Cotnmunity Detit Oral Epidemiol 1997: 25: 284-90 Copyright © Miinksgaani 1997

Printed iti Denmark . Alt rights reserved

Communify Dentistiy
and Oral Epidemiology
ISSN 0301-5661

Derivation and validation of a short- Gary D, Slade

Department of Dental Ecology, University of
North Carolina, USA

form oral health impact profile

Slade GD; Derivation and validation of a short-fortn oral health impact profile.
Comtnunity Dent Oral Epidetniol 1997; 25; 284-90. © Munksgaard, 1997

Abstract - Growing recognition that quality of life is an important outcome of

dental care has created a need for a range of instrutnents to measure oral health-
related quality of life. This study aimed to derive a subset of items from the Oral
Health Impact Profile (OHIP-49) - a 49-itetn questionnaire that tneasures peo-
ple's perceptions of the impact of oral conditions on their well-being. Secondary
analysis was conducted using data from an epidemiologic study of 1217 people
aged 60-1- years in South Austraha. Internal reliability analysis, factor analysis
and regression analysis were undertaken to derive a subset (OHIP-14) question-
naire and its validity was evaluated by assessing associations with sociodetno-
graphic and clinical oral status variables. Internal reliabihty of the OHIP-14
was evaluated using Cronbach's coefficient a. Regression analysis yielded an opti-
mal set of 14 questions. The OHIP-14 accounted for 94% of variance in the OHIP-
49; had high reliability (a=0.88); contained questions from each ofthe seven
conceptual dimensions of the OHIP-49; and had a good distribution of preva-
lence for individual questions. OHIP-14 scores and OHIP-49 scores displayed the
Key words: epidemiology; orai health:
same pattern of variation among sociodemographic groups of older adults. In psychometrics; quality of life
a multivariate analysis of dentate people, eight oral status and sociodemographic
variables were associated {P<0.05) with both the OHIP-49 and the OHIP-14. Gary D. Slade, Department of Dental Ecoiogy,
University of North Caroiina, CB#7450,
While it will be important to replicate these findings in other populations, the Chapei Hili, NC 27599-7450, USA
findings suggest that the OHIP-14 has good reliability, validity and precision.
Accepted for pubiication 4 August, t996

The extension of people's life span and
the enhancement of their quality of life
are two central goals of the Healthy
People 2000 initiative (1). This emphasis
on quality of life is consistent with the
concept that health is a resource and
not simply the absence of disease.
Increasingly, quality-of-life assessment
is being regarded as an essential compo-
nent for as.sessing outcomes of health
care, including outcomes for public
health programs (2). Until a decade
ago, there was a virtual absence of in-
dices to measure quality of life as it re-
lates to oral health. However, there is
now an impressive range of instruments
that assess the impact of oral conditions
on well-being and quality of life (3).
The Oral Health Impact Profile
(OHIP) is one such instrument that
measures people's perception of the so-
cial impact of oral disorders on their
well-being. The development, reliability
and validity of the OHIP have been
described previously (4). The 49 ques-
tions in the OHIP capture seven con-
ceptually formulated dimensions that
are based on Locker's theoretical mod-
el of oral health (Fig. I) (5). The seven
dimensions are: functional limitation,
physieal pain, psychological discom-
fort, physical disability, psychological
disability, social disability and handi-
cap. The hierarchy captures outcomes
that have an increasingly disruptive
itnpact on people's lives. For exatnple,
the functional litnitation qttestions
capture impacts that would be ap-
parent primarily to the individual,
such as; "Have you had difficulty
chewing any foods because of prob-
lems with your teeth, tnouth or den-
tures?" Qtiestions in the disability di-
mension refer to itnpacts on everyday
activities, such as; "Have you had to
interrupt meals because of problems
with your teeth, mouth or dentures?"
while handicap represents the extent of
disadvantage caused by oral health,
such as; "Have you been unable to en-
joy other people's company because of
problems with your teeth, tnouth or
dentures?" Separate subscales can be
calculated for each dimension of the
OHIP, while overall levels of social im-
pact have been computed using all 49
questions. Epidemiological studies that
have used the OHIP have found that
missing teeth, untreated decay, perio-
dontal attachment loss and barriers to
dental care are associated with increas-
ing levels of impact on well-being (6-

