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Objective@#To investigate the clinical efficacy and effects of periodontal endoscope (PE)-assisted subgingival scaling and root planning (SRP) and traditional SRP on the psychological and quality of life of patients with periodontitis.@*Methods@#This study was reviewed and approved by the Ethics Committee, and informed consent was obtained from the patients. Patients with periodontitis who were treated in the Department of Periodontology, Nanjing Stomatological Hospital, Medical School of Nanjing University from April 2018 to December 2022 with residual periodontal pockets (PD ≥ 5 mm) 6 weeks after traditional SRP treatment were enrolled, and the residual periodontal pockets were further treated with PE-assisted SRP (PE+SRP). After 6 weeks of traditional SRP treatment and 3 months of PE+SRP treatment, clinical indicators, including plaque index (PLI), probing depth (PD), clinical attachment loss (CAL) and bleeding on probing (BOP), were measured, and periodontal tissue self-awareness scale scores, oral health impact profile-14 (OHIP-14) score and dental fear scale (DFS) score were collected. Moreover, visual analog scale (VAS) scores were collected after traditional SRP and PE-assisted SRP treatments.@*Results@#Twenty-three patients with periodontitis, including 832 sites of 486 affected teeth, were included in the clinical study. Three months after PE+SRP treatment, all clinical periodontal indicators, PLI (t = 9.254, P<0.001), PD (t = 50.724, P<0.001), CAL (t = 22.407, P<0.001) and BOP (t = 9.217, P<0.001), were significantly improved. Compared with traditional SRP (VAS: 2.48 ± 1.70), the pain caused by PE+SRP (VAS: 2.57±1.80) was not significantly different (t = 0,192, P = 0.850). There was no significant difference in the scores of the periodontal tissue self-awareness scale between the two groups (t = 1.485, P = 0.152). The OHIP-14 (SRP: 12.13±7.63; PE+SRP: 10.26 ± 5.25, t = -1.589, P = 0.126) and DFS (SRP: 40.70 ± 12.63; SRP+PE: 41.57 ± 12.61, t = 0.404, P = 0.690) scores were not significantly different.@*Conclusion@#All clinical periodontal indicators were significantly improved after PE-assisted SRP treatment of residual periodontal pockets, and compared with traditional SRP, PE-assisted SRP had no negative impact on the quality of life or psychological status of patients with periodontitis. Therefore, PE+SRP can be promoted in clinical practice.
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Background: Dental caries is one of the most common dental diseases that affect all population and is associated with the avoidance of care. Research has reported that sense of coherence (SOC) is related to many aspects of health including oral health. SOC determines the quality of health and might have a direct association with the development of subjective assessments of oral health. Objectives: To find the association between SOC, Oral Health?Related Quality of Life (OHRQoL) and caries status among nursing college students in southern state of India. Design: Cross?sectional design using questionnaire and assessment of caries status. Participants: Nursing students from south India. Methods: Convenience sampling method was followed and students who were present on the day of the study and consented to participate were included in the study. The total study sample consisted of 494 nursing students. SOC and OHRQoL were measured by a self?administered questionnaire; caries status was assessed using Decayed, Missing and Filled Tooth (DMFT) index. Results: Association between SOC and Oral Health Impact Profile (OHIP) and caries status and OHIP was found to be statistically significant. Correlation between dental caries and OHIP was found to be statistically significant, with R?value –0.251 shows that OHIP is negatively correlated with caries status. Conclusion: SOC as a psychosocial resource is capable of facilitating the motivation for positive oral health behaviours. These resources along with socio?economic and demographic factors can create an environment that is partially responsible for the individuals’ cognitive and physical functions that can express themselves as the individuals’ well?being and positive health behaviours.
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Background: A quality of life (QoL) assessment tool needs to be translated and validated in the language of the participants to whom it is administered. Therefore, the oral health impact profile-14 (OHIP-14) scale, developed originally in English, has been translated into different languages like Hindi, Gujrati, etc. The Marathi version of OHIP-14 will be useful to assess in regions where the Marathi language is prominently spoken. Thus, the present study was carried out to translate and validate the Marathi version of the OHIP-14 instrument to measure the oral health-related quality of life. Aims & Objectives: To translate and validate the English Version of the OHIP-14 instrument in the Marathi Language. Materials and Methods: This was a descriptive cross-sectional study in which 128 participants were selected through a convenient sampling method. The English version of the OHIP-14 was translated using the forward-backward translation technique, and participants were given English and the Marathi versions of the OHIP-14 questionnaire. The filled questionnaires were subjected to statistical analysis. Result: The difference in mean scores was not statistically significant(p=0.828). Pearson’s correlation coefficient test was 0.999, suggesting that the translated Marathi version is highly correlated with the original English version. Conclusion: The Marathi version of OHIP-14 is a valid, and reliable instrument for assessing QoL among the population who speak Marathi.
