ABSTRACT:

Introduction:

This research aimed to investigate the association between psychosocial aspects and the impact of oral health on quality of life among adults.

Method:

This population-based cross-sectional study was conducted with 1,100 adults aged 20 years or older from a medium-sized city in Rio Grande do Sul, Southern Brazil. The outcome was Oral Health Impact Profile (OHIP-14) in three categories: better (OHIP=0: 50% of lower scores), moderate (OHIP 1-12.6: 25% of intermediate scores), and worse (OHIP≥12.7: 25% of higher scores). The exposures included measurements of social support, resilience, sense of coherence, spirituality, quality of life, and stress. We calculated crude and adjusted odds ratios and their respective 95% confidence intervals using ordinal logistic regression.

Results:

After adjustment for demographic, socioeconomic, and behavioral variables, individuals with low social support, low sense of coherence, low quality of life, and high level of stress were, respectively, 2.16, 2.90, 2.94, and 1.50 times more likely to report a worse impact of oral health on quality of life than those with favorable characteristics.

Conclusions:

The findings suggest that psychosocial aspects can influence the perceived impact of oral health on quality of life. Health policies, programs, and services must recognize the mutual relationship between oral health indicators and psychosocial aspects among adults.

Keywords:
Oral health; Quality of life; Social support; Psychological resilience; Psychological stress; Adult

INTRODUCTION

Oral health is regarded as multidimensional construct. It involves the ability to speak, smile, smell, taste, touch, chew, swallow, and convey emotions through facial expressions with confidence and without pain, discomfort, and diseases¹1. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12): 915-17. https://doi.org/10.1016/j.ajodo.2016.11.010
https://doi.org/https://doi.org/10.1016/... . Oral health is considered fundamental to health and physical and mental well-being, existing along a continuum determined by the values and attitudes of individuals and communities and reflecting important physiological, social, and psychological aspects for the quality of life¹1. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12): 915-17. https://doi.org/10.1016/j.ajodo.2016.11.010
https://doi.org/https://doi.org/10.1016/... . Therefore, oral health relates to people’s experiences, expectations, and adaptability¹1. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12): 915-17. https://doi.org/10.1016/j.ajodo.2016.11.010
https://doi.org/https://doi.org/10.1016/... , affecting them both physically and psychologically, and influencing the way they grow, enjoy life, and socialize²2. Baiju RM, Peter E, Varghese NO, Sivaram R. Oral Health and Quality of Life: Current Concepts. J Clin Diag Res 2017; 11(6): ZE21-ZE26. https://doi.org/10.7860/JCDR/2017/25866.10110
https://doi.org/https://doi.org/10.7860/... . In this regard, subjective instruments, also called socio-dental indicators, have been developed to identify self-reported oral health needs, aiming to assess their impact on quality of life²2. Baiju RM, Peter E, Varghese NO, Sivaram R. Oral Health and Quality of Life: Current Concepts. J Clin Diag Res 2017; 11(6): ZE21-ZE26. https://doi.org/10.7860/JCDR/2017/25866.10110
https://doi.org/https://doi.org/10.7860/... ^,33. Slade GD. Measuring Oral Health and Quality of life. Chapel Hill: Department of dental Ecology, School of Dentistry, University of North Carolina; 1997..

In general, an unfavorable impact of oral health on quality of life has been associated with younger individuals, women, black people, those with low socioeconomic status, low schooling, poor clinical conditions, using inadequate dental prostheses, and in need of dental treatment⁴4. Gabardo MC, Moysés SJ, Moysés ST, Olandoski M, Olinto MT, Pattussi MP. Social, economic, and behavioral variables associated with oral health-related quality of life among Brazilian adults. Ciênc Saúde Colet 2015; 20(5): 1531-40. https://doi.org/10.1590/1413-81232015205.13562014
https://doi.org/https://doi.org/10.1590/... ^,55. Gabardo MC, Moysés ST, Olandoski M, Moysés SJ, Pattussi MP. Autopercepção de saude bucal conforme o Perfil de Impacto da Saude Bucal (OHIP) e fatores associados: revisão sistemática. Rev Panam Salud Publica 2012; 33(6): 439-45.^,66. Bulgareli JV, Faria ET, Cortellazzi KL, Guerra LM, Meneghim MC, Ambrosano GMB, et al. Factors influencing the impact of oral health on the daily activities of adolescents, adults and older adults. Rev Saude Publica 2018; 52: 44. https://doi.org/10.11606/s1518-8787.2018052000042
https://doi.org/https://doi.org/10.11606... . In addition, oral diseases can interfere with the daily activities of individuals due to pain and suffering episodes, psychological embarrassment, such as humor and irritation, and social deprivation⁶6. Bulgareli JV, Faria ET, Cortellazzi KL, Guerra LM, Meneghim MC, Ambrosano GMB, et al. Factors influencing the impact of oral health on the daily activities of adolescents, adults and older adults. Rev Saude Publica 2018; 52: 44. https://doi.org/10.11606/s1518-8787.2018052000042
https://doi.org/https://doi.org/10.11606... .

