Self-esteem and oral health-related quality of life of women with periodontal disease - A cross-sectional study.

Aim: The aim of this study is to assess the effect of periodontal disease on self-esteem and oral health-related quality of life (OHRQoL) in women. Materials and
Methods: A cross-sectional study was conducted among 522 women (mean age - 38.92 ± 14.3 years). Oral hygiene status, plaque level, gingival inflammation, probing depth, and periodontal status were assessed. The self-esteem was assessed using a Rosenberg Self-esteem Scale, and the OHRQoL was measured using a 14-item oral health impact profile (OHIP-14) questionnaire.
Results: Younger, employed women with higher income had significantly better OHRQoL and self-esteem. Women with healthy periodontium had better OHRQoL. Probing depth and community periodontal index scores were found to have a significant positive correlation with most of the sub-scale items and total OHIP-14 score in women with low self-esteem. Women with good OHRQoL and normal self-esteem were seen to be maintaining significantly better oral hygiene. No such statistically significant difference was observed in women with low self-esteem. Multiple regression analysis for the prediction of OHIP-14 score indicated that the best model included probing depth as the only statistically significant predictor (P = 0.002).
Conclusion: Periodontal disease has a significant negative impact on self-esteem and OHRQoL in women. Copyright:

INTRODUCTION

Periodontal disease can have just as severe emotional and psychosocial consequences as an ailment in any other part of the body[1] and thereby affecting their quality of life (QoL) and oral health-related QoL (OHRQoL) in particular.[2] In addition, it may affect the self-esteem of a person. Self-esteem is an indispensable personal trait to normal and healthy self-development and has a value for survival.[3] It includes the feeling of self-worth, self-value, self-image, and self-concept.[4] Low self-esteem is associated with diminished QoL.[5]

Several studies have shown that females experienced a more severe impact of oral disorders on OHRQoL than males despite better oral health.[6] Women bear multiple roles, such as a professional, mother, spouse, and community worker,[78] which is closely related to their self-esteem and QoL. To the best of our knowledge, no prior study has assessed periodontal disease, self-esteem, and QoL, especially women. Therefore, we aimed to assess the association of periodontal disease, self-esteem, and OHRQoL in women.

MATERIALS AND METHODS

The study was a cross-sectional, epidemiological study. Data were collected through questionnaires and clinical examinations using a convenient sampling method. The study protocol was approved and conducted according to the institutional ethical committee's standards and the 1964 Helsinki declaration and its later amendments. All study participants gave their written informed consent before participation in the study. All adult female patients reporting to the outpatients department of periodontics and oral implantology were screened to be included in the study. Patients with dentures or orthodontic appliances, presence of debilitating diseases/conditions, mental or psychological disorder, and the use of antipsychotic drugs were excluded from the study. Pregnant women and lactating mothers were also excluded.

Data were collected as part of the usual screening procedure implemented to assign participants for the treatment. Participants were assured that their participation would not influence the outcome of their treatment. To ensure a high response rate, all participants completed the questionnaires following an explanation of the study's objectives and a face-to-face interview on the same day as the clinical assessment. The interview was carried out by an independent examiner who was blinded to the study goals.

Periodontal status of the participants was assessed by evaluating oral hygiene (oral hygiene index),[9] dental plaque level (plaque index),[10] gingival inflammation (gingival index),[11] probing depth (UNC 15 periodontal probe; Hu-Friedy Mfg. Co., Chicago IL, USA), and periodontal index (Community Periodontal Index) for all participants. The examination was done using sterile mouth mirrors, dental explorers and Community Periodontal Index (CPI) probes in accordance with the recommendations by the World Health Organization.[12] Two well-trained examiners conducted the clinical examinations (RS and NP; inter-examiner agreement of 0.82 for CPI).