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ABSTRACT: Oral ulcers cause high levels of impairment of the patients' quality of life. Therefore, patients having oral ulcers visit clinicians while seeking treatment. This study aims to investigate the extent of patients' suffering till reaching the correct clinician specialty, and therefore, proper diagnosis and treatment. The study included 62 diagnosed oral ulcer patients. They filled a questionnaire about previously visited clinicians and their specialties, causes of their referral and Oral Health Impact Profile-14 indicating their quality of life. The study revealed that participants visit a mean number of 2.93 clinicians before reaching a specialist. Furthermore, the number of the visited clinicians was positively correlated to the impact of the oral ulcer on quality of life. The study reflects the degree of unnecessary suffering of patients having oral ulcers due to unnecessary delay of diagnosis. It, thereby, highlights the necessity for higher awareness about Oral Medicine specialty among medical practitioners and among general population as well.
RESUMEN: Las úlceras orales y su diagnóstico tardío causan un nivel de deterioro significativo en la calidad de vida de los pacientes. Este estudio tuvo como objetivo investigar el nivel de sufrimiento de los pacientes hasta llegar a la especialidad clínica y lograr un diagnóstico y tratamiento adecuado. El estudio incluyó a 62 pacientes diagnosticados con úlcera oral. Los pacientes completaron un cuestionario sobre los médicos consultados previamente, las especialidades, las causas de su derivación y el Perfil de Impacto en la Salud Oral-14, que refleja su calidad de vida. El estudio reveló que los participantes visitaron una media de 2,93 médicos antes de consultar con un especialista. Además, el número de médicos visitados se correlacionó positivamente con el impacto que tiene la úlcera oral en la calidad de vida. El estudio refleja el grado de sufrimiento innecesario de los pacientes que presentan úlceras orales debido a un diagnóstico tardío. Por lo tanto, se destaca la necesidad de una mayor conciencia sobre la especialidad de medicina oral entre los médicos y también de la población en general.
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Expatriate workers are employed to work in various sectors in Saudi Arabia on a large scale. Even though various labour laws, schemes and policies are undertaken by the host country, oral health is not given the importance it deserves. This is reflected in factory workers having hidden adverse oral health issues which can hamper their working efficacy and, also their quality of life. In light of aforementioned we conducted this oral health status and treatment needs survey of factory workers in an industrial city of Jeddah, Saudi Arabia.METHODSThis was a cross-sectional survey study in which 119 males in the age group 18 to 64 years were included. World Health Organization (WHO) basic oral health survey form was used to extract data regarding the oral examination. The data were analysed using Chi-square test. P < 0.05 was considered statistically significant.RESULTSA significant association was seen between different age groups and mobility of teeth (p = 0.002), between education status and missing teeth (p = 0.032), between frequency of brushing and gingivitis (p = 0.009), between smoking habit and gingivitis (p = 0.000) and between smoking habit and missing teeth (p = 0 .010).CONCLUSIONThe results of the study showed that most of the factory workers had poor oral and dental health as a result of unawareness and lack of time to seek dental consultation. Primary oral health‑care programs like dental screening and oral health education at regular intervals should be made mandatory at factory premises, which will help them maintain their oral health, thus improving their quality of life.
