated after adjusting for explanatory variables but remained statistically significant (Model 4, Table 3). In the final fully adjusted model, females (PRR = 1.52, P = 0.006), denture wearers (PRR = 1.87; P = 0.001), older people with an unmet perceived need for dental treatment (PRR = 1.84; P < 0.001) and those who expressed no confidence and trust in their dentist (PRR = 1.74; P = 0.04) had statistically significant higher OHIP-14 score reflecting poorer OHRQoL (Model 4; Table 3).
OHRQOoL and dentist–patient relationships
There were significant associations between OHRQoL and two dentist–patient relationship factors (Table 2). Older people who felt they needed dental treatment had higher OHIP-14
Severity: mean OHIP-14 Score (95% CI)
Prevalence: number (%) reporting one or more impact fairly often/very often
0.75 (0.60, 0.91) 1.72 (1.49, 1.96) 1.09 (0.84, 1.33)
65 (8.41) 141 (19.49) 81 (12.18)
0.88 (0.71, 1.06) 0.81 (0.57, 1.04) 0.42 (0.27, 0.56) 0.49(0.33, 0.65) 6.15 (5.04, 7.26)
69 (8.03) 50 (8.23) 18 (2.54) 41(5.30) 487 (65.22)
........................................ Functional limitation Physical pain Psychological discomfort Physical disability Psychological disability Social disability Handicap Total OHIP-14 score
Discussion This is the first published study from our knowledge to explore dentist–patient relationships and OHRQoL in older people. Older people in our study had a higher prevalence of less severe oral health impacts compared with OHIP-14 estimates reported in the 2009 Adult Dental Health Survey [17]. Unmet dental needs and poor OHRQoL
Older people also had perceived unmet dental treatment needs. Poorer OHRQoL reported by older people with unmet dental needs supports previous research in younger age groups [20], which suggests that perceptions about unmet needs do not diminish with age. Perceived need for dental treatment and denture use were significant predictors of OHRQoL while clinical indicators measuring the two most common oral diseases (i.e. decayed teeth and periodontal diseases) were not associated with OHRQoL. Previous
3
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Seven hundred and ninety-six older people agreed to participate and completed an interviewer-administered questionnaire. Seven hundred and seventy-two older people reported their age, gender and ethnicity allowing survey weighting and inclusion in the final data set. The household response rates in City and Hackney, Tower Hamlets and Newham were 55.9, 53.8 and 52.6%, respectively. Fifty-six percent of older people were female; 53.7% were aged 65–74, 35.7% aged 75–84 years and 10.7% were aged 85 years and over. Eighty percent of older people were White, 10.3% were Asian, 8.3% were Black and 1.2% were from mixed/other ethnic groups. Most older people (81%) had 21 or more teeth and 50% wore a denture. Approximately one in four older people (24.9%) had one or more untreated decayed tooth and 58.2% had periodontal (gum) disease. Fifty percent had a perceived (unmet) need for dental treatment, 63.1% felt that their dentist involved them in decision-making about their care and 67% felt that adequate time had been taken to discuss oral problems. Ninety-seven percent felt treated with respect and dignity and 93.2% expressed trust and confidence in their dentist. Older people reported a mean total OHIP-14 score of 6.15 (95% CI: 5.04, 7.26) (Table 1). Sixty-five percent reported one or more impact experienced fairly often/very often in the past 12 months. The most common impacts were pain and/ or uncomfortable eating (19.5%) and feeling tense and/or self-conscious about the appearance of their teeth and mouth (12.2%) (Table 1). Unadjusted analyses showed that older people aged 85 years and over, those with fewer natural teeth (0–20 teeth) and denture wearers had higher mean OHIP-14 scores (indicative of poorer OHRQoL) than older people aged 65–74 years, those with a functional dentition (21 or more teeth) and people who did not wear dentures (Table 2).