The self-esteem of the participants was assessed using the Rosenberg Self-esteem Scale (RSES).[4] Responses are marked on a four-point scale which ranges from strongly agree to strongly disagree, with items 3, 5, 8, 9, and 10 having a reverse valence. A minimum score of 0 to a maximum score of 30 can be achieved by using this scale (0–15 low self-esteem; 15–25 normal self-esteem; 25–30 high self-esteem). OHRQoL of the participants was measured using a 14-item oral health impact profile (OHIP-14) questionnaire.[13] It is a shorter version of the original long-form (49 questions) of the instrument consisting of 14 questions with seven sub-domains based on the conceptual model of oral health by Locker and Quiñonez.[14]

A pilot survey for OHIP-14 and RSES was carried out among twenty participants with similar sociodemographic and cultural characteristics to check the reliability of results. A test-retest approach showed good reliability and internal consistency (Cronbach's alpha = 0.84 for OHIP-14 and 0.78 for RSES).

The sample size was determined using free, web-based, open-source, operating system-independent software program (OpenEpi, version 3.01; www.OpenEpi.com) at 95% confidence interval, and hypothesized % frequency of outcome factor in the population as 50%, confidence limit of 4.5%, which estimated the required sample size to be 474. Descriptive statistics and comparisons as per the demographic and periodontal parameters were made using the Chi-squared test, unpaired Student's t-test, and one-way ANOVA test. A post hoc analysis with Tukey's test was done to evaluate the significant differences between the groups. Correlations statistics were done by Spearman's rank correlation test. A multiple linear regression analysis was done for the prediction of OHIP-14 score. Data were analyzed using a statistical software program (SPSS, version 21.0, Chicago, IL, USA). A P < 0.05 was considered statistically significant.

RESULTS

A total of 724 women visiting the institute were screened to recruit 522 women participants (mean age 38.92 ± 14.3 years) participated in this study. Table 1 depicts the distribution of the participants as per their sociodemographic characteristics. Table 2 presents the comparison of OHIP-14 and RSES scores among various demographic categories. It was observed that while women who were unmarried (P < 0.001), employed (P < 0.001), younger (P < 0.001), and those having a higher income (P < 0.001) had a significantly better OHRQoL. There was no significant difference in the OHIP-14 scores among women with different education levels (P = 0.69). The comparison of RSES scores revealed that married (P < 0.001), employed (P < 0.001), and those with higher income (P < 0.001) had significantly better self-esteem. There were no significant differences in RSES scores among women of varying ages (P = 0.68) and education levels (P = 0.33).

Table 1

Sociodemographic characteristics of the studied population

Characteristics	n (%)
Age group (years)
Young (18-30)	183 (35.1)
Middle age (31-55)	222 (42.5)
Elderly (>55)	117 (22.4)
Marital status
Unmarried	137 (26.2)
Married	385 (73.8)
Educational status
Uneducated	109 (20.9)
Primary - secondary	243 (46.6)
Graduate	138 (26.4)
Postgraduate	32 (6.1)
Employment status
Unemployed	300 (57.5)
Employed	222 (42.5)
Income status (Rs.)
No income group	300 (57.5)
Low income group (<25,000)	151 (28.93)
Middle income group (25,000-50,000)	59 (11.3)
High income group (>50,000)	12 (2.29)

n – Number of participants; % – Percentage

Table 2

Comparison of oral hygiene impact profile - 14 and Rosenberg Self-esteem Scale scores within demographic parameters

	n	OHIP-14 score		RSES score
		Mean±SD	P	Mean±SD	P
Marital status
Unmarried	137	10.82±12.27	<0.001*	14.2±2.41	<0.001*
Married	385	16.94±11.72		15.2±2.77
F; T		0.01; −5.18		0.7; −3.78
Education level
Uneducated	109	14.88±12.67	0.69#	15.06±2.87	0.68#
School level	243	15.03±12.14		15.02±2.97
Graduate	138	16.39±11.77		14.78±2.21
Postgraduate	32	14.66±12.42		14.56±2
F; df		0.48; 3		0.51; 3
Age group
Young	183	12.24±9.97	<0.001#	15.03±2.54	0.33#
Middle age	222	16.97±12.78		14.74±2.77
Elderly	117	17.07±13.16		15.17±2.87
F; df		0.93; 2		1.103; 2
Employment status
Unemployed	300	16.34±13.29	<0.001*	14.11±2.55	<0.001*
Employed	222	13.97±10.3		16.05±2.53
F; T		22.02; 2.21		0.65; 0.632
Income status
No income group	109	16.34±13.29	0.001#	14.11±2.55	<0.001#
Low income group	243	15.88±10.57		15.74±2.35
Middle income group	138	10.53±8.68		16.03±1.64
High income group	32	6.92±6.35		20.08±4.42
F; df		5.95; 3		37.9; 3