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Introduction: Many factors of tooth loss will compromise chewing and general health and quality of life. Saudi populations demonstrate a high prevalence of caries and a striking increase in dmft/DMFT. Usually, tooth loss is rehabilitated by different prosthetic options including implant, fixed partial denture and removable partial denture. Aim: To evaluate the relation of oral health-related quality of life with the type of prosthesis and oral health status among patients who have removable or fixed partial dentures in King Saud bin Abdulaziz University for health science, college of dentistry. Material and methods: Cross-sectional study would be conducted at the College of Dentistry, King Saud bin Abdulaziz University (KSAUHS) and Dental Centre, KAMC, NGHA. Convenient sampling was carried out by selecting 109 patients from those who visited the dental clinic. Oral health status was captured using the DMFT index. The collected data were entered and analyzed by adapting the SPSS computer software. Result: The type and quality of prosthesis and its effect on the OHRQoL on patients showed no significant relation (p=0.459), but the duration of wearing of prosthesis showed significant relation (p=0.046). Regarding DMF total of (n=109), 61 had low DMF, 48 had high DMF witch was statically significant (p=0.02). Conclusion: At the end of this study we conclude that there were no significant impacts on quality of life in relation to the type of prosthesis. On the other hand, we found a significant relation with OHRQoL in function domain, esthetic part and oral health status.
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Background: The oral health impact profile-14 (OHIP-14) scale developed originally in English has been translated from time to time in different languages revealing to be valid and reliable instruments. Aim: The present study was carried out with an aim to translate and validate Hindi Version of OHIP-14 instrument among geriatrics to measure the oral health-related quality of life. Methodology: This was a descriptive cross-sectional study, which employed 400 individuals aged 60 years and above who were residents of Durg, Chhattisgarh India. Participants were selected through convenient sampling method. The English version of the OHIP-14 was translated into Hindi, pretested and subsequently administered to the participants by a trained interviewer. Each patient signed informed consent and responded to the Hindi version of the questionnaire. Result: Cronbach's alpha of the translated scale was 0.89–0.90 when words were deleted individually. Comparison of English and translated Hindi version of OHIP-14 by unpaired t-test showed no significant difference (P = 0.562). Pearson correlation coefficient test showed very strong positive correlation (0.892). Furthermore, a very strong positive correlation was observed between the recorded OHIP-14 scores and Decayed Missing Filled Teeth (DMFT) scores of examined geriatric individuals (Pearson correlation coefficient = 0.952 and P = 0.001). Conclusion: The Hindi translation of the OHIP-14 is a valid and reliable instrument to measure the oral health-related quality of life in older adults of India.
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Background: Oral submucous fibrosis is very common in Asia. It has many deleterious effects on individual's oral functions. Thus, there is a need to assess the effect of oral submucous fibrosis on quality of life. Objective: To assess the oral health-related quality of life (OHRQoL) in male subjects with oral submucous fibrosis. Methods: Two hundred and thirty male subjects in the age range of 20–40 years were recruited in the cross-sectional, two-group comparative study. Of 230 male subjects, 115 were oral submucous fibrosis subjects who were included in the study group and 115 healthy subjects formed the control group. English version of the oral health impact profile-14 (OHIP-14) was used to assess the OHRQoL. Wilcoxon signed-rank, Kruskal–Wallis, and Bonferroni tests were applied, and the P = 0.05 was considered as level of significance. Results: The mean and median OHIP-14 scores were 19.10 ± 0.66 and 18.00 in the study group and 3.98 ± 3.80 and 3.00 in the control group subjects, respectively (P < 0.001). Mean score of all the seven domains of OHIP-14 was significantly more in oral submucous fibrosis subjects (P < 0.001). All the oral submucous fibrosis subjects had one or more negative effects on OHRQoL compared to 64.34% of healthy subjects. Stage-4 of the oral submucous fibrosis had maximum effect on quality of life compared to other stages (P < 0.001). Conclusions: The quality of life among males is severely affected by oral submucous fibrosis, and Stage-4 of oral submucous fibrosis has maximum effect on the quality of life.
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Oral health of schoolchildren is a strong predictor of their overall well-being. This study was planned to assess and compare the objective and subjective parameters of oral health of South Indian school children. Methodology: Three hundred and sixty school children participated in this cross-sectional study. Their oral hygiene status, dental caries status, and treatment needs were assessed. Two questionnaires were filled by these children, to assess their oral health-related quality of life (OHRQoL) and their knowledge on oral health. Their academic scores were collected from the schools. Statistical analysis was done using Kruskal–Wallis ANOVA test and Spearman correlation test appropriately. Results: Children with no caries had better OHRQoL (P = 0.02). There was a negative correlation between dental caries status and OHRQoL score (P = 0.003) and dental caries treatment needs and OHRQoL score (P = 0.01). There was a positive correlation between knowledge on oral health and OHRQoL score (P = 0.02). Conclusion: Children with no caries had a better OHRQoL when compared to children with caries. Children with caries had more treatment needs, poor oral hygiene, low quality of life, and performed lesser in academics. However, they had adequate knowledge on oral health. Hence, both objective and subjective parameters of oral health should be given importance while treating children.
