Abstract

This research aimed to assess the oral health related to quality of life among hypertensive and diabetic patients in the city of Alfenas, Brazil. This was a domiciliary-based, descriptive-analytical, cross-sectional research with a random, systematic sample stratified by the Family Health Team, consisting of 218 individuals. The following indexes were applied: DMFT, T-Health, FS-T, SiC index, use and need of prosthesis and OHIP-14. Most of the patients (56.42%) had only high blood pressure, were females (67.43%), with an average age of 64.83 (±11.99) years old, varying between 35 and 93 years old. No significant differences on the variables between hypertensives, diabetics and hypertensive-diabetics were noticed. The following data was registered: DMFT=27.16 (± 6.15), with 22.94 (± 10.46) of missing teeth; T-Health=5.23 (± 6.52); FS-T=8.53 (± 10.12) and SiC=32 (± 0.00). 85.78% of the individuals were using prosthesis (58.72% Dentures) and 61.01% needed prostheses (58.26% in the jaw).The correlations between OHIP-14 (5.37 [± 4.95]) and oral health evidenced the increase in the number of teeth affecting psychological dimensions, besides the use and need of prostheses were associated to physical and social impacts (p < 0.05). We concluded that edentulism, use and need of prostheses affected quality of life in hypertensive and diabetic patients concerning psychological, physical and social aspects.

Oral health; Epidemiology; Quality of life

Introduction

Demographic and epidemiologic transitions have reflected on a significant increase on the prevalence of Chronic Non-Communicable Diseases (CNCD)¹1. Mendes EV. As redes de atenção à saúde. Cien Saude Colet 2005; 15(5):2297-2305.. Among them, Systemic Arterial Hypertension (SAH) and Diabetes Mellitus (DM).Both of them reach up to 1.5 billion people in the world²2. Wild S, Roglic S, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27(1):1047-1053.^,33. Willians B. The year in hypertension. J Am Coll Cardiol 2010; 55(1):66-73. and 50 million people in Brazil⁴4. Malta DC, Moura L, Souza FM, Rocha FM, Fernandes, FM. Doenças crônicas não transmissíveis: mortalidade e fatores de risco no Brasil, 1990 a 2006. In: Brasil. Ministério da Saúde (MS). Saúde Brasil 2008. Brasília: MS; 2009. p. 337-362.^,55. Sociedade Brasileira de Diabetes (SBD). Diretrizes da Sociedade Brasileira de Diabetes: 2013-2014. São Paulo: AC Farmacêutica; 2014.. There are some evidences on literature correlating SAH and DM with oral health. Adequate examples of oral manifestations would be the occurance of periodontal severe insertion losses, hyposalivation, microbiota changes, healing difficulties, abscesses, hyperplasias, polyps, cheilitis and clefts associated to physiopathology of the diseases or their drug treatments⁶6. Chávarry NG, Vettore MV, Sansone C, Sheiham A. The relationship between diabetes mellitus and destructive periodontal disease: a meta-analysis. Oral Health Prev Dent 2009; 7(1):107-127.

7. Garcia R. Periodontal treatment could improve glycemic control in diabetic patients. Evid Based Dent 2009; 10(1):20-21.

8. Herring ME, Shah SK. Periodontal Disease and Control of Diabetes Mellitus. JAOA 2006; 106(1):416-421.^-99. Kinane D, Bouchard P. Group of European Workshop on Periodontology. Periodontal diseases and health: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008; 35(8):333-337..

Nevertheless, clinical aspects discussed isolatedly showed us the dichotomous aspect (based on the presence-absence of diseases) of the researches¹⁰10. Gabardo MCL, Moysés SJ, Moysés ST, Olandoski M, Olinto MTA Pattussi MP. Social, economic and behavorial variables associated with oral health-related quality of life among Brazilian adults. Cien Saude Colet 2015; 20(5):1531-1540., as well as their biomedical and unidirectional aspects (focused on the expert). In this way, subjective indicators, based on self-perception and related to social, demographic, economical, psychological and behavioural factors, can fit the purpose of this research and be enlightening, mainly if they inform how specific conditions affect people’s welfare and daily lives¹⁰10. Gabardo MCL, Moysés SJ, Moysés ST, Olandoski M, Olinto MTA Pattussi MP. Social, economic and behavorial variables associated with oral health-related quality of life among Brazilian adults. Cien Saude Colet 2015; 20(5):1531-1540.^,1111. Miotto MH, Barcellos LA, Veltren DB. Avaliação do impacto na qualidade de vida causado por problemas bucais na população adulta e idosa em município da região sudeste. Cien Saude Colet 2012; 17(2):397-406..

Therefore, quality of life has been frequently associated to Oral Health Clinical Conditions (OHCC)¹⁰10. Gabardo MCL, Moysés SJ, Moysés ST, Olandoski M, Olinto MTA Pattussi MP. Social, economic and behavorial variables associated with oral health-related quality of life among Brazilian adults. Cien Saude Colet 2015; 20(5):1531-1540.

