This study investigated the prevalence, risk indicators, and impact of periodontitis on oral health-related quality of life (OHRQOL) among Egyptian geriatric patients. This study aims to provide insights into the broader implications of this disease for quality of life by assessing functional, psychological, and social domains.

A cross-sectional study was conducted among 400 Egyptian participants aged 60 years and older recruited from Ain Shams University's outpatient clinics and the Ministry of Health dental research centers. Sociodemographic and behavioral data were collected via structured questionnaires, whereas OHRQOL was evaluated using the OHIP-14 tool. Clinical periodontal assessments adhered to the 2017 World Workshop classification. Logistic regression was applied to identify associations between periodontitis severity, risk indicators, and OHRQOL impacts.

Among the participants, 66.5% (N = 266) reported a negative impact on OHRQOL, predominantly due to psychological discomfort, physical pain, and disability. Stages II (40%) and III (36.2%) periodontitis were the most prevalent, with PPD Mean ± SD 4.95 ± 1.38, CAL Mean ± SD 4.21 ± 1.38. The key risk factors for severe periodontitis included being male, being older, being less educated, being a smoker, and having diabetes. The study also revealed that irregular tooth brushing, residence in specific urban locations, and advanced periodontitis stages were significantly associated with poorer OHRQOL.

Periodontitis adversely affects OHRQOL among Egyptian elderly individuals, with the psychological and physical domains being the most affected. These findings underscore the need for targeted public health strategies and personalized interventions to mitigate the burden of periodontal disease in this population.

Periodontal disease is an oral infection characterized by an imbalance between the host's immune response and bacterial challenges [1]. It encompasses a range of inflammatory conditions that lead to the degeneration of the periodontium, affecting structures such as the gingiva, periodontal ligament, cementum, and alveolar bone, often resulting in tooth loss. According to the World Health Organization (WHO) reports that approximately 10–15% of the global population suffers from severe periodontal conditions [2]. Significant correlations between periodontal disease and various systemic medical conditions have been identified in recent decades. Although definitive causal relationships have not been fully established, numerous studies highlight both positive and negative associations [3]. Globally, there is a notable demographic shift characterized by an aging population. In 2010, approximately 524 million individuals were aged 65 and older, with projections suggesting this number will rise to 1.5 billion by 2050. This trend highlights a growing population of older adults surpassing the number of young children for the first time in history [4]. According to the United Nations, the proportion of individuals aged 65 and above increased from 6% in 1990 to 9% in 2019, with projections indicating a further rise to 16% by 2050 [5]. This demographic shift necessitates a thorough scholarly investigation to understand its implications for social, economic, and healthcare systems. Despite advancements in understanding aging-related disorders, a gap remains in the literature regarding their organizational, a social, and economic impacts, particularly within the healthcare systems of low- and middle-income countries (LMICs) in the Arab world [6]. Periodontal disease significantly impacts an individual's overall health and quality of life, with prevalence increasing with age. In Western industrialized countries, the elderly population is expanding, and more individuals are choosing to retain their natural teeth, suggesting an expected rise in the incidence of periodontal disease [7]. Life expectancy in Egypt has significantly improved from 1980 to 2020, with projections indicating further increases by 2050. By then, Egypt's population is anticipated to reach 160 million, with a substantial proportion aged 60 or older. Historically labeled as a ‘young country,’ Egypt is expected to see an increase in its mean age, aligning more closely with demographic trends observed in European nations (Central Agency for Public Mobilization and Statistics, 2023) [6, 8]. Among the geriatric population, periodontal disorders are prevalent, with incidence and severity escalating due to progressive tissue degeneration associated with aging. If gingivitis remains untreated, periodontitis can exacerbate in advanced age. An alternative hypothesis for the correlation between periodontal tissue degeneration and aging is the increased vulnerability inherent in the aging process. Older adults are more prone to developing periodontal disease due to alterations in the immune response and prolonged exposure to risk factors. This heightened susceptibility is associated with biological aging, which impairs the body's capacity to maintain periodontal health [9]. Men and individuals with uncontrolled diabetes face an increased risk of periodontal disease as they age, a risk further compounded by smoking and inadequate oral hygiene [10]. Maintaining good oral health is critical for overall well-being. The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being, rather than merely the absence of disease. Through its Global Oral Health Program, the WHO seeks to enhance awareness of oral health worldwide. Despite advancements, oral diseases persist as a significant health challenge, especially in less affluent countries. With the aging global population, there is an urgent need for research and enhanced public health strategies to address the evolving demands of oral health [11]. Oral diseases substantially affect an individual's quality of life due to their psychological and social repercussions.