Different psychosocial aspects, including social support⁷7. Araújo SSC, Freire DBL, Padilha DMP, Baldisserotto J. Suporte social, promoção de saúde e saúde bucal na população idosa no Brasil. Interface (Botucatu) 2006; 10(19): 203-16. https://doi.org/10.11606/s1518-8787.2018052000042
https://doi.org/https://doi.org/10.11606... ^,88. Brennan DS, Spencer AJ. Social support and optimism in relation to the oral health of young adults. Int J Behav Med 2012; 19(1): 56-64. https://doi.org/10.1007/s12529-010-9136-3
https://doi.org/https://doi.org/10.1007/... ^,99. Ford PJ, Cramb S, Farah CS. Oral health impacts and quality of life in an urban homeless population. Aust Dent J 2014; 59(2): 234-9. https://doi.org/10.1111/adj.12167
https://doi.org/https://doi.org/10.1111/... , resilience¹⁰10. Martins AB, Dos Santos CM, Hilgert JB, de Marchi RJ, Hugo FN, Pereira Padilha DM. Resilience and self-perceived oral health: a hierarchical approach. J Am Geriatr Soc 2011; 59(4): 725-31. https://doi.org/10.1111/j.1532-5415.2011.03350.x
https://doi.org/https://doi.org/10.1111/... , sense of coherence¹¹11. Bernabé E, Newton JT, Uutela A, Aromaa A, Suominen AL. Sense of coherence and four-year caries incidence in Finnish adults. Caries Res 2012; 46(6): 523-9. https://doi.org/10.1159/000341219
https://doi.org/https://doi.org/10.1159/... ^,1212. Bernabé E, Watt RG, Sheiham A, Suominen-Taipale AL, Uutela A, Vehkalahti MM, et al. Sense of coherence and oral health in dentate adults: findings from the Finnish Health 2000 survey. J Clin Periodontol 2010; 37(11): 981-7. https://doi.org/10.1111/j.1600-051X.2010.01604.x
https://doi.org/https://doi.org/10.1111/... ^,1414. Freire MC, Sheiham A, Hardy R. Adolescents’ sense of coherence, oral health status, and oral health-related behaviours. Community Dent Oral Epidemiol 2001; 29(3): 204-12. https://doi.org/10.1034/j.1600-0528.2001.290306.x
https://doi.org/https://doi.org/10.1034/... , spirituality¹⁵15. Zini A, Sgan-Cohen HD, Marcenes W. Is religiosity related to periodontal health among the adult Jewish population in Jerusalem? J Periodontal Res 2012; 47(4): 418-25. https://doi.org/10.1111/j.1600-0765.2011.01447.x
https://doi.org/https://doi.org/10.1111/... , and stress¹⁶16. Peruzzo DC, Benatti BB, Ambrosano GM, Nogueira-Filho GR, Sallum EA, Casati MZ, et al. A systematic review of stress and psychological factors as possible risk factors for periodontal disease. J Periodontol 2007; 78(8): 1491-504. https://doi.org/10.1902/jop.2007.060371
https://doi.org/https://doi.org/10.1902/... ^,1717. Vasiliou A, Shankardass K, Nisenbaum R, Quiñonez C. Current stress and poor oral health. BMC Oral Health 2016; 16(1): 88. https://doi.org/10.1186/s12903-016-0284-y
https://doi.org/https://doi.org/10.1186/... , have been associated with oral health indicators, especially clinical ones, such as the number of decayed and missing teeth, the presence of periodontal pockets, dental plaque levels, and dental caries. Moreover, these psychosocial variables have also been associated with oral health-related behaviors, such as toothbrushing frequency, sugar intake, and the use of dental services¹¹11. Bernabé E, Newton JT, Uutela A, Aromaa A, Suominen AL. Sense of coherence and four-year caries incidence in Finnish adults. Caries Res 2012; 46(6): 523-9. https://doi.org/10.1159/000341219
https://doi.org/https://doi.org/10.1159/... ^,1414. Freire MC, Sheiham A, Hardy R. Adolescents’ sense of coherence, oral health status, and oral health-related behaviours. Community Dent Oral Epidemiol 2001; 29(3): 204-12. https://doi.org/10.1034/j.1600-0528.2001.290306.x
https://doi.org/https://doi.org/10.1034/... ^,1818. Reda SM, Krois J, Reda SF, Thomson WM, Schwendicke F. The impact of demographic, health-related and social factors on dental services utilization: Systematic review and meta-analysis. J Dent 2018; 75: 1-6. https://doi.org/10.1016/j.jdent.2018.04.010
https://doi.org/https://doi.org/10.1016/... . Despite the growing number of studies addressing the relationship between psychosocial aspects and oral health, most analyses investigate the association of oral health-related quality of life with sociodemographic aspects, oral conditions, health behaviors, and the use of health services⁴4. Gabardo MC, Moysés SJ, Moysés ST, Olandoski M, Olinto MT, Pattussi MP. Social, economic, and behavioral variables associated with oral health-related quality of life among Brazilian adults. Ciênc Saúde Colet 2015; 20(5): 1531-40. https://doi.org/10.1590/1413-81232015205.13562014
https://doi.org/https://doi.org/10.1590/... ^,55. Gabardo MC, Moysés ST, Olandoski M, Moysés SJ, Pattussi MP. Autopercepção de saude bucal conforme o Perfil de Impacto da Saude Bucal (OHIP) e fatores associados: revisão sistemática. Rev Panam Salud Publica 2012; 33(6): 439-45.^,66. Bulgareli JV, Faria ET, Cortellazzi KL, Guerra LM, Meneghim MC, Ambrosano GMB, et al. Factors influencing the impact of oral health on the daily activities of adolescents, adults and older adults. Rev Saude Publica 2018; 52: 44. https://doi.org/10.11606/s1518-8787.2018052000042
https://doi.org/https://doi.org/10.11606... ^,1919. Bianco VC, Lopes ES, Borgato MH, Silva PM, Marta SN. O impacto das condições bucais na qualidade de vida de pessoas com cinquenta ou mais anos de vida. Ciênc Saúde Coletiva 2010; 15(4): 2165-72.^,2020. Silveira MF, Marôco JP, Freire RS, Martins AMEBL, Marcopito LF. Impact of oral health on physical and psychosocial dimensions: an analysis using structural equation modeling. Cad Saúde Pública 2014; 30(6): 1169-82. https://doi.org/10.1590/0102-311X00072013
https://doi.org/https://doi.org/10.1590/... . Relatively few studies assess a wide range of psychosocial aspects to explain the impact of oral health on quality of life in adults. Thus, this research aimed to investigate the association between psychosocial aspects and the perceived impact of oral health on quality of life among adults from a city in Southern Brazil.