DISEASE
IMPAIRMENT
FUNCTIONAL DISCOMFORT
LIMITATION &PAIN
DISABILITY
Physical
Psychological
Social
I This paper reports findings frotn a sec-
HANDICAP
Eig. 1. Locker's conceptual model of oral
health.
While the OHIP is intended to pro-
vide comprehensive data about percep-
tions of impact on well-being, some re-
search settings do not pertnit use ofthe
full battery of 49 questions in the in-
strutnent. For example, health services
researchers frequently require a more
succinct instrument to assess the per-
ceived impact of oral health as one of
several outcotnes of dental care.
Although there is a general psychomet-
ric principle that reliability of ati index
decreases as the nutnber of items de-
creases (9) other criteria provide a ra-
tionale lor developitig short-fortn in-
dices. STEWART et al. have described
conceptual, statistical and pragtnatic re-
quirements for health status questioti-
naires (10); 1. they should represent
multiple health concepts and a range of
health states pertaining to general func-
tioning atid well-being; 2. they should
have good psychometric properties (re-
liability, validity and precision); and 3.
for clinic settings, they should be simple
and easy to use.
Several statistical techniques have
been used to identify short forms of
health questionnaires including ititernal
reliability analysis, regression atialysis
and factor analysis (11). For example,
the General Health Questionnaire was
shortened frotn 60 itetns to 28 itetns
using factor analysis (12). The Medical
Outcomes Study (MOS) set of 116 core
items was shortened to versions that
contained 20 itetns (SF-20) and 36
itetns (SF-36) by selecting items that
Deriyalion attd yalidation of short-form OHIP 285
had the strongest associations with the response was selected to identify ques-
long-form scales (13). In other in- tions that caused respotidents the great-
stances, such as the final revision of the est problems with interpretation or
Sickness Itnpact Profile, additional cri- completion. Theti, three statistical pro-
teria were used, including the frequency cedures were used with the intention of
with which items were reported and ex- deriving a subset of approxitnately 10-
perience with adtninistration of the in- 15 questions that could capture as
strutnent in research settings (14). much information as possible from the
The purpose of this report is to de- 49-item OHIP questionnaire.
scribe the derivation of a short-form 1. Internal reliability attalysis used
OHIP questionnaire and to report ini- Cronbach's coefficient a to deter-
tial findings concerning its reliability mine whether retnoval of individual
and validity. questions would increase the instru-
tnent's reliability.
2. Prineipctl components factor analysis
Methods was undertaken to identify a set of
underlying factors contributing to
ondary analysis of data collected in OHIP responses. This was followed
1991/92 during a cross-sectional study by promax rotation of the factors
of older adults in South Australia (6). that accounted for the greatest
Subjects in that study were a stratified amoutit of variation, and cotnputa-
randotn satnple of cotntnunity-dwelling tion of factor loadings for each ques-
persons aged 60+ years living in Ade- tioti to idetitify atiy that exceeded
laide, the state capital, and Mt Gatn- 0.4, which was used as a threshold
bier, a rural city in the south-east of the for moderate to high loadings. For
state. Some 1650 people took part in a the factor analysis, cotntnunalities
face-to-face interview that asked about were set to the variable's squared
dental visits, tnedical conditions and multiple correlation with all other
sociodemographic characteristics. The variables.
data for this report come from self- 3. Least-sc/uarcs regression was used
administered OHIP questionnaires, with the total OHIP score (obtaitied
which were cotnpleted by 1217 inter- by summing the coded Likert-type
viewed people, and frotn clinical oral responses from all questions) as the
examinations that were conducted dependent variable and each ques-
among 716 interviewed people who tion was an independent variable. A
were dentate. default stepwise procedure was used
For each of the 49 OHIP questions, in which individual questions were
people were asked how frequently they considered sequentially for their
had experienced the impact in the pre- contribution to total R~, atid the
ceding 12 months. Responses were first 14 items tnaking the largest ad-
tnade on a Likert-type scale and coded dition to R- were selected. A second
4="very often", 3 = "fairly often", 2 = procedure itnposed greater control
"occasionally", l="hardly ever" and over the stepwise procedure; again,
O="nevcr". For this report, descriptive itetns making the greatest contribu-
statistics were created by computing the tion to total R- were added sequen-
mean of the coded response for each tially, except that no tnore than two
itetn which is described below as the se- items frotn each coticeptuai dimen-
verity score for each itetn. In addition, sion were pertnitted to enter the
a threshold of occasionally, fairly often model. This "controlled" regression
or very often was used to dichototnize procedure was also condueted until
responses, thereby indicating people 14 itetns, two from each ditnension,
who had experienced at least sotne itn- were selected.
pact. This is described below as the When the final set of questions was
prevalence of each itetn. identified, the vahdity of the short form
The first step in deriving a short (OHIP-14) was investigated by deter-
fortn begat! by elimitiating items that tnining whether its associations with
applied only to denture wearers and sociodetnographic and clinical variables
items where 5%) or more of responses were sitnilar to the associations between
were left blank or marked "don't the full OHIP (OHIP-49) and those
know". This percentage of non- same variables. This was used to pro-
286 SLADE
vide evidence of discriminant validity
(15). Summary scores for the OHIP-14
and OHIP-49 were obtaining by count-
ing the number of items reported occa-
sionally, fairly often or very often by
each person. Differences between sub-
groups of each sociodemographic vari-
able were evaluated using analysis of
variance.
Additional assessment of validity
used multivariate, least-squares regres-
sion to identify oral status and socio-