Any medical condition that impedes daily activities can adversely affect overall quality of life. Consequently, oral health-related quality of life (OHRQOL) assesses the varied impacts of dental disorders on different life aspects [12]. Oral Health-Related Quality of Life (OHRQOL) is a multidimensional construct that subjectively evaluates functional and emotional well-being, as well as expectations and satisfaction associated with oral and dental health [13]. This assessment is conducted using indicators specific to oral health-related quality of life. The most commonly employed tool for evaluating OHRQOL is the Oral Health Impact Profile (OHIP) and its abbreviated form, OHIP-14, which includes 14 questions. OHIP-14 specifically measures the negative impacts of oral and dental issues, such as periodontal diseases, that compromise oral health [14, 15]. Oral Health-Related Quality of Life (OHRQOL) evaluates the extent to which oral health affects daily life, well-being, and overall satisfaction, taking into account factors such as function, psychological state, social interactions, and pain. Research indicates that poor oral health, particularly periodontal disease, significantly diminishes OHRQOL, especially among older adults who frequently encounter additional health challenges and diminished physical capacity. Therefore, understanding the impact of periodontal disease on the OHRQOL of older Egyptians is essential for developing targeted interventions aimed at enhancing the quality of life within this vulnerable population [16]. Recent studies have demonstrated a significant prevalence of periodontal disease among Egyptians, with marked variations across different ages and regions. A cross-sectional national survey underscored the widespread occurrence of periodontal issues among Egyptian adults, pinpointing critical risk factors such as inadequate oral hygiene, tobacco use, and systemic conditions like diabetes [13].

Elderly Egyptians are particularly susceptible to factors such as limited access to dental care, socioeconomic challenges, and a lack of oral health awareness. Research suggests that older individuals often prioritize systemic health over dental health, potentially exacerbating periodontal issues and affecting their overall quality of life [17]. Additionally, other common oral health problems, such as tooth loss, dental caries, and dry mouth, further contribute to the decline in oral health-related quality of life (OHRQOL) among elderly Egyptians [18]. Considering the substantial burden of periodontal disease and its impact on quality of life, this study aims to investigate the specific effects of periodontal disease on oral health-related quality of life (OHRQOL) among Egypt's elderly population. By analyzing the prevalence, severity, and risk factors associated with periodontal disease in this demographic, the study seeks to offer insights that could inform and improve public health policies and clinical practices. The ultimate objective is to enhance oral health outcomes and overall well-being among Egypt's aging population.

