UNIVERSIDADE FEDERAL DE PELOTAS Faculdade de Odontologia
Programa de Pós-Graduação em Odontologia
Tese
Qualidade de vida em idosos e fatores associados
Fernanda Weingartner Machado Luz
Fernanda Weingartner Machado Luz
Qualidade de vida em idosos e fatores associados
Tese apresentada ao programa de Pós-Graduação em Odontologia da Faculdade de Odontologia da Universidade Federal de Pelotas, como requisito parcial à obtenção do título de Doutora em Odontologia, área de concentração em Clínica Odontológica com ênfase em Prótese Dentária.
Orientadora: Profª. Drª. Noéli Boscato Co orientadora: Profª. Drª. Marília Leão Goettems
Fernanda Weingartner Machado Luz
Qualidade de vida em idosos e fatores associados
Tese apresentada, como requisito parcial, para obtenção do grau de Doutora em Odontologia, área de concentração em Clínica Odontológica com ênfase em Prótese Dentária, Programa de Pós-Graduação em Odontologia, Faculdade de Odontologia, Universidade Federal de Pelotas.
Data da Defesa: 10 de Setembro de 2018
Banca Examinadora:
...
Profª. Drª. Noéli Boscato (Orientadora)
Doutora em Clínica Odontológica (Área de Prótese Dentária) pela Universidade Estadual de Campinas
... Profª. Drª. Fernanda Faot
Doutora em Clínica Odontológica (Área de Prótese Dentária) pela Universidade Estadual de Campinas
... Prof. Dr. Wellington Luiz de Oliveira da Rosa
Doutor em Odontologia (área de concentração em Biomateriais e Biologia Oral com ênfase em Materiais Odontológicos) pela Universidade Federal de Pelotas
... Profª. Drª. Luciana de Rezende Pinto
Doutora em Odontologia (Reabilitação Oral) pela Universidade de São Paulo ... Profª. Drª. Melissa Feres Damian (Suplente)
Doutora em Radiologia Odontológica pela Universidade Estadual de Campinas ... Profª. Drª. Maísa Casarin (Suplente)
Doutora em Odontologia (ênfase em Periodontia) pela Universidade Federal de Santa Maria (UFSM)
Agradecimentos
Agradeço à minha orientadora Profª. Drª. Noéli por estar presente em meus caminhos desde o 7° semestre da graduação e mais próxima desde meu TCC. Teus ensinamentos e seu jeito forte me fizeram amadurecer e me sentir mais segura. Cresci e aprendi não somente como aluna de doutorado, mas como profissional e como pessoa. Obrigada por ter sido orientadora, chamar a atenção quando necessário, sem deixar de elogiar e incentivar quando merecia. Obrigada!
Agradeço à minha co orientadora Profª. Drª. Marília por fazer parte deste trabalho e contribuir em tudo.
Agradeço aos professores Gustavo Nascimento e Alexandre Emídio por contribuir muito com este trabalho.
Agradeço aos meus pais Daisy e Helder por todo incentivo, estímulo e suporte para que sempre pudesse correr atrás de meus objetivos e buscasse ser uma profissional atualizada e humana; e minha irmã Ana Helena por me apresentar e incentivar na profissão que não poderia ter sido outra: Odontologia! Amo vocês.
Agradeço ao meu marido Murilo principalmente pela paciência nos momentos de tensão, por ser tão companheiro e ter tanta sintonia não somente na vida pessoal, mas como colegas e sócios no trabalho. Obrigada por estar e comigo em tudo. Te amo.
Agradeço aos familiares de Pelotas que me hospedaram e tornaram minhas idas muito mais agradáveis.
Agradeço ao Programa de Pós-Graduação em Odontologia da UFPel pela qualidade no ensino, ter estado em um programa nota 6 em minha pós- graduação é motivo de orgulho.
Agradeço a todos que contribuíram na coleta de dados, em especial à Ana Paula Perroni.
Finalmente agradeço a todos os mestres em toda vida acadêmica, em especial aos que me orientaram na pesquisa e extensão: Prof. Evandro Piva, Maximiliano Cenci, Rafael Moraes, Patrícia Jardim, Alexandre Masotti e Rafael Lund.
Notas Preliminares
A presente tese foi redigida segundo o Manual de Normas para Dissertações, Teses e Trabalhos Científicos da Universidade Federal de Pelotas de 2013, adotando o Nível de Descrição – estrutura em “Capítulos não-convencionais” do referido manual. <http://sisbi.ufpel.edu.br/?p=documentos&i=7> Acesso em: 20 de julho de 2018.
O projeto de pesquisa referente a essa tese foi aprovado no dia 17 de novembro de 2015 pela Banca Examinadora composta pelos Professores Doutores Noéli Boscato, Alexandre Emídio Ribeiro da Silva e Andreia Morales Cascaes.
Resumo
LUZ, Fernanda Weingartner Machado. Qualidade de vida em idosos e fatores
associados. 2018. 111f. Tese (Doutorado em Odontologia) – Programa de
Pós-Graduação em Odontologia. Universidade Federal de Pelotas, Pelotas, 2018.
A qualidade de vida relacionada ao envelhecimento requer atenção devido aos aspectos do aumento da expectativa de vida no mundo e às doenças crônicas que acompanham o processo de envelhecimento. Esta tese foi dividida em três capítulos: Capítulo 1- Avaliou a associação entre qualidade de vida relacionada a saúde bucal (QVRSB) e as características clínicas (número de dentes, uso e necessidade de prótese), sociodemográficas e senso de coerência, bem como, se o senso de coerência modifica a influência das condições clínicas na QVRSB.
Capítulo 2- Avaliou o efeito mediador do senso de coerência na associação entre
desordens temporomandibulares e QVRSB e qualidade de vida geral em idosos.
Capítulo 3- Comparou a influência da participação ou não em grupos de convivência
para idosos na QVRSB dos mesmos. No primeiro capítulo, os achados mostraram que indivíduos com alto senso de coerência apresentaram melhor QVRSB, mesmo após ajuste para as condições clínicas e sociodemográficas. Concluiu-se que o senso de coerência modifica o efeito da associação de condições clínicas e sociodemográficas na QVRSB e pode ser um fator de proteção em condições adversas. No capítulo 2, os resultados mostraram que as desordens temporomandibulares não tem efeito direto na QVRSB, e que o baixo senso de coerência media o efeito das desordens temporomandibulares na QVRSB e qualidade de vida geral. Finalmente no capítulo 3, após avaliação dos idosos que participam ou não de grupos de convivência, foi observado que aqueles que participam apresentam melhor QVRSB, independente dos fatores clínicos, sociodemográficos e psicossociais avaliados. Assim, a partir dos resultados obtidos nas pesquisas desenvolvidas nesta tese concluiu-se que o alto senso de coerência influencia positivamente a qualidade de vida geral e a QVRSB, independente dos demais fatores avaliados. Adicionalmente, observou-se que a participação em grupos de convivência para idosos parece ser uma boa alternativa para promover a qualidade de vida.