demographic factors that were signifi-
cantly related to both the OHIP-49 and
the OHIP-14 scores for dentate per-
sons. Models were constructed separ-
ately for each depetident variable by iti-
corporating all clinical and sociodetno-
graphic variables used previously in this
study. The clinical variables were;
number of missing teeth (anterior and
posterior); number of unreplaced
spaces (anterior atid posterior); number
of decayed surfaces (coronal and root);
number of teeth with occlusal attrition
to dentin; number of retained roots;
maximutn periodontal recession; maxi-
mutn periodontal probing depth; and
maximum periodontal attachtnent loss.
Sociodemographic variables were; age;
sex; country of birth; period since last
dental visit; usual reason for dental vis-
its; site of last dental visit; perceived
need for dental treatment; difficulty
paying a AUD 100 dental fee; living
alone; educational attaintnent and
household income. Variables which
were not statistically significant (F-test,
P>0.05) were then eliminated from the
model until a final model of significant
first-order tertns was obtaitied.
The validation process was replicated
by computing new summary scores that
took advantage ofthe full range of cod-
ed responses to OHIP questions. The
method has beeti described previously
(4), and it permitted calculation of stan-
dardized OHIP scores. For all 49 ques-
tions, coded responses (ranging frotn 0
to 4) within each dimension were
multiplied by previously developed
weights, obtained using Thurstone's
method of paired comparisons. The
weights reflected population judgments
about the relative unpleasantness of
each impact. The sutn of the products
within each ditnension represented sub-
scale scores which were then standard-
ized to a common mean and standard
deviation (1.0±1.0), and summed to
produce a standardized score for each
subject. For the 14 items, new weights
were computed from the same data set
of popvtlatioti judgments about the rela-
tive unpleasantness of impacts. The
weights represented the proportion of
people who judged the impact within
each ditnension as more unpleasant
than the other impact in that dimen-
sion. Coded responses to each question
were multiplied by the weights and the
products were added to produce seven
subscale scores that were standardized
(1.0±1.0) and sumtned.
Results
Three of the OHIP-49 questions (Q17,
Q18 and Q30) referred to denture-
related disorders, while seven other
questions were left blank or marked
"don't know" by at least 5% of respon-
dents (Table 1). Consequently, those 10
questions were excluded from the set
for consideration in the short fortn. For
the remaining 39 questions, the preva-
lence of reported impacts (at the thresh-
old of occasionally, fairly often or very
often) ranged from 73.7% (Q7) to 1.6%
(Q48) and the severity scores ranged
frotn 1.96 (Q7) to 0.06 (Q48) (Table 1).
Internal reliability for the 39 ques-
tions was very high (a=0.94) and could
be improved only to the third decimal
place by deletion of individual ques-
tions. Furthermore, reliability was
moderate or high among questions
within the seven conceptual dimensions
(0.66 to 0.89) and could not be im-
proved substantially by deletion of
questions. Correlations between the
sum of coded responses to all OHIP
questiotis atid the individual coded re-
sponses were all statistically signifieant
(P<0.0\) and Pearson's correlation co-
efficients ranged from 0.27 (Q12) to
0.74 (Q36).
Factor atialysis revealed one princi-
pal cotnponent with an eigenvalue of
15.1 that accounted for 69.2"/i of varia-
tion, and an additional three principal
components that had eigetivalues ratig-
ing frotn 1.5 to 1.9. Thirty-two of the
OHIP questions had factor loadings
that exceeded 0.4 for the first rotated
factor. Factor loadings for the ques-
tions with the 14 highest loadings (0.64
or more) are presented in Table 1 (col-
umn headed "Factor loading"). The
high-loading questions ranged in preva-
lence frotn 11.8% (Q34) to 1.6% (Q48)
and severity ranged from 0.40 (Q34) to
0.06 (Q48). This set of 14 questions was
dominated by the two disability dimen-
sions and the handicap dimension.
In the default stepwise regression
procedure, in which the sutn of coded
responses to all OHIP questions was the
dependent variable, the first seven ques-
tions selected (Q23, QI5, Q35, Q20, Q6,
Q9, Q2) had a total R- of 0.92,
although they did not include questions
from the physical disability, soeial dis-
ability or handicap ditnensions (Table
1). After including the next seven ques-
tions, the total R-^ increased to 0.96,
and the set of 14 questions included at
least one from each dimension. The
prevalence of the 14 questiotis ranged
from 34.1% (Q12) to 2.2%, (Q43) and
severity scores ranged frotn 0.91 (Q12)
to 0.10 (Q43) (Table 1). Although not
shown in Table 1, Cronbach's a for this
set of 14 questions was 0.88.
In the controlled stepwise regression
procedure, in which entry into the mod-
el was litnited to two questions frotn
each ditnension, the 14 itetns ranged in
prevalence frotn 33.1%) (Q15) to 1.6%
(Q48) while severity ranged frotn 0.97
to 0.06 (Q48) (Table 1). The total R^ for
this set of 14 questions was 0.94. Eleven
of the questions were identical to the
questions obtained using the default
method of selection. Cronbach's a for
this set of 14 questions was 0.88.
The set of 14 questions from the con-
trolled selection procedure was used to
compute OHIP-14 scores, indicating
that a mean of 1.64 questions were re-
ported occasionally, fairly often or very
often (Table 2). The corresponding
mean for the OHIP-49 score was 7.30.
In bivariate analysis, both sutntnary
seores varied consistently among sub-
groups of older adults in South Austral-
ia. Age group and sex differences in
OHIP-14 scores were stnall and statis-
tically tioti-significant, and the differ-
ences were similarly small and non-
significant using the OHIP-49. How-
ever, for subgroups defined by dentition
status, site of last dental visit, perceived
need for dental treattnent and financial
hardship, OHIP-14 scores differed by as
mueh as a factor of two, and the differ-
ences were statistically significant
{P<O.Ol). Those diffetences were of a
sitnilar magtiitude and were statistically
significant using the OHIP-49 (Table 2).
 Dcriyation and yalidatiott of short-Jorm OHIP 287