In this cross-sectional study, a random sample of 400 Egyptian geriatric patients aged over 60 years, frequently visited four different dental centers as an outpatient clinic, the periodontology department of Ain Shams University, Cairo Governorate, and the research centers of the Ministry of Health and Population, MOHP. The Dentists Training Center in Mansoura, Dakahlia Governorate. The Dentists Training Center in Damnhour, Beheira Governorate. The Specialized Dental Center in Port Said, Port Said Governorate. These centers were chosen based on their high geriatric patient flow and geographic distribution to capture diverse socioeconomic and health backgrounds. A random sampling technique was used within these centers to ensure that participants were not selectively chosen based on their oral health status, increasing the study's generalizability. Conducted in a single visit, thereby eliminating the need for follow-up assessments. Importantly, this specific dental clinic houses a removable dental laboratory, such a facility attracts a high flow of geriatric patients, who are the primary focus of our study, As a result, the sample although not fully representative of the general Egyptian elderly population, is still relevant to the study objective, as it captures a population segment closely aligned with the study focus on geriatric oral health and the impact on oral health-related quality of life. Inclusion/Exclusion Criteria: Inclusion: both genders, male and female patients aged ≥ 60 years diagnosed with periodontitis and willing to participate. Exclusion: Individuals with < 2 remaining teeth, severe cognitive impairments, or severe systemic diseases that might interfere with oral health assessment, direct socioeconomic exclusion criteria were not applied. The research adhered to established ethical guidelines, and the study was approved by the Faculty of Dentistry Ain Shams University Research Ethics Committee (FDASU-REC) with approval number (FDASU-REC IM052302) and the research ethical committee of the Egyptian Ministry of Health and Population, MOHP with approval number (12–2023/16). A participant’s confidentiality was protected, and their data were fully secured following ethical guidelines.

Written informed consent was signed by all participants prior to the clinical examination. In the case of illiterate patients, the consent form was read aloud to the participants. Their full understanding of the study details was ensured, and verbal consent was obtained in the presence of a witness, who then signed the consent form on behalf of the participant. Alternatively, the participants could provide consent by placing a thumbprint on the consent form.

All the participants answered a structured questionnaire before the clinical examination, The questionnaire contained items concerning a sociodemographic background, educational level, smoking habits, medical conditions, medication use, frequency of dental visits, and their regularity, and patterns of teeth brushing. Education levels were assessed by six alternative responses due to the variation in educational levels across the Egyptian population: “illiterate”, “primary”, “preparatory”, secondary”, and “university”. Additionally, smoking habits were assessed by three alternative responses: never smoker”, former smoker, and current smoker. The “Current smoker” was defined as an individual who smoked at least one cigarette daily. Current smokers also reported the number of cigarettes consumed daily. The oral health-related quality of life (OHRQOL) was assessed via the oral health impact profile (OHIP-14) [19, 20]. The questionnaire consists of 14 items divided into seven dimensions: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap.

Ratings are made on a 5-point Likert scale for each item: 0 = never, 1 = hardly ever, 2 = occasionally,

3 = fairly often, and 4 = very often, with the sum of the scores ranging from 0–56. Higher OHIP-14 scores indicate poorer OHRQOL. Participants reporting a negative impact (response codes: 3’fairly often’ and 4’very often’) on one or more of the 14 items were categorized as having a negative impact on OHRQOL, whereas those who had response codes ranging from 0–2 for all items were considered to have fair OHRQOL by the OHIP-14. Language and Cross-Cultural Adaptation of OHIP-14: The OHIP-14 questionnaire was used in Modern Standard Arabic, the primary language of participants. It has been previously validated for use in Arabic-speaking populations. No major cultural adaptations were needed, as the questionnaire's constructs align with standard oral health assessment metrics [21, 22].

Two calibrated periodontists conducted clinical examinations. Inter-examiner reliability was tested using Cohen’s kappa (κ = 0.86), indicating high agreement. The clinical examination was divided into three segments the 1 st segment included recording the prosthesis if available as a removable partial or complete denture, and was fixed as a crown, bridge, or implants; the 2nd segment included registration of the DMF, and the total number of permanent teeth filled, missing, and decaying. Every tooth, excluding the third molars, was included [23, 24]. The 3rd segment included the recording of periodontal parameters such as tooth mobility, periodontal probing pocket depth (PPD), clinical attachment level (CAL), bleeding on probing (BOP), and the plaque index (PI). All periodontal parameters were recorded and written on periodontal charts [25].