Palavras-chave: idosos; qualidade de vida; qualidade de vida relacionada à saúde
Abstract
LUZ, Fernanda Weingartner Machado. Qualidade de vida em idosos e fatores
associados. 2018. 111f. Tese (Doutorado em Odontologia) – Programa de
Pós-Graduação em Odontologia. Universidade Federal de Pelotas, Pelotas, 2018.
The process of aging-related quality of life requires attention due to aspects of the increase in life expectancy worldwide, and the chronic diseases that accompany the aging process. This thesis was divided into three chapters: Chapter 1- Evaluated the association between oral health related quality of life (OHRQoL) and the clinical characteristics (number of teeth, use and need of prosthesis), sociodemographic and sense of coherence, and whether the sense of coherence modifies the influence of clinical conditions on the OHRQoL. Chapter 2- Evaluated the mediating effect of the sense of coherence in the association between temporomandibular disorders and OHRQoL and quality of life in the elderly. Chapter 3- Evaluated the influence of participation or not in social centers for seniors on OHRQoL of the elderly. In the first chapter, the findings showed that individuals with high sense of coherence presented better OHRQoL, even after adjusting for clinical and sociodemographic conditions. It was concluded that the sense of coherence modifies the effect of the association of clinical and sociodemographic conditions on the OHRQoL, and can be a protective factor in adverse conditions. In Chapter 2, the results showed that temporomandibular disorders have no direct effect on OHRQoL and that the low sense of coherence mediates the effect of temporomandibular disorders on OHRQoL and quality of life. Finally, in chapter 3, after evaluation of the elderly who participate or not in social centers for seniors, it was observed that those who participate present better OHRQoL, regardless of the clinical, sociodemographic and psychosocial factors evaluated. Thus, from the results obtained in this thesis it was concluded that the high sense of coherence positively influence the quality of life and the OHRQoL, independently of the other factors evaluated. Additionally, the participation in social centers for seniors seems to be a good alternative to promote quality of life..
Key-words: elderly; quality of life; oral health related quality of life; oral health; sense
Sumário
1 Introdução...9
2 Capítulo 1. O senso de coerência modifica a relação entre condições clínicas e a qualidade de vida relacionada à saúde bucal?...17
3 Capítulo 2. Senso de Coerência media a associação entre desordens temporomandibulares e a qualidade de vida: Abordagem com um Modelo de Equação Estrutural... 34
4 Capítulo 3. Participação em Grupos de Convivência para Idosos na qualidade de vida relacionada à saúde bucal de idosos: um estudo comparativo transversal...58 5 Considerações finais...75 Referências...76 Apêndices...86 Anexos...92
1 Introdução e Revisão de Literatura
1.1 Panorama atual da população idosa
O número de idosos no Brasil em 2017 chegou a 30,2 milhões, um aumento de 18% desde o ano 2012. Nesta faixa etária da população, as mulheres representam a maioria expressiva com 16,9 milhões (56%), enquanto os homens correspondem a 13,3 milhões (44% do grupo) (IBGE, 2018). Diante deste panorama atual da pirâmide etária populacional, onde há o aumento da expectativa de vida e diminuição das taxas de natalidade (IBGE, 2018), torna-se ainda mais importante conhecer os fatores que podem interferir na qualidade de vida desta população, que será a maioria em poucos anos, para que seja possível promover a valorização dos mesmos e garantir políticas públicas adequadas.
A preocupação com a população idosa no Brasil tornou-se mais efetiva na década de 90 quando foi sancionada a lei 8.842, que estabelecia a Política Nacional do Idoso (PNI) e o Conselho Nacional do Idoso no Brasil, em 1994. Esta lei, além de considerar como idoso qualquer pessoa acima de 60 anos de idade, tem como objetivo assegurar os direitos sociais desta faixa etária da população, estabelecendo condições para promover sua autonomia, integração e participação ativa na sociedade (DIÁRIO OFICIAL DA UNIÃO, 1994). Adicionalmente, em 1999, foi estabelecida a Política Nacional de Saúde do Idoso (PNSI) que estabeleceu as diretrizes essenciais que norteiam a definição ou a redefinição dos programas, planos, projetos e atividades do setor na atenção integral às pessoas em processo de envelhecimento e população idosa (DIÁRIO OFICIAL DA UNIÃO, 1999). Finalmente, em 2003 foi sancionado o Estatuto do Idoso pela Lei nº 10.741, o qual expõe entre os direitos fundamentais do idoso, aqueles relacionados à saúde, tais como o atendimento integral pelo Sistema Único de Saúde (SUS) com o atendimento geriátrico em ambulatórios e domiciliar, o fornecimento de medicamentos, próteses e órteses, o direito de opção pelo tipo de tratamento, direito a acompanhante e a proibição de discriminação em plano de saúde. Neste contexto, foi também disponibilizado o treinamento dos profissionais de saúde, dos
cuidadores familiares e dos grupos de autoajuda (DIÁRIO OFICIAL DA UNIÃO, 2003). Desde então, inúmeras outras leis e vantagens foram estabelecidas a fim de favorecer o bem-estar do idoso.
O envelhecimento é um processo natural com diminuição progressiva das respostas adaptativas do corpo, e frente à exposição às doenças, é natural que com o avanço da idade, as doenças crônicas tornem-se mais prevalentes (CARNEIRO et al., 2013). Ainda, o processo de envelhecimento é acompanhado por acontecimentos importantes no âmbito físico, emocional e social, tais como a perda de cônjuge e de pessoas queridas, o abandono por familiares e mudanças socioeconômicas. Estes aspectos culminam em agravamento do bem estar físico e psicológico fazendo com que estes indivíduos necessitem de especifico apoio e alternativas para melhorar a qualidade de vida.
1.2 Problemas psicossociais relacionados aos idosos
Os problemas crônicos advindos do envelhecimento muitas vezes impedem o idoso de realizar suas atividades diárias prejudicando a sua independência e consequentemente o seu equilíbrio emocional. A depressão ou sintomas depressivos são a comorbidade mais comum em pessoas mais velhas com saúde física deficiente (DRAPER et al., 2000; SINNIGE et al., 2013). Tais sintomas são prevalentes em idosos que ainda vivem em suas residências (GARCIA-PENA et al., 2013; HO, et al., 2014), e é ainda mais prevalente entre aqueles que foram hospitalizados por doenças físicas graves, ou institucionalizados devido a comprometimentos físicos e/ou cognitivos (AKYOL et al., 2010; HELVIK et al., 2011; ORDU et al., 2012). É importante considerar que a depressão em idosos é diferente de outros grupos etários, e por isso necessita de atenção especial. Estudos que compararam a depressão entre idosos e indivíduos jovens e adultos, revelaram que os idosos com depressão apresentam maior comprometimento cognitivo (perda de memória subjetiva e diminuição da concentração) e somático (FISKE et al., 2009), bem como, distúrbios do sono, fadiga, perda de interesse, esperança, preocupação com o futuro (CHRISTENSEN et al., 1999) e ansiedade (GOOTTFRIES et al., 1998). Uma das principais diferenças entre pacientes idosos e adultos com depressão é a alta prevalência de ansiedade entre os idosos (SCHOEVES et al., 2005; JESTE et al., 2006).