Dimension
V. E. Muirhead et al. Table 2. Mean Oral Health Impact 14 (OHIP-14) scores by socio-demographic factors, oral health status, dental attendance and dentist–patient relationship explanatory variables for the sample of older people living in East London in 2011 (n = 772) Variables
Mean OHIP-14 (95% CI)
Unadjusted prevalence rate ratios (95% CI)
P-value
.................................................................................... 6.04 (4.90, 7.17) 5.05 (3.94, 6.16) 10.44 (5.68, 15.18)
1 0.84 (65, 1.07) 1.72 (1.09, 2.73)
0.16 0.02
5.23 (4.11, 6.35) 6.87 (5.26, 8.46)
1 1.31 (0.99, 1.74)
0.06
5.91 (4.65, 7.17) 7.37 (5.48, 9.25) 6.43 (5.00, 7.87) 9.63 (4.64, 14.62)
1 1.24 (0.95, 1.63) 1.09 (0.81, 1.47) 1.62 (0.91, 2.89)
0.11 0.58 0.09
6.25 (4.87, 7.64) 9.12 (6.29, 12.09)
1 1.47 (1.00, 2.15)
0.05
3.76 (3.06, 4.46) 8.47 (6.61, 10.31)
1 2.25 (1.71, 2.96)
1 year ago). d Model 4 adjusted for demographic factors, oral health status, dental attendance and dentist–patient factors. *P < 0.05. **P < 0.001. b
Trust in dental providers may be particularly important for older people who are traditionally less likely to engage in shared decision-making than younger people trusting and relying on professionals. Trachtenberg et al. [24] also found that older peoples’ increased trust in physicians reflected
a more compliant and deferential role. Older peoples’ confidence and trust in dental professionals may alleviate stress and uncertainty. Lack of trust in one’s dentist and unmet need for dental treatment could also heighten dental anxiety also known to be associated with poor OHRQoL [25].
5
V. E. Muirhead et al. Public health implications
Key points • Older people had unmet dental treatment needs. • Older people with unmet needs had poorer OHRQoL than older people with no perceived needs. • A lack of trust and confidence in their dentist was related to older peoples’ poor oral health-related quality of life. • Dentist–patient factors should be incorporated into the proposed patient experience quality framework in the new NHS contract.
Conflicts of interest None declared.
Funding This work was supported by Tower Hamlets, Newham and City and Hackney Primary Care Trusts.
Study limitations
We acknowledge this study’s limitations. Firstly, the inherent weakness of a cross-sectional study precludes one from making definitive causal inferences. This study does allow us to surmise how unmet dental needs and lack of trust could theoretically impair OHRQoL in older people. Cyclical relationships or reverse causality whereby impaired OHRQoL actually heightens older peoples’ perceptions of unmet needs or lack of trust in dental care providers are also possible. Further research using longitudinal study designs could explore the possibility of reverse or reciprocal causal relationships. Secondly, although we used a dichotomous indicator reflecting a trust/distrust dichotomy, some theorists view trust as a multidimensional construct existing as a continuum ranging from complete distrust to complete trust [30]. Therefore, future research should explore concepts and antecedents of trust in dental care providers, which may differ from other health providers.
Conclusions
In conclusion, this study clearly showed older peoples’ OHRQoL significantly associated with their perceptions about needing and not receiving dental treatment and their lack of trust and confidence in their dentist. This has direct implications for developing patient experience indicators. Further research should explore trust in dentist–patient relationships to
6
References 1. Downer MC. The changing pattern of dental disease over 50 years. Br Dent J 1998; 185: 36–41. 2. Fuller E, Steele J, Watt R et al. 1. Oral health and function: a report from the adult dental health survey 2009. London: The Health and Social Care Information Centre, 2011. 3. Office for National Statistics SSD. Adult Dental Health Survey, 1998 (computer file). Colchester, Essex: UK Data Archive, 2000. 4. Gerritsen AE, Allen PF, Witter DJ et al. Tooth loss and oral health-related quality of life: a systematic review and meta-analysis. Health Qual Life Outcomes 2010; 8: 126 doi: 10.1186/1477-7525-8-126. 5. Hebling E, Pereira AC. Oral health-related quality of life: a critical appraisal of assessment tools used in elderly people. Gerodontology 2007; 24: 151–61 doi: 10.1111/j.1741-2358. 2007.00178.x. 6. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997; 25: 284–90. 7. Locker D. Measuring oral health: a conceptual framework. Community Dent Health 1988; 5: 3–18. 8. World Health Organization. International Classification of Impairments Disabilities and Handicaps: A Manual of Classification. Geneva: WHO, 1980. 9. Kotzer RD, Lawrence HP, Clovis JB et al. Oral health-related quality of life in an aging Canadian population. Health Qual Life Outcomes, 2012; 10: 50–62.
