Dental Patient-reported Outcomes Research Articles

The Potential Role of Dental Patient-Reported Outcomes (dPROs) in Evidence-Based Prosthodontics and Clinical Care: A Narrative Review.

Oral health problems are associated with poor quality of life, with the potential to cause functional, aesthetic, nutritional, and psychological difficulties, in addition to pain and suffering. Traditionally, dental treatment outcomes are measured using purely clinical parameters; however, this may be ineffective as these parameters cannot adequately capture the full impact of poor oral health on the patient, or their respective coping strategies. From this perspective, there are significant benefits when the patient’s perception of their care is considered, and included in treatment planning and delivery. The impacts perceived by the patient on their treatment outcomes can be measured using patient-reported outcomes (PROS), or more specifically with dPROS, focused on dental patient-reported outcomes. Although there are some instruments available for measuring these outcomes in clinical trials, very little information is available for explaining the context in which these outcomes are considered, and also how to capture this information using appropriate instruments, specially in evidence-based dental practice. This article aims to review the literature, seeking to describe what has been considered about assessing patient’s outcomes, as well as how to measure them, and explore the potential benefits of using dPROS in evidence-based prosthodontics and clinical care of partially and fully edentulous patients.

Should the frequency, severity, or both response scales be used for multi-item dental patient-reported outcome measures?

BackgroundThe Oral Impacts on Daily Performances (OIDP) index asks the respondents to indicate both, the frequency and severity of the impact. However, it is not clear if the two scaling methods are correlated, and if using one scale is sufficient. The purpose of the study was to investigate the correlation between frequency and severity rating scales of the OIDP instrument, and whether only one of the rating scales can be used instead of both.MethodsA battery of patient-reported outcome questionnaires were administered to a consecutive sample of adult dental patients from HealthPartners dental clinics in Minnesota (N = 2,115). Only those who responded to any of the OIDP items were included in the analysis for this study (N = 873). We assessed correlations between the frequency and severity scales for all OIDP items, and for the summary scores of the two OIDP response scales. We additionally fit a categorical structural equation model (SEM) (or an item factor analysis model) and examined the correlation between two latent variables (Frequency and Severity).ResultsThe correlation estimates for all OIDP items were greater than 0.50, indicating large correlations between the frequency and severity scores for each OIDP item. The correlation estimate between the two summary scores was 0.85 (95% CI [0.82–0.86]). When we calculated the correlation coefficient using a latent variable model, the value increased to 0.96 (95% CI [0.93–1.00]).ConclusionOur study findings show that OIDP frequency and severity scores are highly correlated, which indicates the use of one scale only. Based on previous evidence, we recommend applying the frequency rating scale only in research and clinical settings.

Clinical performance of hydrophilic, titanium‐zirconium dental implants in patients with well‐controlled and poorly controlled type 2 diabetes: One‐year results of a dual‐center cohort study

This study assessed the clinical performance of hydrophilic dental implants in a patient cohort with type 2 diabetes mellitus (T2DM). Subjects with T2DM of ≥2-years duration were allocated to either the well-controlled (WC; HbA1c ≤ 7.0%,) or poorly-controlled (PC; 7.5<HbA1c<10%) groups in a dual-center, prospective cohort study. Each subject received a single, titanium-zirconium (Ti-Zr) dental implant with a chemically-modified, hydrophilic (modSLA) surface in a posterior mandibular site. Postoperatively, subjects were followed at 1, 2, 4, 8, and 12-week intervals. Post-loading, subjects were followed at 3, 6, and 12-months. Clinical and radiographic parameters of implant success, and dental patient-reported outcomes were collected. Twenty-one dental patients (NWC =11; NPC =10; mean age: 66.8 ± 7.5 years) were enrolled and the 1-year implant success rate was 100%. Peri-implant bone levels were stable with 0.15 ± 0.06mm mean marginal loss at 1 year without significant inter-group differences (P=0.79). Postoperative pain was minimal at 1-week, and OHIP-5 scores decreased significantly over time as compared with preoperative levels (P<0.001) suggesting significant improvement in patient-perceived oral health following implant therapy. Elevated HbA1c levels>7.5% did not compromise 1-year success rates, or oral health-related quality of life in PC patients receiving modSLA, Ti-Zr implants. Given that implant placement up to 10% HbA1c significantly enhanced oral health-related quality of life without complications or morbidity, the safety and efficacy of implants to improve oral function in T2DM is supported, even without ideal glycemic control.

