Oral Health and Quality of Life of Addicts in Brazilian Population

INTRODUCTION

One in every 20 adults between the ages of 15 years and 64 years (over a quarter of a billion) have used at least one illicit drug in 2014.¹ Consequentially, there is a significant burden on public health systems where health care and prevention of drug addiction is concerned.¹

Drug addicts have far worse oral health compared to that of the general population.^2–4 Addicts tend to allocate lower priority to their oral hygiene; their primary concern is to supply their drug dependence.⁵ Unsatisfactory oral health is usually reported by individuals with substance dependence.²

It is important to account for patient outcome measures because of the importance of knowing an individual’s outlook of their own general and oral health statuses.⁶ This plays a role in public health, enabling direct health strategies to provide for treatment and rehabilitation. Such data are obtained based on oral health-related quality of life (OHRQoL) through so-called sociodental indicators.⁷ In this context, the short version of the Oral Health Impact Profile (OHIP-14) estimates the negative consequences of oral disorders and relates them to quality of life through the evaluation of discomfort, dysfunction, and disability that stem from these disorders.⁸ This instrument has already been implemented recently in research on drug addiction.^9,10

Other relevant factors, such as, age,¹¹ demographic factors,¹² and use of freebase cocaine, have been shown to influence OHRQoL. Oral health conditions, such as, tooth loss,^11,13 periodontitis,^14,15 edentulism,¹⁶ and the use and type of dentures¹⁶ confer negative impacts on OHRQoL. Additionally, the use of the OHIP-14 in different populations has shown that socioeconomic conditions,^17,18 tooth loss,¹⁵ and caries (decayed, missing, and filled teeth—DMFT index scores)¹⁹ are significantly associated with the impact.

Despite the number of investigations regarding OHRQoL, there is a paucity of information regarding the oral health of drug addicts and the impact this has on their quality of life. Understanding the OHRQoL of these often-marginalized individuals could be useful for the planning and implementation of public health policies for these populations.

Therefore, this study aimed to investigate the impact of OHRQoL of drug addicts in rehabilitation at two locations in the state of Paraná, Brazil.

MATERIALS AND METHODS

RESULTS

The mean age of the participants was 35 ± 9.6 years, and they were predominantly white (63.6%), single (75.9%), with <8 years of education (68.6%), employed (61.3%), and with a household income of more than one monthly minimum wage (57.7%). The most common drug used among those listed in the study was tobacco (83.2%), closely followed by a crack (81.2%).

Table 1 shows the mean severity scores and prevalence for each item of the OHIP-14. The mean severity score of the sample was 22.8 (SD = 13.2). The prevalence of negative impact in the sample was 84.9%. The items that had the greatest prevalence of impact were psychological discomfort and psychological disability (69.1 and 61.1%, respectively). Within these categories, the questions that had the most impact were “Have you been self-conscious because of your teeth or mouth?” (63.3%) and “Have you been a bit embarrassed because of problems with your teeth or mouth?” (58.0%). Meanwhile, social disability (73.4%) and functional limitation (68.5%) had the most reports with the absence of impact.

Table 2 shows the DMFT scores and components associated with worse self-perception of impact. The values for missing teeth with presence of impact were statistically significant [n = 338, 4.5 (SD = 5.5), p = 0.027]. The mean DMFT score was 11.7 (SD = 6.8), which was also statistically significant (p = 0.013).

In univariate analysis, the independent variables that were associated with the presence of impact were %3C;8 years of schooling (p = 0,028), no teeth brushing habits (p = 0.034), self-perceived metallic taste (p < 0.001), tooth mobility/loss (p = 0.020), use of LSD (p = 0.059) and oxy (p = 0.007), and DMFT score %3E;10 (p = 0.016) (Table 3). The variables that were significant in univariate analysis were included in multivariate regression. At this stage, the variables that were independently associated with worse impact were <8 years of education (p = 0.021) and self-perceived metallic taste (p < 0.001) (Table 4).

DISCUSSION

This study investigated the OHRQoL of institutionalized drug addicts in southern Brazil. Low schooling and a self-perceived metallic taste in the mouth were independently associated with worse impact.

