Tools Evaluating Child Oral Health–Related Quality of Life

Abstract

Objectives

This study aimed to systemically review the tools developed for evaluating oral health–related quality of life (OHRQoL) in preschool children.

Methods

Two reviewers systematically searched English-language publications within PubMed, Embase, Scopus, and Web of Science. They screened the titles and abstracts and retrieved the full texts of the selected publications. Studies which developed, validated, or culturally adapted an OHRQoL tool used in preschool children were included. They recorded information regarding tool characteristics, item configuration, discriminative validation, the aim of assessment, and the target group.

Results

The study included 59 publications and identified 12 tools for assessing OHRQoL in preschool children. Seven tools were tailored for preschool ages. Most of the scales were generic oral health measures. Dental caries was the most commonly used oral condition for assessing a tool's discriminative validity. Eight tools required parental proxy reports. Three tools were both child-administrated and parent-administrated. One tool was designed to be answered solely by children. Ten tools assessed the oral health–related impact on children, including oral condition–related, functioning, environmental, and emotional/social domains. Four tools included items regarding the impact on both children and family.

Conclusions

This review identified 12 tools developed for evaluating OHRQoL in preschool children, 7 of which were tailored for preschool age. The 12 tools were validated but incomprehensive due to the subjective and multidimensional nature of the OHRQoL concept. Researchers can choose a suitable tool for their studies by understanding the basic characteristics and item setting of the tools. Researchers can have an overview of the tools developed for evaluating OHRQoL in preschool children. They can use the findings from this review to choose a suitable tool for their studies regarding the OHRQoL in preschool children.

Introduction

Oral health was originally defined as “the retention throughout life of a functional, esthetic, natural dentition of not less than 20 teeth and not requiring recourse to a prosthesis.¹” Here the “oral health” was defined in terms of absence of disease.² After the World Health Organization (WHO) expanded the definition of “health” with the inclusion of social well-being, the definition of oral health was also broadened.³ The World Dental Federation developed a new definition of “oral health,” which emphasises an individual's optimum capacity for effective performance of valued tasks and strong integration with the surrounding environment.⁴ In addition to clinical indicators, social–dental indicators, such as oral health–related quality of life (OHRQoL), attributed by the general public can also be recognised as valid parameters in oral health assessment.⁵

OHRQoL has be defined as “a multidimensional construct that includes a subjective evaluation of one's oral health, functional well-being, emotional well-being, expectations and satisfaction with care, and sense of self.”⁶ By incorporating OHRQoL as an additional health outcome in clinical practice, a more comprehensive understanding of the salience of oral health conditions can be provided.⁷ Evidence has shown that poor oral health can have a negative impact on one's OHRQoL.⁸ The WHO has also recognised OHRQoL as an important segment of its Global Oral Health Program.⁹ The OHRQoL measurement approach can be broadly divided into 2 groups: the “hermeneutic” and the “functionalist” approach. The “hermeneutic” approach usually employs a qualitative scale, whereas the “functionalist” approach relies on precoded scales.¹⁰ The functionalist approach can be further divided into 2 categories: generic oral health and disease-/condition-specific measures.³ The generic oral health measures the impact of overall oral health, for instance, the Oral Health Impact Profile (OHIP).¹¹ The disease-/condition-specific measures assess the impact of specific oral diseases or conditions, for example, the Washington Head and Neck Cancer Questionnaire.¹²

The cognitive and linguistic differences amongst preschool children pose challenges in the development of the OHRQoL tool.¹³ Moreover, the childhood period is filled with changes. Not only can psychosocial awareness and physiological development change fast, but dental and facial features may as well, which requires a more appropriate theoretical and conceptual framework.¹⁴ Most of the OHRQoL tools for preschool children adopt proxy rating, but this also raised the argument about how well the reality experienced by a child can be reflected in proxy reports.¹⁵ Hence, as OHRQoL measurement has flourished, the debate and diversity have increased.⁷ A large number of OHRQoL tools have been developed for children in the last decade. Choosing an appropriate tool is important for researchers aiming to identify specific OHRQoL factors.¹⁶ However, there is a dearth of studies reviewing those tools. To the best of our knowledge, no systematic review has yet been published that is centred on OHRQoL assessment tools for preschool children. The assessment of OHRQoL in the child population was confined to the most frequently used tools.¹⁷ Thus, a review of the tools used for preschool children in assessing their OHRQoL is warranted. The aim of the present review is to systemically review the tools developed for evaluating OHRQoL in preschool children and to provide an overview of these tools in terms of tool characteristics, discriminative validation, and item configuration.

