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Social Science & Medicine 59 (2004) 11091116

Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction
Yael Benyaminia,*, Howard Leventhalb, Elaine A. Leventhalc
b

Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv 69978, Israel Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 30 College Avenue, New Brunswick, NJ 089011293, USA c UMDNJ-Robert Wood Johnson Medical School, Gerontological Institute, CAB 2300, 125 Paterson St., New Brunswick, NJ 08903-0019, USA

Abstract Self-rated health (SRH) is a useful summary measure of peoples general health and was found to predict future health outcomes. Self-rated oral health (SROH) is a similarly useful summary measure of peoples oral health. Both are related to quality of life, especially at old age. The objectives of the study were: (1) to assess the independent contribution of SROH to concurrent and future SRH of elderly people, controlling for sociodemographics and health measures, and, (2) to assess whether SROH adds unique information not captured by SRH by testing their independent associations with self-esteem and life satisfaction. Participants were 850 residents of a retirement community (mean age 73) interviewed in their homes at baseline and 5 years later. The interview included single-item self-ratings of general and oral health, self-reports of medical history, recent chronic diseases, medication usage, functional disability, selfesteem and life satisfaction. Multiple regression analyses showed that SROH had an independent effect on concurrent and future SRH, controlling for age and other measures of health status. Both SRH and SROH independently explained a signicant amount of variance in concurrent ratings of self-esteem and life satisfaction. SROH has a unique role in peoples perceptions of their overall health yet is not fully captured by SRH. Therefore, it should be considered by general health care providers in their assessments of the health status of older adults. r 2003 Elsevier Ltd. All rights reserved.
Keywords: Oral health; Self-rated health; Self-assessment; Elderly; Self-esteem; Life satisfaction

Introduction Older persons well being is dependent, among other things, on their health and functional ability. Oral health is one of the domains of health that can affect functioning and hence the overall feeling of health. Oral health problems can result in pain and discomfort and lead to problems in eating, communication, and appearance, and consequently to embarrassment, social
*Corresponding author. Tel.: +972-3-6409075; fax: +972-36409182. E-mail addresses: benyael@post.tau.ac.il (Y. Benyamini), hleventhal@ihhcpar-mail.rutgers.edu (H. Leventhal), eleventh@umdnj.edu (E.A. Leventhal).

problems and low self-esteem (Cushing, Sheiham, & Maizels, 1985; Slade & Spencer, 1993), particularly among older adults (Locker, Matear, Stephens, & Jokovic, 2002; Smith & Sheiham, 1979; Tickle, Craven, & Worthington, 1997). In a review of the relationships between oral health, health, and health-related quality of life, Gift and Atchison (1995) concluded that: Oral health is an integral part of general health and contributes to overall health-related quality of life ywhen oral health is compromised, overall health and quality of life may be diminished. Oral health has generally not been assessed as a component of general health-related quality of life instruments (p. NS68). Indeed, investigations of oral health as a component of general health status, and in particular of self-rated