The OHIP-14, the instrument selected herein, has been previously used in the search to evaluate the OHRQoL of subjects in different populations,^{11,13–15,17,18,24–26} including in drug addicts.^9,10,27 It is translated and validated for Brazilian Portuguese²¹ and its psychometric properties have also been investigated.²²

Knowing that higher OHIP-14 scores indicate worse OHRQoL,⁸ the mean score obtained in this study (22.8) was considered to be substantially high. In a study of drug users from Amsterdam, the sample presented a higher mean OHIP-14 score (40.6)²⁷ than that in this study. In addition, in severely addicted patients in the same city who participated in a study to evaluate the effect of dental treatment on OHRQoL, the mean total score of the impact was 37.1.⁹

In the general adult population, the values are not so impactful, such as in adults from the United Kingdom (UK) (5.1) Australia (7.4),¹¹ and the United States of America (USA) (2.81).²⁵ The prevalence of impact in this study (84.9%) was also considerably greater than those obtained in the USA (15.3%),²⁴ Australia (15.7%) (25), and the UK (15.9%).²⁴ Considering other Brazilian studies, the severity and prevalence in this study were also higher than those obtained in rural Amazon residents (14.03 and 70.3%, respectively),²⁶ adults from São Paulo (10.21 and 48.1%, respectively),¹³ and elderly individuals from southern Brazil (9.1 and 47.7%, respectively).²⁴ Although comparisons are being made with the general population, it is notable that the values in Brazilian samples surpass those in samples of other countries. These results illustrate how perceptions of oral health are subjective and related to certain habits, such as, substance abuse. It is well known that drug usage confers a negative impact on the quality of life,²⁷ as confirmed in this study, and this could be attributed to the significant association of tooth mobility/loss and a self-perceived metallic taste in the mouth with the presence of impact, as identified in this study.

Of the seven dimensions included in the OHIP-14, those that had the greatest impact in this study were psychological discomfort and disability, followed by physical pain. Similarly, a study performed on drug addicts in Amsterdam also revealed the highest prevalence of impact in these subcategories. Therefore, drug addicts primarily report adverse psychological impacts of oral health on their quality of life. Antoniazzi et al.,¹⁰ based on domain analysis, concluded that functional limitation and psychological discomfort were associated with the use of illicit drugs in young adults.

Regarding sociodemographic and socioeconomic factors, a study that evaluated the OHRQoL of Brazilian drug addicts with a similar mean age (37 years)²⁸ did not reveal significant associations between low schooling and outcomes. However, Antoniazzi et al.¹⁰ investigated the impact of the use of crack and other illicit drugs on OHRQoL in 106 young adults at a public treatment center. The authors examined dental caries and periodontal disease, and the outcome was the OHIP-14. In the analysis, after adjustments for sex, age, education level, income, smoking habits, dental caries, and periodontal disease, the outcomes did not change. Another investigation about the association between denture status, demographic factors, and OHRQoL revealed that age and education level did not influence outcomes.¹² In contrast, in the present study, low schooling (<8 years) was associated with a worse perception of the impact, even independently in the multivariate analysis.

In Iranian drug addicts, low educational levels are significantly associated with poor oral hygiene.⁵ In the present study, no teeth brushing showed an association with the presence of impact in univariate analysis, however, when adjusted for multivariate analysis it was not significant. It is possible to deduce that low schooling affects OHRQoL because they are related to poor oral health habits. For example, there are indications in the literature that the mother’s level of education is associated with a higher frequency of toothbrushing.²⁹

Studies performed in the general population have shown that tooth loss is significantly associated with an impact on OHRQoL.^11,13,15,23 Based on the findings of this study, tooth loss also impacted the OHRQoL of drug addicts.

Individuals who experienced a metallic taste in the mouth (dysgeusia) were more likely to have worse OHRQoL. This is comprehensive, as taste is an essential component of an individual’s general sense of well-being and quality of life.³⁰ Common causes of dysgeusia are dental appliances, such as, dental fillings and prostheses; dental procedures, such as, root canals treatments and extractions; aging; medication; and oral infections, such as, periodontitis.³¹ These are plausible motives to explain the association found in drug addicts, especially medication and periodontitis. Some medications that have been demonstrated to be associated with dysgeusia are antidepressants and antimanic drugs,^30,31 which are commonly administered in rehabilitation treatment. It is also possible that periodontitis, for example, an infected periodontal pocket, could cause the self-perceived metallic taste, even though periodontal evaluation was not performed in this study. It has been demonstrated that periodontitis exerts an influence on OHRQoL.^14,15

Regarding caries experience, DMFT is considered a predictor for OHRQoL.¹⁹ A cross-sectional study of users of specific substances evaluated the impact of oral health conditions and socioeconomic status on quality of life, and the authors found a mean DMFT index score of 13.0,²⁸ higher than that found in the present study (11.7). Another DMFT score of addicts found in the literature was 9.8.⁴ In this analysis, the mean DMFT score was statistically significant in univariate analysis. Cury et al.,³ based on the findings of a sample of 40 men who were addicted to crack/cocaine, concluded that the addiction was associated with a greater decayed teeth index score and lower filled and missing teeth index scores.

