STANDARDIZATION OF DENTAL PATIENT-REPORTED OUTCOMES MEASUREMENT USING OHIP-5 – VALIDATION OF “RECOMMENDATIONS FOR USE AND SCORING OF ORAL HEALTH IMPACT PROFILE VERSIONS”

Abstract

Background

Recently, “Recommendations for use and scoring of Oral Health Impact Profile versions” (here abbreviated as Recommendations Project) were proposed by an international group of oral health researchers to standardize assessment of perceived oral health. They recommended a four-dimensional measurement approach consisting of Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact as the set of dental patient-reported outcomes to be measured with the 5-item Oral Health Impact Profile (OHIP-5).

Aim

This study aimed to validate the “Recommendations for use and scoring of Oral Health Impact Profile versions” by replicating the findings they are based on.

Methods

OHIP data came from the “Dimensions of OHRQoL Project.” Its Validation Sample (5,022 prosthodontic patients and general population subjects) as well as its Additional Sample (N = 583 prosthodontic patients and general population subjects) were used. Validation of the Recommendations Project’s findings was performed in two steps. First, correlations among OHIP versions presented in the Recommendations Project were replicated in the Validation Sample. Second, participants of the Additional Sample were subjected to a hypothetical treatment program that assigned two treatments to them according to their level of perceived oral health impact using OHIP versions. The performance of abbreviated OHIP versions was evaluated.

Results

The high correlations among summary scores of 5-, 14-, 19-, and 49-item OHIP versions (r = 0.91–0.98), found in the Recommendations Project, were replicated. All short OHIP versions performed similarly when classifying participants for a hypothetical tailored treatment program.

Conclusions

Findings reported in “Recommendations for use and scoring of Oral Health Impact Profile versions” were validated, thus supporting the feasibility of a standardized assessment of perceived oral health in all settings across all oral diseases. Psychometrically solid and practical assessment can be performed with OHIP-5.

BACKGROUND

Dental patients seek care for current oral health problems or for prevention of such problems in the future. They seek care for improving impaired oral functions (such as chewing and talking), reducing orofacial pain, improving orofacial appearance, or decreasing the psychosocial impact from oral diseases. ¹ Dental patient-reported outcomes (dPROs) capture these problems that matter to dental patients and are, therefore, needed to determine which treatments are most effective from patients’ perspectives. ² dPROs thus provide foundations for evidence-based dentistry, ^{3, 4} value-based oral health care, ⁵ and effective dentist-patient communication. ⁶

Overall, use of dPROs has steadily increased over time, ⁷ but not consistently across all fields. On one hand, for the management of dental and orofacial pains, the “voice of the patient” was always the corner stone for diagnosis and treatment. ⁸ On the other hand, while the significance of the mouth in old age has long been acknowledged, ⁹ successful aging in the oral health context still largely focused on physiological status and rarely on psychosocial aspects.

Two recent systematic reviews identified 20 oral health-generic ¹⁰ and 34 oral disease-specific questionnaires to measure oral disease impact in adult dental patients. ¹¹ In fact, there were even more tools available to assess dPROs when included questionnaires’ abbreviated and disease-specific versions were considered. For example, the Oral Health Impact Profile (OHIP) ¹² has a version that is specific to edentulous subjects. ¹³ Abbreviated versions with 5 ¹⁴ or 14 ¹⁵ items also exist, to name a few. In conclusion, interest in capturing the patient’s oral health perspective has resulted in a plethora of measurement options.

The two earlier mentioned systematic reviews also found that four attributes, called “dimensions of oral health-related quality of life (OHRQoL)”¹⁶ (Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact), were the dPROs that were assessed by all identified multi-item dental patient reported outcome measures (dPROMs). ^{10, 11} While these results were derived in adult dental patients, findings for pediatric dental patients were very similar. ¹⁷

Clearly, a potential to consolidate and standardize currently available multi-item dPROMs into a smaller number of instruments is apparent when all these instruments essentially assess only four attributes. Instruments that have different versions, such as the OHIP, would especially benefit from a synthesis of instrument content. In addition, current dPROMs’ methodological heterogeneity unnecessarily limits their comparability and combinability, for example, through the existence of different types of rating scales. ¹⁸ In the standardization process, these shortcomings can be addressed to strengthen the potential for research synthesis of studies using these measures. Even more important is the applicability of these measures in regular dental practice. ¹⁹ dPRO application needs to be feasible for all dental patients and all oral health care providers. ²⁰