Estudos anteriores demonstraram associação entre ansiedade e renda (BOSCATO et al., 2013; VISEU et al., 2018). Tal problemática é comum aos idosos pela diminuição da renda na aposentadoria e impossibilidade de trabalhar por problemas de saúde. Além disso, a ansiedade está relacionada às desordens temporomandibulares, prejudicando a qualidade de vida (BOSCATO et al., 2013). A felicidade é outro fator psicossocial importante que tem sido estudado na população idosa (CHIRINDA; PHASWANA-MAFUVA, 2018; JANUS; SMROKOWSKA-REICHMANN, 2018; MOEINI et al., 2018). É considerada uma experiência interior positiva que se origina da interpretação cognitiva e emocional sobre a vida (DIENER et al., 2003). Trata-se de sentimento, e seu conceito pode ser considerado subjetivo (JANUS; SMROKOWSKA-REICHMANN, 2018). Nestes estudos, dentre os fatores que estão associados à felicidade em idosos, incluem-se principalmente o suporte social (MOEINI et al., 2018) e questões de saúde (CHIRINDA; PHASWANA- MAFUVA, 2018; JANUS et al., 2018), e portanto não se pode discordar que está intimamente relacionado à qualidade de vida.
1.3 Envelhecimento e as condições de saúde bucal
No âmbito odontológico o envelhecimento também apresenta características acentuadas, sendo a principal delas o edentulismo. A perda dentária é um fenômeno complexo que envolve não somente fatores biológicos, mas também culturais, econômicos e sociais (BARBATO et al., 2007; DE MARCHI et al., 2012), sendo que a cárie dentária é a sua principal causa (JOVINO et al., 2005). Embora o índice de cárie dentária tenha diminuído no Brasil, assim como houve o declínio do edentulismo entre adolescentes (15-19 anos) e adultos de meia idade (35-44 anos), o mesmo não ocorreu entre os idosos (65-74 anos) que ainda apresentam altas taxas de edentulismo (CARDOSO, et al., 2016). Uma das possíveis explicações pode estar relacionada ao fato que embora tenha havido melhorias no estado de saúde bucal da população brasileira, foi somente após 2003 que a especialidade de endodontia, especialidade decisiva no tratamento que pode evitar a perda dentária devido a dor de origem pulpar, começou a fazer parte de tratamento oferecido pelo serviço público. No entanto, este serviço público gratuito, ainda é restrito a uma pequena parcela da população (CARDOSO et al., 2016), o que torna também o fator socioeconômico um determinante da perda dentária (BOSCATO et al., 2015;
CARDOSO et al., 2016). É importante salientar que o edentulismo parcial ou total durante longos períodos, pode resultar em deterioração significativa da saúde bucal originando alterações estruturais patológicas ou adaptativas na articulação temporomandibular, e assim doenças sintomáticas ou assintomáticas, incluindo as desordens temporomandibulares. A sobrecarga na articulação temporomandibular pode ocorrer, não somente pelo edentulismo, mas também pela falta de reposição destes dentes, hábitos parafuncionais e oclusão inadequada ou traumas, o que pode ou não originar sinais e sintomas de disfunção temporomandibular em idosos (ABUD et al., 2009). Além disso, é possível que fatores psicossociais também estejam associados a estas desordens (BOSCATO et al., 2013).
1.4 Qualidade de vida e grupos de convivência para idosos
Considerando em todas essas dificuldades que podem afetar o idoso no período de envelhecimento, é essencial que se conheçam as alterações fisiológicas que acometem o organismo dos mesmos, bem como os aspectos psicossociais que os afetam com o intuito de interceptar fatores que podem afetar a qualidade de vida, e os agravos na saúde desta população. A Organização Mundial da Saúde (OMS) (WHO, 2012) define qualidade de vida como sendo a percepção individual de sua situação de vida, entendida em um contexto cultural, sistema de valores, e em relação aos objetivos, expectativas e padrões de uma sociedade (WHO, 2012). Com o objetivo de amenizar os desafios advindos pelo envelhecimento, surgiram os Centros de Convivência para os Idoso, os quais promovem o desenvolvimento e a preservação da capacidade intelectual e motora destas pessoas. O histórico dos grupos de convivência remonta à década de 70, quando o Serviço Social do Comércio de São Paulo iniciou um programa para a terceira idade (BORGES et al., 2008). Neles predomina o envelhecimento saudável, ou seja, o idoso estabelece relações interagindo com os demais participantes do grupo e da comunidade. As atividades de lazer e a convivência contribuem tanto para manutenção do equilíbrio biopsicossocial, como para diminuir possíveis conflitos pessoais. Estes grupos funcionam de forma multidisciplinar e realizam atividades variadas de cunho cultural, social, educativo, recreativo e de promoção de saúde buscando promover uma melhoria na qualidade de vida destes indivíduos (ARAÚJO et al., 2004). Além disso, é importante pontuar também que o convívio social é um determinante de saúde e é
um dos pilares para um envelhecimento ativo segundo a Organização Mundial da Saúde (WHO, 2002). No Brasil, alguns estudos relacionando qualidade de vida e Grupos de Convivência para Idosos foram realizados (GALISTEU et al., 2006; ALMEIDA et al., 2010; SERBIM; FIGUEIREDO, 2011). Serbim & Figueiredo (2006), apontaram a importância de buscar-se alternativas para uma vida saudável para os idosos, considerando o grupo da terceira idade uma ótima opção a ser explorada. Desde então, poucos estudos foram realizados para avaliar e contribuir no quesito qualidade de vida de idosos frequentadores destes grupos, e, os que existem, em sua maioria não apresentam grupo de comparação, ou apresentam um poder questionável. Cabe aqui ressaltar também a escassez de estudos que avaliem a QVRSB de idosos que frequentam estes grupos.
1.5 Definição de senso de coerência e sua relação com qualidade de vida
Um recente estudo relacionando qualidade de vida e idosos (RANDÓN-GARCíA, et al., 2018) observou em sua análise que se faz necessário considerar e distinguir a saúde, da satisfação com a vida, bem como o que envolve a complacência com a vida do indivíduo, as experiências presentes e passadas. Nesse sentido, muitos gerontologistas afirmam que os idosos que envelhecem com sucesso são aqueles que se sentem felizes e satisfeitos com seu passado e presente, e desfrutam de relações sociais e contatos positivos. Este conceito também refere-se a uma dimensão subjetiva de bem-estar e uma capacidade de adaptar-se, aceitar e reconhecer o ambiente, a fim de obter-se uma melhor percepção de saúde e bem estar. Trata-se de como as pessoas experimentam suas vidas, sua avaliação cognitiva, suas reações emocionais e sua adaptação à vida (RANDON-GARCÍA et al., 2018). Este conceito de capacidade de adaptação e percepção do ambiente afeta diretamente a saúde e o bem estar e é muito semelhante ao conceito de senso de coerência.
