Abstract
Introduction
Hidradenitis suppurativa (HS) is a chronic inflammatory disorder affecting the pilosebaceous unit in intertriginous body areas, and recent research suggests an association with periodontitis.
Aim
To assess oral health-related quality of life (OHRQoL) in patients with HS diagnosed additionally with periodontitis and to compare it to patients with periodontitis alone.
Material and methods
The study involved 55 HS patients, with 25 in the HS + P group (both HS and periodontitis) and matched controls in the periodontitis-only group (P group). Outcomes were assessed using the Oral Health Impact Profile (OHIP-14) questionnaire.
Results
No significant difference was observed in the mean OHIP-14 total score between the HS + P group and the P group. Patients with HS + P were less likely to undergo the dental evaluation and floss their teeth less frequently compared to the P group.
Conclusions
The findings reveal that the coexistence of HS in patients with periodontitis does not significantly influence OHRQoL. Lower dental evaluation frequency and less frequent flossing in HS+P patients suggest reduced attention to oral health practices.
Keywords: hidradenitis suppurativa, periodontitis, oral health-related quality of life
Introduction
Periodontitis is a chronic, inflammatory disease that leads to tissue damage in the periodontal ligament and alveolar bone, possibly resulting in the loss of the affected tooth. The pathogenesis of the disorder is multifactorial and involves complex dynamic interlinkages among dental biofilm, excessive host immune responses, and environmental factors such as smoking [1]. Noteworthy, periodontal status has been reported to be worse in patients with other immune-mediated inflammatory diseases as compared to healthy controls [2–5].
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition defined by recurrent nodules, abscesses, and draining tunnels occurring predominantly in the intertriginous body regions [6]. Characteristic HS lesions commonly lead to scar formation and functional impairment [7]. The prevalence of HS varies between 0.00033% and 4.1% with a female/male ratio of 3 : 1 [8, 9]. The onset of the disease ranges from puberty to the fourth decade of life [6]. The pathogenesis of HS is not fully elucidated. Follicular occlusion is thought to initiate the disease process, trapping bacteria within the pilosebaceous unit. The rupture of the hair follicles activates the innate immune system and results in chronic tissue inflammation [10].
A recent study demonstrated a correlation between HS and the periodontal disease. HS individuals had a significantly higher prevalence of periodontitis and periodontal pathogens than controls [11].
Aim
This study aimed to assess oral health-related quality of life (OHRQoL) via the Oral Health Impact Profile 14 (OHIP-14) questionnaire in patients with HS diagnosed additionally with periodontitis and to compare it to patients with periodontitis alone.
Material and methods
Study group
The study was conducted between December 2021 and May 2022. Individuals with HS were recruited at the Department of Dermatology, Venereology, and Allergology of the Wroclaw University Hospital. A total of 55 patients with HS were evaluated for the presence of periodontitis. Among 55 HS individuals, 25 patients were diagnosed with periodontal disease and those were enlisted in the study (HS + P group). An equal number of controls (healthy individuals diagnosed with periodontitis) was matched with HS subjects regarding age and gender (P group). The exclusion criteria for this investigation were as follows: being under the age of 18, pregnancy, breastfeeding, presence of any other systemic diseases, and concomitant cognitive or psychiatric disorders, which may influence the OHIP response. Before the study commenced, all patients gave their written and informed consent to participate.
Quality of life assessment
For assessing OHRQoL, the validated Polish version of the OHIP-14 questionnaire was used [12]. This tool encapsulates 14 items organised into seven domains: functional limitation, physical discomfort, psychological discomfort, physical disability, psychological disability, social disability, and handicap. A standardized value was assigned for each response on the Likert scale ranging from 0 to 4: score 0 – never, score 1 point – hardly ever, score 2 points – occasionally, score 3 points – fairly often, score 4 points – very often. The OHIP-14 total score is the sum of such ratings from the 14 questions, with a maximum score of 56 points. Higher scores of OHIP-14 correspond to worse OHRQoL [13].