11. Miotto MH, Barcellos LA, Veltren DB. Avaliação do impacto na qualidade de vida causado por problemas bucais na população adulta e idosa em município da região sudeste. Cien Saude Colet 2012; 17(2):397-406.

12. Bianco VC, Lopes ES, Borgato MH, Moura e Silva P, Marta SN. O impacto das condições bucais na qualidade de vida de pessoas com cinquenta ou mais anos de vida. Cien Saude Colet 2010; 15(4):2165-2172.

13. Hernández-Palacios RD, Ramirez-Amador V, Jarillo-Soto EC, Irigoyen-Camacho ME, Mendoza-Núñes VM. Relationship between gender, income and educationand self-percieved oral health among elderly Mexicans: an exploratory study. Cien Saude Colet 2015; 20(4):997-1004.

14. Miotto MHMB, Almeida CS, Barcellos LA. Impacto das condições bucais na qualidade de vida em servidores públicos municipais. Cien Saude Colet 2014; 19(9):3931-3940.^-1515. Silva MES, Villaça EL, Magalhães ES de, Ferreira EF e . Impacto da perda dentária na qualidade de vida. Cien Saude Colet 2010; 15(3):841-850.. However, the World Health Organization (WHO) has officially recognized the importance of an agenda when it presented, as global goal, the decrease of the impact of health and craniofacial diseases on human health and the psychosocial development among populations¹⁶16. Hodbell M, Peterson PE, Clarkson J, Johnson N. Global goals for oral health 2020. Int Dent J 2003; 53(5):285-288.. For the institution, quality of life is a perception of the individual on his/her own life upon the aegis of cultural context, the value system in which the person is set and the relation one has with one’s objectives, expectations, patterns and worries¹⁷17. World Health Organization (WHO). The Whoqol Group. The World Health Organization quality of life assessment (WHOQOL):position paper from the World Health Organization. Soc Sci Med 1995; 41(10):1403-1409..

In 1980, the International Discomfort, Incapacity and Social Disadvantage Classification was published¹⁸18. World Health Organization (WHO). International Classification of Impairment, Disabilities and Handicaps. Geneva: WHO; 1980.. In this model, there is an evolutionary sequence which starts with deficiencies, goes through incapacities and ends up in disadvantages. But in 1980, David Locker proposed some developments. This author declares that functional limitations, pain and discomfort may be consequences of deficiencies and they may cause physical, psychological and social incapacities, or even reach the highest level: social disadvantage¹⁹19. Locker D. An Introduction to Behavioural Sciences and Dentistry. London: Tavistock; 1989..

In 1994, Slade and Spencer²⁰20. Slade G, Spencer AJ. Development and evaluation of the oral health impact profile. Community Dent Health, 1994; 11(1):3-11. developed a questionnaire to assess OHRQL (Oral Health-related Quality of Life): OHIP-49 (Oral Health Impact Profile).Its original version has 49 questions which approach the dimensions proposed by Locker. Slade prepared, reduced and validated the questionnaire (OHIP-14). The author described a hierarchy among dimensions. Functional limitation, physical pain and psychological discomfort are related to questions the individual has to himself/herself in an organic basis. They express impact on speech, sense of taste, besides pain, masticatory discomfort, tension and preoccupation. Physical, psychological and social incapacities refer to individual behavioural aspects which reverberate in daily life, expressing restrained eating behaviour, difficulties to relax, shame, irritation and injury on daily activities in general. Finally, social disadvantage is described as the highest degree of impact and represents social consequences of oral problems. Absence at work and feeling that life has become worse are targets of that dimension. So, the gravity of the impact might be understood according to the affected dimensions. A problem which leads to discomfort and pain brings fewer consequences to quality of life than a problem which leads to incapacities and disadvantages²¹21. Slade GD. Derivation and validation of a short-fortn oral health impact profile. Community Dent Oral Epidemiol 1997; 25(1):284-290.. OHIP-49 and OHIP-14 were submitted to transcultural validation processes into numerous languages and places²²22. Montero-Martin J, Bravo-Pérez M, Albaladeio-Martínez A, Hernández-Martín LA, Rosel-Gallardo EM. Validation of Oral Health Impact Profile (OHIP-14 sp) for adults in Spain. Med Oral Patol Oral Cir Bucal 2009; 14(Supl. 1):44-50.^,2323. Sanders AE, Slade GD, Lim S, Reisine ST. Impact of oral disease on quality of life in the US and Australian populations. Community Dent Oral Epidemiol 2009; 37(2):171-181., but in Brazil its psychometric properties and inner stability were assessed by different researchers²⁴24. Oliveira BH, Nadanovsky P. Psycometric properties of the Brazilian version of the oral health impact profile-short form. Community Dent Oral Epidemiol 2005; 33(4):307-314.^,2525. Alvarenga FAZ, Henriques C, Takatsui F, Montadon AAB, Telarolli Júnior R, Monteiro ALCC, Pinelli C, Loffredo LCM, Pinelli C. Impacto da saúde bucal na qualidade de vida de pacientes maiores de 50 anos de duas instituições públicas do município de Araraquara-SP. Rev Odontol UNESP 2011; 40(3):118-124..