Table 1. Prevalence, means. factor analysis and regression analysis for 49 OHIP items
Sequential R- for;
Prevalence; % reporting item Severity:
% blank/ occasionally, fairly often or item Factor Default Controlled
Conceptual dimension and item don't know very often mean loading' selection- selection-^

Eiitictiotuil litititation
Ql Difficulty chewing 1.2 32.8 1.03
Q2 Trouble pronouncing words 1.3 11.7 0.38 0.016 0.016
Q3 Noticed tooth that doesn't look right 9.5 18.2 0.60 *
18.3 0.58 * *
Q4 Appearance affected 4.6
22.1 * *
Q5 Breath stale 6.1 0.70
Q6 Taste worse 2.7 10.5 0.34 0.032 0.032
Q7 Food catching 0.7 73.7 1.96
10.8 * *
Q8 Digestion worse 5.4 0.37
29.0 0.88 * *
Q17 Dentures not fitting 3.1
Physieal poiti
Q9 Painful aching 0.5 23.8 0.74 0.024 0.024
QIO Sore jaw 1.6 16.5 0.49
4.5 * *
Qll Headaches 7.8 0.15
Ql2 Sensitive teeth 2.5 34.1 0.91 0.004
Ql3 Toothache 3.4 22.2 0.71
QI4 Painful gums 2.3 29.4 0.85 0.008
Q15 Uncomfortable to cat 0.8 33.1 0.97 0.14 0.14
Q16 Sore spots 1.1 44.6 1.18
22.2 0.71 *
Q18 Discomfort (dentures) 2.5
Psychological discotnfort
Qi9 Worried ' 2.7 24.6 0.82 0.007
Q20 Self-conscious 1.0 17.2 0.55 0.057 0.057
Q21 Miserable 1.6 14.5 0.50
Q22 Appearance 1.2 15.6 0.49
Q23 Tense 1.2 12.1 0.42 0.56 0.56
Physical disability
Q24 Speech unclear 2.8 12.7 0.39
Q25 Others misunderstood 7.8 10.7 0.33 *
Q26 Less flavor in food 3.7 9.0 0.31 0.64
Q27 Unable to brush teeth 2.1 8.6 0.29
Q28 Avoid eating 0.7 27.3 0.80
Q29 Diet unsatisfactory 1.2 4.2 0.20 0.003
Q30 Unable to eat (dentures) 1.4 11.8 0.43 *
Q31 Avoid smiling 1.6 8.6 0.29
Q32 Interrupt meals 0.8 15.1 0.48 0.004 0.004

