Dental Pain and Oral Health-Related Quality of life Assignment

Assignment Task

Background and rationale

Oral health is a key indicator of overall health, well-being, and quality of life. It encompasses a range of diseases and conditions that include dental caries, periodontal disease, tooth loss, oral cancer, oral manifestations of HIV infection, oro-dental trauma, noma and birth defects such as cleft lip and palate [1]. Poor oral health affects the quality of life because of pain or discomfort, tooth loss, impaired oral functioning, disfigurement, missing school time, loss of work hours, and sometimes even death [2]. According to the World Health Organization, oral diseases are the most common noncommunicable diseases (NCDs) and affect people throughout their lifetime, causing pain, discomfort, social isolation, loss of self-confidence and disability [1].

Oral health-related quality of life (OHRQoL) is a multidimensional concept that reflects the impact of oral health on the physical, psychological, and social aspects of life. OHRQoL can be measured by various instruments, such as the Oral Health Impact Profile (OHIP), which is a widely used and validated questionnaire that assesses the frequency and severity of oral health problems on 14 domains of daily life. OHRQoL is influenced by several factors, such as socio-demographic characteristics, oral health status, oral health behaviours, dental service utilization, and psychosocial factors [3]. The association between regular dental attendance and improved OHRQoL. Studies have shown that regular dental attenders report a greater positive impact on their quality of life compared to those who attend only when symptomatic. This suggests that consistent dental visits can lead to better oral health outcomes and perceptions, which is crucial for public health messaging and policy. For instance, McGrath and Bedi (2001) found that regular dental attenders perceived oral health to have a greater impact on their quality of life, both in general and positively. This association remained significant even after controlling for socio-demographic factors such as age, gender, and social class [4]. Furthermore, regular dental attendance has been associated with having less dental caries experience, fewer missing teeth, and better OHRQoL[5].

Toothache is one of the most common oral health problems and a major reason for seeking dental care. Toothache can be caused by various dental conditions, such as dental caries, pulpitis, periapical abscess, periodontitis, cracked tooth syndrome, and temporomandibular disorders. Toothache can have a significant negative impact on OHRQoL, as it can interfere with eating, speaking, sleeping, working, studying, and socializing. Toothache can also affect the general health and well-being of individuals, as it can induce stress, anxiety, depression, and lower self-esteem [2]. A direct correlation between the severity of toothache pain and OHIP-14 scores, suggesting that increased pain severity negatively impacts OHRQoL. This addresses the tangible effects of oral pain on patients' daily lives and overall well-being.

Research has consistently shown that toothache and other oral conditions can lead to significant functional limitations, psychological discomfort, and social disability. For example, a systematic review and meta-analysis by Gerritsen et al. (2010) concluded that tooth loss, often a consequence of untreated toothache and oral diseases, is associated with impairment of OHRQoL[6].This impairment is not only due to the physical aspects of tooth loss but also due to the pain and discomfort experienced prior to the loss, which can be quantified using the OHIP-14 scores.

Moreover, the OHIP-14 instrument itself is designed to capture the multidimensional impact of oral health on quality of life, including pain and discomfort [7]. Addressing the severity of toothache within dental practices is not only crucial for immediate patient relief but also plays a significant role in enhancing overall patient outcomes. Recognizing the far-reaching consequences of oral pain, which extend beyond the confines of clinical symptoms, is essential for healthcare providers. By examining the intricate relationship between the intensity of toothache and OHRQoL, our study aims to inform the creation of precise interventions. These interventions are designed to alleviate pain and elevate the quality of life for individuals suffering from dental discomfort. This endeavour is in direct correlation with the broader objective of advancing patient-cantered care in the field of dentistry, ensuring that treatment approaches are tailored to meet the unique needs and experiences of patients.

Dental attendance is a key factor that influences oral health and OHRQoL, as it enables the prevention, diagnosis, and treatment of oral diseases and conditions. Dental attendance can be classified into two patterns: regular and symptomatic. Regular dental attendance refers to visiting the dentist for routine check-ups and preventive care, regardless of the presence or absence of oral problems. Symptomatic dental attendance refers to visiting the dentist only when there is pain or discomfort, or when a dental emergency occurs. Regular dental attendance is associated with better oral health and OHRQoL, as it allows the early detection and management of oral problems, reduces the need for invasive and costly treatments, and enhances the patient-dentist relationship. Symptomatic dental attendance is associated with worse oral health and OHRQoL, as it reflects the neglect of oral health, delays the seeking of dental care, increases the risk of complications and morbidity, and reduces the satisfaction and trust in dental services [2].