Considering the necessity of understanding the role dentition plays on welfare and daily life of hypertensive and diabetic people, a domiciliary research, in Family Health Units(FHU) adjoined territory, was conducted in the city of Alfenas, Brazil, aiming to assess the quality of life related to Oral Health Clinical Conditions (OHCC).

Methodology

This research was approved by the Ethics in Research with Human Beings Commitee from UNIFAL/MG (assessment number 795.485) and by the Alfenas City Health Office.

This was a descriptive-analytical, cross-sectional research which took place in Alfenas, a city in the south of Minas Gerais State, Brazil. This city is ubicated 342km far from the Minas Gerais’s capital, Belo Horizonte, and its estimated population is of 78,176 inhabitants.

The total amount of people to be part of the sample was defined through a formula for finite populations proposed by Silva²⁶26. Silva NN. Amostragem probabilística. São Paulo: EDUSP; 1998., taking the DMFT (Decayed, Missed of Filled Teeth) index as reference to people aged between 35 and 44 and 65 and 74, living in countryside cities in the Southeastern area – both obtained after the national research on oral health SB Brasil 2010²⁷27. Brasil. Ministério da Saúde (MS). SB-BRASIL 2010 - Pesquisa Nacional de Saúde Bucal: Proposta de Projeto Técnico para Consulta Pública. Brasília: MS; 2009.^,2828. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Secretária de Vigilância em Saúde. Departamento de Atenção Básica. Coordenação Geral de Saúde Bucal. SB-BRASIL 2010 - Pesquisa Nacional de Saúde Bucal: Principais Resultados. Brasília: Ministério da Saúde; 2011.. It was established a level of 95% of assurance, with a 10% error possibility. In order to correct the sample size, we used deff (design effect) resource (in which the starting value is doubled) and we considered a 20%-rate of getting no answers. This way, the minimum sample should be of 216 individuals. For it was a domiciliary study, in which the active research is the only tool of captivation and considering the possibilities of refusals and difficulties on finding participants, we decided to organize a reserve register with twice the number of eligible individuals.

To do so, we proceeded to obtaining a random, systematic sample stratified by FHU from hypertensive and diabetic patients. In Alfenas, there are 15 FHU, but, in the beginning, we chose five out of them by dividing the urban area into five areas and raffling off five FHU, one from each region. In the sequence, we mapped out the people registered in the HIPERDIA/SUS system (a system of registry and follow-up of hypertensive and diabetic patients in the Brazilian health public service), in the chosen FHU, coming to a total of 2629 people. In order to select the possible participants of the research, we created a spreadsheet listing a sequence of micro-areas, streets and progressive numbering of the domiciles, according to FHU. The raffle systematized the sample through a regular interval obtained by the division of the total population (2,629) and the doubled sample – referring to the reserve register – (432), and we obtained a 6.1-interval rate. The first person was raffled off within a table of random numbers from 1 to 6. Number 6, the chosen one, was the first component of the list. From this moment on, to every individual who was raffled off, we added the 6,1-interval rate and proceeded to the necessary adjustments on the value. This way, as a matter of course, each stratum (FHU) composed proportionally the 432-person list (reserve register), from which at least 216 (minimum sample) should be arranged for this study.

OHCC were investigated through the following indices: DMFT, according to codes and criteria claimed by WHO²⁹29. World Health Organization (WHO). Oral health surveys: basic methods. 5th ed. Geneva: ORH/EPID; 2013.; T-Health (Tissue Health - through which different values can be attributed to healthy, recovered, decayed or missing teeth. The closer the value gets to 32, the more healthiness the indicatives show)³⁰30. Sheiham A, Maizels J, Maizels A. New composite indicators of dental health. Community Dent Health 1987; 4(4):407-414., according to Barnabé et al.³¹31. Barnabé E, Suominen-Taipale AL, Vehkalahti MM, Nordblad A, Sheiham A. The T-Health index: a composite indicator of dental health. Eur J Oral Sci 2009; 117(4):385-389. researches; c) FS-T (Filled and Sound Teeth – the sum of healthy and filled teeth, aiming to check the amount of teeth presumably functional in the oral cavity - it is important to highlight that the closer the index value is to 32, the higher the quantity of functional teeth will be³⁰30. Sheiham A, Maizels J, Maizels A. New composite indicators of dental health. Community Dent Health 1987; 4(4):407-414.) and d) SiC (Significant Caries Index, an average calculation between DMFT and the third part of the sample in which values are higher, what also serves as a parameter to analyse the distribution of tooth cavity)³²32. Bratthall D. Introducing the Significant Caries lndex together with a proposal for a new global oral health goal for 12-year-olds. Int Dent J 2000; 50(6):378-384.. We also assessed usage and necessity of prostheses, which were divided into types of dentures (partial [fixed permanently or removable] and complete) and extension (related to the quantity of elements to be replaced) in upper and lower arches, according to some codes and criteria adopted in SB Brasil 2010²⁷27. Brasil. Ministério da Saúde (MS). SB-BRASIL 2010 - Pesquisa Nacional de Saúde Bucal: Proposta de Projeto Técnico para Consulta Pública. Brasília: MS; 2009.. The evaluations were done under natural light, with the auxiliary of ballpoint probe (WHO) and plain buccal mirror, while the individuals were in supine position, being the examiner at 12 hours²⁹29. World Health Organization (WHO). Oral health surveys: basic methods. 5th ed. Geneva: ORH/EPID; 2013..