METHODS

We conducted a population-based cross-sectional study with individuals aged 20 years or older, living in the urban area of a medium-sized city in Southern Brazil. We excluded people with any cognitive problem. The estimated population of the city was 225,520 inhabitants, and the primary health care system comprises a general hospital, 28 basic health units, and 17 affiliated health facilities²¹21. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010 [Internet]. Instituto Brasileiro de Geografia e Estatística; 2017 [acessado em 11 out. 2017]. Disponível em: https://cidades.ibge.gov.br/brasil/rs/sao-leopoldo
https://doi.org/https://cidades.ibge.gov... . The primary care system has 12 oral health teams connected to the Family Health Strategy, distributed among basic health units and health centers from the region.

Data were collected through structured interviews with the head of the household.

Sample size calculation was based on data from the pilot study, using a method for proportions with cluster randomization and the outcome “self-perceived general health”²²33. Berkman LF, Glass TA. Social integration, social networks, social support, and health. In: Berkman LF, Kawachi I, editores. Social epidemiology. Nova York: Oxford University Press; 2000. p. 137-73.. Adopting an intraclass correlation coefficient of 0.05 and a 95% confidence level, we estimated that a sample of 1,260 households from 35 census tracts would have an 85% power to detect a difference of 7% in the prevalence of poor self-perceived health among exposed and non-exposed areas. This sample size was increased by 20% in the number of households and 10% in the number of tracts due to possible losses and to control for confounders.