A definição de senso de coerência iniciou com Aaron Antonovski, através de sua Teoria Salutogênica, como sendo uma orientação global para ver o mundo e o ambiente individual de forma compreensível, administrável e significativo. O autor afirmou que a maneira como as pessoas avaliam sua vida tem influência positiva ou negativa na sua saúde (ANTONOVSKI, 1987). Em outras palavras, o senso de coerência trata sobre como as pessoas permanecem bem, mesmo sob condições
desfavoráveis e estressantes tais como o envelhecimento por exemplo). De acordo com Antonovski, o senso de coerência apresenta três componentes:
compreensibilidade, uma medida da extensão em que o indivíduo percebe os
estímulos internos e externos como tangíveis, ou seja, a informação é coesa e estruturada em vez de caótica e inesperada. Manejo é a capacidade de gerenciamento, é o componente de comportamento que tem a ver com a medida em que o indivíduo percebe-se como tendo recursos à sua disposição. E finalmente o
significado, que é o componente motivacional relacionado ao senso de propósito,
que faz com que as tarefas da vida valham o esforço (ANTONOVSKY, 1987).
O senso de coerência está relacionado à promoção de saúde, visto que uma ampla pesquisa realizada em 2006 (ERIKSSON; LINDSTROM, 2006) demostrou a sua ligação com a saúde. É importante pontuar que o senso coerência não é o mesmo que saúde, mas se classificado como alto ou baixo pode interferir na maior ou menor disposição para o desenvolvimento e manutenção de saúde das pessoas (ERIKSSON; LINDSTROM, 2006). Outra pesquisa em 2007, realizada pelos mesmos autores, demostrou que o senso de coerência está relacionado à qualidade de vida e observou que quanto mais alto o senso de coerência, melhor a qualidade de vida (ERIKSSON; LINDSTROM, 2007). Ainda, uma recente revisão sistemática verificou associação entre senso de coerência e qualidade de vida relacionada à saúde bucal (GOMES, et al., 2018). Dessa forma, definir formas de melhorar o senso de coerência visando melhorar a qualidade de vida torna-se essencial, tendo em vista que para o conhecimento dos autores apenas um estudo procurou estudar formas de melhorar o senso de coerência. Neste sentido, é possível inferir que o senso de coerência é um aspecto importante a ser considerado para realizar intervenções com o objetivo de promoção de saúde (GUTURATANA et al., 2014). Assim, considerando o envelhecimento da população mundial, e os aspectos patognomônicos associados a esta faixa etária da população, torna-se essencial que serviços públicos e privados estejam preparados para atender com qualidade e eficiência este novo perfil etário, promovendo um envelhecimento saudável e consequentemente qualidade de vida.
1.6 Objetivo Geral
Avaliar a associação entre fatores sociodemográficos, psicossociais e condições clínicas de saúde bucal na qualidade de vida de idosos.
1.6.1 Objetivos Específicos
• Avaliar a associação entre fatores sociodemográficos, condições clínicas e senso de coerência. Avaliar se o senso de coerência modifica a relação das condições clínicas na qualidade de vida relacionada à saúde bucal de idosos.
• Avaliar se o senso de coerência media a associação entre desordens temporomandibulares e qualidade de vida relacionada à saúde bucal e qualidade de vida geral em idosos.
• Comparar a qualidade de vida relacionada a saúde bucal de idosos que frequentam ou não os grupos de convivência para idosos.
Capítulo 1. O Senso de Coerência modifica a relação entre condições clínicas e a qualidade de vida relacionada à saúde bucal?
Does the Sense of Coherence modify the relationship of oral clinical conditions and Oral Health Related Quality of Life?
Running-title: Sense of Coherence modifies the OHRQoL conditions?
Fernanda W. Machadoa, Ana Paula Perronib, Gustavo G. Nascimentoc, Marília L.
Goettemsd, and Noéli Boscatoe
a,bPhD student, Graduate Program in Dentistry, School of Dentistry, Federal
University of Pelotas, Pelotas, Brazil;
cProfessor, Graduate Program in Dentistry, School of Dentistry, Federal University of
Pelotas, Pelotas, Brazil;
dProfessor, Department of Social and Preventive Dentistry, Epidemiology Division,
School of Dentistry, Federal University of Pelotas, Pelotas, Brazil;
eProfessor, Graduate Program in Dentistry, Prosthodontics Division, School of
Dentistry, Federal University of Pelotas, Pelotas, Brazil.
________________________
O presente artigo foi publicado no periódico Quality of Life Research (Qualis A2, FI: 2,392) em 2017. O manuscrito é aqui apresentado de acordo com as normas do periódico.
Abstract
Purpose: This cross-sectional study aimed to evaluate the association of demographic and clinical characteristics, Sense of Coherence (SOC), clinical conditions (number of teeth, and use of and need for dental prostheses), and Oral Health-Related Quality of Life (OHRQoL); and if the SOC modifies the relationship of clinical conditions and OHRQoL in a sample of elders.
Methods: Trained dentists assessed the participants’ oral health and conducted interviews (n = 110). Information on sociodemographic conditions (sex; age at time of data collection; educational level; household income), SOC, and OHRQoL were investigated. Clinical data included use of and need for dental prostheses; number of decayed, missing, and filled teeth; and number of teeth (categorized by median). OHRQoL was measured using the Oral Health Impact Profile (OHIP-14). Effect modification between SOC and each clinical oral condition on OHRQoL was tested in regression models.
Results: The findings of the present study showed that individuals with high SOC presented better OHRQoL, even after adjustment for sociodemographic and clinical conditions.
Conclusion: SOC modifies the effect in the association between OHIP-14 scores and clinical conditions, and could be a protective factor in adverse conditions.