*Unpaired Student’s t-test; # One-way ANOVA; P<0.05. OHIP-14 – Oral hygiene impact profile - 14; RSES – Rosenberg Self-esteem Scale; n – Number of participants; SD – Standard deviation; P – Probability Value; T – Student’s t statistics; df – Degree of freedom; F – F test Value

Table 3 presents the comparison of OHIP-14 and RSES scores among women with various periodontal parameters. There was no significant difference in OHIP-14 scores among women having different oral hygiene status (P = 0.92), plaque level (P = 0.153), gingival inflammation (P = 0.22), and probing depth (P = 0.67). However, there was a significant difference in the OHIP-14 scores among women with different CPI scores (P = 0.05) where women with healthy periodontium had a better OHRQoL. Similarly, a comparison of RSES scores revealed that there was no significant difference among women having different oral hygiene statuses (P = 0.95), gingival inflammation (P < 0.09), probing depth (P < 0.09), and periodontal status (P < 0.31). However, there was a significant difference in the RSES score among participants with different plaque levels (P < 0.03), where women with lesser plaque had significantly higher self-esteem.

Table 3

Comparison of oral hygiene impact profile -14 and Rosenberg Self-esteem Scale scores within periodontal parameters

	n	OHIP-14 score		RSES score
		Mean±SD	P*	Mean±SD	P*
Oral hygiene status (OHI-S score)
Good (0,1)	74	14.96±12.05	0.92	14.95±2.92	0.95
Fair (2)	411	15.45±12.33		14.92±2.58
Poor (3)	37	14.81±10.51		15.08±3.67
F; df		0.08; 2		0.06; 2
Plaque level (PI score)
Minimal (0,1)	55	12.98±11.79	0.15	17.58±2.57	0.03
Low (2)	384	16.09±12.66		14.83±2.48
Moderate (3)	50	14.46±9.3		15.74±3.34
High (4)	21	11.95±10.58		15.52±4.20
Very high (5)	12	11.42±7.73		14.15±2.50
F; df		1.04; 4		5.71; 2
Gingival inflammation (GI score)
Mild (0,1)	59	12.67±7.91	0.22	13.33±2.29	0.09
Moderate (2)	306	15.92±12.78		14.85±2.61
Severe (3)	136	13.93±10.65		15.20±2.97
F; df		1.53; 2		1.53; 2
Probing depth (mm)
Shallow (1-2)	409	15.26±12.29	0.67	14.97±2.67	0.09
Moderate (2-5)	16	18±8.63		14.81±3.12
Deep (>5)	97	14.71±9.67		12.71±3.90
F; df		0.80; 2		2.43; 2
Periodontal status (CPI score)
Healthy (0)	4	5.00±6.78	0.05	12.50±1.00	0.31
Bleeding observed by probing (1)	98	15.49±12.63		14.83±2.72
Calculus detected by probing and black band visible (2)	220	14.01±11.07		15.04±2.65
Pocket 4-5 mm with black band visible (3)	145	16.56±12.62		15.05±2.79
Pocket 6 mm or more and black band is not visible (4)	55	17.89±13.72		14.64±2.80
F; df		2.38; 4		1.15; 4