While the results of this study present significant findings regarding the OHRQoL of drug addicts, some limitations should be considered. Due to the transversal study design, the associations determined cannot be considered as causative factors.

Results should not be extrapolated to the entire population, gender was a limitation of the study carried out only in men. Additionally, as the OHIP-14 is based on self-reported responses, the results may be susceptible to social desirability and memory biases. However, the design of this study allowed for insight into the OHRQoL of drug addicts. This is an area that has not yet been explored to great extent in the current literature, despite the growing problem that substance abuse poses for public health, as it affects millions of individuals both directly and indirectly causing health, societal, and economic consequences.

CONCLUSION

The findings of this study showed that low schooling and self-perceived metallic taste were independently associated with worse OHRQoL of drug addicts. Therefore, public health strategies for the rehabilitation of these individuals should account for the biopsychosocial aspect of drug addicts, aim to reduce inequity, and include dental treatment as a part of the health care offered to drug addicts under rehabilitation.

CLINICAL SIGNIFICANCE

Drug addicts have poor oral health and quality of life. Thus, public health strategies for the rehabilitation of these individuals should account for the biopsychosocial aspects.

ACKNOWLEDGMENTS

The authors wish to express gratitude to the hospitals San Julian Association and Institute for Research and Treatment of Alcoholism (IPTA) for their collaboration. This study was supported by the Araucária Foundation through grants 568/2014 and 322/2014.

REFERENCES

1. United Nations Office on Drugs and Crime. World Drug Report 2015.;Vienna: United Nations Office on Drugs and Crime https://www.unodc.org/documents/wdr2015/World_Drug_Report_2015.pdf; 2015; [accessed 30 July 2018].

2. D’Amore MM, Cheng DM, Kressin NR, et al. Oral health of substance-dependent individuals: impact of specific substances. J Subst Abuse Treat 2011;41(2):179–185 DOI: 10.1016/j.jsat.2011.02.005.

3. Cury PR, Oliveira MG, de Andrade KM, et al. Dental health status in crack/cocaine-addicted men: a cross-sectional study. Environ Sci Pollut Res Int 2017;24(8):7585–7590 DOI: 10.1007/s11356-017-8404-z.

4. Sordi MB, Massochin RC, Camargo AR, et al. Oral health assessment for users of marijuana and cocaine/crack substances. Braz Oral Res 2017;31(0):e102 DOI: 10.1590/1807-3107bor-2017.vol31.0102.

5. Shekarchizadeh H, Khami MR, Mohebbi SZ, et al. Oral health behavior of drug addicts in withdrawal treatment. BMC Oral Health 2013;13(1):1 DOI: 10.1186/1472-6831-13-11.

6. Locker D, Quiñonez C. To what extent do oral disorders compromise the quality of life? Community Dent Oral Epidemiol 2011;39(1):3–11 DOI: 10.1111/j.1600-0528.2010.00597.x.

7. Reisine ST. Theoretical considerations in formulating sociodental indicators. Soc Sci Med 1981;15(6):745–750 DOI: 10.1016/0271-7123(81)90018-3.

8. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25(4):284–290 DOI: 10.1111/j.1600-0528.1997.tb00941.x.

9. van Wijk AJ, Molendijk G, Verrips GHW. OHRQoL in a sample of alcohol and drug abusers. Open Dent J 2016;10(1):338–346 DOI: 10.2174/1874210601610010338.

10. Antoniazzi RP, Zanatta FB, Ardenghi TM, et al. The use of crack and other illicit drugs impacts oral health-related quality of life in Brazilians. Oral Dis 2018;24(3):482–488 DOI: 10.1111/odi.12786.

11. Steele JG, Sanders AE, Slade GD, et al. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two national samples. Community Dent Oral Epidemiol 2004;32(2):107–114 DOI: 10.1111/j.0301-5661.2004.00131.x.

12. John MT, Koepsell TD, Hujoel P, et al. Demographic factors, denture status and oral health‐related quality of life. Community Dent Oral Epidemiol 2004;32(2):125–132 DOI: 10.1111/j.0301-5661.2004.00144.x.