Introduction
The process of aging-related quality of life requires attention due to aspects of the increase in life expectancy worldwide, and the chronic diseases that accompany the aging process. Aging is a physiological process in life; however, the literature reports that older people are more likely to experience health and mobility problems [1]. In fact, aging has been accompanied by deteriorate oral clinical conditions, including especially tooth loss and edentulism. Oral health has been considered a fundamental component of health and physical and mental well-being. It exists along a continuum influenced by the values and attitudes of individuals and communities, and reflects the physiological, social, and psychological attributes that are essential to the quality of life (QoL). Furthermore, oral health is influenced by the individual’s changing experiences, perceptions, expectations, and ability to adapt to adverse circumstances [2]. Negative impacts of tooth loss on daily activities such as phonation, eating, and socializing are well documented. Thus, there is strong evidence that tooth loss is associated with impairment in Oral Health-Related Quality of Life (OHRQoL) [3, 4]. Studies conducted on elderly populations have shown that perception of OHRQoL is influenced by sociodemographic [5] and clinical factors [6]. However, sociodemographic indicators, may not appropriately describe health and QoL, due to its influence on how people perceive their health status [7, 8]. Individuals should perceive their conditions favorably in order to experience well-being and good QoL. In this context, Sense of Coherence (SOC) is considered as one of the most important factors determining life satisfaction and ability to cope with difficult situations [9]. According to the literature, SOC may explain why some people can remain well even after stressful life events or adverse conditions. Hence, SOC can be defined as the capability to perceive that one can manage adverse situation independent of whatever is happening in life [10]. Additionally, SOC represents the Salutogenic Model, which proposes that challenging situations and conflicts are characteristically inherent to the human condition and focuses on how individuals effectively manage and cope with adverse situations to preserve their health [11]. Only one study investigated the relationship between the SOC and clinical oral health in adults and elders [clinical variables were dental caries, number of teeth, and the absence of need for dental prosthesis], and the results showed that individuals with
strong SOC presented greater number of teeth and reduced need for dental prostheses than those with weak SOC [12]. However, in this study, the OHRQoL was not accessed. Given the aforementioned, there is a lack of studies investigating the association between SOC, OHRQoL, and clinical variables [number of teeth, use of and need for dental prostheses] in elderly people. Thus, this cross-sectional study evaluated whether the SOC modifies the effect of clinical conditions on OHRQoL. It was hypothesized that high SOC could positively influence the perceptions of oral health conditions.
Methods
Study design
This observational cross-sectional study was approved by the Local Human Research Ethics Committee (protocol 70/2013) and reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [13].
Participants
All elders who visited the prosthodontic clinic of the Federal University of Pelotas School of Dentistry, between March 2014 and January 2015, were invited to participate in the study. The subjects were evaluated and enrolled in this study if they presented adequate cognitive capacity to answer the questionnaire. Individuals who agreed to participate, signed a written informed consent based on the Declaration of Helsinki.
Outcome: Oral Health-Related Quality of Life (OHRQoL)
OHRQoL was measured using the Brazilian version of the Oral Health Impact Profile (OHIP-14) [14]. This assessment tool has 14 questions addressing ORHQoL in the previous 12 months based on seven dimensions: functional limitations, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. Each dimension has two questions with scores
ranging from 0 to 4 points: 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, and 4 = very often. The final scores range from 0 to 56 points, with higher scores denoting greater impact on quality of life.
Exposures: oral conditions
Examiners conducted clinical examinations under natural light using a buccal mirror and “ball point” probe, with the participant in the sitting position. Data were collected on the use of and need for dental prostheses, including the presence of prosthetic spaces and the quality of their rehabilitation. The use of and need for dental prostheses were assessed in the upper and lower arches, following the World Health Organization (WHO) criteria [15]. The same individual could use and, at the same time, need prostheses, if their device was considered inappropriate. In this context, a prosthesis was considered to have inadequate quality when it presented instability and lack of retention or when there was a loss of vertical dimension, resulting from either incorrect manufacturing or as a result of wear of artificial teeth or changes because of extended time of use. In the analyses, the need for and use of dental prostheses were considered to be a dichotomous variable. To assess the number of decayed, missing, and filled teeth due to dental caries, the DMF-T index was used [15]. Prior to clinical data collection, calibration of the three examiners was performed to assure data reliability. At first, a theoretical training with multimedia capability lasting 1 h was carried out. Afterwards, clinical examinations with 15 volunteers outside the study were performed. Kappa statistics were calculated to assess inter-examiner reliability. The Kappa values for dental prosthesis use ranged from 0.80 to 0.96 (mean 0.90), from 0.66 to 0.76 (mean 0.74) for need for prosthesis, and from 0.91 to 0.94 (mean 0.93) for dental caries.
Effect modifier: Sense of Coherence (SOC)
The SOC was assessed through a 29-item questionnaire scored with 7-point scales. The total scores in this scale could range from 29 to 203 points, with higher scores indicating stronger SOC. The SOC scale was designed to assess the following three components of SOC: comprehensibility, manageability, and
meaningfulness [11]. For this study, the median was used to categorize SOC as high or low. Higher scores indicate stronger SOC.
Covariates
Individuals were interviewed and the following data were gathered as follows: sex (male and female); age at time of data collection (60, 61–70, and 71–90); educational level (>8 and ≤8 years); and household income (based on the minimum wage in Brazil and categorized as more than 2 wages or 1–2 wages).
Data analysis
The data pattern distribution was analyzed. The OHIP-14 scores had a non-normal distribution and the non-parametric tests were employed. Effect modification between SOC and each clinical oral condition on OHRQoL was tested in regression models. A joint effect variable (cross product term between each exposure and SOC) was included in the model. Due to overdispersion and skewness, multivariable negative binomial regression models were performed to test the overall mean OHIP-14 score with each exposure variable. We firstly performed crude estimates of the interaction between SOC and each clinical variable with OHRQoL (Model 1). In Model 2, we adjusted the analyses from Model 1 for potential confounders (covariates and the remaining oral conditions). Rate ratios, which correspond to the quotient between the average scores of each comparison group, and 95% confidence intervals [95% CI] were estimated. All analyses were conducted in the software Stata 13.1 (StataCorp.; College Station, TX, USA).
Results
Of the 144 individuals invited to participate in the study, 110 (76.4%) were interviewed and clinically examined. The sample was composed essentially by women (96.3%), with an average family income of 1–2 minimum wages (63.2%), aged 61–70 years (55.4%). In relation to clinical conditions, 88 individuals (81.5%) wore dental prostheses, 78 (68.5%) needed dental prostheses, and 54 (49.1%) had less than 12 teeth (Table 1).
The OHIP-14 presented a median value of 3.5, with scores ranging from 0 to 41. Clinical oral conditions (number of teeth, use of dental prostheses) and sociodemographic factors (age, family income, education level, and sex) were associated with OHIP-14 scores. Additionally, individuals with low SOC presented greater OHIP-14 scores (P = 0.002) (Table 1). Significant correlations were observed between OHIP-14 and SOC (rho = 0.381; P < 0.001), and number of teeth (rho = −0.255; P = 0.003). OHIP-14 scores were not correlated to DMF-T index (rho = 0.078; P = 0.438). Crude associations were noted between OHIP-14 and low SOC (RR [Rate Ratio] 2.86; 95% CI 1.65–4.94); OHIP-14 and use of dental prosthesis (RR 2.34; 95% CI 1.09–5.04); OHIP-14 and less than 12 teeth (RR 2.00; 95% CI 1.14– 3.54). No associations were observed between OHIP-14 and need of dental prosthesis (RR 1.24; 95% CI 0.66–2.33). The effect modification of SOC in the association between OHIP-14 scores and clinical conditions was measured in crude and adjusted models. In unadjusted model, individuals with more than 12 teeth and low SOC presented greater impact on quality of life (RR 2.46; 95% CI 1.16–5.25); in those individuals presenting 12 teeth or less and low SOC, the impact was even higher (RR 5.40; 95% CI 2.53–11.52). In the adjusted model, only subjects with 12 teeth or less and low SOC presented higher scores of OHIP-14 (RR 4.47; 95% CI 1.79–11.17), (Table 2). Individuals with low SOC presented higher OHIP-14 scores, independent of the need of dental prosthesis (No need of dental prosthesis: RR 2.82; 95% CI 1.45–5.50; Need of dental prosthesis RR 3.73 95% CI 1.59–8.77). In the model adjusted for sex, age, income, educational level, number of teeth, and use of dental prosthesis, only those individuals with low SOC and that needed dental prosthesis presented higher OHIP-14 scores (RR 4.46; 95% CI 1.78–11.17), (Table 3). In relation to the use of dental prosthesis, in both crude and adjusted model, only individuals with low SOC and that use dental prosthesis presented greater impact on quality of life (Crude: RR 7.05; 95% CI 2.47–20.03; Adjusted: RR 4.04; 95% CI 1.13– 14.43), (Table 4).