*One-way ANOVA; P<0.05. OHIP-14 – Oral hygiene impact profile - 14; RSES – Rosenberg Self-esteem Scale; n – Number of participants; SD – Standard deviation; OHI-S – Oral hygiene index - simplified; PI – Plaque index; GI – Gingival index; CPI – Community periodontal index; P – Probability Value; Df – Degree of freedom; F – F statistics Value

Table 4 presents the correlation between the OHIP-14 scores and periodontal parameters. Probing depth and CPI scores were found to have a significant positive correlation with most of the sub-scale items and total OHIP-14 score in women with low self-esteem compared to those with normal self-esteem. With deepening of periodontal pocket and deterioration of periodontal status, there was a decrease in the level of OHRQoL with women with low self-esteem. Table 5 compares the periodontal parameters between women with good and poor OHRQoL among low and normal self-esteem. While women with good OHRQoL and normal self-esteem were seen to maintain significantly better oral hygiene, no statistically significant difference was observed in women with low self-esteem. Furthermore, a significantly deeper probing depth and poorer periodontal status were observed in women with poor OHRQoL and low self-esteem. No such differences were observed in women with normal self-esteem. Table 6 presents the summary of multiple regression analysis for prediction of OHRQoL (OHIP-14 Score) by periodontal parameters. After adjusting for age, marital status, educational level, employment status, income and self-esteem, the best model revealed probing depth (β =0.13, P = 0.002) as the only significant predictor which explained around 12.45% of the variance (R2 = 0.12, F [11,510] =7.2, P < 0.001).

Table 4

Correlation between oral hygiene impact profile - 14 score and periodontal parameters among women with overall (n=522), low self-esteem (n=217), and normal self-esteem (n=305)

Periodontal parameters	SE	Functional limitation	Physical pain	Psychologic discomfort	Physical disability	Psychologic disability	Social disability	Handicap	OHIP-14 Score
Oral hygiene status (OHI-S score)	Overall
	r	−0.02	0.03	0.06	0.02	−0.03	−0.03	−0.05	0.01
	P*	0.71	0.48	0.16	0.63	0.53	0.43	0.25	0.96
	Low SE
	r	0.03	0.13	0.12	0.09	0.05	0.04	0.02	0.09
	P*	0.70	0.07	0.08	0.21	0.43	0.58	0.76	0.19
	Normal SE
	r	−0.06	−0.07	0.01	−0.04	−0.10	−0.11	−0.13	−0.09
	P*	0.31	0.23	0.87	0.45	0.08	0.07	0.03	0.11
Plaque level (PI score)	Overall
	r	0.02	−0.04	0.01	0.01	−0.04	−0.02	−0.1	−0.03
	P*	0.65	0.35	0.99	0.98	0.39	0.64	0.02	0.43
	Low SE
	r	0.02	0.05	0.06	0.10	0.03	0.04	−0.05	0.05
	P*	0.70	0.07	0.08	0.21	0.43	0.58	0.76	0.19
	Normal SE
	r	0.04	−0.08	−0.03	−0.04	−0.07	−0.04	−0.12	−0.07
	P*	0.54	0.17	0.59	0.44	0.23	0.47	0.03	0.25
Gingival inflammation (GI score)	Overall
	r	0.01	−0.01	−0.02	0.03	0.02	0.03	−0.04	0.01
	P*	0.97	0.79	0.68	0.51	0.68	0.49	0.35	0.98
	Low SE
	r	−0.05	−0.01	−0.05	0.02	0.03	−0.01	−0.04	−0.02
	P*	0.45	0.83	0.45	0.77	0.61	0.92	0.57	0.76
	Normal SE
	r	0.05	0.01	0.01	0.05	0.01	0.07	−0.03	0.03
	P*	0.36	0.85	0.80	0.38	0.88	0.21	0.57	0.58
Probing depth	Overall
	r	0.11	0.08	0.1	0.12	0.16	0.06	0.11	0.14
	P*	0.01	0.07	0.02	0.01	<0.001	0.15	0.01	0.001
	Low SE
	r	0.11	0.17	0.20	0.21	0.20	0.16	0.15	0.23
	P*	0.10	0.01	<0.001	<0.001	<0.001	0.02	0.02	<0.001
	Normal SE
	r	0.12	0.03	0.04	0.07	0.13	0.01	0.09	0.09
	P*	0.04	0.55	0.44	0.20	0.02	0.89	0.12	0.10
Periodontal status (CPI score)	Overall
	r	0.14	0.13	0.08	0.11	0.1	0.07	0.07	0.13
	P*	0.001	0.002	0.07	0.02	0.02	0.11	0.11	0.002
	Low SE
	r	0.14	0.15	0.08	0.11	0.07	0.16	0.13	0.16
	P*	0.03	0.03	0.23	0.09	0.30	0.02	0.05	0.02
	Normal SE
	r	0.10	0.06	0.03	0.01	0.05	−0.06	−0.01	0.03
	P*	0.09	0.27	0.64	0.83	0.40	0.32	0.92	0.54