Methods

Guideline

The systematic review was reported by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.¹⁸

Search strategy

Although the problem/population, intervention, comparison, and outcome (PICO) framework can be adapted to develop research questions that related to prognosis or diagnosis, it is less suitable for other types of clinical information need.¹⁹ This study did not focus on a clinical problem. Therefore, the PICO was adapted accordingly as, “How the tools for evaluating OHRQoL (I) in preschool children (P) were developed or validated or culturally adapted (O) regarding their tool characteristics, discriminative validation, and item configuration (C)?” Two investigators (HHC and SSG) conducted a systematic search of publications with the key words “((preschool children OR preschool child OR young children OR young child OR early childhood) AND (oral health related quality of life OR OHRQoL))” in 4 English databases: PubMed, Embase, Scopus, and Web of Science. The limit of publication time was not set, and the last search was performed at the end of March 2020. A potentially eligible list was generated including all publications that contained the above key words and was used for the first screening of this review.

Selection of studies

The titles and abstracts of all publications in the potentially eligible list were screened manually. The inclusion criteria for this systematic review were English articles that developed or validated or culturally adapted a tool that can be used in measuring preschool children's OHRQoL. Duplicated articles were removed. Literature reviews, case reports, discussion papers, conference summaries, non-English articles, and other irrelevant studies were excluded. Cross-sectional surveys or clinical trials that investigated and reported the OHRQoL status in preschool children were excluded. The full text of the remaining publications was retrieved. Additional studies were identified through manual screening of the bibliography. Finally, eligible studies were selected for further analysis. Two investigators performed the screening separately. In case of decision discrepancies, they discussed these until reaching an agreement; if an agreement could not be reached, a third reviewer (CHC) would be involved. Cohen kappa statistic was performed to measure the agreement between the 2 reviewers.

Data collection and analysis

The included studies were grouped based on different tools. A list of tools for evaluating OHRQoL in preschool children was generated after grouping. The information regarding the basic characteristics of each tool was extracted into a table, including targeted age group, number of items, administration mode, languages in available versions, validated discriminable variables, and tool components. The OHRQoL tools were discussed separately according to the target population: tools tailored for preschool children and tools designed for a wider range of ages including preschool populations.

The Wilson and Clearly model was adopted for assessing the domains tested in different tools. All the items in the identified tools were grouped based on 4 common dimensions from the model, including oral health–related symptoms, function disturbance, environmental disturbance, and emotional/social disturbance to describe the conveyed attributes with respect to the construct intended to be measured. Items related to children and family are separately classified. The aim of assessment and target group of the tool was also recorded.

Results

Result of search

The systematic search yielded 2007 references and, after excluding of 567 duplicates, 1307 references were reviewed through title and abstract. After that, 1372 references were excluded as irrelevant records and 75 references were eligible for the full text reading, including 7 references identified by hand-searching bibliographies. The full text reading resulted in an exclusion of 12 references for different reasons. Finally, a total of 63 full-text articles were included in the review with 12 tools identified. The number of references found per tool ranged from 1 to 31. The flowchart of the search and selection process is shown in the Figure. The kappa value between 2 reviewers was calculated as 0.970.

Fig.

Flowchart of literature search.

Tools tailored for preschool children

There were 7 tools published between 2006 and 2017 which were tailored for application in preschool children only. The information regarding characteristics of identified tools is summarised in Table 1. The items included in the tools are listed in Table 2 based on dimensions in the Wilson and Clearly model, as well as the aim of assessment and target group.

Table 1.

Summary of the tools tailored for preschool children's oral health–related quality of life.