Psychological disability
Q33 Sleep interrupted 1.2 7.7 0.29
Q34 Upset 0.7 11.8 0.40 0.69
Q35 Difticult to relax 0.7 8.1 0.31 0.75 0.087 0.087
Q36 Depressed 0.7 7.4 0.27 0.76
Q37 Concentration affected 2.1 4.2 0.19 0.78
Q38 Been embarrassed 0.7 13.2 0.44 0.005 0.006

Soeial disability
Q39 Avoid going out 0.2 3.7 0.12 0.74
Q40 Less tolerant of others 2.2 4.3 0.16 0.73
Q41 Trouble getting on with others 1.6 1.7 0.09 0.75
Q42 Irritable with others t.5 4.8 0.18 0.70 0.002
Q43 Difficulty doing jobs 1.2 2.2 0.10 0.68 0.007 0.007

Hatidleap
5.3 0.19 *
Q44 Health worsened 4.7
Q45 Financial loss 2.5 6.7 0.20
Q46 Unable to enjoy people's company 0.8 4.3 0.17 0.77
Q47 Life unsatisfying 1.2 7.6 0.26 0.71 0.011 0.011
Q48 Unable to function 0.7 1.6 0.06 0.65 0.001
Q49 Utiable to work 1.3 1.8 0.10 0.64

' 14 questions with highest factor loadings on first rotated factor.

- 14 questions selected to maximize increase in total R^.
-^ 14 questions selected to maximize increase in total R-, with no more than two items per dimension permitted to enter the model.
* Question excluded because it applies only to denture wearers or because of high non-response.
288 SLADE

Table 2. Mean nuinber of OHIP-49 and QHIP-14 items for South Australians aged 60-1- yrs

No. of items reported occasionally,

fairly often or very often
OHIP-49 OHIP-14
Group n mean (SD) mean (SD)
All persons 1217 7.30 (7.75) 1.64 (2.44)
Age 60-69 yrs 576 7.74 (7.83) 1.75 (2.53)
70-79 yrs 473 6.99 (7.66) L56 (2.37)
80-t- yrs 168 6.67 (7.68) 1.51 (2.30)
P-value 0.16 0.33
Sex Male 646 7.54 (7.87) 1,68 (2.51)
Female 571 7.02 (7.60) 1.60 (2.36)
P-valuc 0.24 0.57
Dentition Dentate 905 6.89 (7.37) 1.44 (2.28)
Edentulous 312 8.47 (8.66) 2.20 (2.77)
P-value <O.OI <0.01
Site of last dental visit Private dentist 962 6.43 (6.81) 1.37 (2.12)
Public clinic 245 10.67 (10.01) 2,69 (3.23)
P-value <0.01 <0.01
Perceived need for dental treatment Yes 325 10.82 (9.72) 2.68 (3.11)
No 850 5.93 (6.34) 1.23 (1.96)
P-value <0.01 <0.01
Finaticial hardship; difficulty paying None/hardly any 808 6.47 (6.64) L39 (2.09)
AUD 100 dental fee A littlc/a lot 390 9.12 (9.49) 2.19 (2.99)
P-value <O.OI <0.01