Given the need for dPRO standardization, “Recommendation for use and scoring of Oral Health Impact Profile versions” (the terms Recommendations Project ²¹ or Recommendations ²¹ will be used henceforth) have been proposed to reduce the number of dPROMs and to strengthen the feasibility of their application across all oral conditions and settings. ²¹

The Recommendations ²¹ proposed the 5-item OHIP as a psychometrically sound tool to assess the four OHRQoL dimensions as well as the overall patient-perceived impact. OHIP-5 can be applied pragmatically not only in research settings but also in general dental practice due to the low burden of collecting and interpreting the data. To further support the Recommendations, ²¹ the findings that led to them should be replicated.

Aim

This study aimed to validate the “Recommendations for use and scoring of Oral Health Impact Profile versions” by replicating the findings they are based on.

METHODS

Overview of the “Recommendations for Use and Scoring of Oral Health Impact Profile Versions” Project

In the Recommendations Project ²¹ an international group of oral health researchers assessed how well different versions of OHIP (5 items, ^{14, 22} 14 items, ¹⁵ 19 items, ¹³ 20 items, ²³) measured the overall construct of OHRQoL and its four dimensions. They analyzed de-identified data from the previously conducted “Dimensions of OHRQoL (DOQ) Project.” Several correlations were computed in the DOQ’s Learning Sample (5,173 prosthodontic patients and general population subjects with 49-item OHIP data): ²⁴

• correlations among OHIP versions’ summary scores,

• correlations between OHRQoL dimensions’ scores and OHIP versions’ domain scores, and

• correlations between OHRQoL dimensions’ scores and OHIP-5 s items.

The Recommendations Project’s ²¹ results indicated that summary scores of 5-, 14-, 19- and 49-item versions correlated highly (r = 0.91–0.98), suggesting similar OHRQoL construct measurement across the versions. OHRQoL dimensions - Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact - were best measured by OHIP-14, −19, and −49’s domain scores for Physical Disability, Physical Pain, Psychological Discomfort, and Handicap, respectively. OHIP-5 s items assessed these four dimensions directly.

Based on these findings, recommendations for using and scoring OHIP versions were derived and a four-dimensional measurement approach for perceived oral health that can be implemented in all settings across all oral health conditions with the 5-item OHIP was advocated. ²¹

Overview About Studied OHIP Versions

A brief description of OHIP versions (Table 1) is provided here to facilitate understanding their differences:

Table 1.

49-, 20-, 19-, 14- and 5-item OHIPs’ domain and dimensional structure.

OHIP item	OHIP Domain	49 items	20 items	19 items	14 items	5 items	Dimension according to factor-analytic studies24,25
							Oral Function	Orofacial Pain	Orofacial Appearance	Psychosocial Impact
1. Difficulty chewing	Functional Limitation (FL)	X	X	X		X	X
2. Trouble pronouncing words	FL	X	X		X		X
3. Noticed tooth which doesn’t look right	FL	X							X
4. Appearance affected	FL	X							X
5. Breath stale	FL	X
6. Taste worse		X			X		X
7. Food catching	FL	X	X	X
8. Digestion worse	FL	X
9. Denture not fitting	FL	X	X	X
10. Painful aching	Physical Pain (PP)	X	X	X	X	X		X
11. Sore jaw	PP	X						X
12. Headaches	PP	X						X
13. Sensitive teeth	PP	X						X
14. Toothache	PP	X						X
15. Painful gums	PP	X						X
16. Uncomfortable to eat	PP	X	X	X	X		X
17. Sore spots	PP	X	X	X				X
18. Uncomfortable dentures	PP	X	X	X
19. Worried	Psychological Discomfort (PhyDis)	X	X	X					X
20. Self-conscious	PhyDis	X	X	X	X				X
21. Miserable	PhyDis	X
22. Uncomfortable about appearance	PhyDis	X				X			X
23. Tense	PhyDis	X			X					X
24. Speech unclear	Physical Disability (PD)	X					X
25. Others misunderstood	PD	X					X
26. Less flavor in food	PD	X				X	X
27. Unable to brush teeth	PD	X
28. Avoid eating	PD	X	X	X			X
29. Diet unsatisfactory	PD	X			X		X
30. Unable to eat with dentures	PD	X	X	X
31. Avoid smiling	PD	X							X
32. Interrupt meals	PD	X	X	X	X		X
33. Sleep interrupted	Psychological Disability (PD)	X								X
34. Upset	PD	X	X	X						X
35. Difficult to relax	PD	X			X					X
36. Depressed	PD	X								X
37. Concentration affected	PD	X								X
38. Been embarrassed	PD	X	X	X	X					X
39. Avoid going out	Social Disability (SD)	X	X	X						X
40. Less tolerant of others	SD	X	X	X						X
41. Trouble getting on with others	SD	X								X
42. Irritable with others	SD	X	X	X	X					X
43. Difficulty doing)obs	SD	X			X	X				X
44. Health worsened	Handicap (H)	X								X
45. Financial loss	H	X								X
46. Unable to enjoy people's company	H	X	X	X						X
47. Life unsatisfying	H	X	X	X	X					X
48. Unable to function	H	X			X					X
49. Unable to work	H	X								X