OHRQL evaluation was done through OHIP-14 application on the interview modality²⁴24. Oliveira BH, Nadanovsky P. Psycometric properties of the Brazilian version of the oral health impact profile-short form. Community Dent Oral Epidemiol 2005; 33(4):307-314., considering possible difficulties on reading and writing among elderly individuals. An answer sheet, with a codified instrument scale (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 4 = always) was handed to the participants.We obtained general and dimension scores, multiplied the codified answers (0, 1, 2, 3 or 4) and specific weighted grades, proposed by Slade²¹21. Slade GD. Derivation and validation of a short-fortn oral health impact profile. Community Dent Oral Epidemiol 1997; 25(1):284-290.. The maximum value each dimension would reach would be 4, considering that the general OHIP-14 ranking varies from 0 and 28. This way, the highest the scores are, the worst OHRQL is going to be according to the interviewees.

In order to make a table with the data analysis, we used a statistical pack SPSS^® 22.0. The individuals were organized into groups related to their systemic conditions (Hypertension; Diabetes; Hypertension-Diabetes).We did not observe any abnormality in the distribution of the data (Kolmogorov-Smirnov test, ρ<0.05), we proceeded to the application of non-parametric tests. The average (Kruskal-Wallis) and proportional (McNemar test) rates related to OHCC and OHRQL were compared between the systemic conditions under investigation. Speaman Correlation Coeficient was used to determine associations between OHCC and OHIP-14. In all procedures, we used a 95% level of significancy.

A training step was done, as well as a calibration in two FHU with people who was not part of the final sample. A total of 36 people took part in this stage (16 in the training and 20 in calibration).Taking a pattern examiner (Gold Standard) as reference, we measured kappa inter-examiner to determine DMFT (kappa = 0.91), besides the use and necessity of prostheses (kappa = 1.00).

Results

A total of 218 people took part in this research, which fit our quorum, previously defined (216 individuals). Among the observed people, 33.93% was not found after two communication trials and 9.59% refused to participate in the research. Most of the individuals in this research (56.42%) presented only Arterial Hypertension, is feminine (67.43%) (Table 1), with an average age of 64.83 (± 11.99), varying between 35 and 93 years.

No significant, statistical differences on the OHCC variables among the groups were noticed. There was no disparity on the teeth cavity distribution (Sic=32 [± 0.00]) and the average DMFT to the total sample was 27.16 (± 6.15), with “missing” component prevalence (22.94 [± 10.46]). Nevertheless, among the 9.06 [± 10.46] existing teeth, 8.53 (± 10.12) were functional and only 0.53 (± 1.32) had cavities (Table 2).

Among the examined individuals, 85.78% were using prostheses, being the Dentures the most common (58.72%).However, the necessities of use of prostheses are still high (61.01%), specially for the use of Partial Prostheses (37.16%).When it comes to the arch, the jaw presents most part of the demands (58.26%) (Table 3).

No significant differences among the groups were noticed concerning OHIP-14. In general, the scores showed a low impact on oral health quality of life (Table 4).

In order to obtain correlations between OHCC and OHIP-14, considering the lack of difference among the results from the groups, we considered the total sample. The increase of healthy, filled teeth, supported by fixed prosthesis, and the increase of FS-T and T-Health indexes, as well as the decrease on the quantity of missing teeth, OHCC and the extension of the prostheses used in lower and upper arches, contribute to the increase of psychological discomfort (p < 0.05). But, as healthy feet decrease in number, the increase in teeth loss and FS-T and T-Health indexes, along with OHCC and the demanded prostheses dimension, are physical dimensions, specially when it comes to incapacities, which increase (p < 0.05). Social disadvantage is affected only with the healthy teeth decrease and the increase of necessary extended prostheses. And the general impact (OHIP-14) only grows with the increase of the necessity of prostheses (<0.05) (Table 5).