Dental attendance patterns are influenced by several factors, such as socio-economic status, oral health literacy, perceived need, dental anxiety, availability and accessibility of dental services, and cultural beliefs and attitudes. Some of these factors can function as barriers to dental attendance, especially for vulnerable and disadvantaged groups, such as the elderly, people with disabilities, the poor, and the rural residents. Barriers to dental attendance can prevent or limit the access to and utilization of dental services, resulting in unmet oral health needs and poor OHRQoL. Therefore, it is important to identify and address the barriers to dental attendance among different populations and settings, and to develop strategies to improve the access to and quality of dental care [2].

Coping mechanisms are the cognitive and behavioural strategies that individuals use to manage the stress and emotions caused by adverse situations, such as toothache and oral problems. Coping mechanisms can be classified into two types: problem-focused and emotion-focused. Problem-focused coping mechanisms are aimed at solving or reducing the source of stress, such as seeking dental care, taking medication, or applying home remedies. Emotion-focused coping mechanisms are aimed at regulating or relieving the emotional response to stress, such as sleeping, watching television, praying, or talking to someone. Coping mechanisms can have different effects on OHRQoL, depending on their type, frequency, and effectiveness. Some coping mechanisms can enhance OHRQoL, by alleviating pain, improving oral function, and restoring self-confidence. Other coping mechanisms can impair OHRQoL, by aggravating oral problems, delaying dental care, and inducing negative emotions. Therefore, it is important to explore and understand the coping mechanisms for toothache and oral problems among different populations and settings, and to provide appropriate support and guidance to improve OHRQoL[8].

South Africa is a middle-income country with a population of about 60 million people, of which 80% are Black Africans. South Africa has a high burden of oral diseases and conditions, especially among the Black population, due to the social and economic inequalities, the lack of oral health awareness and education, the limited availability and accessibility of dental services, and the low priority given to oral health in the health system. According to the South African National Oral Health Survey, the prevalence of dental caries among adults was 60%, the mean number of decayed, missing, and filled teeth (DMFT) was 3.2, and the proportion of untreated caries was 80%. The prevalence of periodontal disease among adults was 85%, and the proportion of tooth loss due to periodontal disease was 40%. The prevalence of oral cancer among adults was 0.02%, and the proportion of oral cancer deaths was 0.4%. The prevalence of oro-dental trauma among adults was 10%, and the proportion of oro-dental trauma due to interpersonal violence was 50% [9,10].

Umlazi is a township in the province of Kwa-Zulu-Natal, South Africa, with a population of about 400,000 people, of which 99% are Black Africans. Umlazi is one of the largest and poorest townships in South Africa, with high rates of unemployment, crime, violence, and HIV infection. Umlazi has only one state-run dental clinic, located at the Prince Mshiyeni Memorial Hospital, which provides basic dental services, such as examinations, extractions, fillings, and dentures, to the residents of Umlazi and surrounding areas. The dental clinic is understaffed, under-equipped, and over-crowded, with long waiting times and frequent interruptions of service. The dental clinic also faces challenges in terms of infection control, waste management, and record keeping. The demand for dental services in Umlazi exceeds the supply, and many people suffer from unmet oral health needs and poor OHRQoL [6]. Assessing OHRQoL is crucial in populations like Umlazi for several reasons. OHRQoL is a multidimensional construct that reflects an individual's subjective evaluation of their oral health, functional well-being, emotional well-being, expectations, satisfaction with care, and sense of self. It is an integral part of general health and well-being and is recognized by the World Health Organization as an important aspect of the Global Oral Health Program. In communities facing socioeconomic challenges, such as Umlazi, where dental services are scarce and the burden of oral diseases is high, assessing OHRQoL can provide insights into the broader impacts of oral health on individuals' lives. It can highlight the need for improved dental services and inform health policy to address oral health disparities [11]. Moreover, understanding OHRQoL in this context can guide the development of patient-centric and culturally acceptable oral health policies [12].