The first stage of selection involved a random draw of census tracts among the 270 existing in the urban area of the city. Next, blocks from the tracts were randomly selected, and all households were visited until reaching the required number.

When those responsible for the household were absent, three return visits were made.

Structured interviews were conducted using a standardized and previously tested questionnaire consisting of demographic, socioeconomic, behavioral, and psychosocial variables. The interviewers were health undergraduate and graduate students. A pilot study with 100 individuals was conducted to assess the quality of the instruments, train the interviewers, and adjust the research logistics. The quality control of data collection was done by telephone, with a random sample of 10% of the participants, using an instrument similar to that of the study, with variables that would not change in a short interval.

The outcome was the socio-dental indicator Oral Health Impact Profile (OHIP). The instrument has 14 items and assesses the impact of oral health on quality of life, addressing aspects such as dysfunction, discomfort, and disability attributed to oral conditions³3. Slade GD. Measuring Oral Health and Quality of life. Chapel Hill: Department of dental Ecology, School of Dentistry, University of North Carolina; 1997.. The answers to these items ranged from never (0) to always (4), and the corresponding points were added to generate a score between 0 and 56. The higher the score, the worse the impact of oral health on quality of life.

The main exposures were social support, resilience, sense of coherence, spirituality, quality of life, and stress. We measured social support with the Medical Outcomes Study (MOS) scale²³23. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991; 32(6): 705-14. https://doi.org/10.1016/0277-9536(91)90150-B
https://doi.org/https://doi.org/10.1016/... , which comprises 19 items that assess the material, affectionate, and emotional support, positive social interaction, and information; in Brazil, Griep et al.²⁴24. Griep RH, Chor D, Faerstein E, Lopes C. Apoio social: Confiabilidade Teste-reteste de Escala no Estudo Pró-Saúde. Cad Saúde Pública 2003; 19(2): 625-34. https://doi.org/10.1590/S0102-311X2003000200029
https://doi.org/https://doi.org/10.1590/... ^,2525. Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde. Cad Saúde Pública 2005; 21(3): 703-14. https://doi.org/10.1590/S0102-311X2005000300004
https://doi.org/https://doi.org/10.1590/... validated this scale. The answers range from never (1) to always (5), and higher scores represent greater social support.

Resilience was evaluated with the Wagnild and Young’s scale²⁶26. Wagnild GM, Young HM. Development and psychometric evaluation of the resilience scale. J Nurs Meas 1993; 1(2): 165-78., validated for Brazil by Pesce et al.²⁷27. Pesce RP, Assis SG, Avanci JQ, Santos NC, Malaquias JV, Carvalhaes R. Adaptação transcultural, confiabilidade e validade da escala de resiliência. Cad Saúde Pública 2005; 21(2): 436-48. https://doi.org/10.1590/S0102-311X2005000200010
https://doi.org/https://doi.org/10.1590/... . It consists of 25 items, including serenity, perseverance, self-confidence, life meaning, and self-sufficiency. The items are positively described with responses varying from strongly disagree (1) strongly agree (7). The total score ranges between 25 and 175 points, and higher values represent greater resilience.

We assessed the sense of coherence using the short version of Antonovsky’s scale²⁸28. Antonovsky A. Unraveling the mystery of health: How people manage stress and stay well. San Francisco; 1987., validated for Brazil by Freire et al.¹⁴14. Freire MC, Sheiham A, Hardy R. Adolescents’ sense of coherence, oral health status, and oral health-related behaviours. Community Dent Oral Epidemiol 2001; 29(3): 204-12. https://doi.org/10.1034/j.1600-0528.2001.290306.x
https://doi.org/https://doi.org/10.1034/... . It includes 13 items, whose answers range between 1 (extremely negative) and 7 (extremely positive). The sum of the items generates a score in which higher values correspond to a greater sense of coherence.

The spirituality variable was assessed with the Spiritual Involvement and Beliefs Scale, validated for the Portuguese language²⁹29. Marques LF, Sarriera JC, Dell’Aglio DD. Adaptação e validação da Escala de Bem-estar Espiritual (EBE): Adaptation and validation of Spiritual Well-Being Scale (SWS). Av Psicol 2009; 8(2): 179-86.. The scale has 26 items, with answers ranging from strongly disagree (1) to strongly agree (5), and higher scores indicating a greater level of spirituality.

