Impacts of oral health condition on the quality of life of hospitalized cardiac patients Oral health and quality of life of hospitalized cardiac patients

doi:10.21203/rs.3.rs-2841241/v1

Background

Cardiac patients are unaware that oral problems can negatively affect their quality of life.

Methods

This is a cross-sectional study with individuals of both sexes hospitalized in a ward and a cardiac intensive care unit, where sociodemographic and clinical data were collected. An oral bedside inspection was carried out, and the Oral Health Impact Profile questionnaire with 14 questions (OHIP-14) was applied to assess the impact of oral health on quality of life, which addresses 07 dimensions: functional limitation, physical pain, psychological discomfort, physical limitation, psychological limitation, social limitation, and incapacity. The Mann-Whitney test was used to compare OHIP-14 and oral condition. Univariate and multivariate Poisson regression evaluated the factors suggestive of an impact on health-related quality of life. Data processing was performed in SPSS.

Results

Eighty patients were examined, and 68.8% were men, 73.75% had tooth loss, and 21.25% used partial dentures. Edentulous individuals (p = 0.004), partially edentulous (p = 0.002), with the use of dental prostheses (p = 0.008), had worse quality of life concerning oral health, and the factors most suggestive of explanation for this negative impact were coronary fractures (RP adjust. 0.026) and use of prostheses (RP adjust. 0.009).

Conclusion

Edentulism, tooth loss, and coronary fractures were the clinical indicators of oral health that most impacted the quality of life of individuals with heart disease.

Oral infections

Cardiovascular diseases

Health assessment

Quality of life

Cardiovascular diseases (CVD) are a group of diseases of the heart and blood vessels and are the leading cause of death worldwide, accounting for around 32% of all global deaths [1]. In Brazil, the economic impact of CVD over the past five years has resulted in CVD mortality accounting for 28% of all deaths and 38% of deaths in the working age group (18 to 65 years). [2].

In this perspective, studies lead to understanding the multicausal relationship between chronic noncommunicable diseases and oral diseases [3–5]. Dysbiosis of biofilm pathogens leads to inflammation of the gingival epithelium that releases chemical mediators such as interleukins, prostaglandin E2, tumor necrosis factor-alpha, and metalloproteinases [6]. The mechanisms mediated by oral microorganisms and the inflammation triggered by them have been used to explain their involvement in atherogenesis [7].

The relationship between unfavorable social determinants and the manifestation of worse oral health conditions is a relevant topic for scientific investigation. In this complex context, oral health goes beyond the concept of keeping teeth healthy, being an essential point to guarantee the well-being and good health of the individual, as it is inserted in the context of general health, also interfering with the quality of life. [8].

The quality of life related to clinical conditions of oral health was reported in a study that evaluated 218 hypertensive and diabetic individuals through the application of the Oral Health Impact Profile (OHIP-14) with an instrument capable of addressing psychological and social aspects through self-perception and the survey of the impacts caused on the individual's quality of life. The instrument demonstrated that the absence of teeth and the use and need for prostheses were associated with physical and social impacts, affecting psychological dimensions [9].

Given the above, the present study aimed to identify the main oral conditions that impact the quality of life of individuals with heart disease admitted to a high-complexity hospital.

This is a cross-sectional and analytical study with a quantitative approach. Data collection occurred from September 2019 to December 2020 in the cardiology ward and the adult cardiology ICU (Intensive Care Unit) of a high-complexity hospital in São Luís – Maranhão, Brazil. The procedures of this study were approved by the Research Ethics Committee of Ceuma University, under opinion number 3.540.164.

The sample was composed for convenience, including 80 individuals with a clinical diagnosis of heart disease. As inclusion criteria were used: patients of both genders, aged between 23 and 70 years, who agreed to participate in the study, signing the Free and Informed Consent Form (TCLE). As non-inclusion criteria: those who presented any condition that made oral inspection impossible and answered the proposed questionnaire.

Sociodemographic, anthropometric, diagnosis, comorbidities, nutritional risk, medications in use, risk factors such as smoking and alcoholism, and vital signs were extracted from the electronic medical record used in the studied service.

The oral health indicators were analyzed from the dental anamnesis consisting of (1) General Information; (2) Systemic conditions; (3) Oral Health Conditions (dental conditions, periodontal conditions, conditions of the oral mucosa, presence of visible dental biofilm, degree of tongue coating and assessment of salivary secretion); (4) Treatment strategy; (5) Complementary Examinations. The oral health inspection was performed at the bedside, visually, using a wooden spatula and flashlight.