Clinical and sociodemographic fac-
tors that were associated with OHIP-49
and OHIP-14 scores for dentate people
are summarized in the multivariate re-
gression analysis (Table 3). There were
three clinical factors and four noti-
clinical factors that met the criteria for
model building (P<0.05) when OHIP-
49 was the dependent variable. The
same factors remained signifieant when
the OHIP-14 was the dependent vari-
able, and in addition country of birth
was significant (^=0.04) in that model.
Table 4 presents the 14-OHIP ques-
tions obtained from the controlled se-
Table 3. Multivariate least-squares regression models for 716 dentate persons aged 60-1- yrs
no. of items reported occasionally.
Explanatory variable
No. of missing anterior teeth
No. of missing unreplaced anterior teeth
No. of teeth with attrition
No. of reported medical conditions
Attended public dental clinic*
Perceived need for dental treatment*
Age (yrs)
Born outside Australia
*Dummy variables coded 0=no, l=ycs.
lection procedure, along with the (P=0.05), although not significant
weights that refiect population judg- usitig the standardized OHIP-14 {P=
ments about the unpleasantness of each 0.07). Both indices yielded significant
pair of items within ditnensions. When differences (P<0.01) between other
the weights were used to compute sub- subgroups in Table 2. For the multivari-
scales and a standardized OHIP-14 ate analysis, 10 explanatory variables
score, the results were generally compa- were significant in a model using the
rable to the results obtained with the standardized OHIP-49 score as the de-
standardized OHIP-49. In the bivariate pendent variable, and all but one of
analysis, there were non-significant dif- thetn (financial hardship, P=0.12) were
ferences amotig age groups using both significant when the standardized
the statidardized OHIP-49 {P=O.IO) OHIP-14 score was the dependent vari-
and the standardized OHIP-14 (P= able.
0.33). However, sex differences were
significant using standardized OHIP-49
Discussion
Of the three statistical methods that
were explored in order to derive a sub-
set of OHIP questions, internal reliabil-
Dependent variable;
ity analysis and factor analysis yielded
fairly often or very often the least satisfactory results. This can
OHIP-49 OHIP-14 be attributed to the tnoderate or high
correlation that each item had with the
F P F P
overall OHIP score. Cronbach's a, used
31.1 <0.01 30.0 <O.OI in internal reliability analysis, is a sutn-
11.8 <0.01 9.0 <0.01 mary statistic which captures the extent
15.7 <0.01 II.O <0.01
of agreetnent between all possible sub-
12.5 <0.01 5.7 0.01
14.2 <0.01 11.2 <0.01 sets of questions, and conseqtiently
32.8 <0.01 29.8 <0.01 high intercorrelations tneant that the
12.0 <0.01 5.3 0.02 OHIP had very high a values which
3.0 0.09 4.4 0.04 could not be substantially itnproved by
R'=0.19 R2= =0.17
deletion of items. High intercorrelation
also appeared to be the teason that only
 Deriyalion and yalidatiott of short-form OHIP 289