ROLE OF LIBRARIANS AND INFORMATION PROFESSIONALS IN IDENTIFYING dPROS IN THE EVIDENCE.

While dental patient-reported outcomes provide important insight to why patients seek oral health care, finding research literature on these outcomes as well as measures for dental patient-reported outcomes is quite difficult due to a lack of standardization in both indexing terms as well as reporting practices. This results in these outcomes and measures often being underutilized. Librarians and information professionals are experts in navigating and managing research literature. Additionally, librarians are powerful collaborators for evidence-based practice, and can provide support for research methodology design and reporting. This article explores how partnering with librarians and information professionals can benefit clinicians and researchers to further the utilization of dental patient-reported outcomes in patient care.

CORE OUTCOME SETS AND DENTAL PATIENT REPORTED OUTCOMES.

In clinical research, outcomes are the results or 'endpoints' that are measured to assess whether clinical interventions have been successful or whether one treatment works better than another. There are a vast number of outcomes that have been reported in dental trials; the number, diversity and questionable relevance of these outcomes can lead to research wastage. Ultimately, this can lead to uncertainty for patients and dental professionals as to the most effective prevention and treatment options available as the evidence available may not use outcomes important to them. This article introduces the reader to core outcome sets (COS), covering the background to this area of research; their purpose and role; as well as the methodology of development. The authors reflect on their experience of leading the development of a core outcome set for periodontal trials and we highlight other dental COSs already developed and their inclusion of dental Patient Reported Outcomes (dPROs).

DENTAL THERAPY AND DENTAL PATIENT-REPORTED OUTCOMES (dPROs).

Dental therapy was introduced into the dental team as an advanced practice provider with the intention to increase access to care while providing high quality care in a cost-effective manner. It is essential that the dental therapist is able to provide patient-centered care to minimize patients' suffering. In order to assess patients' suffering, it is critical to understand the impact of care and dental patient-reported outcomes (dPROs). The use of dPROs in evidence-based clinical practice can assess the impact that the advanced practice provider has in dentistry. The presence of dPROs in evidence-based clinical practice will show the equivalence and differences in impact of the dental therapist and dentist. Currently, there is limited research regarding the use of dPROs in dental therapy. A roadmap in this paper demonstrates possible ways to collect dPROs in dental therapy and advance evidence-based dental practice. Recommendations in ways to achieve the roadmap, possible research designs, and expansion in knowledge of dental therapy and dPROs are provided. It is important to explore the advanced practice provider and the possibilities in evidence-based dentistry with the usage of dPROs.

USING DENTAL PATIENT-REPORTED OUTCOMES (dPROs) IN META-ANALYSES: A SCOPING REVIEW AND METHODOLOGICAL INVESTIGATION.

Many studies use dental patient-reported outcomes (dPROs) to evaluate treatments and interventions. However, the consensus on the methodology for combining results of dPROs for meta-analysis has not yet been fully established or widely discussed. The aim of this study is to conduct a scoping review for the methodological issues and difficulties specific to meta-analysis of dPROs and to put forward recommendations for improving quality of meta-analyses of dPRO. We searched the Google Scholar and PubMed databases and identified meta-analysis with dPROs in English. A total of 22 meta-analyses were included in our scoping review, and their characteristics, such as reported outcomes, questionnaires, and effect measures, were extracted. We identified several methodological issues within current literature: (1) synthesizing results from studies with different rating scales; (2) meta-analyses with few studies; (3) the interpretation of standardized mean difference; (4) including studies of different cut-off values in a meta-analysis; and (5) systematic errors due to different instruments. According to each issue mentioned, we provided guidance and recommendations on how to resolve those issues, including using the same Likert scale, conducting an overall and subgroup meta-analysis, using a random-effects model in a meta-analysis, etc. More efforts are required to improve the conduct and interpretation of meta-analyses on dPROs.

PATIENT-REPORTED OUTCOME MEASURES FOR PEDIATRIC DENTAL PATIENTS: A METHODOLOGICAL REVIEW AND MAPPING EXERCISE.