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Our study is particularly timely given the recently published NHS Patient Experience framework developed to improve patients’ experience of healthcare services [26]. It encompassed the key domains included in the framework such as expressed needs; shared decision-making; information, communication and access to care. Since studies have found links between patient trust and medical care including willingness to seek care and adhere to treatment recommendations [27], enhancing trust in dental providers could not only improve older peoples’ OHRQoL but also increase their uptake of oral health services and complex treatment [28]. The new NHS primary dental care contract pilot project also includes patient experience indicators as part of the Dental Quality and Outcomes Framework (DQOF) [29]. However, only one of the seven DQOF indicators assesses NHS Patient Experience framework domains. Based on our study, we suggest that the DQOF should include dentist–patient factors supported by research which are strongly related to patients’ OHRQoL. Evidence-based patient experience indicators which affect patient outcomes could also be used to compare and reward healthcare services for positive patient experiences.
enhance older peoples’ patient experiences and address their perceptions about unmet dental needs.
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Received 16 May 2013; accepted in revised form 6 September 2013
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10. Tsakos G, Marcenes W, Sheiham A. The relationship between clinical dental status and oral impacts in an elderly population. Oral Health Prev Dent 2004; 2: 211–20. 11. Hassel AJ, Danner D, Schmitt M et al. Oral health-related quality of life is linked with subjective well-being and depression in early old age. Clin Oral Investig 2011; 15: 691–7 doi: 10.1007/s00784-010-0437-3. 12. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002; 15: 25–38. 13. Lee Y-Y, Lin JL. How much does trust really matter? A study of the longitudinal effects of trust and decision-making preferences on diabetic patient outcomes. Patient Educ Couns 2011; 85: 406–12 doi: http://dx.doi.org/10.1016/j.pec.2010.12.005. 14. Ong LML, Visser MRM, Lammes FB et al. Doctor–patient communication and cancer patients’ quality of life and satisfaction. Patient Educ Couns 2000; 41: 145–56 doi: http://dx.doi. org/10.1016/S0738-3991(99)00108-1. 15. Slade M, Leese M, Cahill S et al. Patient-rated mental health needs and quality of life improvement. Br J Psychiatry 2005; 187: 256–61. doi: 10.1192/bjp.187.3.256. 16. British Dental Association. Oral Healthcare for Older People 2020 Vision. Check up January 2012, 2012. 17. Nuttall N, Tsakos G, Lader D et al. Outcome and Impact: Report from the Adult Dental Health Survey 2009. London: The Health and Social Care Information Centre, 2011. 18. NHS Information Centre. Foundation Report: Adult Dental Health Survey 2009 (Technical Information), 2011. 19. Gotfredsen K, Walls AWG. What dentition assures oral function? Clin Oral Implants Res 2007; 18: 34–45 doi: 10.1111/ j.1600-0501.2007.01436.x. 20. Sanders AE, Slade GD, Lim S et al. Impact of oral disease on quality of life in the US and Australian populations. Community
© The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]
Do health provider–patient relationships matter? Exploring dentist-patient relationships and oral health-related quality of life in older people VANESSA ELAINE MUIRHEAD1, WAGNER MARCENES1, DESMOND WRIGHT2 1
Address correspondence to: V. E. Muirhead. Tel: 0207 882 8637; Fax: 0207 882 5842. Email: [email protected]
Abstract Background: patient experience is now a key parameter in health care. Yet, very little is known about the possible impact of dentist–patient relationships on patient-centred outcomes including older peoples’ oral health-related quality of life (OHRQoL). Objective: this study assessed the relationship between OHRQoL and dentist–patient relationships related to perceived unmet dental needs; shared decision-making; time spent discussing oral health problems; respect and confidence and trust. Participants: older people aged 65 years and over living in East London, UK in 2011. Methods: a cross-sectional study using stratified random sampling recruited a representative sample of older people (n = 772). Participants completed an oral examination and a structured