Table 4. Questions and weights for the OHIP-14* health concepts with a range of preva-
Weiaht
lences for the short-form OHIP, the
Dimension Question
method of factor analysis was foutid to
Functional Have you had trouble protiouticing any ^vords because of problems with be unsatisfactory.
limitation your teeth, mouth or dentures? 0.51
Regression analysis resulted in selec-
Have you felt that your seti.se of taste has worsened because of problems
with your teeth, mouth or dentures? 0.49 tion of itetns that had a greater range
in prevalence atid severity compared
Physical Have you had paltiful aching in your mouth? 0.34
pain Have you found it uticottifortable to eat any foods because of problems
with the range obtained with factor
with your teeth, mouth or dentures? 0.66 analysis. With the default regression
Psychological Have you been self-cotiscious because of your teeth, mouth or dentures? 0.45 procedure, an R- value of 0.92 could be
discomfort Have you felt teii.se because of problems with your teeth, mouth or obtained with only seven variables,
dentures? 0.55 although those itetns (Table 2, R- of
Physical Has your diet been unsatisfactory because of problems with your teeth, 0.016 or greater) excluded the physical
disability mouth or dentures? 0.52 disability, social disability and handicap
Have you had to interrupt ttieols because of problems with your teeth, ditnensions. However, when 14 vari-
mouth or dentures? 0.48 ables were selected by the default tneth-
Psychological Have you found it difftatlt to relax because of problems with your teeth, od, at least one item from each concep-
disability mouth or dentures? 0.60
tual dimension was included, with a
Have you been a bit etiiborras.sed bec-dwx of problems with your teeth, small increase of R- to 0.96. By control-
mouth or dentures? 0.40
litig the process, it was possible to retaiti
Social Have you been a bit irritable with other people because of problems with
0.62 two items frotn each ditnension with
disability your teeth, mouth or dentures?
Have you had difficulty doittg your usual jobs because of problems with only a small reduction in R- to 0.94.
0.38 At first appearance, there is little to
your teeth, mouth or dentures?
Handicap Have you felt that life in general was le.ss .satisfying because of problems distinguish between the subsets of 14
0.59 items obtaitied usitig the default selec-
with your teeth, motith or dentures?
Have you been totally utiable tofittictioti because of problems wilh your tion procedure atid the controlled selec-
teeth, mouth or dentures? 0.41
tion procedure. The subsets have 11
* Responses are made on a 5-point scale, coded O = ncvcr, l=haidly ever. 2 = occasionally 3 = itetns in cotntnon, both account for
fairly often, 4=very often. Within each dimension, coded responses can be multiplied by more than 9O'Mi of variation in total
weights to yield a subscale score. OHIP scores, and both have excellent
internal reliability (a=0.88). However,
closer inspection reveals that the con-
one principal component dominated the pattern of responses indicating that trolled regressioti procedure yielded
the factor analysis. This interpretation little distitiction was tnade between di- more questions that had low prevalence
is based on the finding that there was a tnensions of oral ill-health that manifest (six questions reported by lO'/o or less
very rapid reduction in eigenvalues for as dysfunction, pain, disability or hand- of people) cotnpared with the default
the second and subsequent principal icap. While this result could be used as procedure (three questions with preva-
cotnponents, corresponding to the "el- justification for the selection of the 14 lence of 10% or less).
bow" in the scree plot of eigenvalues. highest-loading factors to represent a The prevalence of items within a bat-
This elbow represents a useful criterion unidimensional index of social itnpact, tery of questions becotnes a critical fac-
for the selection of principal compo- the factor loadings in Table 1 indicated tor when the precision of the index is
nents for subsequent rotatioti (16). that a large nutnber of conceptually itn- evaluated within different populations.
While some researchers advocate use of portant items would be eliminated, in- Precision refers to the ability of an
all principal components that have ei- cluding all of the pain, discomfort and itidex to discritnitiate betweeti sub-
genvalues greater than one (four of functional limitation itetns. In addition, groups. KESSLER & MROCZEK regard the
which were found in this analysis), that only items with relatively low preva- triad of precision, reliability and validi-
criterion was judged to be too arbitrary lences of 11.8% or less were selected ty as critical psychometric properties
in this itistance. with this method. These litnitations of for health status tneasures and they ar-
ATCHISON & DoLAN have reported a factor analysis as a tool for developing gue that it is itnportant to retain less
similar phenotnenon with the Geriatric indices of health status have been ob- frequently reported items in order to
Oral Health Assessment Index, where served by others. KAPLAN ct al. found diseritninate between subgroups frotn
only one principal component emerged that factors and items that contribute populations with high levels of disease
frotn their analysis of the 12 questions little to explaining variance in occur- or disability (for exatnple, some clinical