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This study examined 191 pregnant women before delivery in an obstetrics and gynecology clinic in North Gyeongsang Province from May to September 2016 by using a questionnaire after obtaining informed consent for voluntary participation in the study. The study was performed to investigate the association of depression with sociodemographic characteristics, pregnancy-related characteristics, social support, sleep quality and Oral Health Impact Profile (OHIP) in pregnant women. The prevalence of depression among the pregnant women was 25.1% in the healthy group and 74.9% in the depression group. The depression level was significantly higher in women in the depression group who were unsatisfied with their marriage life, had no occupation, had lower social support, had poor sleep quality and had higher OHIP scores. The results of the logistic regression analysis indicated that, the risk ratio for more severe depression was significantly higher in the group with no experience of miscarriage and induced childbirth than in the group with childbirth experience. Conversely, the risk ratio for more severe depression was significantly lower in the group with high social support than in the group with low social support. Depression in the respondents significantly positively correlated with sleep quality and OHIP score but significantly negatively correlated with social support. The multiple regression analysis revealed that the depression level was significantly higher by 22.3% among pregnant women with lower marital satisfaction, no childbirth experience, lower social support and higher OHIP scores. In summary, depression was related to marital satisfaction, childbirth experience, social support, and OHIP score, among others, in pregnant women in this study. Therefore, further investigation is warranted to construct programs and measures that will help build positive thinking by designing and verifying a three-dimensional study model by taking into consideration various variables to reduce the incidence of depression in pregnant women.
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Femenino , Humanos , Embarazo , Aborto Espontáneo , Depresión , Ginecología , Incidencia , Consentimiento Informado , Modelos Logísticos , Matrimonio , Obstetricia , Ocupaciones , Oportunidad Relativa , Salud Bucal , Parto , Mujeres Embarazadas , Prevalencia , Factores Sociológicos , Encuestas y Cuestionarios , PensamientoRESUMEN
The purpose of this study was to analyze the relationship between objective oral health status determined by dentists, self-perceived subjective oral health status, and oral health related quality of life (OHRQoL) in the elderly. The related factors affecting OHRQoL in the elderly were also surveyed. Four hundred and thirty elderly individuals who visited the three public health centers and four dental clinics in Busan were selected by convenience sampling. Twelve dental hygienists investigated the subjective oral health status and OHRQoL using the 14-item Oral Health Impact Profile (OHIP-14) and twentyone dentists examined the objective oral health status, including healthy remaining teeth, treated remaining teeth, functional remaining teeth, missing teeth, and non-treated missing teeth. Data were analyzed using SPSS ver. 12.0. OHRQoL was higher when oral and periodontal status was perceived as healthy, when there was no toothache, no interference in mastication, and when study subjects had the ability of food softening. It was also higher when study subjects had ≥20 remaining teeth and <9 missing teeth, and were wearing denture. The related factors affecting OHRQoL of the elderly were the type of medical insurance, toothache, ability of food softening, perception of periodontal status, and the number of healthy remaining teeth. There was a significant relationship between the subjective-objective oral health status and OHRQoL in the elderly. A continuous oral health care system aimed at retaining ≥20 healthy remaining teeth is needed to improve oral health and OHRQoL for the elderly, especially for the elderly receiving medical aid.