Tools	BRFQ	COHIP-PS	DDQ	ECOHIS	OH-ECQOL	POQL-PS	SOHO-5
Age group (years)	<5	2–5	2–5	3–5	2–5	3–5	5
No. of items	12	10	12	13	16	6	7 + 7 (for child)
Mode of administration	Proxy	Proxy	Proxy	Proxy	Proxy	Proxy	Proxy + self (for child)
Language [Reference no.]	English20	English21	English22	English23	English40	English42	English43
Language used in translated version [Reference no.]	–	–	–	Arabic24 Chinese25 Farsi26 French27 German28 Hindi29 Lithuanian30 Malagasy31 Malay32 Malayalam33 Nigerian Pidgin English34 Portuguese35 Spanish36 Spanish37 Spanish38 Turkish39	Manipuri41	–	Chinese44 Indonesian45 Portuguese46 Spanish47
Validated discriminable variables	–	Caries Cleft	Caries Toothache	Caries Dental need	Caries	Caries	Caries Dental sepsis Pulp involvement

BRFQ, Pediatric Oral Health Quality of Life Domain of Basic Research Factors Questionnaire; COHIP-PS, Child Oral Health Impact Profile, Preschool Version; DDQ, Dental Discomfort Questionnaire; ECOHIS, Early Childhood Oral Health Impact Scale; OH-ECQOL, Oral Health-Related Early Childhood Quality of Life; POQL-PS, Pediatric Oral Health-Related Quality of Life Preschool Version; SOHO-5, Scale of Oral Health Outcomes for 5-Year-Old Children.

Table 2.

Tool items for evaluating preschool children's oral health and related quality of life.

Tools	COHIP-PS	DDQ		ECOHIS		OH-ECQOL		POQL-PS	SOHO-5
Items related to children
Oral health–related symptoms	Oral facial pain Bleeding gums Discolored teeth	Oral facial pain	Oral facial pain		Pain Swelling Fever Bad breath Trapped food		Oral facial pain		–
Function disturbance	Eating Cleaning	Eating Cleaning	Eating Drinking Speech Sleep		Eating Cleaning Mouth breathing Sleep		Eating		Eating Drinking Speech Playing Sleep
Environmental disturbance	–	–	Missed school		Missed school		Missed school		–
Emotional/social disturbance	Self-confidence Anxiety Avoided smiling Happiness	Crying	Irritability Avoided smiling Avoided talking		Crying Irritability Informed about bad teeth		Crying Irritability Anxiety		Self-confidence Avoided smiling
Items related to children's family
Environmental disturbance	–	–	Financial burden Interfered work		Finance burden Interfered work		–		–
Emotional/social disturbance	–	–	Guilty feeling Being upset		Family conflict Anxiety		–		–
Aim of assessment and target group
Aim of assessment Target group	To measure oral health and related conditions Children	To predict toothache Children	To measure oral health and related quality of life Children and their families		To measure oral health and related quality of life North Indian Children		To measure oral health and related quality of life Children and parents from low-income or minority families		To measure oral health and related quality of life Children

COHIP-PS, Child Oral Health Impact Profile, Preschool Version; DDQ, Dental Discomfort Questionnaire; ECOHIS, Early Childhood Oral Health Impact Scale; OH-ECQOL, Oral Health-Related Early Childhood Quality of Life; POQL-PS, Pediatric Oral Health-Related Quality of Life Preschool Version; SOHO-5, Scale of Oral Health Outcomes for 5-Year-Old Children.

The Early Childhood Oral Health Impact Scale (ECOHIS), the Scale of Oral Health Outcomes for 5-Year-Old Children (SOHO-5), the Child Oral Health Impact Profile, Preschool Version (COHIP-PS), the Pediatric Oral Health-Related Quality of Life, Preschool Version (POQL-PS), and the Oral Health-Related Early Childhood Quality of Life (OH-ECQOL) are generic oral health scales assessing the impact of overall oral health, whereas the Dental Discomfort Questionnaire (DDQ) is a condition-specific scale designed to focus on dental pain. The Basic Research Factors Questionnaire (BRFQ), as a generic health measure, has been included in this review because it contains a specific domain for assessing preschool children's OHRQoL with 12 items, named the Pediatric Oral Health Quality of Life domain.

