Background
Oral health lead to serious health problems and have a negative impact on oral health-related quality of life. Oral health is known to be related to health conditions and stress, which may affect work performance. Dental pain has a considerable impact on quality of life and can lead to poor work performance [
1,
2]. Poor dental appearance and halitosis are related to psychological stress and depression and can make individuals reluctant to engage in social communication in the workplace, thus adversely affecting their work performance [
3,
4]. Significant oral symptoms and problems also adversely affect dietary lifestyle and nutrition intake [
5]. Individuals with oral problems may experience a decline in their oral health related quality of life [
6,
7].
Previous studies have reported that systemic health conditions and stress affect work performance [
8‐
10]. Since oral health is known to be related to health conditions and stress [
11‐
15], it also possibly affects work performance [
16,
17]. However, the impact of oral health on work performance has rarely been addressed. The economic impact of dental diseases on society encompasses both direct and indirect costs. The direct costs are attributed to dental treatment by dental professionals, whereas the indirect costs are attributed to time loss from work and activities due to dental problems and treatment [
18‐
20]. Early studies have demonstrated that $187.61 billion was lost worldwide in 2015 due to productivity loss, representing the time loss caused by the treatment of oral symptoms and diseases [
21].
Recent critical measures of poor work performance encompass absenteeism and presenteeism; absenteeism is defined as an absence from work due to a disease or an accident, whereas presenteeism is defined as the physical presence of workers with dysfunctional conditions induced by health problems in the workplace [
16]. In addition to work absenteeism, work presenteeism reduces work productivity [
22]. Although the association between oral health status and work presenteeism has been previously reported [
16,
17], few studies have examined the details of work participation, such as the type of productivity loss caused by oral health problems. As oral health has various functions, there is a possibility that poor oral health affects various types of work presenteeism. Determining the adverse effects of oral health problems on work performance will provide recommendations for reducing productivity loss due to oral health problems.
Therefore, the aim of this study was to examine the association of oral health status with various types of work problems. We hypothesized that oral health related work problems were prevalent among the workers with poor oral health status.
Results
Table