We analyzed the quality of life based on the WHO-8: EUROHIS scale, consisting of eight items derived from the short version of the WHOQOL, which covers self-satisfaction, satisfaction with personal relationships, income, housing conditions, health status, and the performance of daily activities, as well as the perceived overall quality of life, and the energy to face the everyday life³⁰30. Power M. Development of a common instrumente for quality of life. In: Nosikov A, Gudex C, editores. EUROHIS: developing common instruments for health surveys. Europa: Biomedical and Health Research; 2003. p. 145-63.. The scale has been validated for the Portuguese language in the Brazilian version of WHOQOL-Bref³¹31. Rocha NS, Power MJ, Bushnell DM, Fleck MP. The EUROHIS-QOL 8-item index: comparative psychometric properties to its parent WHOQOL-BREF. Value Health 2012; 15(3): 449-57. https://doi.org/10.1016/j.jval.2011.11.035
https://doi.org/https://doi.org/10.1016/... . The responses vary from very dissatisfied (1) to very satisfied (5), and higher scores represent a better quality of life.

In order to make the scores comparable, the sum of OHIP, social support, sense of coherence, resilience, spirituality, and quality of life scores was standardized from 0 to 100, according to the following formula (Equation 1)

Due to the asymmetry in outcome distribution, the latter was rated as better (OHIP=0: 50% of lower scores), moderate (OHIP 1-12.6: 25% of intermediate scores), and worse (OHIP≥12.7: 25% of higher scores). The sum of the scores of each psychosocial variable was categorized in the same way (high, moderate, low), based on quartiles.

Lastly, we assessed the level of stress using a face scale with a single item. The scale displayed seven stylized faces composed of circles with equal eyes and mouths that varied from a smile to a frown, showing different stages between well-being and malaise. The interviewees were asked if any of the faces expressed their level of stress in the previous three months. The first three cheerful faces indicated a normal level of stress; the last three sad faces pointed to a high level of stress, while the middle one represented the moderate level. The authors of the scale tested its construct validity by administering six items to 22 adults and reported a median correlation of 0.82 for the scale of one item³²32. Andrew FM, Withey SB. Social Indicators of Well-Being. Nova York: Plenum; 1976..

The demographic variables included gender, age (10-year groups), ethnicity (white and black/multiracial), and marital status (married, single, and separated/widow). The socioeconomic variables were level of schooling (high: ≥12 years; moderate: 5-11 years; and low: ≤4 years) and income, calculated based on quartiles (high: ≥R$ 3,185; moderate: R$ 1,050-3,184; and low: ≤R$ 1,049). The behavioral variables were: consumption of candies (low: does not eat or <1 time per week; moderate: 1 to 3 times per week; and high: more than 4 times per week or daily); smoking (non-smoker, ex-smoker, and smoker), self-perceived oral health (good/very good/excellent and regular/poor), and dentist visit in the previous 12 months (no and yes).

We performed double data entry in the software Epi-data 3.1 and compared them after to avoid typing errors. All analyses were conducted using the software Stata 12.1.

We performed descriptive analyses with absolute and relative frequencies. We used the χ² test for linear trend to verify the proportions of OHIP according to the independent variables. The association between psychosocial aspects and OHIP was calculated by ordinal logistic regression, estimating crude and adjusted odds ratios (ORs). The ordinal regression generates the ORs that estimate the chance of a dependent variable to increase and move to a higher category, following the increment in the independent variable. For the proportional odds assumption, we used the ‘gologit2’ command with the ‘autofit’ option to adjust the coefficients of the categories of variables that had the assumption violated.

Only the possible confounding factors were used in the multivariate analysis. To be considered a confounding factor, the variable should be associated with both the exposure and the outcome, adopting a significance level lower than 5% (p<0.05).

Chart 1 describes the associations of psychosocial aspects according to demographic, socioeconomic, and behavioral variables, with the control following these results. All analyses accounted for the complex sample design.

The Research Ethics Committee of Universidade Vale do Rio dos Sinos (Unisinos) received and approved this research project. We requested that all participants signed the informed consent form and guaranteed data confidentiality.

RESULTS

The main reasons for losses were inhabited houses or stores (8%), refusals (4%), and the absence of those responsible for the household in all three visit attempts (2%). In total, 1,100 people from 36 census tracts were interviewed. We lost five participants due to incomplete OHIP data; therefore, this analysis involved 1,095 individuals. The mean scores - from 0 to 100 - for OHIP, social support, resilience, sense of coherence, spirituality, and quality of life were, respectively, 7.4 (SD=13.6), 84.7 (SD=19.4), 65.4 (SD=16.9), 71.5 (SD=8.8), 70 (SD=10.8), and 60.5 (SD=13.3).