questionnaire including the Oral Health Impact Profile-14 (OHIP-14) measuring OHRQoL and five dentist–patient relationship questions taken from the UK 2009 Adult Dental Health Survey. Multivariate Poisson regressions modelled the association between OHRQoL and dentist–patient factors adjusting for socio-demographic factors, clinical oral indicators, and dental attendance. Results: having a perceived unmet need for dental treatment (PRR = 1.84; 95% CI: 1.32, 2.56) and expressing a lack of trust and confidence in one’s dentist (PRR = 1.74; 95% CI: 1.01, 2.98) were significant predictors of poor OHRQoL among older people. Conclusions: these findings suggest that older people with unmet dental needs and those who expressed a lack of trust and confidence in their dentist were more likely to experience poor OHRQoL reinforcing the importance of the dental patient experience in healthy ageing and well-being. Keywords: oral health, dentists, quality of life, patient–provider relationships, older people
Introduction Dramatic improvements in oral health over the past 50 years in most industrialised countries now mean that more people retain their natural teeth into older age [1]. UK Adult Oral Health Surveys have shown a decline in the percentage of older people with no natural teeth from 78% in 1978 to only 24% in 2009 [2]. The preference for keeping teeth is socially entrenched even among older people. Eighty-five percent of people aged 55 years and over in the UK in 1998 expected to keep their teeth throughout their lifetime [3]. Maintaining one’s oral health is important for psychosocial well-being [4]. Holistic definitions of oral health now recognise the importance of patients’ perceptions of their own oral
health and not just clinical indicators of oral disease. Several validated oral health-related quality of life (OHRQoL) measures have captured older people’s patient-centred outcomes [5]. The Oral Health Impact Profile-14 (OHIP-14) [6] is a widely used OHRQoL measure based on Locker’s [7] adaptation of the WHO Classification of Impairment, Disability and Handicap [8]. The OHIP-14 incorporates five hierarchical psychosocial consequences of oral disease: impairment, functional limitation, pain/discomfort, disability and handicap [6]. Several studies have shown the negative impact of oral diseases on older peoples’ OHRQoL [9, 10]. However, OHRQoL is multifaceted and complex. While studies have found associations between OHRQoL and intrapersonal factors such as depression [11], we know very little about the
1
Downloaded from http://ageing.oxfordjournals.org/ at University of Nebraka-Lincoln Libraries on April 10, 2015
Centre for Clinical and Diagnostic Oral Sciences, Institute of Dentistry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK 2 Public Health England, London Region, London, UK
V. E. Muirhead et al.
Methods
contained two items assessing functional limitations (difficulty pronouncing words and altered taste); physical pain (painful aching mouth and uncomfortable eating); psychological discomfort (self-consciousness about one’s dental appearance and feeling tense); physical disability (unsatisfactory diet and disrupted meals); psychological disability (difficulty relaxing and embarrassment); social disability (irritability and work difficulties) and handicap (life dissatisfaction and inability to function) [6]. All OHIP-14 items were scored on a 5-point scale (very often = 4, fairly often = 3, occasionally = 2, hardly ever = 1 and never = 0). Five dichotomous (yes/no) dentist–patient relationship questions were related to (i) their perceived need for treatment, (ii) time taken to discuss any problems; (iii) patient involvement in decision-making; (iv) respect and (v) confidence and trust. One dental attendance question asked about the time since their last dental visit with seven categories ranging from within the last 6 months to >10 years ago. Validated questions from the UK Census 2001 assessed socio-demographic factors including age, gender and ethnicity. Clinical examination
Participants also completed an oral examination carried out by calibrated dentists in their own home. Dentists followed the 2009 UK Adult Dental Health Survey protocol [18] and recorded the total number of teeth, denture use, the number of decayed teeth and pocket depths to assess patients’ periodontal (gum) conditions. Larger pockets depths indicated more severe periodontal disease.