Discussion

Oral health clinical conditions

Few teeth could be assessed in the quantity of people in the study, as well as other researches indicate³³33. Barroso Júnior JB, Costa KLL, Taboza ZA, Dias CC, Furlaneto FAC, Lima, V, Rêgo RO. Perda dentária e controle glicêmico de idosos diabéticos do tipo 2. Rev Odontol UNESP 2011; 40(5):241-247.^,3434. Moreira RS, Nico LS, Tomita NE. O risco espacial e fatores associados ao edentulismo em idosos em município do sudeste do Brasil. Cad Saude Publica 2011; 27(10):2041-2053.. Absence of natural teeth is supplied, in part, by prostheses, specially dentures. Besides they are available at public service and present relatively low cost in comparison to other modalities, an important consideration should be done: its use is frequently associated to a higher comfort³⁵35. Oliveira AGRC. Edentulismo. In: Antunes JLF, Peres MA. Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Kogan; 2006. p. 205-218..

On the other hand, partial edentulism is not associated to the use of prostheses which substitute natural teeth (in the evaluated group, we found 37.16% of prostheses needs).

It is also necessary to highlight that the more constant use on the upper arch than in the lower arch does not indicate any occurrence of a more noticeable edentulism in the jaw. Contrariwise, it ratifies a historical failure in Odontology. The difficult to adapt to jaw prostheses leads to their uncountable edentulous abandonments, causing deficient alimentation and other aesthetic, functional and psychological injuries³⁶36. Costa AM, Guimarães M do CM, Pedrosa SF, Nóbrega OT, Bezerra ACB. Perfil da condição bucal de idosas do Distrito Federal. Cien Saude Colet 2010; 15(4):2207-2213..

The current adult and elderly population suffers the consequences of conditions which they have experienced in an accumulative process during life cycle. So, it is possible to observe sequels left by cavities along the course of life (edentulism), yet the activity of disease among the analyzed ages is unusual. WHO and other actors¹⁶16. Hodbell M, Peterson PE, Clarkson J, Johnson N. Global goals for oral health 2020. Int Dent J 2003; 53(5):285-288.^,3737. Jain M, Kaira LS, Sikka G, Singh SK, Gupta A, Sharma R, Sawla L, Mathur A. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two states samples of Gujarat and Rajasthan. J Dent (Tehran) 2012; 9(2):135-144. have frequently referred to a minimum of twenty functional teeth or, at times, a certain number of posterior contacts as a goal or simple way to define satisfactory function and oral health. The result we present here reflect how the analyzed population is far from that level, which does not differ, however, from the data found in similar aged populations in the same country²⁸28. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Secretária de Vigilância em Saúde. Departamento de Atenção Básica. Coordenação Geral de Saúde Bucal. SB-BRASIL 2010 - Pesquisa Nacional de Saúde Bucal: Principais Resultados. Brasília: Ministério da Saúde; 2011..

Unlike what happens with young populations concerning cavities and their consequences, the SiC = 32 among hypertensive and diabetic adults and seniors examined here shows a situation close to the edentualism to which the sample is submitted, without any inequality among subgroups of this population. That becomes clearer when we observe the prevalence of “lost” compound in DMFT, confirmed by previous researches³⁸38. Sa IPC, Almeida Junior LR de, Corvino MPF, Sa SPT. Condições de saúde bucal de idosos da instituição de longa permanência Lar Samaritano no município de São Gonçalo-RJ. Cien Saude Colet 2012; 17(5):1259-1265.^,3939. Silva DD, Sousa MLR, Wada RS. Oral health in adults and elderly in Rio Claro, São Paulo, Brasil. Cad Saude Publica 2004; 20(2):626-631..

The absence of public health policies focused on the universal⁴⁰40. Botazzo C. A saúde bucal nas práticas coletivas de saúde. São Paulo: Instituto de Saúde; 1994. (Série Tendências e Perspectivas em Saúde 1) promotion and prevention and the presence of Oral Health Attention models focused on the market, the mutilation and the once existed artificialism of prothesis³⁵35. Oliveira AGRC. Edentulismo. In: Antunes JLF, Peres MA. Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Kogan; 2006. p. 205-218.^,4141. Souza ECF. Formação e trabalho em Odontologia: ampliar a clínica para construir uma nova cultura de cuidado em saúde bucal. Texto para subsidiar a III Conferência Estadual de Saúde Bucal do RN. Natal: SES/RN; 2004. have led masses of people to mutilations, falsely repairable due to recent technology.Garrafa⁴²42. Garrafa V. Saúde bucal e cidadania. Saúde debate 1993; 41(1):50-57. affirms current dentistry is technically worth the praise (due to the level of quality and sophistication reached among the specialties), scientifically open to discussion (once it has not demonstrated competence in expanding this quality to most part of the population) and socially chaotic (for the inexistence of social impact before initiatives and collaborative programs implemented).Such characteristics can be translated into the clinical daily routine and the “dentristry-centeredness” in which the technique is mythified and the artificial prosthesis superposes the natural condition. Goldsmithery and sculpture are placed in a more comfortable position than the promotion of health is. As a consequence, the “naturalization of dental loss” is embodied as a mutilation culture, the “prothesism” is promoted and oral health and dental treatment are drawn near, reinforcing the odontotechnique, ruled by a critical and iatrogenic market³⁵35. Oliveira AGRC. Edentulismo. In: Antunes JLF, Peres MA. Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Kogan; 2006. p. 205-218.^,4141. Souza ECF. Formação e trabalho em Odontologia: ampliar a clínica para construir uma nova cultura de cuidado em saúde bucal. Texto para subsidiar a III Conferência Estadual de Saúde Bucal do RN. Natal: SES/RN; 2004.. Ironically, we may affirm that there was no inequality on the cavity distribution and its evils to the population.In a universe made of individuals exposed to health illnesses risks, everyone (or nearly all of them) were affected by dental loss.