*Spearman’s rank correlation; P<0.05. OHI-S – Oral hygiene index - simplified; PI – Plaque index; GI – Gingival index; CPI – Community periodontal index; n – Number of participants; SE – Self-esteem; r – Correlation coefficient; OHIP-14 – Oral hygiene impact profile-14; P – Probability Value

Table 5

Comparison of periodontal parameters between women with good oral health-related quality of life and poor oral health-related quality of life among those with overall, low and normal self-esteem

Periodontal parameter	SE	OHRQoL	n	Mean rank	Sum of ranks	Mean±SD	U	P*
Oral hygiene status	Overall	Good	399	267.61	106777.50	1.76±0.74	22099.50	0.095
		Poor	123	241.67	29725.50	1.70±0.73
	Low SE	Good	157	108.31	17004.00	1.74±0.78	4601.0	0.792
		Poor	60	110.82	6649.00	1.85±0.89
	Normal SE	Good	242	159.93	38703.50	1.56±0.52	5945.50	0.007
		Poor	63	126.37	7961.50	1.78±0.71
Plaque level	Overall	Good	399	261.38	104289.00	1.67±0.75	24489.0	0.973
		Poor	123	261.90	32214.00	1.59±0.51
	Low SE	Good	157	105.98	16639.00	1.55±0.60	4236.0	0.252
		Poor	60	116.90	7014.00	1.61±0.48
	Normal SE	Good	242	155.26	37572.50	1.76±0.82	7076.50	0.381
		Poor	63	144.33	9092.50	1.57±0.53
Gingival inflammation	Overall	Good	399	261.53	104351.00	1.83±0.46	24526.0	0.993
		Poor	123	261.40	32152.00	1.81±0.48
	Low SE	Good	157	108.92	17100.00	1.80±0.49	4697.0	0.975
		Poor	60	109.22	6553.00	1.76±0.51
	Normal SE	Good	242	152.84	36988.00	1.85±0.45	7585.0	0.951
		Poor	63	153.60	9677.00	1.85±0.44
Probing depth	Overall	Good	399	252.85	100889.00	3.61±1.26	21089.0	0.018
		Poor	123	289.54	35614.00	3.99±1.71
	Low SE	Good	157	101.54	15941.50	3.46±1.11	3538.5	0.005
		Poor	60	128.53	7711.50	3.95±1.53
	Normal SE	Good	242	151.18	36585.00	3.71±1.35	7182.0	0.479
		Poor	63	160.00	10080.00	4.03±1.88
Periodontal status (CPI score)	Overall	Good	399	255.03	101755.50	2.24±0.89	21955.5	0.062
		Poor	123	282.50	34747.50	2.43±0.99
	Low SE	Good	157	103.97	16324.00	2.18±0.92	3921.0	0.045
		Poor	60	122.15	7329.00	2.50±1.02
	Normal SE	Good	242	151.31	36617.50	2.28±0.87	7214.5	0.49
		Poor	63	159.48	10047.50	2.37±0.97