The most important dental patient-reported outcome (dPRO) is oral health-related quality of life (OHRQoL) which was commonly based on the following four dimensions: Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact. However, until now, analyses linking dPROSs to the four dimensions have only been done in adults. We therefore examined if the existing dental patient-reported outcome measures (dPROMS) for pediatric patients could also be mapped to these four domains. We performed a literature search to identify generic dPROMs administered in children and adolescents. Two researchers independently assessed titles, abstracts and full texts and extracted pediatric dPROMs and items. dPROM items were then mapped to the four OHRQoL dimensions. We identified 701 articles. After abstract screening, 118 articles were reviewed in full text. Fifteen articles met the inclusion criteria. Twelve instruments were identified, including 6 modified versions of the questionnaires. All questionnaires and their included items could be mapped to the four dimensions. In some cases, items were linked to two dimensions. The four OHRQoL dimensions (Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact) are also applicable for existing dPROMs in pediatric dental patients. These dimensions should therefore be considered when measuring OHRQoL in children and adolescents in future studies.

THE VOICE OF THE PATIENT IN OROFACIAL PAIN MANAGEMENT.

As pain cannot be measured objectively, the use of patient reported outcomes (PROs), and specifically dental PROs (dPROs), is essential for adequate assessment and management of the patient with orofacial pain. For orofacial pain conditions, some of the suitable PROs are specific to dentistry and hence can be labelled dPROs, whereas others are not. There is also a need to understand which outcomes and domains are most relevant to the patient with pain complaints within the context of the biopsychosocial model. Acute pain in the orofacial area is most often related to toothache, whereas the most common chronic orofacial pain are temporomandibular disorders. Other chronic pains in the orofacial area include neuropathic pain and unknown or idiopathic pain. PROs have been fundamental in the development of both screening procedures and diagnostic criteria in temporomandibular disorders. PROs are now often a prerequisite for the most common temporomandibular disorder pain diagnoses. Furthermore, PROs form the basis for decision-making with regard to treatment, prognostics, and referrals. Future areas of development include the standardized use of PROs in the screening and diagnostics of the less common orofacial pain conditions, together with development of core outcomes sets and standardized protocols for the use of PROs in evaluation of treatment including efficacy, compliance, adherence, and side-effects.

Dental Patient-Reported Outcomes Update 2021

Patients' needs and preferences have long been one of the three essential elements of evidence-based dentistry. However, in most areas of dental research, the voices of dental patients have been overlooked, resulting in findings with limited value for dental practice and a high level of avoidable research waste. Previous studies have shown that the appropriate use of dental patient-reported outcomes (dPROs) is essential for dental research to fully reflect the impact of oral diseases or oral health care on patients and to directly support dentist-patient communication. Therefore, the Journal of Evidence-Based Dental Practice decided to put together this Special Issue, to further promote the wide use of dPROs and to provide novel insights into the measurement and analytical methods for dPROs. This article briefly introduces the manuscripts contained in this issue, which cover a wide range of topics: standardization of dPRO-related methodology; current usage of dPROs in published research; significance and relevance of dPROs usage; identification of dPROs in the evidence; as well as dPROs and value-based oral health care.

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

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). 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. 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. 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. 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.

Including the patient's oral health perspective in evidence-based decision-making.

How to approach the assessment of patient-perceived oral health is of fundamental importance for the evaluation of clinical and public health interventions because the patient's assessment should be used as an adjunct to objective dental findings in order to decide which interventions work. This review article aims to provide an overview of the principles, current status, and future outlook for how a patient's oral health perception can and should be assessed. The hierarchical position of dental patient-reported outcomes, oral health-related quality of life (OHRQoL), and dental patient-reported outcome measures within the hierarchical concepts of quality of life and its component, health-related quality of life, is presented. The Mapping Oral Disease Impact with aCommon Metric project is outlined as an international effort to describe current approaches to standardize the measurement of oral impact using the four OHRQoL dimensions of oral function, orofacial pain, orofacial appearance, and psychosocial impact. Ultimately, these four dimensions of OHRQoL provide apractical and psychometrically solid way to collect and analyze OHRQoL data for all oral diseases in all settings, and eventually for all treatments through the use of astandardized, universal measurement tool. This universal impact metric capturing the patient's oral health perspective is the key to moving evidence-based dentistry and value-based oral health care forward.