Study design
This cross-sectional survey included older people aged 65 years and over living in three inner city London boroughs in 2011. Our sample size calculation estimated a minimum sample of 731 older people based on a 5% margin of error, a 95% confidence interval, a design effect (DEFF = 4), an 80% power and an estimated 37% prevalence of older people reporting at least one oral health impact derived from the 2009 UK Adult Oral Health Survey [17]. Stratified random sampling selected a representative sample from 80 electoral wards (strata). After excluding commercial addresses and vacant premises, the final sampling frame consisted of 1,270 households. At least one older person aged 65 years and over residing in valid addresses received a postal invitation to participate and complete an interviewer-administered questionnaire and an oral examination. Data collection Interviewer-administered structured questionnaire
Trained interviewers administered the questionnaire in participants’ own homes. The questionnaire included the OHIP-14 and validated questions taken from the 2009 Adult Dental Health Survey about their relationship with their dentist at their most recent visit [18]. The OHIP-14 assesses the impact of dental conditions on participants’ daily functioning over the past 12 months related to seven domains [6]. Each domain
2
Data analysis
Data were analysed using STATA/IC 11 taking into account survey weights and the complex survey design. The main outcomes were the total OHIP-14 score and the seven domain (subscale) scores reflecting the severity of oral health impacts. Subscale scores ranged from 0 to 4 and total OHIP-14 scores ranged from 0 to 56; higher scores indicated worse OHRQoL. The prevalence of negative oral health impacts was also calculated as the percentage of participants reporting one of more OHIP-14 items ‘fairly often’ or ‘very often’. The main explanatory variables were the five dentist–patient variables related to perceived need for treatment, time taken to discuss problems, patient involvement in decision-making, respect and dignity and confidence and trust. Other explanatory variables included ethnicity (i.e. White, Black, Asian and mixed/other), age, gender, oral health status and dental attendance. Four dichotomised oral health status variables assessed untreated decayed teeth (i.e. no decayed teeth/one or more untreated decayed tooth), periodontal (gum) disease (no teeth with pockets depths/one or more teeth with pocket depths ≥4 mm), denture usage (no dentures/dentures) and the number of teeth with a cut-off of 21 or more teeth to indicate a functional dentition. Research has shown that people can function adequately with a minimum of 21 teeth [19]. One dichotomised dental attendance variable assessed the time since their last visit (last visit within the past year/last dental visit >1 year ago).
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effect of interpersonal relationships on OHRQoL beyond one’s immediate social network. What effect the relationship between a dentist and a patient has on a patient’s OHRQoL is an underexplored research area. Although few OHRQoL studies have explored patient–provider dynamics, studies involving other health conditions infer that positive patient experiences such as patient communication, trust, empathy and respect can affect patient outcomes and quality of life [12]. For example, Lee et al.’s longitudinal study of diabetic patients found that patient autonomy and trust in their physician improved patients’ physical and mental health-related quality of life when combined with high information provision [13]. Ong et al.’s cancer study found that patient communication related to asking questions was negatively associated with global quality of life scores [14]. Slade et al. [15] also studied quality of life and unmet need for community mental health services and found that patients’ quality of life decreased with increasing unmet physical health needs. This raises the possibility that older peoples’ perceptions about their need for dental care may also be an important dentist–patient correlate of OHRQoL. Older people have more contact with dental providers than younger patients [2]. Dentist and older-patients’ relationships may also be more problematic with ill health, increasing disability and co-existing systemic diseases in older age [16]. This study addressed this knowledge gap by assessing the relationship between dentist–patient relationship factors and OHRQoL in older people living in East London, UK.
Do health provider–patient relationships matter? Hierarchical Poisson regression models tested the relationship between total OHIP-14 scores and dentist–patient factors. This involved incrementally adding explanatory variables into four regression models to produce adjusted prevalence rate ratios (PRR). Model 1 included socio-demographic factors (i.e. age, gender and ethnicity); Model 2 adjusted for the socio-demographic factors and oral health status confounders: untreated decayed teeth, gum pocketing ≥4 mm, denture use and functional dentition (i.e. >21 natural teeth). Model 3 added dental attendance to Models 1 and 2. The final fully adjusted Model 4 included Model 3 variables and the five dentist–patient relationship variables. The level of statistical significance for all tests was set at P < 0.05. The NHS East London Research Ethics Committee (REC) approved the study.