1. OHIP-49: The original OHIP is a 49-item instrument. ¹² Items are grouped into seven domains: Functional Limitation (9 items), Physical Pain (9 items), Psychological Discomfort (5 items), Physical Disability (9 items), Psychological Disability (6 items), Social Disability (5 items), and Handicap (6 items). For each of the 49 OHIP questions, subjects’ rate on an ordinal scale (0 “never,” 1 “hardly ever,” 2 “occasionally,” 3 “fairly often,” 4 “very often”) how frequently they have experienced a specific oral health impact.

2. OHIP-19: An OHIP version specifically adapted for edentulous subjects (OHIP-Edent) has 19 items ¹³ : Functional Limitation (3 items), Physical Pain (4 items), Psychological Discomfort (2 items), Physical Disability (3 items), Psychological Disability (2 items), Social Disability (3 items), and Handicap (2 items). A 20-item version, ²³ also for edentulous subjects, is very similar to the 19-item version, but the Functional Limitation domain contains 4 instead of 3 items. Because of this similarity, analyses for OHIP-20 are omitted in this study.

3. OHIP-14: The most widely used OHIP version has 14 items with 2 items for each of the seven domains. ¹⁵

4. OHIP-5: The shortest OHIP version has 5 items. ¹⁴ Contrary to the 49-, 20-, 19-, and 14-item OHIP versions, OHIP-5 does not categorize items into a set of seven domains. OHIP-5 was designed to capture 90% of the information contained in the OHIP-49 summary score with a minimum number of items. Because OHRQoL information in OHIP is contained in the dimensions Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact, OHIP-5 contains one item for each of these four dimensions together with a second item for Oral Function. The items “chewing difficulty” or “felt less flavor in food,” “painful aching,” “uncomfortable about appearance,” and “difficulty doing usual jobs” are, from a conceptual point of view, single-item measures for the dimensions of Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact, respectively.

OHIP-49, −20, −19 and −14 have seven domain scores and one summary score. OHIP-5 has four dimension scores and one summary score.

Study Design and Data

“Single studies, whether they pursue novel ends or confront existing expectations, never definitively confirm or disconfirm theories.”²⁶ The Recommendations ²¹ were based on one study, and even though the study was large and study participants represented important target populations for OHRQoL assessment, corroborating the findings that led to the recommendations is necessary to advance their credibility.

Consequently, the present replication study, defined as “a study that is an independent repetition of an earlier, published study, using sufficiently similar methods (along the appropriate dimensions) and conducted under sufficiently similar circumstances,”²⁷ was initiated. Two parts can be differentiated:

1. The Recommendations Project’s ²¹ main findings were replicated using the DOQ Project’s Validation Sample ²⁸ (N = 5,022 prosthodontic patients and general population subjects.)

2. OHRQoL application in a typical clinical setting was investigated, providing evidence of the utility of the Recommendations. ²¹

A typical application for OHRQoL scores is clinical decision-making. Based on the score magnitude, different treatments could be tailored to patients with a particular oral disease. For example, for TMD patients suffering more from the condition, that is, having high OHIP scores, a multimodal treatment strategy, that is, several treatments are applied simultaneously or consecutively, may be indicated. For TMD patients suffering less from the condition, that is, having low OHIP scores, a unimodal treatment may be sufficient. Consequently, patients with high scores (“high impact”) need to be separated from the remaining patients (“typical impact”) to receive multimodal treatment. When OHIP short-form scores are used to assign multimodal treatments to patients, misclassification occurs compared to using the long OHIP-49 instrument that could be considered the standard tool. Some patients assigned to multimodal treatment based on their OHIP-49 scores would wrongly receive unimodal treatment according to the short-form scores. False assignment of multimodal treatment by short OHIP also occurs. The misclassification errors in replacing longer with shorter OHIP versions would be informative for OHIP short forms’ utility for clinical decision-making.