1 shows the descriptive distribution of oral conditions by age, sex, educational attainment, income, the presence of diabetes, and industrial classifications. The participants in this study included 3,930 (2,057 males and 1,873 females) workers. The mean age of the participants was 43.3 ± 11.7 years. Among the participants, 244 (6.2% of the total) reported that oral problems interfered with their work.
Table 1
Descriptive distribution of the oral conditions by age, gender, education, income, and systemic diseases (n = 3930)
Age |
Under 30 | 625 (15.9) | 23.5 | 17.9 | 14.7 | 14.8 | 7.0 | 9.4 | 17.0 | 20.8 | 18.2 | 13.9 |
30〜39 | 969 (24.7) | 30.3 | 27.0 | 24.8 | 20.4 | 20.4 | 17.1 | 25.9 | 28.9 | 27.8 | 22.0 |
40〜49 | 1011 (25.7) | 22.8 | 26.1 | 26.2 | 24.9 | 29.6 | 24.6 | 25.9 | 24.5 | 25.5 | 26.0 |
50〜59 | 888 (22.6) | 14.7 | 19.7 | 22.8 | 27.1 | 29.6 | 29.5 | 21.4 | 18.2 | 19.2 | 25.4 |
Over 60 | 437 (11.1) | 8.8 | 9.3 | 11.5 | 12.8 | 13.4 | 19.4 | 9.7 | 7.5 | 9.3 | 12.7 |
Sex |
Male | 2057 (52.3) | 45.3 | 50.3 | 53.4 | 54.6 | 54.9 | 62.5 | 50.7 | 56.0 | 51.8 | 52.4 |
Female | 1873 (47.7) | 54.7 | 49.7 | 46.6 | 45.4 | 45.1 | 37.5 | 49.3 | 44.0 | 48.2 | 47.6 |
Educational attainment |
1* | 1416 (36.0) | 30.3 | 27.2 | 37.1 | 42.9 | 53.5 | 45.9 | 34.4 | 52.2 | 36.8 | 34.2 |
2* | 839 (21.3) | 20.2 | 22.4 | 22.2 | 19.8 | 16.2 | 18.9 | 21.8 | 17.0 | 20.7 | 22.2 |
3* | 1675 (42.6) | 49.5 | 50.4 | 40.8 | 37.2 | 30.3 | 35.2 | 43.9 | 30.8 | 42.5 | 43.6 |
Income |
2 < million yen | 577 (14.7) | 11.7 | 12.8 | 15.0 | 16.9 | 16.9 | 15.1 | 14.6 | 18.9 | 15.6 | 13.7 |
2 ≥ to < 4 million yen | 1479 (37.6) | 37.1 | 35.5 | 38.2 | 38.7 | 39.4 | 39.1 | 37.4 | 39.0 | 37.9 | 37.3 |
4 ≥ to < 6 million yen | 810 (20.6) | 20.2 | 23.3 | 19.6 | 19.7 | 21.1 | 21.9 | 20.4 | 18.2 | 22.0 | 19.8 |
6 ≥ to < 8 million yen | 299 (7.6) | 9.8 | 9.7 | 6.0 | 7.6 | 7.7 | 8.9 | 7.4 | 8.8 | 6.7 | 8.2 |
8 ≥ million yen | 210 (5.3) | 4.6 | 6.3 | 5.7 | 4.6 | 1.4 | 4.1 | 5.6 | 1.9 | 3.9 | 6.7 |
Unknown | 555 (14.1) | 16.6 | 12.3 | 15.6 | 12.5 | 13.4 | 10.9 | 14.7 | 13.2 | 13.9 | 14.3 |
Diabetes |
Absence | 3806 (96.8) | 98.0 | 98.8 | 96.5 | 95.0 | 95.8 | 93.2 | 97.4 | 93.7 | 97.6 | 96.5 |
Presence | 124 (3.2) | 2.0 | 1.2 | 3.5 | 5.0 | 4.2 | 6.8 | 2.6 | 6.3 | 2.4 | 3.5 |
Industry |
Primary industry | 305(7.8) | 10.4 | 6.8 | 7.9 | 7.7 | 7.0 | 9.8 | 7.4 | 7.5 | 7.2 | 8.2 |
Secondary industry | 1097(27.9) | 24.8 | 26.6 | 28.5 | 28.8 | 31.7 | 29.7 | 27.6 | 33.3 | 27.8 | 27.6 |
Tertiary industry | 2528(64.3) | 64.8 | 66.7 | 63.6 | 63.5 | 61.3 | 60.5 | 65.0 | 59.1 | 65.0 | 64.2 |
Table
2 shows the prevalence (%) of oral health related work problems by oral status (
n = 3930). On average, 6.2% of the workers had experienced some influence on their work due to oral health problems in the past year. The most common problem was a reduced ability to concentrate at work. Generally, the participants with oral health problems tended to have work problems. The results of other variables are shown in Additional Table
5.