0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2003.12.021

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health (SRH), are not common. Since the mouth and teeth are parts of the whole person, it is conceivable that when they restrict functioning and create discomfort, they would also affect self-rated general health. The objective of the current study is to assess to what extent oral health plays a unique role in elderly peoples perceptions of general health, self-esteem, and quality of life. Specically, we examined the independent contribution of self-rated oral health (SROH) to concurrent and future SRH and to mortality in a sample of independently living older persons, controlling for other measures of health status. In addition, we tested the independent contributions of SRH and SROH to selfesteem and quality of life, controlling for demographics and other health measures. SRH, typically measured by a single question with a response scale of four or ve points, seems to be an integrative summary of ones status in many healthrelated domains. In the past two decades, multiple studies have assessed the relationship of SRH to future health outcomes such as morbidity and mortality, controlling for a variety of measures of medical status, and physical, social, mental, and cognitive functioning. Researchers have reported that SRH has independent effects on mortality (Benyamini & Idler, 1999; Idler & Benyamini, 1997), new morbidity (Ferraro, Farmer, & Wybraniec, 1997; M^ller, Kristensen, & Hollnagel, 1996), functional ability (Idler & Kasl, 1995; Kaplan, Strawbridge, Camacho, & Cohen, 1993), health care utilization and hospitalization (Mutran & Ferraro, 1988; Wolinsky, Culler, Callahan, & Johnson, 1994), and recovery from illness (Wilcox, Kasl, & Idler, 1996). Highly salient experiential factors such as physical symptoms, level of energy, and limitations in functioning, have the greatest impact on self-assessments of health (Benyamini, Leventhal, & Leventhal, 2003). Some of the factors affecting it account in part for its association with survival (e.g., function, medication usage, serious diseases) while other factors associated with SRH are unrelated to survival (e.g., mild diseases; Benyamini et al., 1999). Given that oral health problems could be very disruptive and are therefore highly salient to the person rating their health, it is likely that oral health would impact on self-rated general health. However, since most dental conditions are not lifethreatening, with the exception of oral neoplasms (Reisine, 1988), we would not expect self assessments of oral health to be related to mortality. Associations between self-perceptions of general health status and oral health have been reported in several studies (Dolan, Gooch, & Bourque, 1991; . Lundgren, Osterberg, Emilson, & Steen, 1995; Matthias, Atchison, Lubben, De Jong, & Schweitzer, 1995; Rosenberg, Kaplan, Senie, & Badner, 1988; Tickle et al., 1997). Poor oral health can be related to a variety . of diseases and medications (Norl! n, Ostberg, & Bjorn, e .

1991; Rosenberg et al., 1988), and limitations in physical functioning can be associated with poor oral health outcomes and hygiene (Atchison, Der-Martirosian, & Gift, 1998; Avlund, Holm-Pedersen, & Schroll, 2001; Jette, Feldman, & Douglass, 1993; Lundgren et al., 1995). Therefore, if diseases, medications, and physical limitations contribute both to poorer subjective oral health and they also contribute to poorer self-rated general health (Johnson & Wolinsky, 1994; Rakowski & Cryan, 1990), it is not surprising that these measures are correlated. However, in order to know whether SROH has a unique impact on self-rated general health, it is important to assess its independent contribution to SRH, controlling for age and additional measures of health status. We focused on a single-item global rating of oral health that has often been used in research (e.g., Jones et al., 2001; Locker et al., 2002; Matthias et al., 1993). It was found to be associated with measures of oral functional impairment and discomfort, as measured by more comprehensive subjective assessments of oral health (Atchison & Dolan, 1990). It is also related, though less strongly, to clinical dental measures (Matthias et al., 1995; Reisine, Fertig, Weber, & Leder, 1989). SROH was found to correlate with dentists ratings of oral health, even though dentists seemed to base their ratings more on clinical measures while their patients ratings were more closely related to subjective aspects of functioning (Atchison et al., 1993). Our rst aim was to assess whether SROH captures a unique component of SRH that is not captured by other health measures. We hypothesized that SROH would have an independent contribution to elderly peoples self-ratings of health, concurrently and 5 years later, controlling for socio-demographic measures, medical history, recent chronic diseases, limitations in functioning, and medication usage. We also examined the association of both SROH and SRH with mortality to determine whether SROH accounts for part of the association between SRH and mortality. Two studies reported that oral health predicted future mortality. In one of these studies self-reports of having four or fewer natural teeth were related to a greater mortality risk (Avlund et al., 2001). In the second, participants wearing dentures and those not wearing dentures but judged by dental examination as having a functionally inadequate dental status, were at greater mortality risk compared with those whose natural dental status was functionally adequate (Appollonio, Carabellese, Frattola, & Trabucchi, 1997). To the best of our knowledge, the mortality risk associated with self-rated global oral health status was not investigated. Our second aim was to assess whether SROH captures additional information that is not entirely incorporated into SRH. Both of these measures were found to be related to well-being, as indicated by self-esteem

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(Berkey, Call, & Loupe, 1985; Cott, Gignac, & Badley, 1999, for SRH and SROH respectively) and life satisfaction (Locker, Clarke, & Payne, 2000; Palmore & Luikart, 1972, for SRH and SROH respectively). We explored whether SRH and SROH each have an independent contribution to the self-esteem and life satisfaction reported by our study participants.