The Oral Health Impact Profile (OHIP) questionnaire was applied in its simplified version consisting of 14 items (OHIP-14) to measure the perceptions and feelings of individuals about their oral health and its impact on their quality of life and consists of 14 questions aiming to measure 07 dimensions: functional limitation, physical pain, psychological discomfort, physical limitation, psychological limitation, social limitation, and incapacity. Each item contains five response options, according to the Likert scale: "Never" (score 0), "Rarely" (score 1), "Sometimes" (score 2), "Repeatedly" (score 3), and "Always" (score 4). The score was evaluated by multiplying the response by the respective question weight (10), considering the presence of effects when OHIP-14 was ≥ 1.

The data were entered into an electronic spreadsheet in the Excel program. Data processing was performed using the SPSS software, version 17.0 (Chicago, IL, USA)

Descriptive statistical analysis used absolute and relative frequencies, median, and interquartile range. The Kolmogorov-Smirnov test was performed to assess normality, the Mann-Whitney test was used to compare OHIP-14 score by oral characteristics, and Poisson Regression was performed to verify the association between oral variables and quality of life using the adjusted prevalence ratio (PR) as an interpretation parameter. A significance level of 5% was considered.

Eighty patients were included in the study. Table 1 presents the demographic and clinical cardiac characteristics, observing that most of the sample comprised eutrophic men with an ejection fraction above 51%.

Table 2 presents the risk factors for heart diseases and comorbidities for CVD, with a more significant presence of patients with hypertension being observed.

Table 3 presents the dental characteristics, noting that most of the sample was partially edentulous.

Table 4 presents the impact on quality of life according to oral health conditions. Edentulism, partial tooth loss, and prostheses use impacted individuals' quality of life. There was a significant direct difference between the dimensions of functional limitation, physical and social limitation of the OHIP-14 and edentulism, and a direct correlation between the dimensions of functional limitation and physical limitation and partial tooth loss and between functional limitation and the use of prosthesis.

Table 5 presents, through univariate and multivariate regression, the independent variables that impacted the quality of life of patients with heart disease. Being overweight, edentulism, partial tooth loss, coronary fractures, and prostheses seem to explain the worst impact on the quality of life of individuals.

The main findings of this study were: i) edentulous heart disease patients, partially edentulous and those using dental prostheses, had a worse quality of life; ii) the oral conditions of coronary fracture and use of prostheses are suggestive explanations for the negative impact on quality of life-related to oral health.

Concerning oral health indicators, during the inspection of oral health, alteration in the face was the first health condition to be studied, followed by the evaluation of lymph nodes and oral mucosa. The condition of normality was found in 97.08% of the sample. For the dental evaluation, partial loss (73.75%), followed by the presence of caries (38.75%), and the use of prostheses (37.25%) were more prevalent in this population. Tooth loss was an independent risk factor for cardiovascular events after multivariable analysis adjusted for cardiovascular, behavioral, and income risk factors. Having five or more missing teeth substantially increased the risk of cardiovascular outcomes, and even a small number of missing teeth (1 to 4) was associated with an increased risk of MI, stroke, and death (11).

In this study, edentulism directly impacted the quality of life in the OHIP-14 dimensions of functional limitation (impaired speech and taste), physical limitation (decreased eating), and social limitations (difficulty in performing activities of daily living), as well as partial tooth loss presented a direct correlation between the functional limitation and physical limitation dimensions and the use of prosthesis in the functional limitation dimension. The same was found in the study by Carvalho et al. [12] concluded that edentulism, use, and need for prostheses affected the quality of life in psychological, physical, and social aspects

Additionally, the oral conditions of coronary fracture and the use of prostheses seem to be the factors that suggest the explanation for the negative impact on the quality of life related to oral health. In a cross-sectional study, where the oral health indicator variables were: functional dentition, edentulism, hyposalivation, xerostomia, root caries, and periodontitis, they concluded that the presence of edentulism among older adults with and without multimorbidity (that is, two or more chronic diseases) was higher in individuals with multimorbidity [13].

Finally, it is understood that the need for referral to dental care is an indicator that can demonstrate inequality in access to treatment. In this study, 71.25% required outpatient dental treatment, as observed in a study with 106 patients after cardiovascular surgery, where 74.2% needed dental treatment [14].