ECOHIS

Amongst the 7 tools tailored for preschool-aged children, ECOHIS is the one most widely used worldwide. This tool was developed originally in the US in 2007 and contains 13 items. The ECOHIS is answered by caregivers. The measurement aspects include impact on both children themselves and their family. ECOHIS has shown a good ability in distinguishing patients with dental caries. ECOHIS has also been applied in discriminating between with and without an expressed need for dental care.

SOHO-5

The SOHO-5 is the only tool that has both a child version and a parent version in all 7 tools tailored for application in preschool children. It was originally developed in the UK in 2012 and has been adapted into 4 other languages.41, 42, 43, 44 It has been validated and can distinguish participants with dental caries, dental sepsis, and pulp involvement. Most of the items in the child version and parent version are the same, except that the item “Affected self-confidence” in the parent version has been replaced by “Difficulty drinking” in the child version, as children at this age have not been proven to be able to report on their own circumstance in terms of these psychological aspects.

Other tools (BRFQ, DDQ, OH-ECQOL, POQL-PS)

BRFQ, DDQ, OH-ECQOL, POQL-PS were all developed using English. The number of items varied from 6 to 16. All of them used proxy administration methods. POQL-PS was developed with an emphasis on specific populations, and OH-ECQoL focussed on children in a North Indian population. Both of them have shown a validated discrimination power in patients with dental caries. DDQ is a condition-specific questionnaire aimed at predicting toothache in preverbal children through the items identifying toothache-related behaviours.⁴⁸ BRFQ is basically a measurement to assess potential predictors, and the Pediatric Oral Health Quality of Life domain of the BRFQ was designed for predicting toothache and assessing common factors related to early childhood caries.

Tools designed for child populations

For tools designed for a wider range of child populations, including preschool age strata, a total of 5 tools, developed between 2002 and 2018 in different English-speaking countries, were identified. The information regarding the characteristics of identified tools is summarised in Table 3. The items of each tool are listed in Table 4 based on dimensions in the Wilson and Clearly model, as well as the aim of assessment and target group.

Table 3.

Summary of the tools for children's oral health–related quality of life.

Tools	CARIES-QC	COHQOL	FHC—OHRQOL-Q	Michigan-OHRQoL	PedsQL OHS
Age group (years)	5–16	2–14	Intellectually disabled	4–16	2–18
No. of items	12 (for child)	45	41	10 + 13 (for child)	5 + 5 (for child)
Mode of administration	Self (for child)	Proxy	Proxy	Proxy + self (for child)	Proxy + self (for child)
Language [Reference no.]	English49	English50,51	English54	English56	English57
Language used in translated version [Reference no.]	–	Chinese52 Portuguese53	Spanish55	-	Portuguese58 Spanish59
Validated discriminable variables	Caries	Caries Cleft Malocclusion	–	Caries	Caries Child's oral health status

CARIES-QC, Caries Impacts and Experiences Questionnaire for Children; COHQOL, Child Oral Health Quality of Life Questionnaire; FHC—OHRQOL-Q, Franciscan Hospital for Children Oral Health-Related Quality of Life Questionnaire; Michigan-OHRQoL, Michigan Oral Health-Related Quality of Life Scale; PedsQL OHS, Pediatric Quality of Life Inventory Oral Health Scale.

Table 4.

Tool items for evaluating children's oral health and related quality of life.