Self-rated oral health Close to the end of the interview, the participant was asked: How would you describe the overall condition of your teeth, dentures, or gums?. The same poor-toexcellent response scale was used. Medical history (disease diagnoses) Medical history was assessed by a detailed review of approximately 70 diseases from 19 illness categories, with open-ended probes for additional illnesses in each category. Six internists rated the mean severity of each disease, from a low of 1 if it were trivial to a high of 100 if it was extremely life threatening. The Cronbachs alpha reliability coefcient for these six ratings across 427 disease codes was 0.97. The judge-total correlation was high and similar for all six judges (ranging from 0.89 to 0.93). To determine weights for each illness, the highest and lowest physician rating were dropped and the remaining four ratings averaged. The mean range of these four ratings was 9.9 on the 100-point scale. An illness burden score was computed for each participant by summing the illnesses reported in his or her medical history, each illness weighted by its mean severity rating. Note that this measure takes into account the typical severity of each illness, not its severity as manifested in each individual respondent and therefore it is more crude than an actual physician examination of each participant. However, it is based on a very extensive review of the individuals medical history, and reported illnesses are weighted by their severity, a more elaborate procedure than is typically used when extracting medical history from self-reports. Recent chronic diseases In addition to the detailed medical history, participants were asked about the onset or are-up of illnesses in the past 3 months, which were coded by the interviewer and later by a physician as acute or chronic. Only the number of recent chronic illnesses was used in the current study. Note that all major illnesses were recorded in the medical history. If any of them had begun or ared-up within the 3 months preceding the interview, it was coded both in the medical history and the recent illness sections. Medication usage Medication usage was dened as the number of medications reported to be taken daily by doctors recommendation. Functional disability Functional disability was assessed with the following four items (a 0:71; all reliability coefcients reported are for the present sample): Does your health limit the kinds or amounts of: (a) vigorous activities you can do, such as running, lifting heavy objects or participating in

Methods Sample The sample consisted of 850 residents of a retirement community in the Northeast USA who participated in the Rutgers Aging and Health (RAH) Study, a longitudinal survey study of older adults (an additional participant of the RAH study was excluded because of missing data on SROH). Their mean age was 7377.50, 60% females, 61% married. The sample was predominantly White (99%) and well educated (81% had more than full high school education). Additional details about the characteristics of the sample and recruitment procedures were published elsewhere (Benyamini, Idler, Leventhal, & Leventhal, 2000). Of the original 850 participants, 525 (62%) took part in an interview 5 years later, 110 were deceased, 195 were traced alive, and mortality status could not be determined for 21, bringing the valid number for the analysis involving mortality down to 830 (a mortality rate of 13.3%). Procedure The longitudinal study included face-to-face annual interviews, which were mostly (95%) conducted in respondents homes, the remainder in the community clubhouse. The study objectives were described to each participant, who then signed a detailed consent form. Interviewers read all questions aloud and recorded the participants responses directly into the computer. The average duration for the baseline interview was 21 h: The 2 interviewers, advanced undergraduates and graduate students in psychology, sociology, and medicine, were trained by a board certied internist and geriatrician (EAL) on techniques for probing for medical conditions and recording medications. Measures Self-rated health The lead question in each interview asked for a rating of SAH: In general, would you say your health isy poor, fair, good, very good, or excellent? (1=poor, 5=excellent).