Most of the study population consisted of women (71.8%), white people (84%), married individuals (56%), those aged between 20 and 49 years (62.5%), with moderate household income (52.9%), and moderate level of schooling (65.3%) (Table 1). With respect to behavioral characteristics, 47% of the interviewees reported low frequency of consumption of candies, 55% declared being non-smokers, 63.5% reported good, very good, or excellent self-perceived oral health, and 66.2% claimed having visited the dentist in the previous 12 months (Table 2).

Women, older individuals, smokers, those with lower schooling, lower income, and who reported having poor or regular oral health presented the worst OHIP scores. Except for the spirituality dimension, all psychosocial variables were associated with the outcome, with worse psychosocial conditions corresponding to a worse perceived impact of oral health on quality of life (Tables 1 and 2).

Table 3 shows the crude and adjusted ORs for the different levels of OHIP, according to psychosocial variables of the sample. In the crude analysis, psychosocial aspects, such as social support, sense of coherence, resilience, quality of life, and stress, showed a statistically significant association with the perceived impact of oral health on quality of life.

These effects remained after adjustment for possible confounding factors. Individuals with low social support, low sense of coherence, low quality of life, and high level of stress were, respectively, 2.16, 2.90, 2.94, and 1.50 times more likely to report a worse impact of one of these conditions on quality of life than those with opposite (favorable) characteristics (Table 3). In contrast, the psychosocial variables resilience and spirituality were not statistically associated with the outcome in the adjusted analysis.

DISCUSSION

The results of this study showed that adverse psychosocial conditions were associated with a worse impact of oral health on quality of life, even after adjustment for demographic, socioeconomic, behavioral, and oral health service-related variables. A possible explanation for the greater impact in individuals with a worse psychosocial profile would be the fact that these variables, directly and indirectly, affect attitudes and behaviors that represent a risk to health³³33. Berkman LF, Glass TA. Social integration, social networks, social support, and health. In: Berkman LF, Kawachi I, editores. Social epidemiology. Nova York: Oxford University Press; 2000. p. 137-73.^,3434. Brennan DS, Spencer AJ, Roberts-Thomson KF. Socioeconomic and psychosocial associations with oral health impact and general health. Community Dent Oral Epidemiol 2019; 47(1): 32-9. https://doi.org/10.1111/cdoe.12419
https://doi.org/https://doi.org/10.1111/... . For example, lower levels of social support were associated with a worse perceived impact of oral health on quality of life. Social support covers the structure and quality of the network of social relationships, involving the personal satisfaction with the support received and with manifestations of love and affection, which, consequently, lead to positive life outcomes³³33. Berkman LF, Glass TA. Social integration, social networks, social support, and health. In: Berkman LF, Kawachi I, editores. Social epidemiology. Nova York: Oxford University Press; 2000. p. 137-73.. Social support acts as an agent that integrates the individual into society, minimizing the risks of social exclusion and damage to health⁷7. Araújo SSC, Freire DBL, Padilha DMP, Baldisserotto J. Suporte social, promoção de saúde e saúde bucal na população idosa no Brasil. Interface (Botucatu) 2006; 10(19): 203-16. https://doi.org/10.11606/s1518-8787.2018052000042
https://doi.org/https://doi.org/10.11606... ^,88. Brennan DS, Spencer AJ. Social support and optimism in relation to the oral health of young adults. Int J Behav Med 2012; 19(1): 56-64. https://doi.org/10.1007/s12529-010-9136-3
https://doi.org/https://doi.org/10.1007/... ^,3232. Andrew FM, Withey SB. Social Indicators of Well-Being. Nova York: Plenum; 1976.. Besides its protective nature, it also works as an instrument of autonomy for individuals as they learn and share ways of dealing with health and disease processes in the community³³33. Berkman LF, Glass TA. Social integration, social networks, social support, and health. In: Berkman LF, Kawachi I, editores. Social epidemiology. Nova York: Oxford University Press; 2000. p. 137-73.. Thus, it can be regarded as a synergistic relationship in which the fragility of social ties could amplify the perceived impact of negative oral health, and the latter, in turn, could also increase the individual’s isolation.