Discussion
In this study, the effect modification of SOC in the association between OHIP-14 and use of and need for dental prostheses and number of teeth was measured. The hypothesis tested was accepted because our results showed that SOC modifies
the effect of clinical conditions on OHRQoL. It was found that SOC is a protective factor in the perception of oral conditions in relation to quality of life. Overall individuals with low SOC presented greater OHIP-14 scores. Findings suggest that SOC can be a promising resource for establishing a positive self-perception of oral health [12]. Considering the number of teeth, unadjusted and adjusted models showed that individuals with more than 12 teeth and low SOC presented greater impact on quality of life, and among those individuals presenting 12 teeth or less and low SOC, the impact was higher. Results showed that in this sample of elders, the number of teeth affected OHRQoL; however, SOC modified OHRQoL perception, as the association was noted only among those with low SOC. These findings are corroborated by previous published data showing that SOC is known as good predictor and contributor to positive state of health and QoL [9]. Since the severity of diseases can change over time, SOC investigation is important because it may explain why the same people can remain well even after adverse oral conditions. Thus, SOC has been used to understand factors that influence oral health [16], and the findings of some studies with dentate participants suggest that strong SOC may be associated with better oral health behaviors [17,18]. In relation to the use of dental prosthesis, individuals with low SOC and using dental prosthesis presented greater impact on QoL. It has been shown that biological, mechanical, aesthetic, and psychological factors are related to acceptance of prosthesis and success of treatment [19]. In addition, patient’s satisfaction and self-assessment of their dental prostheses are subjective and differs from individual to individual. Patient’s dissatisfaction with removable dentures could be due to the modality of the prosthetic treatment. This treatment is no expensive and ease of fabrication; nonetheless, the removable denture requires periodic maintenance to keep suitable aesthetic and functional performance [20]. In many cases, when the quality of the dental prosthesis is not satisfactory, patient reports that it hinders more than it helps. This was found to contribute to poor satisfaction with the use of prostheses and loss of patient motivation.
According to Antonovsky’s salutogenic theory [21, 22], strong SOC promotes adaptive health behavior and ability for resilience. It might explain why the need of prosthesis and high SOC had little impact on OHRQoL. Furthermore, the need of prosthesis showed greater impact on OHRQoL in individuals that presents low SOC, confirming that high SOC is a protective factor. It has been reported that
patient-based outcomes of therapeutic success, such as OHRQoL, could also be influenced by SOC. Thus, stronger SOC could positively affect patient’s perception and self-reported impacts of oral health status, use of or need for dental prosthesis [18].
This study has some limitations. First, it is a cross-sectional study therefore it precludes inferences about causal directions. However, little is known about personal factors that affect the perception of OHRQoL and our findings contribute to the understanding about it. Second, the sample was composed predominantly by women. There is a large body of literature confirming that women outlive men worldwide [23, 24]. It reflects the current scenario of the Brazilian elder population, with a higher predominance of women compared to men [25]. Furthermore, women are more likely than men to adopt preventive health behaviors [like dentist visits or medical check-up], and men tend to adopt less healthy habits [26, 27]. Nonetheless, it was shown that SOC is a construct that is not linked with gender [28]. Yet, it is also important to take into account that negative oral conditions experienced by older people are experienced for longer periods; this aspect could culminate in adaptability to current dental state by the elderly. Additionally, we used the DMF-T index to record dental caries. Despite its widely use, the DMF-T index does not consider the presence of root caries, what can be of relevance in old age individuals. As this measure was used for analytical adjustment purpose, it is not possible to eliminate residual confounding due to root caries in our analysis. This study also presents some strengths that should be highlighted. The internal validity of this study was assured by adequate calibration among the examiners and the use of standardized and validated questionnaires. Also, the use of criteria established by the World Health Organization (WHO) allows these results to be compared directly with future research employing the same criteria.
A recent study with elderly people investigated if high SOC protects against adverse health outcomes in patients aged 80 years and older. The findings indicated that the protective effect of the SOC extends beyond perceived health and QoL towards mortality and functional decline, even in a population with a high vulnerability to adverse outcomes [29]. In addition, the findings counter the argument that SOC would be merely the inverse of depression [29, 30]. Due to the protective effect of high SOC, lower OHIP-14 scores were observed independently of the health outcomes evaluated; thus, our findings agree with literature and suggest a possible adaptive process by people with high SOC to the existing chronic oral disabilities.
Further interventions for increasing SOC in people with low scores are recommended in order to improve their capacity to cope with life stressors and maintain their health [29]. It is important since SOC has been considered as a psychosocial determinant of oral health behaviors in adults [12, 28, 31]. Indeed, a systematic review showed that stronger SOC was associated with more favorable behaviors of tooth brushing frequency, daily smoking, and dental attendance [32].
Given the gradual increase in the elders worldwide, besides of targeting on clinical interventions, public health services and policy makers should focus on strategies aiming to improve QoL among this population.
Conclusion
The findings of the present study showed that individuals with high SOC presented better OHRQoL, even after adjustment sociodemographic and clinical conditions. Furthermore, the results showed that SOC modifies the effect in the association between oral clinical conditions and OHIP-14 scores.
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Table 1. Sample distribution and univariate analysis between sociodemographic and psychosocial factors and oral clinical conditions related to OHIP-14 scores. Pelotas, Brazil, 2015, (n=110).