Previous studies have indicated that routine dental attendance is associated with better OHRQoL outcomes. For instance, regular dental visits have been linked to lower scores on the OHIP-14, suggesting a positive correlation between consistent dental care and improved quality of life [13]. Conversely, infrequent dental attendance can lead to neglect of oral health issues, exacerbating the negative impact on OHRQoL [14].This underscores the importance of regular dental services and the need to address barriers to dental care in underserved communities.

There is a lack of research on the oral health status, OHRQoL, dental attendance patterns, barriers to dental attendance, and coping mechanisms for toothache and oral problems among the residents of Umlazi, especially those who attend the state-run dental clinic at the Prince Mshiyeni Memorial Hospital. This study aims to fill this gap by exploring and comparing the OHRQoL and toothache of symptomatic and regular dental attenders in Umlazi, and by identifying the factors that influence their dental attendance patterns, barriers, and coping mechanisms. This study will use a mixed-methods approach, combining quantitative and qualitative data collection and analysis, to provide a comprehensive and in-depth understanding of the research problem. This study will contribute to the existing knowledge and evidence on oral health and OHRQoL in South Africa and will provide useful information and recommendations for oral health policy makers, planners, and practitioners, to improve the access to and quality of dental care in Umlazi and similar settings.

Aims and Objectives

Aim

A quantitative and qualitative comparison of the effects of toothache and its severity, measured by a Visual Analogue Scale (VAS), on symptomatic and regular dental attenders’ OHRQoL, measured by OHIP-14, in those attending the dental clinic of Prince Mshiyeni Memorial Hospital Umlazi, Kwa-Zulu-Natal, South Africa from June 2024.

Objectives

• Assessing the history and severity of dental pain using a questionnaire and VAS in patients who attend the Prince Mshiyeni Memorial Hospital in June 2024 due to toothache.
• Assessing the oral health-related quality of life of patients who attend the Prince Mshiyeni Memorial Hospital Umlazi in June 2024 due to toothache using OHIP-14 questionnaire.
• Assessing the dental attendance pattern of patients who attend the Prince Mshiyeni Memorial Hospital Umlazi in June 2024 using a self-administered questionnaire.
• To compare the VAS and OHIP-14 scores between symptomatic and regular dental attenders among patients who attend the Prince Mshiyeni Memorial Hospital Umlazi in June 2024 due to toothache by August 2024.
• To investigate the relationship between VAS and OHIP-14 scores of symptomatic and regular dental attenders among patients who attend the Prince Mshiyeni Memorial Hospital Umlazi in June 2024 due to toothache by August 2024.
• To explore the impact of toothache on life, barriers to regular attending dental clinics, coping mechanisms, and feedback of patients who attend the Prince Mshiyeni Memorial Hospital Umlazi in June 2024 due to toothache using semi-structured interviews of symptomatic and regular dental attenders and thematic analysis by August 2024.

Research questions

• What is the history and severity of dental pain among patients attending the Prince Mshiyeni Memorial Hospital in June 2024 due to toothache, as measured by specific questions and the Visual Analogue Scale (VAS)?
• What is the average OHRQoL among patients attending the Prince Mshiyeni Memorial Hospital in June 2024 impacted by toothache, as measured by the OHIP-14 questionnaire?
• What are the percentages of symptomatic versus regular dental attenders among patients attending the Prince Mshiyeni Memorial Hospital in June 2024?
• What are the experiences and perceptions of symptomatic and regular dental attenders regarding the impact of toothache on their OHRQoL, barriers to regular dental clinic attendance, coping mechanisms, and overall feedback, as reported in semi- structured interviews at the Prince Mshiyeni Memorial Hospital Umlazi in August 2024?

Hypotheses

• The patients with regular dental attendance at the Prince Mshiyeni Memorial Hospital Umlazi in June 2024 will have a higher OHIP-14 score and VAS score, indicating a worse OHRQoL and a higher perception of pain severity, compared to those with a symptomatic dental attendance pattern.
• The severity of toothache pain is directly proportional to the OHIP-14 scores among patients attending the Prince Mshiyeni Memorial Hospital Umlazi in June 2024, indicating that higher pain severity is associated with a greater negative impact on OHRQoL.
• The thematic analysis of semi-structured interviews will reveal significant differences in the reported impact of toothache on life, barriers to regular dental clinic attendance, coping mechanisms, and patient feedback between symptomatic and regular dental attenders at the Prince Mshiyeni Memorial Hospital Umlazi in August 2024.