Development of a one-item version of the Orofacial Esthetic Scale

ObjectivesOrofacial appearance is increasingly recognized as an important dental patient-reported outcome making instrument development and refinement efforts to measure the outcome better necessary. The aim of this study was to derive a one-item version of the Orofacial Esthetic Scale (OES).Materials and methodsOES data were collected from a consecutive sample of a total of 2113 adult English- or Spanish-speaking dental patients from HealthPartners dental clinic in Minnesota. Participants with missing data were excluded and analysis were performed using data from 2012 participants. Orofacial appearance was assessed with the English and the Spanish language version of the OES. Linear regression analysis was performed, with the OES item 8 (“Overall, how do you feel about the appearance of your face, your mouth, and your teeth?”) as the predictor variable and the OES summary score as the criterion variable, to calculate the adjusted coefficients of determination (R2).ResultsThe value of adjusted R2 was 0.83, indicating that the OES item 8 score explained about 83% of the variance of the OES summary score. The difference in R2 scores between the two language groups was negligible.ConclusionThe OES item 8 can be used for the one-item OES (OES-1). It is a psychometrically sound instrument for measuring orofacial appearance.Clinical relevanceDue to its easy application and sufficient psychometric properties, the OES-1 can be used effectively as an alternative to longer OES instruments in all areas of dental practice and research.

Mapping oral disease impact with a single metric - Special Issue introduction.

Dental patient-reported outcomes (dPROs) describe how dental patients suffer from oral diseases.1 Thus, dPROs are fundamental for evidence-based dentistry across dental disciplines.2 They are essential to evaluate treatment efficacy and to reduce research waste by addressing questions relevant to clinicians and capturing what matters most to patients.3 Doctor-patient communication centers around them,4 and they are necessary components for value-based oral health care, a concept that relates outcomes to costs.5 Oral health-related quality of life (OHRQoL) is the most important dPRO. Recent studies have demonstrated that OHRQoL has four main components, so called dimensions - Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact.6-8 These four dimensions, characterized by four scores, would allow to "map" all 1,323 oral diseases1 with one, single metric, thus describing oral disease impact with a standardized impact metric across all conditions in all settings. Meta-analytic statistical techniques are available to synthesize these multiple outcomes from differences sources.

Psychometric properties of North Macedonian version of the oral health impact profile for edentulous subjects

Introduction/Objective. Dental patient-reported outcome measures are very important in a diseasespecific population such as edentulous subjects. The aim of the study was to adapt the Oral Health Impact Profile for Edentulous Subjects (OHIP-EDENT) in the cultural environment of North Macedonia. Methods. This study adapted the original 19-item version of the OHIP-EDENT. After the forward?backward translation according to international standards, the OHIP-EDENT-MAC was psychometrically tested in 109 complete denture wearers. Results. The Cronbach?s ? coefficient of 0.892 confirmed good internal consistency. Test?retest reliability was confirmed by high intraclass correlation coefficient of the summary scores (0.986; 95% confidence interval 0.968?0.993). The concurrent validity was confirmed by the Spearman?s rank correlation coefficient (r = -0.654) between the OHIP-EDENT-MAC summary scores and a single question which rated satisfaction with the existing removable dentures using a five-point scale (1 = unsatisfied, 5 = completely satisfied). Construct validity was confirmed by exploratory factor analysis. All item loadings were above 0.4. Items grouped in four factors (dimensions), which explained 66.25% of the variance, in both non-rotated and rotated matrices. Good responsiveness was confirmed in 33 participants after complete denture relining. Their OHIP Summary score (33.09 ?} 11.61) decreased significantly (t = 7.68; df = 32; p &lt; 0.001) after treatment (24.39 ?} 8). The standardized effect size was 0.75, representing moderate to large effect. Conclusion. The OHIP-EDENT-MAC showed satisfactory psychometric properties providing evidence for its use in edentulous population of North Macedonia.

A parallel 3-group randomised clinical trial comparing different implant treatment options for the edentulous mandible: 1-year effects on dental patient-reported outcomes and chewing function.

This parallel three-group randomised clinical trial compared the 1-year changes in dental patient-reported outcomes and chewing function associated with three treatment strategies for the edentulous mandible: single-implant (G-I; n=11) or two-implant overdentures (G-II; n=13), and fixed 4-implant complete denture (G-III; n=13). Complete denture (CD) treatment was provided to all participants and after an adaptation period, they were randomly assigned to one of the three study groups. Implants (Neodent TI Cortical, Brazil) were inserted using single-stage surgery and conventional loading. The mandibular dentures were incorporated into implants using specific retention systems and procedures according to the treatment group: O'ring/ball attachments for G-I and GII, and mini-conical abutments for G-III. Patients were assessed at baseline (CD stage) and up to 1-year after implant-retained prosthodontic treatment. Treatment outcomes included oral health-related quality of life (OHIP-Edent), satisfaction with the dentures and chewing function using a mixing ability test. Data analyses included pairwise comparison tests, estimates of effect sizes and regression analysis using Generalized Estimating Equations. Results showed improvement in patient-reported outcomes (lower OHIP-Edent scores and higher satisfaction) and chewing function, compared to baseline. No significant between-group differences were found, although effect sizes were lower for G-III. All treatments improved the assessed outcomes after transition from the baseline condition. Findings suggest that simplified implant treatments for edentulous patients result in favourable outcomes and may be considered as suitable alternatives to more complex interventions.