Variables Number of people Percentage (%) Mean OHIP-14 SD P values Sociodemographic factors 110 100 6.52 (8.64) Sex Male 4 3.64 11.5 (12.39) P=0.029* Female 106 96.36 6.33 (8.49) Family income
More than 2 wages 35 36.84 4.06 (5.12) P=0.233*
1-2 wages 60 63.16 7.18 (9.91) Age group ≤ 60 11 10.00 12.72 (12.39) P=0.097** 61-70 61 55.45 6.33 (7.71) 71-90 38 34.55 5.00 (8.27) Level of education > 8 years 71 64.55 6.18 (8.12) P=0.760* ≤ 8 years 39 35.45 7.13 (9.61) Psychosocial characteristics Sense of coherence Low 54 45.45 9.85 (10.4) P<0.002* High 60 54.55 3.32 (4.76) Clinical Conditions Use of dental prostheses No 20 18.52 4.35 (7.65) P=0.061* Yes 88 81.48 7.10 (8.89)
Need for dental prostheses No 34 31.48 4.35 (7.65) P=0.959* Yes 74 68.52 7.10 (8.89) Number of teeth > 12 56 50.91 4.73 (6.66) P=0.017* ≤ 12 Number of decayed, missing, and filled teeth (DMFT) 0-10 11-20 21-32 54 16 28 63 49.09 14.95 26.17 58.88 8.39 11.00 4.12 6.32 (10.03) (13.05) (3.77) (7.74)
P< 0.05 indicates the presence of statistically significant differences; SD= standard deviation;
*Mann-Whitney; **Kruskal-Wallis.
Table 2. Effect modification of Sense of Coherence in the association between OHIP-14 scores and number of teeth. Pelotas, Brazil, 2015, (n=110).
RR: Rate ratio; CI: Confidence interval.
Model 1: Unadjusted results;
Model 2: Adjusted for income, educational level, age, DMF-T, and use and need of dental prosthesis.
Number of teeth RR 95%CI P-value
Model 1 >12 teeth/High SOC (ref.) 1.00 - - ≤12 teeth /High SOC 1.71 0.80-3.66 0.165 >12 teeth /Low SOC 2.46 1.16-5.24 0.019 ≤12 teeth /Low SOC 5.40 2.53-11.52 <0.001 Model 2 >12 teeth/High SOC (ref.) 1.00 - -
≤12 teeth /High SOC 1.48 0.59-3.66 0.398 >12 teeth /Low SOC 2.08 0.88-4.94 0.094 ≤12 teeth /Low SOC 4.47 1.79-11.17 0.001
Table 3. Effect modification of Sense of Coherence in the association between OHIP-14 scores and use of dental prosthesis. Pelotas, Brazil, 2015, (n=110).
Use of dental prosthesis RR 95%CI P-value Model 1 No use/High SOC (ref.) 1.00 - -
Use/High SOC 2.54 0.89-7.26 0.082 No use/Low SOC 3.18 0.86-11.98 0.087 Use/Low SOC 7.05 2.47-20.03 <0.001 Model 2 No use/High SOC (ref.) 1.00 - -
Use/High SOC 1.51 0.42-5.41 0.520 No use/Low SOC 2.24 0.56-9.02 0.255 Use/Low SOC 4.04 1.13-14.43 0.031 RR: Rate ratio; CI: Confidence interval.
Model 1: Unadjusted results;
Model 2: Adjusted for income, educational level, age, number of teeth, DMF-T and need of dental prosthesis.
Table 4. Effect modification of Sense of Coherence in the association between OHIP-14 scores and need of dental prosthesis. Pelotas, Brazil, 2015, (n=110).
Need of dental prosthesis RR 95%CI P-value Model 1 No need/High SOC (ref.) 1.00 - -
Need/High SOC 1.27 0.56-2.92 0.560 No need/Low SOC 2.82 1.45-5.50 0.002 Need/Low SOC 3.73 1.59-8.77 0.002 Model 2 No need/High SOC (ref.) 1.00 - -
Need/High SOC 1.31 0.54-3.12 0.547 No need/Low SOC 2.23 1.06-4.71 0.034 Need/Low SOC 4.46 1.78-11.17 0.001 RR: Rate ratio; CI: Confidence interval.
Model 1: Unadjusted results;
Model 2: Adjusted for income, educational level, age, number of teeth, DMF-T, and use of dental prosthesis.
Capítulo 2. Senso de Coerência media a associação entre desordens temporomandibulares e a qualidade de vida: Abordagem com um Modelo de Equação Estrutural
Sense of Coherence mediates the association between temporomandibular disorders and quality of life: a Structural Equation Modelling Approach
Short running title: TMD and quality of life in elderly
Fernanda W. Machado Luz, MSc1, Ana Paula Perroni, MSc1, Gustavo G. Nascimento, PhD2, Marília L. Goettems, PhD1, and Noéli Boscato, PhD1
1 Graduate Program in Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil
2 Section of Periodontology, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
________________________
O presente artigo foi submetido para o periódico Geriatrics & Gerontology international (Qualis B1, FI: 2,656) em 2018. O manuscrito é aqui apresentado de acordo com as normas do periódico.
Abstract
Aim: The occurrence of temporomandibular disorders (TMD) can be associated with
individual’s psychosocial characteristics and this condition could influence perception about quality of life. This study evaluated whether the Sense of Coherence (SOC) mediates the association between temporomandibular disorders (TMD) and Oral Health Related Quality of Life (OHRQoL) and quality of life (QoL) in elders.
Methods: Trained dentists assessed the participants’oral health and conducted
interviews (n=110). Information was collected on sociodemographic conditions, psychological factors, and presence or absence of TMD. OHRQoL was measured using the Oral Health Impact Profile (OHIP-14) and QoL using the WHOQoL-BREF. Structural Equation Modeling (SEM) was employed to estimate the standardized direct effect of TMD on OHRQoL and on QoL, and the indirect effect mediated by SOC.
Results: TMD had no direct effect on OHRQoL; an indirect effect mediated by SOC
was noted (P<0.001). Regarding QoL, TMD had direct effect on WHOQoL (P<0.05), however, the effect mediate by SOC was higher than the direct effect (P<0.001).
Conclusion: Low SOC mediated the effect of TMD on oral and general quality of life
perception.
Keywords: sense of coherence, temporomandibular joint disorders, oral health,
Introduction
Temporomandibular disorder (TMD) is a collective term embracing a number of clinical conditions that involve the masticatory muscles, the temporomandibular joint (TMJ) and associated structures1. Even though studies have shown that TMD-pain is found in all age groups2, the prevalence of TMJ disorders is higher among younger adults and women3. The etiology of this orofacial pain is considered multifactorial because several risk factors appear to predispose, trigger, or prolong this condition. Biological factors (e.g., sex hormones), endogenous opioid function, differences in anatomical genotypes, trauma, occlusal changes and parafunctions are among the risk factors often described in the literature. Furthermore, the role of psychological and psychosocial factors (e.g., stress exposure, pain coping, stress, catastrophizing, and emotions) has been emphasized4 and there is a consensus that
these elements are associated with TMD5.
TMD can result in pathological or adaptive degenerative bone changes linked to symptomatic or asymptomatic TMJ diseases, including noises and limited extension of mandibular movement6,7. In turn, compromised mandibular movement can impair basic primary functions such as phonation and mastication. The later has been pointed out as a potential risk factor for the development of cognitive dysfunction8 and inadequate nutritional status, which could negatively influence on quality of life5,9.