Oral evaluation
To reduce evaluation biases, a standardized periodontal examination was conducted in all patients by a single examiner from the Department of Periodontology, Wroclaw Medical University. The dentist used the UNC 15 calibrated periodontal probe to evaluate the condition of the periodontal tissue and assess the presence and severity of periodontal disease. A complete periodontal inspection using probing depth and attachment loss evaluation was performed. The diagnosis of periodontitis was established according to the new classification and case definition of periodontitis revised in 2018. The current study defined periodontitis as the presence of interdental clinical attachment loss (CAL) at two or more non-adjacent teeth or the presence of buccal or oral CAL no less than 3 mm with pocketing more than 3 mm at two or more teeth [13]. The severity of the disease and the complexity of its management were evaluated with the use of the staging: stage I (initial periodontitis), stage II (moderate periodontitis), stages III and IV (severe periodontitis), and the progression rate of the periodontal disease was evaluated with the use of the grading: grade A (slow), grade B (moderate) and grade C (rapid rate of progression) [1]. In addition, oral health self-care behaviours (the rate of dental evaluation, brushing, toothbrush replacement and flossing) were assessed for each subject.
Dermatological evaluation
A single examiner from the Department of Dermatology, Venereology and Allergology of Wroclaw University Hospital evaluated all subjects in the study from the dermatological point of view. Patients diagnosed with HS without any other concomitant cutaneous or systemic disorders were enlisted in the HS group. The HS severity stage was assessed using the Hurley staging system and the International Hidradenitis Suppurativa Severity Score System (IHS4) [14, 15]. Disease severity bands for IHS4 have been established as follows: mild (≤ 3 points), moderate (> 3 and ≤ 10 points), and severe HS (> 10 points) [14, 15].
Statistical analysis
The statistical analysis of the results was performed using IBM SPSS Statistics version 27 software (SPSS INC., Chicago, USA). The data underwent examination for parametric or non-parametric distribution, and calculations were made for the minimum, maximum, mean, and standard deviation values. Quantitative variables, depending on their distribution, were evaluated either through the t-Student test (normal data) or Mann-Whitney U test (non-normal), while the χ2 test was employed for qualitative data. Correlations were assessed with Spearman and Pearson correlations depending on the data distribution. For the comparison of more than two groups, the ANOVA test or Kruskal-Wallis one-way analysis of variance on ranks were used. All multiple comparisons were adjusted using the Bonferroni correction. A two-sided p-value of ≤ 0.05 was considered statistically significant.
Results
Participants’ characteristics
The study groups’ characteristics (demographic data, periodontal status, and oral healthcare habits) are presented in Table 1.
Table 1.
Patients’ characteristics
| Variable | HS + P group (n = 25) | P group (n = 25) | P-value |
|---|---|---|---|
| General characteristics: | |||
| Age [years] mean ± SD (range) | 40.68 ±10.91 (21–63) | 46.36 ±14.53 (25–74) | NS |
| Sex (female) n (%) | 10 (40.0) | 12 (48.0) | NS |
| Periodontal status: | |||
| Staging of periodontitis: | NS | ||
| Stage I | 2 (8.0%) | 5 (20.0%) | |
| Stage II | 10 (40.0%) | 6 (24.0%) | |
| Stage III | 7 (28.0%) | 8 (32.0%) | |
| Stage IV | 6 (24.0%) | 6 (24.0%) | |
| Grading of periodontitis: | NS | ||
| Grade A | 6 (24.0%) | 5 (20.0%) | |
| Grade B | 2 (8.0%) | 10 (40.0%) | |
| Grade C | 17 (68.0%) | 10 (40.0%) | |
| Oral healthcare habits: | |||
| Dental evaluation (number per year) mean ± SD | 2.59 ±3.63 | 3.64 ±2.27 | 0.01 |
| Brushing (number per day) mean ± SD | 1.76 ±0.52 | 2.32 ±0.85 | NS |
| Toothbrush replacement (number per year) mean ± SD) | 6.68 ±6.02 | 6.44 ±4.80 | NS |
| Flossing (number per day) mean ± SD | 0.24 ±0.44 | 0.56 ±0.51 | 0.021 |
HS – hidradenitis suppurativa, P – periodontitis, SD – standard deviation, NS – not statistically significant.
A comparable age and gender structure was found in both groups. Oral health evaluation revealed no significant difference in the staging and grading of periodontitis between HS + P patients and P individuals. Patients with HS + P were less likely to undergo the dental evaluation and floss their teeth less frequently compared to the P group (p = 0.01, p = 0.021, respectively).
The severity of the HS in the majority of individuals (16 patients, 64.0%) was assessed as Hurley stage II, in 7 individuals (28.0%) as Hurley stage I, and in 2 individuals (8.0%) as Hurley stage III. As for IHS4, 8 (32.0%) patients presented with mild HS, 8 (32.0%) patients presented with moderate HS, and 9 (36.0%) patients presented with severe HS. The mean IHS4 score in the HS group was calculated as 12.52 points.