Oral health-related quality of life

Low OHIP-14 scores (Table 4) facing the high edentulism may sign to an individuals’ reduced perception of precarious oral health⁴³43. Silva SRC, Fernandes RAC. Autopercepção das condições de saúde bucal por idosos. Rev Saude Publica 2001; 35(4):349-355., existence of low evaluating cultural contexts to self-care³⁷37. Jain M, Kaira LS, Sikka G, Singh SK, Gupta A, Sharma R, Sawla L, Mathur A. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two states samples of Gujarat and Rajasthan. J Dent (Tehran) 2012; 9(2):135-144. or even tool’s questionable reliability⁴⁴44. Marcias AVG. Avaliação das condições de saúde bucal em idosos asilados no município de Campos – RJ [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2008.. The reduced impact on OHRQL has been reported by authors who use OHIP-14¹¹11. Miotto MH, Barcellos LA, Veltren DB. Avaliação do impacto na qualidade de vida causado por problemas bucais na população adulta e idosa em município da região sudeste. Cien Saude Colet 2012; 17(2):397-406.^,4545. Chapelin CC, Barcellos LA, Miotto MHMB. Efetividade do tratamento odontológico e redução do impacto na qualidade de vida. UFES Rev Odontol 2008; 10(2):46-51.. Nevertheless, the questionnaire is widely used in versions considered simple, reliable, representative and coherent²²22. Montero-Martin J, Bravo-Pérez M, Albaladeio-Martínez A, Hernández-Martín LA, Rosel-Gallardo EM. Validation of Oral Health Impact Profile (OHIP-14 sp) for adults in Spain. Med Oral Patol Oral Cir Bucal 2009; 14(Supl. 1):44-50.

23. Sanders AE, Slade GD, Lim S, Reisine ST. Impact of oral disease on quality of life in the US and Australian populations. Community Dent Oral Epidemiol 2009; 37(2):171-181.^-2424. Oliveira BH, Nadanovsky P. Psycometric properties of the Brazilian version of the oral health impact profile-short form. Community Dent Oral Epidemiol 2005; 33(4):307-314.^,3737. Jain M, Kaira LS, Sikka G, Singh SK, Gupta A, Sharma R, Sawla L, Mathur A. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two states samples of Gujarat and Rajasthan. J Dent (Tehran) 2012; 9(2):135-144.^,3939. Silva DD, Sousa MLR, Wada RS. Oral health in adults and elderly in Rio Claro, São Paulo, Brasil. Cad Saude Publica 2004; 20(2):626-631.^,4545. Chapelin CC, Barcellos LA, Miotto MHMB. Efetividade do tratamento odontológico e redução do impacto na qualidade de vida. UFES Rev Odontol 2008; 10(2):46-51.. It is important to consider that oral health is one of the many factors which influence quality of life. Therefore, depending on the cultural context and the perception the individuals have, real low levels of impact can be observed⁴⁴44. Marcias AVG. Avaliação das condições de saúde bucal em idosos asilados no município de Campos – RJ [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2008.. Another possible consideration is that, even facing low scores of OHIP-14, we could notice significant associations between OHIP-14 and OHCC (Table 5).

The correlations between OHCC and the psychological discomfort dimension suggest the incidence of teeth can be motive of tension and preoccupation. To Oliveira³⁵35. Oliveira AGRC. Edentulismo. In: Antunes JLF, Peres MA. Epidemiologia da saúde bucal. Rio de Janeiro: Guanabara Kogan; 2006. p. 205-218. and Souza⁴¹41. Souza ECF. Formação e trabalho em Odontologia: ampliar a clínica para construir uma nova cultura de cuidado em saúde bucal. Texto para subsidiar a III Conferência Estadual de Saúde Bucal do RN. Natal: SES/RN; 2004., the population has a historical lack of access to oral health services and there is a tradition of mutilation in Dentistry, which contribute to understand tooth and problem as almost synonyms. This said, if problems (it means, teeth)no longer exist, there is - almost - no reason to worry anymore. On the other hand, the physical dimensions demonstrate an inverse relation between T-Health and FS-T indexes. It seems logical that the interruption of meals, as well as the exclusion of specific food from the diet, are related to the reduction of the number of teeth. Within social sphere, the reduction of healthy teeth is associated to the absenteeism to work and feeling that life has become worse (social disadvantage).Such findings corroborate Locker’s¹⁹19. Locker D. An Introduction to Behavioural Sciences and Dentistry. London: Tavistock; 1989. model: healthy teeth are associated to psychological discomforts, but their reduction implies masticatory deficiencies which surpass the impairment scope, reflecting on aspects such as work and feeling that life has become worse to them (social disadvantage).