Table 2
Prevalence (%) of oral health-related work problems by oral status (n = 3930)
Total | 3930 (100.0) | 6.2 | 5.5 | 5.6 | 5.3 | 5.1 | 4.9 | 4.7 | 5.3 |
Self-reported oral health |
Excellent | 307 (7.8) | 3.9 | 3.3 | 3.3 | 2.9 | 2.9 | 2.0 | 2.3 | 2.3 |
Very good | 948 (24.1) | 4.6 | 4.0 | 4.1 | 4.1 | 4.1 | 3.6 | 3.0 | 3.9 |
Good | 1676 (42.6) | 3.9 | 3.5 | 3.6 | 3.5 | 3.3 | 3.2 | 3.2 | 3.6 |
Fair | 857 (21.8) | 10.6 | 9.2 | 9.7 | 9.0 | 8.2 | 8.2 | 8.4 | 8.9 |
Poor | 142 (3.6) | 21.8 | 20.4 | 20.4 | 19.0 | 18.3 | 19.0 | 18.3 | 19.0 |
Number of teeth |
19 or fewer teeth | 562 (14.3) | 12.6 | 11.4 | 11.2 | 11.2 | 10.9 | 11.2 | 11.9 | 10.9 |
20 or more teeth | 3368 (85.7) | 5.1 | 4.5 | 4.7 | 4.4 | 4.1 | 3.8 | 3.5 | 4.3 |
Bleed when brush teeth |
Always | 159 (4.0) | 22.6 | 19.5 | 19.5 | 19.5 | 18.2 | 18.9 | 17.0 | 18.9 |
Sometimes | 1607 (40.9) | 7.8 | 6.6 | 7.0 | 6.5 | 6.1 | 6.1 | 5.9 | 6.5 |
Never | 2164 (55.1) | 3.8 | 3.6 | 3.6 | 3.5 | 3.3 | 2.9 | 3.0 | 3.3 |
Tables
3,
4 and
5 show the results of the logistic regression analysis for the association between oral health status and work problems. The odds ratios of the presence of work problems and seven work problems were high for all oral health problems. Workers with poorer oral status tended to have all specific work problems.
Table 3
Logistic regression analysis of the association between self-reported oral health and work problems (n = 3930)
| Presence of work problems due to oral symptoms or diseases | Stress | Lack of focus | Lack of sleep |
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable |
| Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) |
| Very good | 1.20 (0.62;2.30) | 1.14 (0.59;2.20) | 1.24 (0.61;2.52) | 1.21 (0.59;2.47) | 1.27 (0.63;2.58) | 1.23 (0.60;2.52) | 1.42 (0.68;2.97) | 1.38 (0.66;2.91) |
Self-reported oral health | Good | 1.01 (0.54;1.89) | 0.92 (0.49;1.75) | 1.08 (0.55;2.14) | 1.03 (0.52;2.06) | 1.12 (0.57;2.21) | 1.07 (0.53;2.13) | 1.19 (0.58;2.42) | 1.13 (0.55;2.33) |
(Ref: Excellent) | Fair | 2.92 (1.58;5.41)* | 2.13 (1.12;4.04)* | 3.02 (1.54;5.90)* | 2.33 (1.16;4.66)* | 3.19 (1.63;6.22)* | 2.46 (1.23;4.91)* | 3.27 (1.62;6.60)* | 2.49 (1.21;5.14)* |
| Poor | 6.87 (3.41;13.84)* | 3.58 (1.70;7.56)* | 7.62 (3.60;16.15)* | 4.28 (1.93;9.51)* | 7.62 (3.60;16.15)* | 4.35 (1.97;9.63)* | 7.77 (3.55;17.04)* | 4.30 (1.87;9.86)* |
| Lack of energy | Lack of communication due to halitosis | Lack of communication due to appearance | Lack of ability to work due to dental-related pain |
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable |
| Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) |
| Very good | 1.42 (0.68;2.97) | 1.37 (0.65;2.88) | 1.87 (0.78;4.49) | 1.74 (0.72;4.22) | 1.30 (0.56;3.02) | 1.22 (0.52;2.84) | 1.74 (0.77;3.95) | 1.69 (0.74;3.86) |
Self-reported oral health | Good | 1.12 (0.55;2.30) | 1.05 (0.51;2.17) | 1.67 (0.71;3.92) | 1.50 (0.63;3.57) | 1.40 (0.63;3.11) | 1.30 (0.58;2.92) | 1.59 (0.72;3.52) | 1.53 (0.68;3.41) |
(Ref: Excellent) | Fair | 2.95 (1.45;5.97)* | 2.19 (1.06;4.55)* | 4.46 (1.92;10.38)* | 3.09 (1.30;7.34)* | 3.93 (1.79;8.64)* | 2.85 (1.27;6.42)* | 4.17 (1.90;9.15)* | 3.21 (1.43;7.18)* |
| Poor | 7.42 (3.38;16.32)* | 4.02 (1.75;9.28)* | 11.78 (4.74;29.27)* | 5.77 (2.22;14.96)* | 9.61 (4.06;22.74)* | 4.97 (2.00;12.32)* | 10.06 (4.26;23.75)* | 5.63 (2.29;13.86)* |
Even after accounting for the covariates, workers with poor oral health status tended to have a higher odds ratio for having work problems. Those with poor self-reported oral health were 3.58 (95% CI = 1.70;7.56) times more likely to have adverse work performance than those with excellent oral health after adjusting for the covariates. The odds ratio of 19 or fewer teeth compared to 20 or more teeth was 2.19 (95% CI = 1.60;3.01). The odds ratios of those who reported always and sometimes bleeding were 4.43 (95% CI = 2.75;7.12) and 1.76 (95% CI = 1.30;2.37), respectively.