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Anciano , Humanos , Clínicas Odontológicas , Higienistas Dentales , Odontólogos , Dentaduras , Seguro , Masticación , Salud Bucal , Salud Pública , Calidad de Vida , Diente , OdontalgiaRESUMEN
This study examined the relationship between oral health behaviors and in senior citizens to determine how to improve their happiness index. The subjects in this study were 260 senior citizens aged 65 years or older, who resided in North Jeolla Province. A survey was conducted from June 17 to 30, 2016. The happiness index of elderly people who brushed their teeth more often and had dental checkups on a regular basis was significantly higher (p<0.05). Evaluation of subfactors associated with quality of life related to oral health showed significant differences in functional disturbances according to gender, age, the presence or absence of a spouse, and the use or nonuse of dentifrice (p<0.05). Physical pain significantly varied with the presence or absence of a spouse, educational level, monthly mean allowance, and regular dental checkups (p<0.05); significant differences were found in psychological discomfort according to gender, tooth brushing frequency, and regular dental checkups (p<0.05). There were significant differences in declining physical capacity according to gender, age, educational level, and monthly mean allowance (p<0.05); waning mental capacity significantly differed with age, living alone or with another person, the presence or absence of a spouse, and regular dental checkups (p<0.05). The factors that influenced the happiness index in senior citizens were age, living alone or with another person, educational level, monthly mean allowance and the Oral Health Impact Profile score (p<0.05). The study showed that measures are needed to improve the quality of life and happiness index in elderly people, including the development of oral health programs for this population.
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Anciano , Humanos , Dentífricos , Felicidad , Morinda , Salud Bucal , Calidad de Vida , Esposos , DienteRESUMEN
OBJECTIVES: The purpose of this study was to analyze the OHIP-14 (Oral Health Impact Index) and EQ-5D (health-related quality of life) scores for women in some areas, and to provide basic data as the basis for oral health and systemic health-related quality of life methods improving. METHODS: The subjects included 418 women aged 20-65 years, living in Busan and Gyeongnam between July 20 and September 30, 2014. RESULTS: OHIP-14 and EQ-5D scores increased with age and educational level; scores were lower in subjects with systemic disease and those with a non-professional occupation. Increased oral health awareness and recognition are both bad health, menopause oral health in one person was related to quality of life, and health-related quality of life scores were significantly lower (P<0001). When considering the oral care OHIP-14 score for more than a year and a time in the scaling 56.07 points, if not receiving was found as a factor affecting the OHIP-14 with 53.33 points (P<0.05), OHIP-14. Higher EQ-5D indicated a significant difference (P<0.001). The OHIP-14 score for factors affecting oral health behavior, depression score, menopause, dry mouth, monthly income, presence of systemic disease, and dentures showed a significant difference for body weight (P<0.01). Significant differences in EQ-5D scores were found for systemic diseases, subjective general health, depression score, and menopause score (P<0.01). CONCLUSIONS: OHIP-14 and EQ-5D will be helpful in the development of oral care and oral health education programs for women.
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Femenino , Humanos , Peso Corporal , Dentaduras , Depresión , Educación , Menopausia , Boca , Ocupaciones , Salud Bucal , Calidad de VidaRESUMEN
El aislamiento geográfico y condiciones medioambientales hacen a la población de Juan Fernández altamente vulnerable, siendo relevante conocer la calidad de vida relacionada con salud oral. Se realizó un estudio transversal en 137 habitantes mayores de 14 años. Se aplicó OHIP-14 para medir calidad de vida relacionada con salud oral previo consentimiento informado. El análisis estadístico fue realizado STATA 12.0. Un 51,8% es población femenina, con una edad media de 42,26 (DE 16,5). Un 91,97%, percibe que la salud oral afecta su calidad de vida, siendo levemente mayor en mujeres. Las molestias psicológicas son una manifestación en 80,29% de los encuestados. Un 75,91% percibe incomodidad por dolor en su boca, 62,77% manifiesta problemas de incapacidad psicológica. Existe mayor impacto en la calidad de vida relacionada con salud oral a medida que aumenta la edad. Por cada año de vida, el valor del OHIP-14 aumenta 0,07 (IC:95% 0,040,1). Los resultados obtenidos sugieren la necesidad de generar políticas públicas que consideren la salud oral desde una perspectiva integral, con énfasis en poblaciones altamente vulnerables considerando la mejora en la calidad de vida como un resultado a esperar