Facing an almost total edentualism situation, with few natural teeth, prostheses that are more extensive can substitute natural elements. The more extensive the prostheses are on the upper and lower arches (fixed prostheses, with few elements, or even complete dentures), the smaller the psychological discomfort is. For dentition is seen as hassle in this population, it seems reasonable that people eager for eliminating the remaining teeth by substituting them for complete prostheses. By contrast, whereby there are more demands for more extensive prostheses, physical dimensions are lifted until they also reverberate social disadvantage and general impact (Table 5).

If, on one hand, the natural dentition is taken as a disturb due to the imminent risk of person becoming ill, on the other hand the prostheses which substitute this risk (or the necessity of using them) bring the burden of more tension, preoccupation, embarassment, pain and masticatory issues, which impact negatively on work and quality of life. However, people who have experienced mutilation and “prothesist” dentistry may face difficulties in accepting the importance of teeth maintenance as a salutary syllogism.

Considerations about the research

We did not notice any significant differences on OHCC or OHRQL among the groups of hypertensive, diabetic and hypertensive-diabetic.Besides, the results for OHCC registered here are similar to the results obtained in researches with non-hypertensive and non-diabetic adult and elderly populations²⁸28. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Secretária de Vigilância em Saúde. Departamento de Atenção Básica. Coordenação Geral de Saúde Bucal. SB-BRASIL 2010 - Pesquisa Nacional de Saúde Bucal: Principais Resultados. Brasília: Ministério da Saúde; 2011.^,3434. Moreira RS, Nico LS, Tomita NE. O risco espacial e fatores associados ao edentulismo em idosos em município do sudeste do Brasil. Cad Saude Publica 2011; 27(10):2041-2053.^,3636. Costa AM, Guimarães M do CM, Pedrosa SF, Nóbrega OT, Bezerra ACB. Perfil da condição bucal de idosas do Distrito Federal. Cien Saude Colet 2010; 15(4):2207-2213.^,3838. Sa IPC, Almeida Junior LR de, Corvino MPF, Sa SPT. Condições de saúde bucal de idosos da instituição de longa permanência Lar Samaritano no município de São Gonçalo-RJ. Cien Saude Colet 2012; 17(5):1259-1265.^,3939. Silva DD, Sousa MLR, Wada RS. Oral health in adults and elderly in Rio Claro, São Paulo, Brasil. Cad Saude Publica 2004; 20(2):626-631.^,4343. Silva SRC, Fernandes RAC. Autopercepção das condições de saúde bucal por idosos. Rev Saude Publica 2001; 35(4):349-355.^,4444. Marcias AVG. Avaliação das condições de saúde bucal em idosos asilados no município de Campos – RJ [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2008. and with populations in which the DM incidence is related⁶6. Chávarry NG, Vettore MV, Sansone C, Sheiham A. The relationship between diabetes mellitus and destructive periodontal disease: a meta-analysis. Oral Health Prev Dent 2009; 7(1):107-127.

7. Garcia R. Periodontal treatment could improve glycemic control in diabetic patients. Evid Based Dent 2009; 10(1):20-21.

8. Herring ME, Shah SK. Periodontal Disease and Control of Diabetes Mellitus. JAOA 2006; 106(1):416-421.^-99. Kinane D, Bouchard P. Group of European Workshop on Periodontology. Periodontal diseases and health: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008; 35(8):333-337.^,3333. Barroso Júnior JB, Costa KLL, Taboza ZA, Dias CC, Furlaneto FAC, Lima, V, Rêgo RO. Perda dentária e controle glicêmico de idosos diabéticos do tipo 2. Rev Odontol UNESP 2011; 40(5):241-247.^,4646. Tomita NE, Chinellato LEM, Franco LJ, Iunes M, Freitas JAS, Lopes ES. Condições de saúde bucal e diabetes mellitus na população nipo-brasileira de Bauru-SP. J Appl Oral Sci 2003; 11(1):15-20.. Although the evidences of relations in CNCD, specially the DM, such as OHCC⁶6. Chávarry NG, Vettore MV, Sansone C, Sheiham A. The relationship between diabetes mellitus and destructive periodontal disease: a meta-analysis. Oral Health Prev Dent 2009; 7(1):107-127.

7. Garcia R. Periodontal treatment could improve glycemic control in diabetic patients. Evid Based Dent 2009; 10(1):20-21.

8. Herring ME, Shah SK. Periodontal Disease and Control of Diabetes Mellitus. JAOA 2006; 106(1):416-421.^-99. Kinane D, Bouchard P. Group of European Workshop on Periodontology. Periodontal diseases and health: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008; 35(8):333-337.^,3333. Barroso Júnior JB, Costa KLL, Taboza ZA, Dias CC, Furlaneto FAC, Lima, V, Rêgo RO. Perda dentária e controle glicêmico de idosos diabéticos do tipo 2. Rev Odontol UNESP 2011; 40(5):241-247., it is possible that other factors, such as other pathologies associated (age, gender; economical, social and cultural aspects) and variable aspects that remain unclear, play a more relevant role on determining health issues in adult and, specially, elderly populations (considering 64.83 the average registered age), concealing or dissimulating the comorbidity role, such as SAH and DM on oral diseases.