Discussion
The results of this study showed that among the participants of 3,930 workers, 6.2% had experienced some degree of interference with their work because of oral symptoms in the past year (Table
2). Even after considering covariates, the results of the logistic regression analysis showed that workers who experienced poorer self-reported oral health, had fewer remaining teeth, and had frequent gum bleeding when tooth brushing, tended to have a higher odds ratio of less efficiency or problems performing their work than those without any oral health problems (Tables
3,
4 and
5). Consequently, the results of our study suggest that oral health is associated with various types of work problems. The present results are consistent with previous studies that showed the association between poorer oral health and worsened quality of life [
6,
14,
30], and between periodontal disease or tooth loss and quality of life [
31,
32].
Table 4
Logistic regression analysis of the association between the number of teeth and work problems (n = 3930)
| Presence of work problems due to oral symptoms or diseases | Stress | Lack of focus | Lack of sleep |
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable |
| Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) |
Number of teeth | 19 or fewer teeth | 2.67 (1.99;3.58)* | 2.19 (1.60;3.01)* | 2.74 (2.01;3.72)* | 2.23 (1.60;3.11)* | 2.55 (1.88;3.46)* | 2.08 (1.49;2.90)* | 2.77 (2.03;3.77)* | 2.26 (1.62;3.17)* |
(Ref: 20 or more teeth) |
| Lack of energy | Lack of communication due to halitosis | Lack of communication due to appearance | Lack of ability to work due to dental-related pain |
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable |
| Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) |
Number of teeth | 19 or fewer teeth | 2.85 (2.08;3.91)* | 2.34 (1.66;3.29)* | 3.20 (2.33;4.38)* | 2.59 (1.84;3.65)* | 3.70 (2.70;5.06)* | 3.10 (2.20;4.35)* | 2.69 (1.96;3.68)* | 2.20 (1.57;3.09)* |
(Ref: 20 or more teeth) |
Table 5
Logistic regression analysis of the association between gum bleeding and work problems (n = 3930)
| Presence of work problems due to oral symptoms or diseases | Stress | Lack of focus | Lack of sleep |
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable |
| Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) |
Bleed when brushing teeth | Always | 7.34 (4.77;11.30)* | 4.43 (2.75;7.12)* | 6.48 (4.12;10.19)* | 3.71 (2.24;6.12)* | 6.48 (4.12;10.19)* | 3.76 (2.28;6.19)* | 6.75 (4.28;10.63)* | 3.89 (2.36;6.44)* |
(Ref: Never) | Sometimes | 2.12 (1.59;2.81)* | 1.76 (1.30;2.37)* | 1.89 (1.40;2.55)* | 1.54 (1.13;2.11)* | 2.02 (1.50;2.72)* | 1.65 (1.21;2.25)* | 1.93 (1.42;2.61)* | 1.58 (1.15;2.17)* |
| Lack of energy | Lack of communication due to halitosis | Lack of communication due to appearance | Lack of ability to work due to dental-related pain |
| Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable | Univariable | Multivariable |
| Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) | Odds Ratio (95% CI) |
Bleed when brushing teeth | Always | 6.48 (4.07;10.33)* | 3.96 (2.37;6.63)* | 7.76 (4.85;12.41)* | 4.55 (2.71;7.66)* | 6.71 (4.14;10.88)* | 3.71 (2.17;6.35)* | 6.76 (4.26;10.72)* | 3.91 (2.35;6.50)* |
(Ref: Never) | Sometimes | 1.89 (1.38;2.58)* | 1.59 (1.15;2.21)* | 2.17 (1.57;2.99)* | 1.78 (1.27;2.50)* | 2.06 (1.49;2.85)* | 1.63 (1.16;2.29)* | 2.03 (1.49;2.76)* | 1.65 (1.20;2.27)* |
Regarding the impact on work performance, a previous study evaluating absenteeism and presenteeism due to oral health problems reported a negative association between oral health problems and work performance [
16]. However, significant presenteeism was reported due to the presence of periodontal diseases (over 4 mm deep periodontal pockets) with an odds ratio of 2.011 [
16]. In this study, we added the detailed information about presenteeism related to oral health problems, including its impact on both physical and mental health as it relates to work performance. To the best of our knowledge, previous studies have not investigated detailed types of work problems caused by oral health problems. In particular, frequent gum bleeding (always bleeding) when brushing teeth showed a higher odds ratio for both physical and mental health problems related to work performance, ranging between 6.48 and 7.76 in the univariable analysis and between 3.71 and 4.55 in the multivariable analysis (Table
5).