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strenuous sports or activities?; (b) Moderate activities you can do, such as moving a table, carrying groceries, bending or lifting?; Do you have any trouble: (c) walking one block, uphill, or a few ights of stairs?; (d) Eating, dressing, bathing, and using the toilet? (the response scale was from 1=not at all to 5=very much). A mean of the four items was computed. This 4-item scale was found to be highly correlated (r 0:84) with an 18item disability and activity limitations measure (see Johnson & Wolinsky, 1994 for this measure), assessed on a sub-sample of 522 of our participants 5 years post baseline. Self-esteem Self-esteem was assessed with the Rosenberg Self-Esteem Scale (Rosenberg, 1965), a 10-item measure of positive and negative aspects of self-esteem (a 0:87). The items were rated on a 4-point response scale from 1=disagree strongly to 4=agree strongly. Satisfaction with life Satisfaction with life was assessed using the following four items (a 0:73): (1) I am very satised with my life; (2) These are the best years of my life; (3) My life could be happier than it is now; and, (4) The quality of my life is poor (the latter two items were reverse coded). Items 2 and 3 were taken from a larger inventory of life satisfaction, the Life Satisfaction Index, which was validated in elderly populations (Neugarten, Havighurst, & Tobin, 1961); items 1 and 4 were designed for the RAH study. The items were rated on a 5-point response scale from 1=disagree strongly to 5=agree strongly.

Results Means, standard deviations, and intercorrelations among all study measures are shown in Table 1. SROH was correlated with SRH. Its correlations with other health measures were weak and only those with medical history and functional disability were signicant. There were no gender differences in SRH and SROH or in the correlation between them and other results were also generally similar in the two gender groups. Therefore, tests of gender differences are not reported. We conducted a hierarchical regression analysis predicting baseline SRH. Baseline measures were entered in three steps (see Table 2): (I) sociodemographics; (II) health status measures; and, (III) SROH. In line with our hypothesis, SROH alone added 5.4% to the variance explained in self-rated general health, after sociodemographics, medical history, recent chronic ares/onsets, medication usage, and functional disability were entered in the model. In addition, baseline SROH signicantly predicted SRH 5 years later, controlling for baseline SRH and all other baseline measures. Next, we examined mortality rates among people differing in their SROH. These self-ratings were combined into three groups: poor/fair (24% of the sample), good (39%), and very good/excellent (37%). Mortality rates in these three groups were 16%, 14%, and 11%, respectively. These differences were not signicant, indicating that SROH was unrelated to mortality in our sample. We conducted two additional regression analyses using baseline data to assess the independent associations of SROH and SRH with self-esteem and life satisfaction. Initially, all sociodemographic and health

Table 1 Zero-order correlations among study measures (N 850) Measure Self-rated health Self-rated oral health Medical history Recent chronic illnesses Medication Functional ability Self-esteem Mean SD Self-rated health Self-rated oral health 0.30 Medical history 0.37 0.08 Recent chronic illnesses 0.21 0.02 0.21 Medication Functional disability 0.42 0.06 0.53 0.16 0.47 0.12 0.35 0.18 0.39 Selfesteem 0.30 0.27 0.10 0.05 0.11 0.17 Life satisfaction 0.27 0.22 0.11 0.12 0.17 0.28 0.42 3.52 0.67

3.51 0.97

3.21 1.03

165.25 103.84

0.43 0.71

2.16 2.09

1.75 0.81

3.18 0.39

po0:05; po0:01; po0:001:

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Y. Benyamini et al. / Social Science & Medicine 59 (2004) 11091116 1113 Table 2 Summary of the hierarchical regression analyses predicting self-rated health from sociodemographics, health status indicators, and selfrated oral health Baseline measures Standardized regression coefcients Baseline (N=850) Step I Self-rated health Age Sex (high=male) Education Medical history Recent chronic illnesses Medication Functional disability Self-rated oral health R2
po0:05; po0:01; po0:001:

Year 5 (N=525) Step II 0.06 0.08 0.09 0.12 0.10 0.22 0.31 0.32 Step III 0.05 0.08 0.07 0.11 0.10 0.22 0.29 0.24 0.38 0.41 0.12 0.00 0.07 0.07 0.02 0.06 0.14 0.09 0.38

0.19 0.04 0.07

0.04

Table 3 Summary of the hierarchical regression analyses predicting selfesteem and life satisfaction from self-rated health and self-rated oral health (N 850) Standardized regression coefcients Measures Self-rated health Self-rated oral health Age Sex (high=male) Education Functional disability R2 Self-esteem 0.21 0.19 0.11 0.04 0.13 0.02 0.16 Life satisfaction 0.15 0.14 0.05 0.12 0.02 0.17 0.14

Note: additional health measures (medical history, recent chronic illnesses, and medication usage were omitted from the models because their effects were not signicant). po0:05; po0:01; po:001:

measures in the study were included in the model. However, since medical history, recent illnesses and medication usage were unrelated to either outcome, they were omitted from the models. The nal regression models are shown in Table 3. Though the overall amount of variance explained was not high, both selfratings, of general and of oral health, had signicant independent contributions of similar magnitude to selfesteem and life satisfaction.

Discussion SROH contributed to SRH of our elderly participants, beyond the contributions of demographics, medical history, recent chronic diseases or are-ups,

medication usage, and functional disability. Moreover, it also predicted future levels of SRH. It was weakly related to other health measures (i.e., medical history and functional disability) and unrelated to mortality in our sample, within the follow-up period of 5 years. Both SRH and SROH had similar independent associations with self-esteem and life satisfaction in our sample (these associations were signicant but not strong). These ndings raise the possibility that SROH should be included in the list of factors that are known to affect elderly peoples self-ratings of health. Similar to other factors that inuence SRH, it captures information that is highly salient to elderly people: It is related to peoples perceptions of themselves and their ability to function well and these perceptions are important when rating their health. In another study, elderly peoples ratings of the appearance of their teeth were found to be related to self-rated general health (Matthias et al., 1993). When older adults were interviewed in depth about the signicance of oral health in their lives, their responses clearly indicated that the discomfort and hygienic problems associated with the mouth were related to general health and present challenges with which they must cope (Macentee, Hole, & Stolar, 1997). Several researchers have concluded that oral health is an important part of health-related quality of life and hence of general quality of life (Gift & Atchison, 1995; Gift, Atchison, & Dayton, 1997; Reisine et al., 1989; Williams, Gadbury-Amyot, Krust Bray, Manne, & Collins, 1998), again attesting to its salience for older adults. At later years, many oral problems are chronic, related to general health problems, or co-occur with these problems. Oral health may symbolize, in a very concrete way, old age and its concomitantsfears of limited function, dependence, poor looks, discomfort and pain.

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There are many similarities between the self-ratings of general health and oral health: the measures share similar wording and use the same response scale. However, our ndings suggest that these similarities do not explain the association between them. In other words, the contribution of SROH to self-rated general health is not due only to a method effect. First, SROH contributed to future SRH even after baseline SRH was accounted for. Second, the associations of both self-ratings with self esteem and life satisfaction were independent of one another. Thus, SROH affects elderly peoples assessments of their overall health status, capturing unique information that is not included in measures of disease, functioning, and medication. However, it is not fully captured by SRH but rather adds unique information that is related to psychological well-being at old age. Each of these measures is a summary measure, which can be useful as a simple measure that integrates a wealth of information otherwise captured by a long list of questions (Benyamini et al., 1999; Locker & Jokovic, 1996). As Locker (1988) and Coulter, Marcus, and Atchison (1994) have noted, in oral health, similar to general health, there has been a movement from the biomedical paradigm, which equates health with the absence of disease, to more holistic models of illness, and consequently the measurement of health has moved towards more comprehensive, composite indicators and towards subjective measures, with increasing focus on patient-centered measures. Indeed, research shows that peoples views of their health are based on different factors than their physicians views (Hall, Epstein, & McNeil, 1989), and similarly people base their global self-ratings of oral health on different factors than those used by their dentists to rate the patients global oral health (Atchison et al., 1993). Both of these measures expand the view of health beyond disease and impairment: They tap the full illnesswellness continuum, measuring health in its broader sense (Benyamini et al., 2000; Locker, 1988). Matthias et al. (1995) also suggested that self-rated oral health is actually measuring health rather than morbidity, the general focus of clinical ratings (p. 203) and that in this sense it is a very useful measure, which captures important information that may be missed if only clinical measures are employed. Though these two measures are related, both contribute to the overall multi-dimensional assessment of health (Dolan et al., 1991) and also contribute independently to morale and life satisfaction, as reported in the current study and others (Locker et al., 2000, 2002). Limitations of the study and implications for future research Our study has several limitations. First, as noted above, our sample is not representative of the general