Concerning OHRQL, there are plenty of cases in literature, determined by OHIP-14¹¹11. Miotto MH, Barcellos LA, Veltren DB. Avaliação do impacto na qualidade de vida causado por problemas bucais na população adulta e idosa em município da região sudeste. Cien Saude Colet 2012; 17(2):397-406.^,1212. Bianco VC, Lopes ES, Borgato MH, Moura e Silva P, Marta SN. O impacto das condições bucais na qualidade de vida de pessoas com cinquenta ou mais anos de vida. Cien Saude Colet 2010; 15(4):2165-2172.^,1414. Miotto MHMB, Almeida CS, Barcellos LA. Impacto das condições bucais na qualidade de vida em servidores públicos municipais. Cien Saude Colet 2014; 19(9):3931-3940.^,1515. Silva MES, Villaça EL, Magalhães ES de, Ferreira EF e . Impacto da perda dentária na qualidade de vida. Cien Saude Colet 2010; 15(3):841-850.^,2323. Sanders AE, Slade GD, Lim S, Reisine ST. Impact of oral disease on quality of life in the US and Australian populations. Community Dent Oral Epidemiol 2009; 37(2):171-181.^,3737. Jain M, Kaira LS, Sikka G, Singh SK, Gupta A, Sharma R, Sawla L, Mathur A. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two states samples of Gujarat and Rajasthan. J Dent (Tehran) 2012; 9(2):135-144.^,4444. Marcias AVG. Avaliação das condições de saúde bucal em idosos asilados no município de Campos – RJ [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2008.^,4545. Chapelin CC, Barcellos LA, Miotto MHMB. Efetividade do tratamento odontológico e redução do impacto na qualidade de vida. UFES Rev Odontol 2008; 10(2):46-51., related to OHCC in adults and elderly people. Although some of these studies are related to diabetic people⁴⁷47. Drumond-Santana T, Costa FO, Zenóbio EG, Soares RV, Santana TD. Impact of periodontal disease on quality of life for dentate diabetics. Cad Saude Publica 2007; 23(1):637-644., researches which include both conditions (SAH and DM)⁴⁸48. Gabardo MCL, Moyses ST, Moyses SJ. Autopercepção de saúde bucal conforme o Perfil de Impacto de Saúde Bucal (OHIP) e fatores associados: revisão sistemática. Rev Panam Salud 2013; 33(6):439-445. are rare. This way, this paper can be considered one of the first investigations to address OHRQL and OHCC in these populations on a comparative perspective.

Concerning edentualism, OHCC is similar in some populations with and without SAH and DM, but when we compare it to OHRQL some findings are pretty off-key. We highlight the incidence of natural dentition and naturalization of dental loss in the population we analyzed, aspects evidenced mainly through the correlation between the psychological dimensions from OHIP-14 and T-Health, FS-T and DMFT compounds. Such relations can integrate a complex amount of grievances of CNCD which surpass physical aspects (clinical indicators), echoing psychological and behavioural components.

OHRQL could be more explained by factors other than OHCC, these predictors being a reduced part of impact. Cultural, social and economical factors tell us more about health than biological aspects exclusively, in according to what the social health determining model⁴⁹49. Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Arbetsrapport: Institute for Future Studies; 1991. has already been alerting specialists about. Likewise, it is important to search for actions to analyse oral health from the healthy structure point of view, apart from the biomedical tradition of looking at events focusing on the illness behind them. In this research, we attempted to connect traditional, descriptive OHCC indicators and alternatives which prize health measurement instead of illness (FS-T, T-Health), besides trying to subjectively measure the aftermath of oral health on people’s welfare and daily life: OHRQL. Nonetheless, the non-inclusion of social-economical variables related to OHCC and OHRQL is often considered a limitation. Besides, the results lead to the necessity of wide approaches, incorporating qualitative methodologies and longitudinal follow-ups to a social-humanistic perspective in order to better elucidate matters such as the lack of faith on natural dentition, the naturalization of dental loss and the “prothesism” culture – what urges for further investigation.

Conclusions

Edentualism and protheses conjugate a significant binomial impact on the quality of life of the analyzed population, not only in physical terms, but in psychological and social aspects as well. High edentulism rates address incredulity on natural dentition, making a path for considering dental loss natural. On the other hand, “artificial” dentition does not meet the masticatory demands, reverberating social dimensions and impacting quality of life.

Such results redirect us to public policies in order to make the assistance (which is so important to this population) be marked by actions which vehemently reach the “prothesism”/dental loss naturalization culture, which negatively reverberates on quality of life of hypertensive and diabetic people.

References

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