Periodontal status was assessed based on the consensus report from the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions (2018 EFP/AAP classification) [26]. Plaque index (PI): Supragingival plaque presence was recorded on four tooth surfaces using this index. Plaque was documented as present (+) or absent (−), and the plaque incidence was calculated as a percentage [26]. Gingivitis Index (Bleeding on Probing (BOP): Gingival bleeding was assessed on all tooth surfaces, with bleeding recorded as either present (+) or absent (-). Gingivitis severity was expressed as a percentage [27, 28]. Clinical Attachment Loss (CAL): Indicates junctional epithelium migration and connective tissue loss, key in periodontitis assessment. Measured from the cementoenamel junction (CEJ) to the periodontal pocket base. CAL Calculations: Gingival margin at CEJ → CAL = PD, Coronal to CEJ → CAL = PD – GML, Apical to CEJ → CAL = PD + GML. CAL was recorded as a means of patient periodontal status. Periodontal Pocket Depth: Using a calibrated probe, measure six sites per tooth to assess periodontal health, PPD recorded as the mean of the patient's status. Periodontal health was comprehensively assessed by measuring probing depths and clinical attachment loss (CAL) at six sites per tooth. These individual measurements were summed to calculate the total probing depth and total CAL for each patient. The mean values were then determined by dividing these totals by the number of sites measured [29, 30]. Periodontitis is divided into four stages based on clinical attachment loss (CAL), bone loss, and probing pocket depth (PPD). Stage I has CAL of 1–2 mm and bone loss under 15%. Stage II shows CAL of 3–4 mm and bone loss of 15–33%. Stage III and IV involve CAL of 5 mm or more, bone loss to the middle root, and PPD of 6 mm or more, with Stage IV requiring complex treatment due to the loss of five or more teeth [31].

Outcome (Dependent Variable): The primary focus of this study is the impact on Oral Health-Related Quality of Life (OHRQOL).

Main Exposure Variables (Key Predictors of OHRQOL): Periodontitis is assessed through periodontal parameters, including probing pocket depth (PPD), clinical attachment loss (CAL), and bleeding on probing (BOP).

Mediators (Pathways through which exposures affect OHRQOL): The Decayed, Missing, and Filled Teeth (DMF) index acts as a mediator, influencing the functional and aesthetic dimensions of quality of life. Additionally, the presence of dental prostheses affects functional capacity, aesthetic considerations, and adaptation to missing teeth.

Confounders (Factors influencing both exposure and outcome, potentially biasing the effect estimate): Age serves as a significant confounder, impacting both periodontal health and OHRQOL. Gender affects health behaviors and perceptions of quality of life, while educational level influences awareness of oral hygiene and access to dental care. Medical conditions such as diabetes and cardiovascular diseases also affect periodontal health and overall well-being. Smoking is a strong confounder, affecting both periodontal and systemic health.

Colliders (Variables influenced by two or more other variables, introducing potential bias if adjusted for improperly): Variables such as tooth brushing and dental visits are influenced by education level and affect plaque presence and periodontal status. These variables must be carefully considered to avoid introducing bias in the analysis (Fig. 1).

Directed Acyclic Graph (DAG) representing the relationships among periodontitis risk factors and OHRQOL

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The sample size was determined using G*Power software based on previous epidemiological data on periodontitis prevalence in geriatric populations (effect size = 0.3, power = 80%, α = 0.05). A random sampling approach was used within each center to minimize selection bias. Assuming a confidence limit of 5% and a confidence level of 95%, the minimum required sample size was 345 elderly patients. An additional 10% was added to compensate for potential losses, resulting in a total sample size of 400 cases after rounding. The collected data were analyzed using SPSS (Statistical Package for the Social Sciences), version 22. Quantitative data were tested for normality using the Kolmogorov‒Smirnov test and were then described as means and standard deviations for normally distributed data, and as medians and ranges for non-normally distributed data. Qualitative data were presented as numbers and percentages. The Chi-square test was used to examine associations between categorical variables (e.g., gender, age, education level) and their relationship with oral health-related quality of life (OHRQL). The Chi-square test also used to assess the stage of periodontitis in relation to oral health-related quality of life (OHRQOL). Logistic regression analysis was employed to evaluate the association between periodontitis severity and OHRQOL impairment, adjusting for potential confounders such as age, gender, and smoking habits. The results of the regression analyses were presented as odds ratios (ORs) with 95% confidence intervals (CIs). The level of significance was set at p < 0.05. The Kolmogorov–Smirnov test was used to assess normality prior to applying statistical tests.