Data Analyses

Validation Step 1: Replication of Previously Presented Results

Recommendations Project’s ²¹ correlations among OHIP versions’ summary scores and between dimensions scores, on the one hand, and domain scores or OHIP-5 items, on the other hand, will be replicated using independent data. How these correlations were computed in the Recommendations Project ²¹ is reproduced here.

• 1It was studied how well the overall OHRQoL construct (represented by the sum of all OHIP items) with different OHIP versions was measured when shorter instead of longer versions were used.

Pearson correlation coefficients among all OHIP summary scores were computed.

• 2It was studied how well the OHRQoL dimensions were captured by OHIP versions with 49, 20, 19, 14, and 5 items (OHRQoL dimensions Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact were represented by sum scores of the 10, 7, 6, and 18 OHIP items, respectively, that formed these dimensions in factor analyses). ^{24, 25}

Pearson correlation coefficients between all OHIP domains (OHIP-49, −19, −14) and OHRQoL dimensions were computed. In addition, Pearson correlation coefficients between all OHIP-5 items and OHRQoL dimensions were computed.

Validation Step 2: Assessment of the Short Forms’ Clinical Utility

The 583 subjects of the DOQ Project’s Additional Sample ²⁸ would undergo a hypothetical tailored treatment program to investigate OHIP short forms’ utility. Twenty-five percent of patients with the highest OHIP scores would receive multimodal treatment and the remaining 75% would receive unimodal treatment. OHIP versions’ classification of “high” and “typical” impact patients are compared.

All OHIP versions’ summary scores were dichotomized to classify each of the 583 subjects as belonging to the “high” or “typical” impact group. Dichotomized scores would then be cross-tabulated for each of the six OHIP version pairs (49 vs 19, 49 vs 14, 49 vs 5, 19 vs 14, 19 vs 5, 14 vs 5.) A 2 by 2 cross-tabulation derived four numbers:

1. the proportion of patients identified with both OHIP versions as needing multimodal treatment (= multimodal treatment agreement)

2. the proportion of patients identified with both OHIP versions as needing unimodal treatment (= unimodal treatment agreement)

3. the proportion of patients identified by one OHIP version as needing multimodal treatment and by the other OHIP version as needing unimodal treatment

4. the proportion of patients identified by one OHIP version as needing unimodal treatment and by the other OHIP version as needing multimodal treatment

These four numbers will be graphically presented for all six OHIP version pairs.

RESULTS

Replication of Correlation Results

Correlations Between OHIP Version Summary Scores

The 49-, 19-, 14- and 5-item versions correlated linearly and very highly (Figure 1). Summary scores between the six version pairs correlated from r = 0.91 to 0.98 (Table 2) being identical to those correlations found in the Recommendations Project. ²¹ All OHIP versions measured OHRQoL equally well. OHIP scores were practically interchangeable.

Figure 1.

Graphical presentation of correlations between OHIP summary scores with different numbers of items for 5,022 prosthodontic patients and general population subjects.

Table 2.

Correlations between OHIP summary scores with different number of items for 5,022 prosthodontic patients and general population subjects.

Correlation matrix		OHIP version
		49	19	14
OHIP version	19	0.98	−	−
	14	0.97	0.96	−
	5	0.93	0.93	0.91

Correlations Between OHIP Domain and OHRQoL Dimension Scores

Except for one out of the 12 correlations (the three instruments OHIP-19, −14, and −5 measure each 4 dimensions) that formed the pattern of domain-dimension relationships (Table 3), results were identical to the previously reported pattern. ²¹ The exception was OHIP-14’s domain Functional Limitation. The domain was minimally higher correlated with Oral Function (r = 0.85) than the domain Physical Disability was with Oral Function (r = 0.84) – a difference considered trivial.

Table 3.

Correlations between OHIP-49, −19, and −14 domain scores and OHRQoL dimension scores (expected correlation pattern shaded, highest correlation per OHRQoL dimension in bold).