Tools	CARIES-QC	COHQOL	FHC—OHRQOL-Q	Michigan-OHRQoL	PedsQL OHS
Items related to children
Oral health–related symptoms	Oral facial pain Trapped food	Oral facial pain Bleeding gums Mouth sores Bad breath Trapped food	Oral facial pain Bleeding gums Mouth sores Bad breath Broken teeth Dry mouth Mouth blisters Swelling	Oral facial pain Hypersensitive teeth	Oral facial pain Bleeding gums Discoloured teeth
Function disturbance	Eating Cleaning	Eating Drinking Sleep Speech Mouth breathing	Eating Sleep	Eating Sleep Playing	Eating Drinking
Environmental disturbance	Schoolwork	Missed school Attention in school	Missed school	Attention in school	–
Emotional/social disturbance	Crying Irritability Sleeping	Anxiety Personality Happiness Irritability Being bullied Avoided smiling Avoided talking Informed about bad teeth	Personality Irritability Being bullied Avoided smiling	Happiness Being bullied	–
Items related to children's family
Environmental disturbance	–	Financial burden Interference with work Family life Family conflict Parental attention to the child	Interference with work Family life	–	–
Emotional/social disturbance	–	Anxiety Personality Guilty feeling Being upset	Anxiety Social life Irritability	–	–
Aim of assessment and target group
Aim of assessment Target group	To measure caries-specific quality of life Children	To measure effects of oral and orofacial disorders Children and their families	To describe daily life problems and symptoms related to oral health Children with special health care needs and their families	To investigate the effects of early childhood caries on children's oral health-related quality of life Children	To evaluate the quality of life (with the PedsQL 4.0 Generic Core Scales and disease-specific modules) Children and adolescents

CARIES-QC, Caries Impacts and Experiences Questionnaire for Children; COHQOL, Child Oral Health Quality of Life Questionnaires; FHC—OHRQOL-Q, Franciscan Hospital for Children Oral Health-Related Quality of Life Questionnaire; Michigan-OHRQoL, Michigan Oral Health-Related Quality of Life Scale; PedsQL OHS, Pediatric Quality of Life Inventory Oral Health Scale.

The Michigan Oral Health-Related Quality of Life Scale (Michigan-OHRQoL), the Pediatric Quality of Life Inventory Oral Health Scale (PedsQL Oral Health Scale) and the Child Oral Health Quality of Life Questionnaire (COHQOL) are generic oral health measures, whereas the Caries Impacts and Experiences Questionnaire for Children (CARIES-QC) and the Franciscan Hospital for Children Oral Health-Related Quality of Life Questionnaire (FHC—OHRQOL-Q) are condition-specific measures designed for caries-specific QoL and children with special healthcare needs, respectively.

Child oral health quality of life questionnaire (COHQOL)

The Parental-Caregiver Perceptions Questionnaire (P-CPQ) and The Family Impact Scale (FIS) are two parts of the COHQoL questionnaire, with P-CPQ evaluating the impact on the child with 31 items and FIS assessing the impact on the family with 14 items.^50,51 P-CPQ and FIS were developed in Canada in 2002 used in 2–14-year-old children and have been adopted in other two languages. The discriminating ability of P-CPQ/FIS regarding caries-affected and caries-free participants has been demonstrated. The P-CPQ/FIS also showed good discrimination capacity in oral conditions of cleft and malocclusion.

Other tools (CARIES-QC, FHC—OHRQOL-Q, Michigan-OHRQoL, PedsQL Oral Health Scale)

The CARIES-QC was designed to measure OHRQoL specially affected by dental caries. The CARIES-QC only has a child version, to be reported by children aged 5 to 16 years old. Both the Michigan-OHRQoL and the PedsQL Oral Health Scale have a child version together with a guardian version. The Michigan-OHRQoL was originally developed to investigate the effect of early childhood caries on OHRQoL, whereas the PedsQL Oral Health Scale was intended to evaluate generic child oral health. The discrimination ability of these 2 tools regarding caries affected and caries-free participants has been demonstrated. The PedsQL Oral Health Scale only has 5 items and its use has been suggested in conjunction with the PedsQL Core Scales.⁵⁴ The FHC—OHRQOL-Q is a condition-specific tool designed for children with special health care needs. It contains 41 items, with 9 of them evaluating the impact on the family.

Discussion

This review provides information on the tools developed for evaluating OHRQoL in preschool children. A total of 12 tools were identified. Health care professionals should make an effort to choose the appropriate one to carry on the evaluation of OHRQoL rather than only using the most frequently used tools. Different research purposes and conditions can affect the choice of the optimum OHRQoL tool. Conversely, the pros and cons of the chosen tool can impact on the results and quality of the research.