Oral health-related quality of life
The comparative analysis of questionnaire scores between the two study groups is detailed in Table 2. In summary, no significant difference was observed in the mean OHIP-14 total score between the HS + P group and the P group. This implies that patients affected by HS did not experience worse OHRQoL. Specifically, the OHIP-14 subscale health domain scores were also not significantly different in both groups. Noteworthy, HS severity assessed both with Hurley and IHS4 scales revealed no correlation with OHRQoL, as measured by the OHIP-14 questionnaire (detailed data not shown).
Table 2.
Comparison of OHIP-14 Score between the HS + P and P group
| OHIP-14 domains | OHIP-14, mean ± SD | P-value | |
|---|---|---|---|
| HS + P group | P group | ||
| Functional limitation | 0.88 ±1.36 | 0.40 ±0.71 | NS |
| Pain | 2.36 ±1.71 | 2.32 ±1.63 | NS |
| Discomfort | 3.80 ±1.94 | 4.00 ±2.12 | NS |
| Physical disability | 1.64 ±1.66 | 1.68 ±1.95 | NS |
| Psychological disability | 2.56 ±1.71 | 2.48 ±2.29 | NS |
| Social disability | 1.76 ±1.42 | 1.72 ±1.84 | NS |
| Handicap | 1.52 ±1.81 | 1.84 ±2.32 | NS |
| Total OHIP-14 score | 14.52 ±8.71 | 14.44 ±9.98 | NS |
HS – hidradenitis suppurativa, P – periodontitis, SD – standard deviation, NS – not statistically significant.
Discussion
Many studies have examined the impact of oral problems on the quality of life of patients with systemic diseases [16, 17]. OHRQoL was observed to be poorer among cardiovascular patients, attributed to oral issues such as xerostomia as well as increased plaque, gingival, and sulcular bleeding indices [18]. Patients with rheumatic diseases exhibited diminished OHRQoL, with several differences between the entities. Specifically, those diagnosed with rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, ankylosing spondylitis, and psoriatic arthritis demonstrated higher OHIP-14 sum scores compared to the average score in the healthy population. In contrast, individuals with vasculitis exhibited a total OHIP-14 score within the reference range, representing unaffected OHRQoL [19]. The OHIP-14 scores in individuals with chronic kidney disease showed a significant correlation with the estimated glomerular filtration rate (eGFR) stage. Patients at more advanced disease stages, indicated by higher eGFR stages, manifested poorer OHRQoL [20].
Recent findings showed a positive correlation between HS and worse periodontal health. HS exhibited a heightened prevalence of periodontitis in comparison to the rates observed in healthy subjects. Nevertheless, the exact interlinkages of HS with periodontitis are not elucidated [11]. Remarkably, as indicated by the findings of this study, the existence of HS in individuals with periodontitis showed no discernible effect on the OHRQoL score. Additionally, the evaluation of HS severity, conducted through both the Hurley and IHS4 scales, demonstrated no significant correlation with the sum score of the OHIP-14, indicating that the extent of HS severity, as measured by these scales, did not appear to have a notable impact on the overall OHRQoL assessed by the OHIP-14. While HS appears to be linked to the development of periodontitis, there seems to be no correlation between the severity of HS and OHRQoL. In the present study, the sole disparities we observed point to lower frequencies of dental evaluations and flossing among HS patients in comparison to the control group. This observation may suggest that individuals with HS tend to exhibit reduced attention to their oral health practices, potentially reflecting a lower level of oral healthcare engagement within this specific population.
This study was conducted within the limitations of a cross-sectional design. The absence of follow-up examinations precludes an assessment of the long-term impact of HS on periodontal status and OHRQoL. The relatively low number of individuals with HS included in the study is another limitation; therefore, our study should be regarded as a pilot study for further investigation.
Conclusions
The presence of HS in patients with periodontitis does not influence OHRQoL. Nevertheless, considering the chronic nature of HS, longitudinal cohort studies with long-term follow-up should be performed to observe the overall trend in OHRQoL among HS individuals.
Funding Statement
Funding This study was funded by the Research Grant from Wroclaw Medical University (number: SUBZ.B050.22.066).
Ethical approval
The study protocol complies with the Declaration of Helsinki and was accepted by the local ethical committee (consent no. 919/2021).
Conflict of interest
The authors declare no conflict of interest.
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