*Man–Whitney U-test; P<0.05. SE – Self-esteem; OHRQoL – Oral health-related quality of life; CPI – Community periodontal index; n – Number of participants; SD – Standard deviation; P – Probability Value; U – Man-Whitney U test statistics

Table 6

Summary of multiple linear regression analysis for prediction of oral health-related quality of life (oral hygiene impact profile -14 score) by periodontal parameters

Predictors of OHRQoL	B	SE	β	t	95% CI of B (lower–upper)		P*
Constant	−0.59	4.01		−0.15	−8.47-7.30		0.88
Oral hygiene status	−0.15	0.75	−0.01	−0.19	−1.62-1.33		0.85
Plaque level	−1.51	0.86	−0.09	−1.76	−3.19-0.17		0.08
Gingival inflammation	0.64	1.10	0.02	0.58	−1.53-2.80		0.56
Probing depth (mm)	1.16	0.37	0.13	3.09	0.42-1.89		0.002
CPI score	0.73	0.61	0.05	1.20	−0.46-1.92		0.23
				Analysis of variance
Multiple R	0.37			Source	Sum of squares	df	Mean square
R 2	0.13			Regression	10341.19	11	940.11
Adjusted R2	0.12			Residual	66623.14	510	130.63
SE of estimate	11.43			Total	76964.33	521
						F=4.29; P<0.001**

*Multiple linear regression (adjusted for age, marital status, education level, employment status, income and self-esteem), significance level at P<0.05, **One-way ANOVA, significance level at P<0.05. OHRQoL – Oral health-related quality of life; OHIP-14 – Oral hygiene impact profile-14; CPI – Community periodontal index; CI=Confidence interval, B=Unstandardized beta coefficient; SE – Standard error; t – T statistics value; β – Beta coefficient; df – Degrees of freedom;

F – F statistics value; P – Probability Value; R – Multiple correlation coefficient

DISCUSSION

This cross-sectional study was conducted to assess the impact of periodontal disease on the quality (OHRQoL) of life and self-esteem in women. The findings show that periodontal disease has a significant negative impact on OHRQoL and self-esteem in women. It is the first study in which the impact of periodontal disease was assessed on women's self-esteem and OHRQoL.

Periodontal disease has been reported to influence the OHRQoL adversely.[1516171819] However, self-esteem has not been the subject of research as often as the QoL, especially concerning oral health. While Chin and Chan[20] reported that participants with higher self-esteem had better clinical oral health status, de Couto Nascimento et al.[21] reported that dental treatment enhanced patients’ self-esteem.

The findings of our study are in agreement with Ng and Leung,[17] Bernabé and Marcenes,[22] López and Baelum[23] and Jansson et al.,[24] all of whom reported that periodontal disease has a considerable impact on the OHRQoL. However, in these studies, the impact of periodontal disease was assessed in both males and females. Lawrence et al.[6] reported that the impact of oral conditions on females was more severe than males even though they had lesser caries experience, fewer missing teeth, and a lower prevalence of periodontal disease. Hence, it may be understood that some psychosocial factors may influence OHRQoL in women, not oral health status alone.

Younger women had a better OHRQoL in our study, which was in accordance with the findings of Araújo et al.[25] and Steele et al.[26] who also found an increase in OHIP-14 score with increasing age, in contrast to the findings of studies by McGrath and Bedi[27] and John et al.[7]

Bryła et al.,[28] while reporting the findings from their study on city-dwelling older adults, noted that not age alone but when in the presence of comorbid conditions such as systemic disease, mental and physical disabilities could significantly influence the QoL. The co-existence of chronic medical conditions may lower QoL in an additive rather than synergistic or subtractive fashion.[29] Only systemically healthy women participated in our study to eliminate the probable confounding effect systemic disease may have on OHRQoL.