The present study identified that lower levels of sense of coherence were also associated with a worse impact of oral health on quality of life. Studies conducted with Finnish¹¹11. Bernabé E, Newton JT, Uutela A, Aromaa A, Suominen AL. Sense of coherence and four-year caries incidence in Finnish adults. Caries Res 2012; 46(6): 523-9. https://doi.org/10.1159/000341219
https://doi.org/https://doi.org/10.1159/... ^,1212. Bernabé E, Watt RG, Sheiham A, Suominen-Taipale AL, Uutela A, Vehkalahti MM, et al. Sense of coherence and oral health in dentate adults: findings from the Finnish Health 2000 survey. J Clin Periodontol 2010; 37(11): 981-7. https://doi.org/10.1111/j.1600-051X.2010.01604.x
https://doi.org/https://doi.org/10.1111/... ^,1313. Savolainen J, Suominen-Taipale AL, Hausen H, Harju P, Uutela A, Martelin T, et al. Sense of coherence as a determinant of the oral health-related quality of life: a national study in Finnish adults. Eur J Oral Sci 2005; 113(2): 121-7. https://doi.org/10.1111/j.1600-0722.2005.00201.x
https://doi.org/https://doi.org/10.1111/... and Brazilian³⁵35. Davoglio RS, Abegg C, Fontanive VN, Oliveira MMC, Aerts DRGC, Cavalheiro CH. Relationship between Sense of Coherence and oral health in adults and elderly Brazilians. Braz Oral Res 2016; 30(1): e56. https://doi.org/10.1590/1807-3107BOR-2016.vol30.0056
https://doi.org/https://doi.org/10.1590/... ^,3636. Machado FW, Perroni AP, Nascimento GG, Goettems ML, Boscato N. Does the Sense of Coherence modifies the relationship of oral clinical conditions and Oral Health-Related Quality of Life? Qual Life Res 2017; 26(8): 2181-7. https://doi.org/10.1007/s11136-017-1558-9
https://doi.org/https://doi.org/10.1007/... adults reported that a strong sense of coherence is connected to better oral health and healthier behaviors. Adults who had a low sense of coherence also presented worse levels of OHIP, which are indirectly related to poor oral health¹¹11. Bernabé E, Newton JT, Uutela A, Aromaa A, Suominen AL. Sense of coherence and four-year caries incidence in Finnish adults. Caries Res 2012; 46(6): 523-9. https://doi.org/10.1159/000341219
https://doi.org/https://doi.org/10.1159/... ^,1313. Savolainen J, Suominen-Taipale AL, Hausen H, Harju P, Uutela A, Martelin T, et al. Sense of coherence as a determinant of the oral health-related quality of life: a national study in Finnish adults. Eur J Oral Sci 2005; 113(2): 121-7. https://doi.org/10.1111/j.1600-0722.2005.00201.x
https://doi.org/https://doi.org/10.1111/... ^,3636. Machado FW, Perroni AP, Nascimento GG, Goettems ML, Boscato N. Does the Sense of Coherence modifies the relationship of oral clinical conditions and Oral Health-Related Quality of Life? Qual Life Res 2017; 26(8): 2181-7. https://doi.org/10.1007/s11136-017-1558-9
https://doi.org/https://doi.org/10.1007/... . In general, the authors support the idea that the sense of coherence has a protective behavioral effect based on regulating the emotion caused by stress factors and on the pursuit of health promotion behaviors. The effect of the sense of coherence on the incidence of dental caries is explained by oral health behaviors (for example, toothbrushing frequency, dental care, and frequency of sugar intake), as a strong sense of coherence might be associated with the adoption of healthier behaviors³⁶36. Machado FW, Perroni AP, Nascimento GG, Goettems ML, Boscato N. Does the Sense of Coherence modifies the relationship of oral clinical conditions and Oral Health-Related Quality of Life? Qual Life Res 2017; 26(8): 2181-7. https://doi.org/10.1007/s11136-017-1558-9
https://doi.org/https://doi.org/10.1007/... ^,3737. Elyasi M, Abreu LG, Badri P, Saltaji H, Flores-Mir C, Amin M. Impact of Sense of Coherence on Oral Health Behaviors: A Systematic Review. PLoS One 2015; 10(8): e0133918. https://dx.doi.org/10.1371%2Fjournal.pone.0133918
https://doi.org/https://dx.doi.org/10.13... . On the other hand, it is also plausible that a negative oral condition could affect the sense of coherence.