This study has some limitations that should be mentioned. Different laboratories performed the clinical analysis of the levels of specific cardiac markers, which presented results for CK-MB and troponin following different guidelines.

This study concluded that edentulism, tooth loss, and coronary fractures were the clinical indicators of oral health that most affected the quality of life of people with heart disease. Knowledge of the importance of maintaining good oral health status and its impact on cardiac outcomes remains poor, underscoring the need for health professionals to examine the oral cavity in this patient population and, when possible, refer for dental care.

Acute Coronary Syndrome (ACS), Acute Myocardial Infarction (AMI), Coronary Artery Disease (CAD), Diastolic Blood Pressure (DBP), Heart Failure (HF), Oral Health Impact Profile (OHIP), Heart Rate (HR), Body Mass Index (BMI), Peripheral Obstructive Arterial Disease (PAOD), Systolic Blood Pressure (SBP).

Ethics approval and consent to participate

This study was carried out in accordance with declaration of Helsinki and was approved by the Ceuma University Research Ethics Committee (protocol number 3.540.164), whose guidelines have followed Helsinki's Declarations. All respondents participated in this study freely and signed an informed consent form.

Consent for publication

Not applicable.

Availability of data and materials

The data and materials in this paper are available from the corresponding author upon request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) – Brasil – Finance Code 001.

Author's contributions

NCC: Conception, design, acquisition, data interpretation. MCF: data analysis, data interpretation. RCC: design, review. RRDJ: design, review. LLFL: review. PCL: review. RSS: revision. ADGA: data analysis, data interpretation, final revision. DBD: data analysis, data interpretation, final review.

Acknowledgement

Not applicable

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Table 1 – Description of the demographic characteristics of patients with heart disease.

Characteristics	Median (interquartile range) or n (%)
Age (years)	56.00 (13.75)
Gender (Male)	53 (68.8%)
Weight (kg)	63.50 (16.00)
Height (m)	1.63 (0.07)
BMI ¹(kg/m²)	24.69 (4.90)
Ejection fraction (%)	54.00 (37.75)
SBP ²(mmHg)	112.50 (16.75)
DBP³ (mmHg)	70.00 (20.00)
HR⁴ (bpm)	77.00 (16.00)

¹Body Mass Index. ²Systolic Blood Pressure. ³Diastolic Blood Pressure. ⁴Heart Rate.

Table 2 – Risk factors for heart diseases and comorbidities for CVD in the study patients (n = 80).

Characteristics	n (%)
AMI ¹	40 (50.0)
CAD ²	10 (12.5)
Valvular heart disease	9 (11.3)
Atrial fibrillation	2 (2.5)
ACS ³	2 (2.5)
HF ⁴	1 (1.25)
Aortic aneurysm	1 (1.25)
Bradycardia	2 (2.5)
POAD ⁵	1 (1.25)
Diabetes Mellitus type 2	24 (30)
Arterial hypertension	51 (63.8)
Alcoholism	34 (42.5)
Smoking	25 (31.3)
Dyslipidemia	9 (11.3)
Renal insufficiency	5 (6.3)

¹Acute Myocardial Infarction; ²Coronary Artery Disease; ³Acute Coronary Syndrome; ⁴Heart failure; ⁵Peripheral Obstructive Arterial Disease.

Table 3 – Indicators of oral health of patients with heart disease (n = 80).

Dental feature	n (%)
Edentulous	11 (13.8)
Partial toothless	59 (73.8)
Caries	31 (38.8)
Residual roots	15 (18.8)
Coronary fractures	9 (11.3)
Presence of prosthesis	30 (37.3)
Type of prosthesis
Partial	17 (21.3)
Total	15 (18.8)

Table 4. Association between oral conditions and impact on the quality of life of study patients (n=80).