We found that unmarried women had a better OHRQoL, which was in contrast to studies by Locker et al.[30] and Pereira et al.,[31] who found no significant relationship between marital status and OHRQoL. However, the participants in these studies were in the elderly age group. Employed women had better OHRQoL, which was in accordance to the study by Lou and McGrath[32] and Sanders et al.[33] Income levels were also significantly associated with OHRQoL in the present study, agreeing with Araújo et al.[25] In the present study, women with higher income had a better OHRQoL and self-esteem. Similar results were found in Sander et al.[33] and Locker and Quiñonez.[14] This may be due to higher oral health expectations in women with better income than the lower-income categories.[27] Individuals with low income have been reported to have a higher prevalence of the periodontal disease.[3435] However, they have less access to dental services; consequently, the accumulation and aggravation of oral problems may negatively affect their OHRQoL.

No significant association was found between OHRQoL and education level in our study, which is similar to the findings of other studies by Acharya et al.,[36] Brennan and Spencer[37] and Emami et al.[38] However, Caglayan et al.[39] and Walter et al.[40] reported that more educated individuals had a better OHRQoL. Our results may be attributed to the fact that the majority of the participants had only finished the lower level of education, which is similar to the findings by Papaioannou et al.[41] Employed women in our study had significantly higher self-esteem than unemployed women, which agreed to Trivedi et al.[42] and Rao et al.[43] The financial dependence of homemakers on their spouses often results in low self-esteem. In their study, Moonzwe Davis et al.[44] reported that Indian women dependent on their spouses faced high economic hardships and emotional stress, causing low self-esteem. These findings were in accordance with our study, where women with lower income had low self-esteem. A plausible reason for this could be the need to contribute to their families and society; the inability to do so in a competitive world might lower their self-esteem.

With deeper periodontal pockets and the increasing severity of periodontal diseases, there was a decrease in QoL in those with lower self-esteem. This was in accordance with the study by Araújo et al.[25] and Simona et al.,[45] who showed the highest impact on OHRQoL in patients with aggressive periodontitis. The mean OHIP score was the highest for the group with the highest CPI score, indicating that severe periodontal disease had a significant influence on the OHRQoL which was in agreement with studies by Ng and Leung[17] and Cunha-Cruz et al.[15] Since chronic periodontal disease may often not have initial signs and symptoms, it may not affect their OHRQoL.[6161722] In contrast to our findings, Biazevic et al.[46] found that in their study, adolescents with lower severity of periodontal disease did not find any impact of periodontal disease on the QoL.

Functional limitation and psychologic disability were the dimensions that had the most impact on OHRQoL, which was in agreement with the study by Locker and Quiñonez.[14] Further, psychologic discomfort, social disability, and handicap were not associated with periodontal disease, according to Ng and Leung[17] and Meusel et al.[47] Notably, probing depth was significantly correlated with physical, psychologic, and social sub-domains of OHIP-14 in women with low self-esteem, clearly demonstrating the wider extent of the impact of deepening probing depth. Psychological disability in the context of worsening periodontal disease may be related to embarrassment due to functional and esthetic concerns caused by loosening of teeth, gingival recession, and teeth migration.[47] Appearance is of greater concern in women, who are more self-conscious and concerned. Bedos et al.[48] and Jansson et al.[24] described the importance people place on the appearance of their dentition and the potentially devastating impacts of oral disease.

Studies by Sanders et al.[33] and Lawrence et al.[6] have shown that caries, malocclusion, and tooth loss have adverse effects on the OHRQoL. Therefore, these conditions were excluded to minimize any probable confounding effect. Further, a cross-sectional study has its limitations of gathering information at a singular point in time; only longitudinal studies with more extended time intervals will assess periodontal disease's actual impact on self-esteem and QoL. In the present study, oral health practices, the number of dental visits and habits were not included, which could have influenced the obtained results. Furthermore, while most of the parameters of periodontal health have been assessed, tooth mobility and loss of attachment would have provided additional information.

CONCLUSIONS

Within the limitation of this study, it may be concluded that periodontal disease has a significant negative impact on the OHRQoL and self-esteem in women. Participants with severe periodontal disease and low self-esteem demonstrated the highest impacts on their OHRQoL, affecting a wide range of OHRQoL domains.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.