OHIP version with domainsa	OHRQoL dimensionb
	Oral Function	Orofacial Pain	Orofacial Appearance	Psychosocial Impact
OHIP-49
Functional Limitation [9 items]	0.87	0.70	0.83	0.82
Physical Pain [9 items]	0.76	0.98	0.70	0.73
Psychological Discomfort [5 items]	0.74	0.67	0.92	0.78
Physical Disability [9 items]	0.96	0.65	0.74	0.83
Psychological Disability [6 items]	0.74	0.62	0.70	0.85
Social Disability [5 items]	0.66	0.52	0.56	0.85
Handicap [6 items]	0.71	0.56	0.61	0.92
OHIP-19
Functional Limitation [3 items]	0.79	0.63	0.66	0.69
Physical Pain [4 items]	0.81	0.85	0.68	0.77
Psychological Discomfort [2 items]	0.67	0.63	0.91	0.68
Physical Disability [3 items]	0.88	0.58	0.63	0.69
Psychological Disability [2 items]	0.69	0.58	0.72	0.74
Social Disability [3 items]	0.64	0.51	0.55	0.80
Handicap [2 items]	0.66	0.49	0.59	0.84
OHIP-14
Functional Limitation [2 items]	0.85	0.51	0.56	0.67
Physical Pain [2 items]	0.78	0.80	0.66	0.68
Psychological Discomfort [2 items]	0.71	0.62	0.82	0.74
Physical Disability [2 items]	0.84	0.59	0.61	0.73
Psychological Disability [2 items]	0.68	0.55	0.68	0.78
Social Disability [2 items]	0.61	0.50	0.50	0.81
Handicap [2 items]	0.63	0.48	0.53	0.83

^asee Table 1 which items form the domains.

^bsee Table 1 which items form the dimensions.

Differences between correlations observed here and previously reported results ²¹ were not larger than 0.01 for three quarter of the 84 correlations shown in Table 3. The largest observed difference was 0.03.

Overall, across OHIP-49, −19, and −14 (Table 3) a pattern was observed:

• The dimension Oral Function was best measured by Physical Disability domain scores.

• The dimension Orofacial Pain was best measured by Physical Pain domain scores.

• The dimension Orofacial Appearance was best measured by Psychological Discomfort domain scores.

• The dimension Psychosocial Impact was best measured by Handicap domain scores.

For OHIP-5 items, the pattern of item-dimension relationships (Table 4) was identical to the previous reported pattern. ²¹ Differences between correlations observed here and reported previously ²¹ were not larger than 0.02 for the 16 correlations.

Table 4.

Correlations between OHIP-5 scores and OHRQoL dimension scores (expected correlation pattern shaded, highest correlation per OHRQoL dimension in bold).

OHIP-5 item*	OHRQoL dimensiona
	Oral Function	Orofacial Pain	Orofacial Appearance	Psychosocial Impact
Difficulty chewing any foods	0.79	0.58	0.61	0.61
Painful aching in your mouth	0.57	0.80	0.52	0.55
Felt uncomfortable about the appearance of teeth, mouth, or dentures	0.63	0.54	0.86	0.66
Difficulty doing your usual jobs	0.58	0.45	0.45	0.74

^*OHIP-5 item “felt less flavor in food” is also a measure of Oral Function but is omitted here.

^asee Table 1 which items form the dimensions.

Classification of Subjects for a Hypothetical Tailored Treatment Strategy

When short OHIP versions are used to assign unimodal or multimodal treatments to patients according to their level of OHRQoL impairment, shorter OHIP versions performed well classifying the patients.

Figure 2, Panel A illustrates this. As defined in the hypothetical tailored treatment program, for each 100 patients participating, 75 patients would receive unimodal treatment and 25 would receive multimodal treatment as determined by OHIP-49 scores. When OHIP-19 scores would be used instead, 73 of the 75 patients would also receive unimodal treatment and 21 of the 25 patients would also receive multimodal treatment. Two errors would occur. Two of the 75 patients would receive a multimodal instead of a unimodal treatment, and 4 of the 25 patients would receive a unimodal instead of a multimodal treatment.

Figure 2.

Pairwise comparisons of dichotomized OHIP-49, −19, −14, and −5 scores to classify 583 subjects for a hypothetical tailored treatment program according to their “high” or “typical” perceived oral health impact – Percentages represent the four cell entries of 2 by 2 cross-tabulations for two OHIP versions based on a 25–75% split of OHIP scores.