elderly population. Racial and ethnic differences in oral health have been reported before (Gooch, Dolan, & Bourque, 1989; Hunt, Slade, & Strauss, 1995), as have been socio-economic differences (Tickle et al., 1997). As noted earlier, dental status according to self-reports or to a dental examination predicted survival in other studies (Appollonio et al., 1997; Avlund et al., 2001). In our sample SROH was related to self-rated general health, as in other studies, but was not one of the factors that accounts for the association of self-rated general health with mortality. It is also possible that in more diverse samples, the relationship between SROH and diseases or survival would have been stronger: Our sample is relatively educated and afuent and therefore may have access to quality dental care. In addition, the mortality rate in our sample was not high over the 5year follow-up period (13%). In a frailer or more economically deprived sample, oral health might have a stronger association with mortality. Therefore, the generalizability of our ndings should be tested by replicating them in other populations. Such replications are also important in light of the fact that some of the associations found in the current study are signicant but not strong. Second, our study did not include clinical measures or examinations by physicians and dentists, and therefore the results pertain only to the associations found between self-reports of health. There is no way of knowing to what extent these self-reports correspond with our participants clinical general and oral health status. SROH is just one aspect of oral health (Gift et al., 1997). It is possible that other indicators of oral health are more closely related to participants medical history or to their survival. Future studies could benet from adding clinical measures of oral health and from exploring the effects of other self-reported measures, such as satisfaction with oral health (which was also found to be strongly related to more comprehensive measures of oral health-related quality of life; Locker, Matear, Stephens, Lawrence, & Payne, 2001). Conclusions and practical implications The results underscore the importance of attending to older peoples perceptions of their oral health not only in dental practices, but also by other health care providers. Older people should be encouraged to maintain good oral health practices. Dental care at old age could affect not only dental status, but also individuals sense of general health and therefore their well being. Indeed, dental care led to improvements in self-image and social interaction (Fiske, Gelbier, & Watson, 1990) and morale and self-esteem improved as a result of an intervention to promote oral self-care (Kiyak & Mulligan, 1987). In the latter study, selfreported health status also improved.

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Moreover, general and dental health behaviors seem to be related. Some of the connections between oral diseases and general diseases may be due to an accumulation of unhealthy habits (Ylostalo, Ek, Laitinen, & Knuuttila, 2003). Both SRH and SROH correlate with general adherence (Verweij, Oosterveld, & Hoogstraten, 1998). Positive oral health beliefs were found to be related to general SRH, and conversely lower value placed on preventive dental health practices was found among those reporting poor self-rated general health (Nakazono, Davidson, & Andersen, 1997). To conclude, it seems important for health care providers to inquire about their patients perceptions of their oral health as a routine part of their assessment of the patients general health status and to encourage them to adhere to dental health behaviors.

Acknowledgements This research was supported by Grant AG03501 from the National Institute on Aging. We thank Susan Brownlee and Frances Sisack for their assistance in this research.

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