Table 1. Severity and prevalence of oral health impacts by OHIP-14 subscale and total scores for the sample of older people living in East London in 2011 (n = 772)
Results
scores (mean OHIP-14 = 8.97) than older people with no perceived unmet dental needs (mean OHIP-14 = 3.41) (P < 0.001) (Table 2). Similarly, older people who lacked trust or confidence in their dentist (mean OHIP-14 = 12.32) had higher scores than those who expressed confidence and trust in their dentist (mean OHIP-14 = 5.74) (P = 0.005) (Table 2). We tested the relationship between OHIP-14 score and dentist–patient relationship adjusting for other explanatory variables in the hierarchical Poisson regression models (Table 3). The significant associations between OHRQoL and perceived need for treatment and OHRQoL and older people’ trust and confidence in their dentist attenuated after adjusting for explanatory variables but remained statistically significant (Model 4, Table 3). In the final fully adjusted model, females (PRR = 1.52, P = 0.006), denture wearers (PRR = 1.87; P = 0.001), older people with an unmet perceived need for dental treatment (PRR = 1.84; P < 0.001) and those who expressed no confidence and trust in their dentist (PRR = 1.74; P = 0.04) had statistically significant higher OHIP-14 score reflecting poorer OHRQoL (Model 4; Table 3).
OHRQOoL and dentist–patient relationships
There were significant associations between OHRQoL and two dentist–patient relationship factors (Table 2). Older people who felt they needed dental treatment had higher OHIP-14
Severity: mean OHIP-14 Score (95% CI)
Prevalence: number (%) reporting one or more impact fairly often/very often
0.75 (0.60, 0.91) 1.72 (1.49, 1.96) 1.09 (0.84, 1.33)
65 (8.41) 141 (19.49) 81 (12.18)
0.88 (0.71, 1.06) 0.81 (0.57, 1.04) 0.42 (0.27, 0.56) 0.49(0.33, 0.65) 6.15 (5.04, 7.26)
69 (8.03) 50 (8.23) 18 (2.54) 41(5.30) 487 (65.22)
........................................ Functional limitation Physical pain Psychological discomfort Physical disability Psychological disability Social disability Handicap Total OHIP-14 score
Discussion This is the first published study from our knowledge to explore dentist–patient relationships and OHRQoL in older people. Older people in our study had a higher prevalence of less severe oral health impacts compared with OHIP-14 estimates reported in the 2009 Adult Dental Health Survey [17]. Unmet dental needs and poor OHRQoL
Older people also had perceived unmet dental treatment needs. Poorer OHRQoL reported by older people with unmet dental needs supports previous research in younger age groups [20], which suggests that perceptions about unmet needs do not diminish with age. Perceived need for dental treatment and denture use were significant predictors of OHRQoL while clinical indicators measuring the two most common oral diseases (i.e. decayed teeth and periodontal diseases) were not associated with OHRQoL. Previous
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Seven hundred and ninety-six older people agreed to participate and completed an interviewer-administered questionnaire. Seven hundred and seventy-two older people reported their age, gender and ethnicity allowing survey weighting and inclusion in the final data set. The household response rates in City and Hackney, Tower Hamlets and Newham were 55.9, 53.8 and 52.6%, respectively. Fifty-six percent of older people were female; 53.7% were aged 65–74, 35.7% aged 75–84 years and 10.7% were aged 85 years and over. Eighty percent of older people were White, 10.3% were Asian, 8.3% were Black and 1.2% were from mixed/other ethnic groups. Most older people (81%) had 21 or more teeth and 50% wore a denture. Approximately one in four older people (24.9%) had one or more untreated decayed tooth and 58.2% had periodontal (gum) disease. Fifty percent had a perceived (unmet) need for dental treatment, 63.1% felt that their dentist involved them in decision-making about their care and 67% felt that adequate time had been taken to discuss oral problems. Ninety-seven percent felt treated with respect and dignity and 93.2% expressed trust and confidence in their dentist. Older people reported a mean total OHIP-14 score of 6.15 (95% CI: 5.04, 7.26) (Table 1). Sixty-five percent reported one or more impact experienced fairly often/very often in the past 12 months. The most common impacts were pain and/ or uncomfortable eating (19.5%) and feeling tense and/or self-conscious about the appearance of their teeth and mouth (12.2%) (Table 1). Unadjusted analyses showed that older people aged 85 years and over, those with fewer natural teeth (0–20 teeth) and denture wearers had higher mean OHIP-14 scores (indicative of poorer OHRQoL) than older people aged 65–74 years, those with a functional dentition (21 or more teeth) and people who did not wear dentures (Table 2).