Moreover, our study results suggest the possibility that general oral health status also relates to both physical and mental health problems regarding work presenteeism. The odds ratio calculated by logistic regression analysis showed higher values for “poor” self-reported oral health than for “very good”, “good”, or “fair” self-reported oral health (Table
3). The odds ratios of work problems for “very good” self-reported oral health ranged between 1.20 and 1.87 in the univariable analysis and between 1.14 and 1.74 in the multivariable analysis, and they were not significant. Nevertheless, the odds ratios for “poor” self-reported oral health ranged between 6.87 and 11.78 in the univariable analysis, and between 3.58 and 5.77 in the multivariable analysis. These results highlight the significance of the analysis for both physical and mental health problems for work presenteeism, which were not reported in previous studies.
There are several possible mechanisms for the impact of oral symptoms and diseases on work presenteeism. First, oral health affects social relationships. Poor dental appearance due to tooth loss decreases social interactions [
4]. Halitosis, often related to poor oral hygiene, also decreases in-person communication with others [
3,
15,
33]. Our results showed significant association between oral health status and concerns about one’s appearance, as well as “bad breath”, resulting in work problems. Communication problems due to poor oral health also contribute to the deterioration of work performance. Second, acute dental pain can have a significant impact on work presenteeism. Previous studies have reported that dental pain causes stress and decreased QOL [
1,
2,
13]. Our study also found that dental pain leads to presenteeism (Tables
3,
4 and
5). Stress and decreased quality of life due to dental pain are thought to adversely affect work performance. Third, the disruption of sleep due to oral health problems affects work performance. Our questionnaire asked about sleep problems due to oral health, and compared individuals with poor oral health to those with excellent oral health. Those with poor oral health were prone to sleep problems and were more likely to have work problems. In previous studies, it has been reported that orofacial pain causes sleep disorders [
34,
35]. Sleep problems are known to decrease work performance and to increase presenteeism [
36,
37].
The results of the logistic regression analysis clearly showed that poor oral health status was significantly associated with various types of work problems and increased the odds ratios of these problems. This study has some limitations. We used a self-report questionnaire, did not assess oral status clinically and did not validate the questionnaire. In a self-administered questionnaire, inaccurate responses are likely to occur, which can lead to misclassifications. This may result in a bias toward the overestimation or underestimation of the association between oral health status and work problems, or widening the confidence interval of the association. It is not possible to determine the direction of the bias. However, the present finding obtained from logistic regression analysis that the more oral health problems, the more work problems related to oral health problems appears theoretically valid.
This study was a cross-sectional study, and the temporal relationship could not be observed. While we believe in the possibility of reverse causality that oral health related work problems cause oral health problems, this is not a realistic supposition. The strength of this study is that the observed associations were strong. Some odds ratios exceeded 3 to 5, making it less likely that the observed associations could be explained by unmeasured confounders.
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