13. Batista MJ, Lawrence HP, De Sousa MDLR. Impact of tooth loss related to number and position on oral health quality of life among adults. Health Qual Life Outcomes 2014;12(1):1–10 DOI: 10.1186/s12955-014-0165-5.

14. Palma PV, Caetano PL, Leite ICG. Impact of periodontal diseases on health-related quality of life of users of the Brazilian unified health system. Int J Dent 2013;2013150357 DOI: 10.1155/2013/150357.

15. Llanos AH, Silva CGB, Ichimura KT, et al. Impact of aggressive periodontitis and chronic periodontitis on oral health-related quality of life. Braz Oral Res 2018;32(0):e006 DOI: 10.1590/1807-3107bor-2018.vol32.0006.

16. AlZarea BK. Oral health related quality-of-life outcomes of partially edentulous patients treated with implant-supported single crowns or fixed partial dentures. J Clin Exp Dent 2017;9(5):e666–e671 DOI: 10.4317/jced.53661.

17. Colussi PR, Hugo FN, Muniz FW, et al. Oral health-related quality of life and associated factors in Brazilian adolescents. Braz Dent J 2017;28(1):113–120 DOI: 10.1590/0103-6440201701098.

18. Gabardo MCL, Moysés ST, Moysés SJ. Autopercepção de saúde bucal conforme o Perfil de Impacto da Saúde Bucal (OHIP) e fatores associados: revisão sistemática. Rev Pan Salud Pública 2013;33(6):439–445.

19. Vigu AL, Stanciu D, Lotrean LM, et al. Complex interrelations between self-reported oral health attitudes and behaviors, the oral health status, and oral health-related quality of life. Patient Prefer Adherence 2018;12539–549 DOI: 10.2147/PPA.S159621.

20. World Health Organization. Oral Health Surveys, Basic Methods.Geneva: World Health Organization; 2013;.

21. Almeida AA, Loureiro CA, Araujo VE. Um estudo transcultural de valores de saúde bucal utilizando o instrumento OHIP-14 (oral health impact profile) na forma simplificada. Parte I: adaptação cultural e linguística. UFES Rev Odontol 2004;6(1):6–15.

22. Oliveira BH, Nadanovsky P. Psychometric properties of the Brazilian version of the oral health impact profile-short form. Community Dent Oral Epidemiol 2005;33(4):307–314 DOI: 10.1111/j.1600-0528.2005.00225.x.

23. Slade GD, Spencer AJ, Locker D, et al. Variations in the social impact of oral conditions among older adults in South Australia, Ontario, and North Carolina. J Dent Res 1996;75(7):1439–1450 DOI: 10.1177/00220345960750070301.

24. Slade GD, Nuttall N, Sanders AE, et al. Impacts of oral disorders in the United Kingdom and Australia. Brit Dent J 2005;198(8):489–493 DOI: 10.1038/sj.bdj.4812252.

25. Sanders AE, Slade GD, Lim S, et al. Impact of oral disease on quality of life in the US and Australian populations. Community Dent Oral Epidemiol 2009;37(2):171–181 DOI: 10.1111/j.1600-0528.2008.00457.x.

26. Cohen-Carneiro F, Rebelo MA, Souza-Santos R, et al. Psychometric properties of the OHIP-14 and prevalence and severity of oral health impacts in a rural riverine population in Amazonas state, Brazil. Cad Saude Publica 2010;26(6):1122–1130 DOI: 10.1590/S0102-311X2010000600006.

27. Van Wijk AJ, Verrips GH, Kieffer JM, et al. Quality of life related to oral health among addicts. Ned Tijdschr Tandheelkd 2011;118(4):219–221 DOI: 10.5177/ntvt.2011.04.10258.

28. Marques TC, Sarracini KL, Cortellazzi KL, et al. The impact of oral health conditions, socioeconomic status and use of specific substances on quality of life of addicted persons. BMC Oral Health 2015;15(1):38 DOI: 10.1186/s12903-015-0016-8.

29. Casanova-Rosado JF, Vallejos-Sánchez AA, Minaya-Sánchez M, et al. Frequency of tooth brushing and associated factors in Mexican schoolchildren six to nine years of age. West Indian Med J 2013;62(1):68–72.

30. Naik BS, Shetty N, Maben EVS. Drug-induced taste disorders. Eur J Intern Med 2010;21(3):240–243 DOI: 10.1016/j.ejim.2010.01.017.

31. Bromley S. Smell and taste disorders: a primary care approach. Am Fam Physician 2000;61(2):427–436.