A three-dimensional Oral health-related quality of life framework for temporomandibular joint disorders: A structural analysis of the Oral Health Impact Profile-14

Temporomandibular disorders (TMD) are neuromuscular conditions that affect 5 to 12% of the general population and represent a public health problem [1]. Generally, they are classified into three groups related to the masticatory muscles (muscular TMD), to the temporomandibular joint (temporomandibular joint disorders [TMJD]), or both [2,3]. TMJD integrate structural alterations with a high prevalence in adults (31%) and include internal disorders (ID) and degenerative joint disease (DJD; equivalent to osteoarthritis/osteoarthrosis), which are the most common with a prevalence of 25.9% (disk displacement) and 9.8%, respectively [2].

Oral health-related quality of life (OHRQoL) is a multidimensional construct based on the International Classification of Impairments, Disabilities and Handicaps. It is closely related to the World Health Organization's definition of health as 'individuals' perception of their position in life in the context of the culture and value systems in which they live and about their goals, expectations, standards and concerns [4,5]. Therefore, OHRQoL is a global concept on various aspects such as physical health, psychological state, social relationships, beliefs or other aspects related to the environment [5]. It is a culturally and contextually sensitive concept used to measure the impact of dental conditions, and even beyond this environment [4].

The physical and psychological impact of TMDs is assumed to be detrimental to OHRQoL. A recent study linked this deterioration in TMD subgroups to a greater intensity and duration of pain [6]. Patients with muscle disorders and arthralgia/osteoarthritis/osteoarthrosis were found to have worse OHRQoL compared to those with disk displacements due to their higher pain levels [6]. Poorer OHRQoL, especially in the Orofacial Pain and Psychosocial Impact components, has also been observed in young adults with TMJD and pain-related symptoms [7]. This deterioration, with the chronic course of TMDs, has increased OHRQoL as a primary or complementary measure to classic clinically measurable outcomes such as pain and functional limitation, as a determining factor in clinical decision-making and resource allocation [6,8].

Patient-reported outcomes (PROs), such as those collected in questionnaires assessing OHRQoL, capture what matters to patients and assess therapeutic efficacy from their perspective [9]. Evidence-based care of TMD patients is currently a priority and requires combining patient-related outcomes with clinically measurable outcomes. For this purpose, disease-generic (e.g., OHIP-49, OHIP-14 and OHIP-5) and disease/condition-specific (OHIP for TMD) PRO measures are available. While diseases-generic instruments are preferable for comparing OHRQoL across orofacial conditions in epidemiological studies, the OHIP-TMD provides brevity and specificity for TMD [10,11]. From a practical point of view, the OHIP-14 has the advantage of being valid for many diseases/conditions and is shorter than the OHIP-TMD. Furthermore, this instrument captures relevant OHRQoL attributes and is suitable for TMD [12].

The Oral Health Impact Profile-14 (OHIP-14) is the most widely used summary version of the OHIP-49 [13]. It is based on Locker's theoretical model and groups the 14 items consecutively into seven dimensions (Functional limitation, Physical pain, Psychological discomfort, Physical disability, Psychological disability, Social disability, and Handicap) [14]. Although initially designed to measure the negative physical, psychological, and social impact of oral health conditions, it has also been used in different populations and settings: dental, oral, orofacial conditions, healthy volunteers, students, indigenous people, etc. [15]. The global score of the instrument is accepted; however, its underlying structure is variable: from one [16] to seven dimensions (theoretical model).

The brevity and simplicity of the OHIP-14 have led to its widespread use. However, the inconsistencies identified in the theoretical model have led to various proposals for dimensional or factorial modifications [9,17]. Although it is accepted that the total score of the instrument measures the negative impact on OHRQoL, no empirical support for the domains, dimensions or factors, in patients with TMD has been provided. Thus, OHIP-14 has been shown to fit well with dental patients, but is limited to patients who do not require dental treatment ("non-dental" patients) and, is affected by age and cultural background [18]. In addition, there have been reports of items with uncertain boundaries between dimensions that could have variable properties across cultures [15]. Even so, there have been frequent reports of the theoretical dimensions as independent subscales in TMD patients [19,20].

As has been pointed out recently, there is a need to verify the properties of OHIP-14 in specific scenarios [18]. Therefore, it is essential to understand which OHIP-14 structure best fits patients with TMD and its behavior in different settings and cultures. Otherwise, interpretations could be misleading. The appropriate OHIP-14 structure for TMD is controversial, and empirical support for using of theoretical dimensions as independent measures may be inadequate [9]. Furthermore, the studies are poor on the links between the structural components of OHRQoL in TMD patients. Therefore, this study aimed to investigate the dimensional structure of the OHIP-14 and the links between its components (items and factors) in patients with temporomandibular joint (TMJ) disorders using two analytical approaches and their spatial display. The null and alternative hypotheses of this study are as follows, H0: the OHIP-14 theoretical structure fits TMJD patients, versus H1: the OHIP-14 theoretical structure does not fit TMJD patients.

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