in that index (17). The results with the rence or frequency are considered unitn- populatiotis) (11). The short Ibrtns of
OHIP are consistent with that finding, portant in factor analysis (15). How- the MOS instrument illustrate this prin-
and indicate that there is one single ever, they reject this substitution of ciple; while the SF-20 had good reliabil-
construct underlying the responses to "variation in frequency for variation in ity and validity, it failed to show further
OHIP questions tnade by these older social itnportance" when developing decrements in a satnple of hospital pa-
adults. The construct could be interpre- health status indicators. Since it was tients who scored at the lowest levels of
ted to represent "oral ill-health", with deetned itnportant to capture multiple health in sotne subscales (13). This led
290 SLADE
to the development of the SF-36 which
included questions about more severe
levels of disability.
Precision has also been cited as an
important requirement for oral health
indices, since different subgroups may
have vastly different oral conditions,
and therefore experience impacts on
qualitatively different aspects of their
lives (18). In the current study, preva-
lence and severity scores have been de-
rived from a sample of independently
living older adults who generally are
free of severe oral disease. However,
questions with low prevalence in this
population would be reported more
frequently in subgroups of people with
more severe oral disease, and therefore
those questions diseritninate tnore ef-
fectively within those subgroups. For
example, when the OHIP-49 was ad-
ministered to a sample of dental pa-
tients aged 21-49 years with HIV in-
fection, their levels of social impact
were more than twice as high as the
levels reported by general dental pa-
tients (19).
The findings frotn the OHIP-14 indi-
cate that the items obtained from the
controlled selection method were as ef-
fective as the OHIP-49 items in de-
tecting differences among subgroups of
older South Australians. In some re-
spects, this should not be surprising,
since the 14 items were selected speci-
fically because they accounted for most
of the variance in the summed OHIP
responses. However, both the OHIP-14
and OHIP-49 (Tables 2 and 3) were
computed by counting the number of
items reported oecasionally, fairly often
or very often, and therefore they rely on
a threshold of reported itnpact. While
this measure is simple to compute and
interpret, it fails to take advantage of
the full range of responses to each ques-
tion. Furthertnore, the use of this
threshold probably contributes to "false
positive" reports (for example, an im-
pact that is rare, but which is incorrect-
ly reported at the "occasional thresh-
old"). For these reasons, standardized
scores are a preferred method for exam-
ining associations betweeti explanatory
factors and reported impact. Standard-
ized scores also utilize the weights re-
fiecting lay judgments about the severi-
ty of impacts. Nonetheless, when stan-
dardized scores were computed the
satne conclusion was reached - the 14
questions were effective in detecting the
same associations with clinical and
sociodemographie factors that were ob-
served using the 49 questions.
An important caveat in this study re-
lates to the use of a single source of
data for both derivation of a subset and
validation of that subset of questions.
Consequently, it will be important to in-
vestigate the reliability and validity of
the OHIP-14 in other populations.
Furthermore, not all research settings
will be concerned with cross-sectional
associations, and therefore it will be ne-
cessary to evaluate the perfortnance of
the OHIP-14 using other research de-
signs, such as longitudinal studies and
experimental trials. Nonetheless, these
cross-sectional findings provide encour-
aging results, suggesting that the OHIP-
14 has good statistical properties and
validity, with the obvious benefit that
the data could be collected with less
fieldwork effort and respondent burden.
In conclusion, a controlled regression
procedure permitted identificatioti of a
subset of 14 questions about the social
itnpact of oral disease that accounted
for 94% of variation in total OHIP
scores and which had an internal reli-
ability coefficient (a) of 0.88. Sutnmary
scores based on the OHIP-14 displayed
the satne pattern of variation among
sociodemographic groups that was ob-
served using the OHIP-49, and both the
OHIP-14 and the OHIP-49 resulted in
sitnilar tnultivariate models relating
oral status and sociodetnographic vari-
ables to social impact. The OHIP-14
contains questions that retain the origi-
nal conceptual ditnensions contained in
the OHIP, and those questions have a
good distribution of prevalences, sug-
gesting the instrument should be useful
for quantifying levels of impact on well-
being in settings where only a limited
number of questions can be adminis-
tered.
Acknowledgtnents - The author acknow-
ledges with gratitude the comments provided
by Dr Ronald Hunt and Dr Dan Shugars
during the preparation of this manuscript.
Original data for this analysis were collected
with financial assistance from the Australian
National Health and Medical Research
Council and the US National Institute of
Dental Research (Grant No. R0I-DE09588).
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