Dimension
V. E. Muirhead et al. Table 2. Mean Oral Health Impact 14 (OHIP-14) scores by socio-demographic factors, oral health status, dental attendance and dentist–patient relationship explanatory variables for the sample of older people living in East London in 2011 (n = 772) Variables
Mean OHIP-14 (95% CI)
Unadjusted prevalence rate ratios (95% CI)
P-value
.................................................................................... 6.04 (4.90, 7.17) 5.05 (3.94, 6.16) 10.44 (5.68, 15.18)
1 0.84 (65, 1.07) 1.72 (1.09, 2.73)
0.16 0.02
5.23 (4.11, 6.35) 6.87 (5.26, 8.46)
1 1.31 (0.99, 1.74)
0.06
5.91 (4.65, 7.17) 7.37 (5.48, 9.25) 6.43 (5.00, 7.87) 9.63 (4.64, 14.62)
1 1.24 (0.95, 1.63) 1.09 (0.81, 1.47) 1.62 (0.91, 2.89)
0.11 0.58 0.09
6.25 (4.87, 7.64) 9.12 (6.29, 12.09)
1 1.47 (1.00, 2.15)
0.05
3.76 (3.06, 4.46) 8.47 (6.61, 10.31)
1 2.25 (1.71, 2.96)
1 year ago). d Model 4 adjusted for demographic factors, oral health status, dental attendance and dentist–patient factors. *P < 0.05. **P < 0.001. b
Trust in dental providers may be particularly important for older people who are traditionally less likely to engage in shared decision-making than younger people trusting and relying on professionals. Trachtenberg et al. [24] also found that older peoples’ increased trust in physicians reflected
a more compliant and deferential role. Older peoples’ confidence and trust in dental professionals may alleviate stress and uncertainty. Lack of trust in one’s dentist and unmet need for dental treatment could also heighten dental anxiety also known to be associated with poor OHRQoL [25].
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V. E. Muirhead et al. Public health implications
Key points • Older people had unmet dental treatment needs. • Older people with unmet needs had poorer OHRQoL than older people with no perceived needs. • A lack of trust and confidence in their dentist was related to older peoples’ poor oral health-related quality of life. • Dentist–patient factors should be incorporated into the proposed patient experience quality framework in the new NHS contract.
Conflicts of interest None declared.
Funding This work was supported by Tower Hamlets, Newham and City and Hackney Primary Care Trusts.
Study limitations
We acknowledge this study’s limitations. Firstly, the inherent weakness of a cross-sectional study precludes one from making definitive causal inferences. This study does allow us to surmise how unmet dental needs and lack of trust could theoretically impair OHRQoL in older people. Cyclical relationships or reverse causality whereby impaired OHRQoL actually heightens older peoples’ perceptions of unmet needs or lack of trust in dental care providers are also possible. Further research using longitudinal study designs could explore the possibility of reverse or reciprocal causal relationships. Secondly, although we used a dichotomous indicator reflecting a trust/distrust dichotomy, some theorists view trust as a multidimensional construct existing as a continuum ranging from complete distrust to complete trust [30]. Therefore, future research should explore concepts and antecedents of trust in dental care providers, which may differ from other health providers.
Conclusions
In conclusion, this study clearly showed older peoples’ OHRQoL significantly associated with their perceptions about needing and not receiving dental treatment and their lack of trust and confidence in their dentist. This has direct implications for developing patient experience indicators. Further research should explore trust in dentist–patient relationships to
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Received 16 May 2013; accepted in revised form 6 September 2013
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