Moreover, we identified a strong association between the quality of life and OHIP among the participants - the lower the quality of life, the worse the perceived impact of oral health on quality of life. This low quality of life might reflect poor socioeconomic conditions, which could also be associated with other factors, such as behavioral characteristics²2. Baiju RM, Peter E, Varghese NO, Sivaram R. Oral Health and Quality of Life: Current Concepts. J Clin Diag Res 2017; 11(6): ZE21-ZE26. https://doi.org/10.7860/JCDR/2017/25866.10110
https://doi.org/https://doi.org/10.7860/... ^,33. Slade GD. Measuring Oral Health and Quality of life. Chapel Hill: Department of dental Ecology, School of Dentistry, University of North Carolina; 1997.^,1818. Reda SM, Krois J, Reda SF, Thomson WM, Schwendicke F. The impact of demographic, health-related and social factors on dental services utilization: Systematic review and meta-analysis. J Dent 2018; 75: 1-6. https://doi.org/10.1016/j.jdent.2018.04.010
https://doi.org/https://doi.org/10.1016/... . Similarly, participants in the present study who had an unfavorable socioeconomic status also reported lower quality of life. In contrast, we emphasize that OHIP and quality of life express, in some measure, concurrent constructs, which could partly justify the association found.

As to stress, our study identified that poor perceived well-being was related to a worse impact of oral health on quality of life, corroborating other findings¹⁶16. Peruzzo DC, Benatti BB, Ambrosano GM, Nogueira-Filho GR, Sallum EA, Casati MZ, et al. A systematic review of stress and psychological factors as possible risk factors for periodontal disease. J Periodontol 2007; 78(8): 1491-504. https://doi.org/10.1902/jop.2007.060371
https://doi.org/https://doi.org/10.1902/... ^,1717. Vasiliou A, Shankardass K, Nisenbaum R, Quiñonez C. Current stress and poor oral health. BMC Oral Health 2016; 16(1): 88. https://doi.org/10.1186/s12903-016-0284-y
https://doi.org/https://doi.org/10.1186/... . Thus, stress might increase anxiety, directly affecting the immune system and decreasing the salivary flow. In addition to this process, we could infer that anxiety, psychological stress, and depression could indirectly influence the oral health, leading, for example, to greater consumption of candies, facilitating the progression of dental caries and periodontal diseases³⁴34. Brennan DS, Spencer AJ, Roberts-Thomson KF. Socioeconomic and psychosocial associations with oral health impact and general health. Community Dent Oral Epidemiol 2019; 47(1): 32-9. https://doi.org/10.1111/cdoe.12419
https://doi.org/https://doi.org/10.1111/... ^,3838. Deinzer R, Granrath N, Spahl M, Linz S, Waschul B, Herforth A. Stress, oral health behaviour and clinical outcome. Br J Health Psychol 2005; 10(Pt 2): 269-83. https://doi.org/10.1348/135910705X26858
https://doi.org/https://doi.org/10.1348/... . However, in the present study, the consumption of candies was not associated with either the outcome or the perceived stress. In this case, we underline that the relationship between stress and the negative impact of oral health on quality of life is mediated by different emotional and behavioral coping strategies developed by individuals, besides eating habits, an aspect not evaluated in this study.

The results of this study must to be interpreted in the light of some limitations. The cross-sectional design may lead to reverse causality bias because both the exposure and the outcome were measured at the same time. For instance, we might assume that worse oral health or a worse impact of oral health can also impair the psychosocial status of the individual. Therefore, this association should be better investigated by studies with a longitudinal design, in which both the exposure and the outcome are measured repeatedly and prospectively. A positive aspect of this research is the fact that all variables - outcome and exposures - were assessed with validated scales, which to some extent may have minimized the measurement error.

CONCLUSION

The present study showed the association between some psychosocial aspects and the perceived impact of oral health on quality of life, a subject little explored in the national literature. Lower levels of social support, sense of coherence, and perceived overall quality of life, as well as higher stress scores, were related to worse evaluations of the impact of oral health. The use of subjective oral health indicators can complement the clinical information and provide knowledge about the individual’s perception of their oral health and the need for treatment. It is also important to assess these indicators within the psychological and social context of the individual. In this regard, the findings reported herein indicate the need for public health policies, programs, and services that take into account the mutual relationships between psychosocial aspects and oral health.

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