Wilson and Clearly model

The present review applied the most widely tested and comprehensive conceptual model of HRQoL, namely the Wilson and Clearly model. This model explicitly explains the variables that have an influence on life quality.⁶⁰ The model was adopted in the OHRQoL area, and different OHRQoL measurements have been derived with following 5 common dimensions: oral health, functional, social/emotional, environmental, and treatment expectations.⁶ Amongst all 12 tools that have been identified, the dimension of “treatment expectations” in the Wilson and Clearly model was not mentioned in any of them.

A robust OHRQoL tool

Because of the specific characteristics and inherited problems of preschool children, there are many factors that need to be taken into consideration when developing an OHRQoL tool. To date, most of the existing tools are generic oral health measures. It may also be valuable to investigate the potential impact caused by one oral disease or the impacts on one specific population through a condition-specific tool. Some condition-specific tools can be a useful adjunct to a generic tool for assessing oral health or even general health.⁶¹ The theoretical basis of OHRQoL verifies the links between existing OHRQoL measures and biological, functional, and emotional characteristics of participants. These 3 aspects have been included in almost all identified tools. However, assessment related to treatment has not been attempted by any of the tools. In line with patient-centred care modes, the perceived need for dental treatment by caregivers is as crucial as clinical judgements. It is recommended that treatment-related assessment be incorporated into these tools.⁶²

The identified tools, other than COHIP-PS and Michigan-OHRQoL, focussed only on negative states and measured decrements in oral health, which may result in an underestimation of the impact of oral health and neglecting the improvement caused by successful treatments.⁶³ Referring back to the concept of health, a health state goes far beyond merely getting rid of negative state. Even the answers to questions indicating an absence of negative behaviours do not necessarily mean a positive state. Furthermore, it is believed that a negative and positive state can coexist.⁶⁴ Thus, by enquiring about positive dimensions, more of the participant's experience as well as the impact on their QoL can be captured.

Selection of an OHRQoL tool

COHRQoL is a complex and subjective concept to measure. None of the existing tools contains an entire spectrum of variables underlying COHRQoL.³ To choose a suitable tool, it is crucial to understand the initial purpose of the development and its pros and cons. First, researchers should choose a tool that corresponds with the target population.⁶⁵ Even within the preschool age group, tools specific for one age generation, such as SOHO-5, exist. Second, the chosen tool should comply with the purpose of the measurement. Condition-specific tools can be used in clinical trials in assessing the effects caused by specific oral conditions, whereas generic oral health tools are suitable for application in population-based surveys. Moreover, besides proxy administration modes, self-reporting can be included to obtain a deeper insight into the impact on oral health.⁴³ Researchers should understand the discriminative ability of different measures under different circumstances to achieve the intended study situation. It is also vital to make sure that the tool is validated in the native language. If not, testing of the reliability and validity, as well as verifying the suitability of application in the local population, is necessary before application. Finally, the number of items in a tool should be in an acceptable range for respondents and still be able to reflect the metric properties the research intended to measure.⁷

Study limitations

There are limitations that need to be addressed. First, this study did not focus on a clinical problem. It is less suitable to use PICO as the framework to formulate a research question. Moreover, the quality of identified tools and the development are not included in the outcome of the present review. Risk of bias assessment was not performed. Second, it is possible that other tools, not included in this review, exist. However, in order to maximise avoidance of it, a sensitive search strategy was applied, together with manually screening of the bibliography.

Conclusions

This review identified 12 tools applicable in evaluating preschool children's OHRQoL. However, none of them can be regarded as a comprehensive tool due to the subjective and multidimensional nature of the OHRQoL concept. No consensus was available for the development of a OHRQoL tool. Each tool has its own qualities to suit the intended aim of the research. The selection of the evaluation tools should consider several criteria including the target age group, the administration mode, the specific conditions or disease, and the psychometric properties of the tool.

Author contributions

Conceptualisation: HHC and SSG. Resources: HHC, SSG, and KJC. Writing—original draft preparation: HHC, SSG, and CHC. Writing—review and editing: KJC and DD. Supervision: ECML and CHC. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by General Research Fund No. 17100421.

Conflict of interest

None disclosed.