 Methodology

Research design

This study employs a mixed-methods approach, integrating both quantitative and qualitative research methodologies to provide a comprehensive understanding of the effects of toothache on individuals' quality of life[15].

Population

Patients attending the Prince Mshiyeni Memorial Hospital dental clinic due to toothache in June 2024 will be asked to complete these questionnaires. The research participants will be adult patients (aged 18 years and above) who attend the dental clinic at Prince Mshiyeni Memorial Hospital, Umlazi, Kwa-Zulu-Natal, South Africa in June 2024. The collected data will then be analysed to determine the distribution of dental pain severity and its impact on quality of life.

Given the hospital's significant daily outpatient attendance, the patient population is likely to be varied, encompassing a wide range of socioeconomic backgrounds and oral health needs. The hospital attends to an average of 1,500 patients per day in the outpatient clinics, which suggests a substantial pool of potential participants for the study[16].

In terms of dental pain and its impact on quality of life, studies have shown that dental pain can significantly affect individuals' daily activities, psychological state, and social interactions [17,18,19]. By focusing on adult patients who attend the dental clinic due to toothache, the proposed study will tap into a critical aspect of oral health that has direct implications for patients' quality of life.

It is also important to consider the potential for underrepresentation of certain groups within the population. For instance, individuals from lower socioeconomic backgrounds or those with limited access to regular dental care may experience higher levels of dental pain and more significant impacts on their quality of life[20]. Ensuring a representative sample of the hospital's diverse patient population will be crucial for the validity and applicability of the study's findings.

Quantitative Cross Sectional Design

In the first phase, a cross-sectional design will be utilized. The quantitative data collection will involve the use of standardized instruments: in the form of one self-answered questionnaire provided to patients who read the information sheet and sign the informed consent form. The instruments consist of:

• Information sheet
• Informed consent form
• Visual Analogue Scale (VAS): To measure the severity of dental pain.
• Oral Health Impact Profile-14 (OHIP-14): To assess the oral health-related quality of life.
• Evaluating patterns of dental attendance through a self-administered questionnaire
• A question regarding their interest to attend the Phase 2 (semi-structured interviews) to tick and provide a contact number.

Qualitative Thematic Analysis

The second phase will consist of a qualitative study using thematic analysis. This method is chosen for its flexibility and ability to identify, analyse, and report patterns (themes) within data. It will involve:

• Semi-structured interviews: Individual semi- structured interviews will be conducted within the two different groups, symptomatic dental attenders and with regular dental attenders. These discussions aim to explore the personal experiences and perceptions related to toothache and dental attendance.
• Thematic Analysis: The discussions will be transcribed and analysed to identify recurring themes related to the impact of toothache on daily life, barriers to regular dental clinic attendance, coping mechanisms, and patient feedback.

Sampling

The participants will be selected using a mixed methods sampling strategy[21]. The sampling methods for Phase 1 (Quantitative) and Phase 2 (Qualitative) can be described as follows:

Sampling Method

Convenience sampling will be employed in this study by inviting patients who visit the dental clinic during the data collection period to participate. All patients attending the clinic due to toothache will be invited to participate in the study from day one until the desired sample size is reached. Prior to participation, each patient will be provided with a short verbal information and then, if they show interest, the detailed letter of information sheet that outlines the study's purpose, procedures, potential risks, and benefits. This letter will also clarify the voluntary nature of participation and the confidentiality measures in place to protect patient data [refer to Appendix A]. Following this, informed consent will be obtained from each participant, by providing them a separate sheet to read, print their name, sign, and date, ensuring they have understood the information provided and agree to participate willingly [refer to Appendix B]. This consent process is crucial to uphold the ethical standards of research and respect for participant autonomy [22].

The sample size calculation will be based on the following formula, utilizing a simple random approach. Simple random sampling calculations are often used as a basis for determining sample sizes in convenience sampling to estimate and adjust for potential biases and variability in the sample. This acknowledges the methodological considerations taken when applying probability sampling techniques to non-probability sampling methods [23.24].

The sample size calculation will use the following assumptions:

• The confidence level is 95%, which corresponds to a Z-score of 1.96.
• The estimated proportion of the population with poor OHRQoL is 50%, which is the most conservative estimate that gives the largest sample size.
• The margin of error is 5%, which is the maximum allowable difference between the sample estimate and the population parameter.

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