Geographic isolation and environmental conditions make the population of Robinson Crusoe Island, in the Juan Fernández archipielago highly vulnerable. It is therefore relevant to know the quality of life related to oral health (QOLRTO). In this report a cross sectional study in 137 inhabitants over 14 years of age was carried out. OHIP-14 was applied to measure QOLRTO, after informed consent was obtained. Statistical analysis was made in STATA 12.0. The population is 51.8% female, mean age 42.26 (SD 16.5) being similar in both sexes. Of the subjects studied, 91.97% perceived that oral health affects their quality of life, being slightly higher in women. Psychological distress was a manifestation in 80.29% of subjects, while 75.91% perceived discomfort and mouth pain, and 62.77% reported psychological disability issues. There is a greater impact of oral health issues with increasing age. For each year of life, the value of the OHIP-14 increased 0.07 (CI 95%, 0.04 to 0.1). The results suggest that public health policies that include a comprehensive oral health perspective, with emphasis on highly vulnerable populations should be considered
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Adulto Joven , Calidad de Vida , Salud Bucal , Modelos Lineales , Chile , Factores Sexuales , Estudios Transversales , Encuestas y CuestionariosRESUMEN
OBJECTIVES: The aim of this study was to determine the association between oral health status and oral health impact profile (OHIP-14) among patients undergoing treatment in a dental hospital, in order to develop an oral health care method for improving oral health related quality of life (OHRQoL). METHODS: A total of 980 patients aged 7-89 years were selected from a dental hospital between May 2011 and March 2014. Questionnaires on oral health impact profile (OHIP-14K) were distributed to the patients, and their dental records were examined to find out their oral health status. RESULTS: OHIP-14 scores of patients with periodontal pockets over 4 mm and presence of chronic general disease were significantly higher than those without pockets and chronic disease (P<0.05). Factors such as age, gender, having prosthesis or dental implant, regular oral health care over a period of 1 year were not significantly associated with OHIP-14 scores. CONCLUSIONS: Periodontal health status and chronic general disease could be factors associated with OHRQoL. Thus, improving oral symptoms through professional oral care may help improve OHRQoL.
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Humanos , Enfermedad Crónica , Implantes Dentales , Registros Odontológicos , Corea (Geográfico) , Salud Bucal , Enfermedades Periodontales , Bolsa Periodontal , Prótesis e Implantes , Calidad de Vida , Encuestas y CuestionariosRESUMEN
Aim: To assess the oral health related quality of life(OHQoL) of a selected population of Malaysian adults andto compare the OHQoL by periodontal status. Material& Methods: This cross-sectional study comprises aconvenient sampling of fifty subjects from the PrimaryCare Unit, Faculty of Dentistry, University of Malaya.OHQoL was assessed using the Malaysian versionof Oral Health Impact Profile-14 (OHIP-14). Basicperiodontal examination (BPE) was performed on allsubjects to determine their periodontal status. Descriptivestatistics and bivariate analysis were performed. Results:Psychological discomfort, physical pain and psychologicaldisability domains were the most affected dimensions inthis population. Subjects with income levels >RM2,500had higher impacts on their OHQoL as compared to thosefrom other income levels (p0.05). Conclusion:Subjects with high income levels had high impacts ontheir OHQoL. Those with periodontitis experiencedhigher impacts on their OHQoL as compared to those whohad a healthy periodontium or gingivitis and affected awide range of domains of quality of life.
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PURPOSE: This study assessed the impact of self-reported periodontal health on the oral health-related quality of life among elderly Koreans. METHODS: Four hundred twenty one elderly Koreans in Seoul and suburban areas were selected with a cluster (institution) sampling method, and were requested to take oral examinations and finish questionnaires on the Oral Health Impact Profile-14(OHIP-14), and self-reported periodontal health status, such as periodontal symptoms, self-rated periodontal health and periodontal treatment need. As the dependent variable, OHIP-14 showed a positive skewed distribution (skewness: 1.17), we transformed to square-root form to apply parametric analyses. Bivariate analysis by t-test and ANOVA, and multivariate analysis with the two-level regression model accounting clusters were implemented. RESULTS: Mean age of the subjects was 74.6 years and 66.5% were women. Fourteen items of OHIP-14 were summarized to one factor explaining 78.6% of total variance and produced the Chronbach alpha coefficient of 0.92. Results from the multivariate model, adjusting for age, sex, type of institutions, ability to pay, and number of teeth present, showed significantly lower OHIP-14 with reporting less than 3 periodontal symptoms (p<0.0001), rating their own periodontal health as above average level (p=0.0144), and thinking they don't need any periodontal treatments in the near future (p=0.0148), than their counterparts. The intraclass-corrrelation estimated by the final model was 0.028. CONCLUSION: This study demonstrates a significant association between self-reported periodontal health status and the oral health-related quality of life.