Sense of coherence (SOC) is a psychological factor defined as the capability to perceive that one can manage adverse situation independent of whatever is happening in life10.The Salutogenic Model represented by SOC proposes a broader understanding of health, meaning a recognition of health as the result of the adaptive
capacity of the human being to stress. This theoretical model also seeks to understand how individuals can manage their life despite adverse conditions11, which makes SOC a useful instrument to investigate general quality of life (QoL)10,12.
Despite its widespread use in the medical and social sciences, there is scarce evidence on how SOC influences the perception and impact of oral conditions on general and oral-health-related quality of life13,14.
Accordingly, this study aimed to answer the following questions: i) Does SOC mediate the association between TMD and OHRQoL in elderly?; ii) Does SOC mediate the association between TMD and QoL in elderly? Based on the current literature, it was hypothesized that low SOC would negatively influence the perceptions of OHRQoL and QoL associated with TMD.
Methods
Study Design
This cross-sectional study was approved by Institutional Review Board (protocol 70.2013), and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used to guide the reporting of the study15.
Ethics
Elderly people who visited Prosthodontics Clinic of the School of Dentistry, between March 2014 and January 2015, were invited to participate of the study (n=110), if they presented adequate cognitive capacity to answer the questionnaire. After an explanation about the research, individuals who agreed to participate signed a written informed consent based on the Declaration of Helsinki.
Outcome1- Oral Health Related Quality of Life (OHRQoL)
OHRQoL was measured using the Oral Health Impact Profile (OHIP-14)16. This assessment tool has 14 questions addressing ORHQoL in the previous 12 months based on 7 domains: functional limitations, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. Each domain has 2 questions with scores ranging from 0 to 4 points: 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often and 4 = very often. The final scores range from 0 to 56 points, with higher scores denoting greater impact on quality of life.
Outcome 2- Quality of Life (WHOQoL)
The short form of WHOQoL-100 was used in order to measure QoL. The WHOQoL-BREF is a 26-item questionnaire that correlates well with the original 100-item questionnaire. It is scored in physical, psychological, social and environmental domains, plus two global questions addressing overall QoL and health satisfaction. It evaluates perceived quality of life using 26 items categorized into Physical domain (7 items), Psychological domain (6 items), Social Relations domain (3 items), and Environment domain (8 items). The scale of the WHOQOL-BREF consisted of frequency, intensity, capability, and evaluation in a 5-point response format (scored from 1 to 5). Each dimension score was calculated by multiplying the mean of all facet scores in the same domain by a factor of 4, with a higher score indicating a better QoL (range 4–20)17. The latent construct was created based on the four domains of the instrument, which converged with appropriate fit in the exploratory and confirmatory measurement models.
Exposure- Temporomandibular disorders (TMD)
The presence and severity of signs and symptoms of TMD were determined using a questionnaire composed by questions regarding common TMD symptoms based on the modified Helkimo’s anamnestic index18 which has been previously used in other studies18. The following aspects were considered: 1–difficulty in opening mouth and 2–moving the mandible laterally; 3–stress/muscular pain during masticatory movements; 4–headache; 5– pain in the occipital region; 6–pain in the ear region; 7–noises in the temporomandibular region during mastication or 8– opening; 9–clenching/grinding; 10–psychological status. A score was given based on the presence and severity of each item above, and the sum of these scores was used to classify the TMD into two categories: [absent (score 0, when no symptom was reported)] and presence [ mild (score 1, from 1 to 3 symptoms reported), moderate (score 2, from 4 to 6 symptoms reported) and/or severe (score 3, from 7 to 10 symptoms reported)]. For analysis purposes, individuals were classified as absence or presence of symptoms of TMD.
Mediator- Sense of Coherence (SOC)
The SOC was assessed through 29 items scored with 7-point scales questionnaire. The total scores in this scale could range from 29 to 203 points, with higher scores indicating stronger SOC. The scale was designed to assess the following three components of SOC: comprehensibility, manageability and meaningfulness19.The latent construct was created following the three components of the SOC instrument. Nevertheless, the components ‘manageability’ and ‘meaningfulness’ were parceled in order to improve the fit of the model.
Covariates
Individuals were interviewed and the following sociodemographic factors were gathered: sex (male and female); age at time of data collection (60, 61-70 and 71-90); educational level (> 8 years and ≤ 8 years, which in Brazil corresponds to primary school); household income (based on the minimum wage in Brazil and categorized as more than 2 wages or 1–2 wages).
To assess psychological factors (anxiety and depression), the Hospital Anxiety and Depression Scale (HADS) was used. The HADS consists of seven items for depression (HADSd) and seven items for anxiety (HADSa). There are four answer choices for each item, each with a score that can vary from 0 to 3. The total HADS scores vary from 0 to 21 points (0 to 21 points for anxiety and 0 to 21 points for depression). The main characteristics of the HADS are that the items covering the somatic symptoms of anxiety and depression have been eliminated, and for the statistical analyses, anxiety levels were considered in dichotomous variable: [1st (scores from 0 to 8 were interpreted as no case of anxiety = absence)]; 2nd (scores from 9 to 10 were interpreted as possible cases = low); and presence of symptoms [3rd (scores from 11 to 21 were interpreted as probable cases = high anxiety)20]. Table 1 summarizes information related to exposure, outcomes, mediator and covariates used in this study.
Data Analysis
Exploratory and confirmatory factor analyses were performed for the construction of the latent variables of OHRQoL, QoL, and SOC. Exploratory factor analysis (EFA) revealed three domains for OHRQoL, labled as “physical”, “social” and “psychological” domains (Appendix I). To avoid misspecification of the model, which requires a latent variable with at least four observed variables to perform all
models estimates, the “social” domain was parceled in two different indicators. Empirical justifications for the parceling include increasing reliability, simplifying interpretation, and improving the fit of the model. Confirmatory factor analysis (CFA) confirmed the consistency of the variable, as indicated by model fit parameters. Similar procedures were performed for the WHOQoL instrument. In Appendix II, it is possible to see the factorial loadings of all questions according to the four factors revealed by the EFA. The robustness of the variable was checked with CFA. Exploratory and confirmatory factor analyses identified five factors for SOC, which were used in the structural equation models (Appendix III).
Preliminary confirmatory factor analysis was carried out to assess the fit of the measurement model, which included two latent variables at a time. Structural Equation Modeling was employed to estimate the relationship between TMD, SOC and QoL. The Weighted Least Square estimation method was used in all models.
Standardized direct, indirect and total effects on WHOQOL and OHIP scores were estimated. Total effects are composed of both direct effects (a path direct from one variable to another) and indirect effects (a path mediated through other variables). To evaluate the fit of analytical models, the Comparative Fit Index (CFI) and the Tucker Lewis Index (TLI), considering a minimum value of 0.95 as indicative of fit, and the Root Mean Square Error of Approximation (RMSEA), considering values from zero to 0.08, were used. In order to examine alternative models and obtain better indices of fit, modification indices were estimated, which were implemented if appropriate better-fitting models were found. Covariates with no statistical significance were removed from the analysis in order to assure the parsimony of the models. Statistical significance was taken to be less than 5.0 %.