Overall, the proportion of correctly identified subjects by the short forms varied from 97% (23% + 74%), when OHIP-49 and OHIP-14 were used (Figure 2, Panel B), to 91% when OHIP-5 was compared to OHIP-49 (Figure 2, Panel C) or to OHIP-14 (Figure 2, Panel F).

Between 3% (1% + 2%) of the patients, when OHIP-49 and OHIP-14 were used (Figure 2, Panel B), to 9% (3% + 6%), when the two shortest OHIP versions were compared (Figure 2, Panel F), would be misclassified.

DISCUSSION

In this study, findings from the Recommendations Project ²¹ were validated. In a first validation step, previously reported correlation findings were replicated. In a second validation step, in a hypothetical clinical scenario, OHIP-5′s clinical utility was demonstrated.

OHIP-19, an instrument that claims to be disease-specific for edentulous subjects, is an OHIP with 19 items without disease-specific characteristics, suggesting it could also be used for other oral conditions and, vice versa, other OHIPs can be used for edentulous subjects. This instrument and OHIP-20, a minimally different dPROM, were considered equivalent because of the information overlap.

Echoing the previous Recommendations Project’s21 guidance to standardize oral health impact measurement, OHIP-5, a practical instrument for research and dental practice that is able to replace longer OHIP versions, is recommended.

Comparison With the Literature

OHIP-5 was developed to explain 90% of the variance of OHIP-49 scores, representing a correlation of 0.95 between scores.14 In analyses to replicate findings, a correlation between OHIP-5 and OHIP-49 of r = 0.94 was observed in 163 German general population subjects and r = 0.91 was observed in 175 German TMD patients ¹⁴ - values very close to r = 0.93 previously ²¹ and reported here. It is remarkable how consistent findings in many international studies across very different settings were. For example, in 245 Dutch TMD patients “Correlations between summary scores of the OHIP-NL [the 49-item version], OHIP-NL14 and OHIP-NL5 were all high and above 0.90”²⁹– the criterion used in this study for interchangeable scores. In 239 Japanese dental patients, OHIP-5 correlated 0.92 with OHIP-49, ³⁰ exactly the same value as in a very different population–1,309 adult subjects from the Swedish general population. ³¹ The Spanish- language OHIP-5 correlated with the 14- as well as the 49-item version with r = 0.95 in 331 Spanish-speaking dental patients in a US health care setting. ³² While not all OHIP-5 versions were compared with longer versions, factor analytic methods, investigating OHIP-5 s structural validity, provided consistent results across Arabic, ³³ English-language, ²² Chinese, ³⁴ and Persian ³⁵ versions, supporting the short version’s validity through a different methodological approach.

The high correlations among OHIP versions translated into misclassification errors that are acceptable in many clinical settings where categorized OHIP scores could be used for clinical decision-making. When OHIP short-form scores were previously categorized, for example, into 10 groups to create normative values, findings were consistent across abbreviated OHIPs ³⁶ – a finding that is in line with results observed in this study.

Strengths and Limitations of the Validation Project

It is a strength that findings are based on 35 individual studies contained in the Dimension of OHRQoL Project, representing a large and diverse pool of international prosthodontic patients and general population subjects from six countries.

While the hypothetical tailored treatment scenario used a different sample of subject than the correlation analyses – a methodological strength – the cut off of what is considered “high” perceived oral health impact is setting-specific, that is, depends on the patient population and applied treatments. In the current study, a statistical criterion, that is, the quarter of subjects with the highest scores, was used to illustrate principles.

Conclusion

Perceived oral health needs to be placed in context. Together with clinical measures, dPROMs can be part of core outcomes sets to complementarily describe oral health using a bio-psycho-social model of disease. ³⁷ Combined with cost indicators of treatment, the value of dental interventions can be characterized. ¹⁹ The validated “Recommendations for use and scoring of Oral Health Impact Profile versions”²¹ provide a robust four-dimensional measurement strategy for the assessment of perceived oral health. Therefore, OHIP-5 is the core metric suggested for future studies ³⁸ in the project “Mapping Oral Disease Impact with a Common Metric.”³⁹ This project aims to provide four-dimensional oral health impact information in adults ^40–43 and children. ⁴⁴ Four OHRQoL scores, describing Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact, accompanied by an instrument summary score, describing the entire OHRQoL construct, offer a standardized assessment of perceived oral health in all research and clinical practice settings.