oral conditions	Functional limitation	Physical pain	Psychological discomfort	Physical limitation	Psychological limitation	Limitation Social	Inability	Total score
	Md±SD	Md±SD	Md±SD	Md±SD	Md±SD	Md±SD	Md±SD	Md±SD
Edentulous
No	1.23±1.61	1.91±2.36	2.35±2.36,	1.06±1.90	2.26±2.24	0.29±0.81	0.86±1.42,	9.96±8.69
Yes	2.82±1.72	3.00±2.04	2.64±3.17	3.55±2.94	2.55±2.06	1.09±1.37	1.73±1.90	17.36±11.88
p-value	0.004*	0.070	0.971	0.002*	0.558	0.008*	0.097	0.048*
partial toothless
No	2.33±1.75	2.40±2.13	2.20±2.83,	2.73±2.89	2.60±2.02	0.80±1.26	1.40±1.76,	14.47±11.47
Yes	1.25±1.64	1.98±2.36	2.43±2.39,	1.09±1.95	2.23±2.25	0.31±0.82	0.88±1.44	10.17±8.84
p-value	0.020*	0.352	0.558	0.022 *	0.429	0.070	0.244	0.205
Residual roots
No	1.46±1.76	2.14±2.27	2.33±2.53	1.44±2.32	2.37±2.15	0.40±0.94	0.94±1.45	11.08±9.27
Yes	1.41±1.50	1.76±2.51	2.59±2.26	1.24±1.88	2.06±2.46	0.41±0.93	1.12±1.72	10.59±10.41
p-value	0.889	0.371	0.560	0.995	0.461	0.950	0.819	0.706
Caries
No	1.52±1.81	1.98±2.14	2.30±2.48	1.64±2.42	2.45±2.19	0.41±0.92	1.05±1.50	11.34±9.71
Yes	1.36±1.58	2.17±2.53	2.50±2.47	1.11±1.96	2.11±2.24	0.39±0.96	0.89±1.52	10.53±9.26
p-value	0.814	0.943	0.713	0.336	0.414	0.872	0.519	0.778
Coronary fractures
No	1.35±1.70	2.06±2.34	2.34±2.54	1.37±2.27	2.17±2.18	0.39±0.94	0.90±1.52	10.58±9.68
Yes	2.22±1.64	2.11±2.14	2.78±1.78	1.67±1.93	3.33±2.23	0.44±0.88	1.56±1.33	14.11±7.14
p-value	0.093	0.792	0.404	0.361	0.147	0.730	0.075	0.778
Use of prosthesis
No	1.13±1.58	1.98±2.27	2.26±2.42	1.00±1.75	2.09±2.29	0.38±0.92	0.89±1.53	9.72±9.55
Yes	1.91±1.79	2.18±2.39	2.58±2.55	1.97±2.69	2.61±2.07	0.42±0.96	1.09±1.48	12.76±9.17
p-value	0.038*	0.697	0.589	0.098	0.208	0.882	0.368	0.110

*p-value≤0,05.

Table 5. Univariate and multivariate Poisson regression regarding the factors that suggest an explanation for the impact on quality of life-related to oral health (n=80).

Independent variables	_grossPR	CI95%	P	_adjustedRP	CI95%	P
Gender (Male)	0.949	0.767-1.175	0.631	0.985	0.771-1.259	0.906
Age 60 to 69 (years)	0.909	0.700-1.181	0.476	1,317	0.967-1.792	0.080
Age 49 to 59 (years)	0.901	0.696-1.167	0.429	1.105	0.892-1.369	0.359
Diabetes	1.035	0.835-1.283	0.751	---	---	---
SAH¹	0.974	0.788-1.204	0.807	---	---	---
Alcoholism	0.921	0.750-1.131	0.433	---	---	---
Smoking	1.132	0.936-1.370	0.201	1.115	0.928-1.340	0.247
Dyslipidemia	0.647	0.358 to 1.169	0.149	0.723	0.449-1.166	0.184
Overweight	0.628	0.443-0.890	0.009	0.712	0.525-0.965	0.029
Edentulous	1.255	1.114-1.413	<0.001	0.925	0.703-1.216	0.575
Partial toothless	0.785	0.691-0.891	<0.001	0.768	0.590-1.001	0.051
Residual roots	0.824	0.596-1.137	0.239	---	---	---
Caries	0.901	0.730-1.111	0.329	---	---	---
Coronary fractures	1,246	1.110-1.398	<0.001	1,262	1.029-1.548	0.026
Use of prosthesis	1,261	1.045-1.523	0.016	1,359	1.078-1.713	0.009

¹Systemic Arterial Hypertension; RP: razão de prevalência; Obesidade: IMC ≥ 30 Kg/m²; Sobrepeso: IMC ≥ 25 e ≤ 29,9 Kg/m²; Eutrófico: IMC ≥ 18,5 e ≤ 24,9 Kg/m²; Low weight: BMI < 18.5 Kg/m².

No competing interests reported.

Impacts of oral health condition on the quality of life of hospitalized cardiac patients Oral health and quality of life of hospitalized cardiac patients

Status:

Version 1

Abstract

Introduction

Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1