Methodological considerations when measuring oral health-related quality of life.

Dental patient-reported outcomes (dPROs) and their measures, dPROMs, are fundamental for evidence-based dentistry. However when selecting, applying and evaluating an instrument with a focus on OHRQoL assessment for adults, several methodological considerations are essential to derive valid and meaningful results. In this review article, criteria for selecting the appropriate OHRQoL instrument, aspects of administering the instrument and how to evaluate resulting scores of single and multiple assessments are presented and critically assessed. Oral disease-generic and dimension-generic instruments capturing the entire construct OHRQoL allow for best comparability of findings across different diseases, settings and populations, with the Oral Health Impact Profile (OHIP) being the most often used and methodologically best investigated one. It is available in several versions with the 5-item version being the one with the lowest burden for the patient. Responses are given on a 5-point ordinal rating scale, the recommended response scale for dPROMs. A 7-day recall period allows for assessment of short-term effects. Clinically relevant effects of item or instrument order or administration method on OHIP scores do not seem to be likely. OHIP summary and dimension scores can be compared to norms from general population or different patient populations. Change scores should be set into context with the minimal important difference of the instrument. OHIP-5 has greatest potential to be used across all settings for assessment and evaluation of OHRQoL in adults. It allows a comprehensive characterising of patients suffering from oral diseases and of this impact using OHRQoL dimensions.

Health Outcomes Reported by Dental Patients

To assess the impact of care on patients, patient-reported outcomes (PROs) are essential because they characterize patients' suffering. Patient-reported outcome measures (PROMs) are the instruments to assess PROs. Any report of the patient's oral health condition that comes directly from the patient is a dental patient-reported outcome (dPRO). Similar to oral health being a component of health in general, dPROs are a part of PROs. dPROs target four major areas of patients' suffering because dental patients typically seek care to improve oral function and orofacial appearance as well as to decrease pain and psychosocial impact related to oral conditions. dPROs capture what matters to dental patients. They characterize the specific influences of oral health on patients' lives. Dental patient–reported outcome measures (dPROMs) capture this influence and express it numerically in a score. Consequently, dPROs in general and Oral Function, Orofacial Appearance, Orofacial Pain, as well as Psychosocial Impact (related to oral conditions) in particular are the major targets for dental interventions in clinical practice as well as for oral health research.

The stability of the lower labial segment: A cephalometric survey: By J. R. E. Mills. D. Practitioner 18: 293–306, April, 1968

Ten years ago, Chalmers and Glasziou pointed out in the Lancet that 85% of all biomedical research was being avoidably wasted because of imbalanced research question/outcome selection, as well as poor study design, execution, and reporting. According to findings of recent “research on research” studies, a high level of such kind of avoidable waste should also exist in orthodontic research. This warrants efforts to improve each stage of the research production and reporting process.Nowadays, patients' psychosocial function is considered a core element of oral health. Also, their treatment needs and preferences have formed a main component of evidence-based dentistry. Therefore, to achieve shared decision-making, orthodontists need to have an adequate understanding of each patient's values and perceptions.In this context, orthodontic research should be patient-centered so that the knowledge and perception gaps between clinicians and patients can be reduced, and research evidence that is suitable for patients to understand can be provided. In addition, patient-centered outcomes that can reflect patients' perceptions and psychosocial status should be widely used.However, recent scoping reviews have shown that during the past decade, patient-centered outcomes including those regarding adverse effects, health service resource utilization, and quality of life have remained under-represented in orthodontic trials. Thus, the use of dental patient-reported outcomes and dental patient-reported outcome measures should be promoted to facilitate the provision of a patient-centered evidence base, reduce the avoidable waste related to research question/outcome selection, and thereby increase the value of orthodontic research.