This cross-sectional study was conducted in a single visit, ensuring there was no participant attrition due to follow-up requirements. The study involved 400 participants, all aged 60 and above, consisting of 228 males (57%) and 172 females (43%). Among them, 169 participants (42.3%) were aged between 66 and 70 years. 141 participants (35.3%) had no formal education. Stage II periodontitis was present in 160 participants (40% of the sample), while Stage III periodontitis was observed in 145 participants (36.2%). With PPD Mean ± SD 4.95 ± 1.38, CAL Mean ± SD4.21 ± 1.38. Sociodemographic characteristics of the study population in relation to periodontitis stage shown in Table 1.

OHIP questionnaire

In this study, the Oral Health-Related Quality of Life (OHRQOL) was assessed using the abbreviated Norwegian version of the Oral Health Impact Profile (OHIP-14). Participants responded to each item using a 5-point Likert scale, with options ranging from 0 (never) to 4 (very often). The findings showed that 266 out of 400 participants, or 66.5%, experienced a negative impact, indicating poor oral health-related quality of life. OHRQOL outcome and statistical summary of its score shown in Table 2.

Our findings suggest that Stage II and Stage III periodontitis were the most frequently observed stages in our sample. Among the 266 individuals who reported a negative impact on Oral Health-Related Quality of Life (OHRQOL), 40.2% (107 participants) had Stage II periodontitis, while 99 individuals had Stage III. Similarly, among those who reported a fair impact, Stage II was the most common (39.6%, 53 participants), followed by Stage III (34.3%, 46 participants). Statistical analysis indicated a significant association between periodontitis stage and OHRQOL impact (p = 0.001), suggesting that individuals with more advanced periodontitis may be more likely to experience a greater negative impact on their OHRQOL. the impact of periodontists’ stage on OHRQOL among the study population shown in Tables 3. Table 4 presents the summary statistics of OHRQOL domain scores in relation to periodontitis stage. Figure 2 illustrates the distribution of periodontitis stages among the study population according to their OHRQOL scores.

Frequency of the periodontitis stage of the study population according to their OHRQOL score

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Analysis of the responses revealed that psychological discomfort (Domain 3) had the highest frequency, ranking first. This was followed by psychological disability (Domain 5) in second place, and physical pain (Domain 2) in third place. Frequencies and percentages of the highest scores on the ORHQOL items are shown in Table 5.

Our findings suggest that 66.5% of participants (266 out of 400) reported experiencing a negative impact on their Oral Health-Related Quality of Life (OHRQOL), while 33.5% (134 participants) reported a fair impact. The highest proportion of negative impact was observed in Damanhour at 28.6% (76 individuals). In contrast, Ain Shams and Port Said each had 30.6% (41 participants) reporting a fair impact. Statistical analysis indicated an association between study site and OHRQOL impact (p = 0.015). Gender analysis suggested a significant association, with 51.9% of males and 48.1% of females reporting a negative impact (p = 0.004). The 66–70 age group had the highest proportion of individuals reporting a negative impact (43.2%), though this association was not statistically significant. Among illiterate participants, 39.8% reported a negative impact, but this was also not statistically significant. That shown in Table 6, Figs. 3 and 4.

Frequency of study settings of the study population according to their OHRQOL impact

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Frequency of the study population according to their OHRQOL impact

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The average of DMF among the studied sample according to their QHRQOL Impact

This study explored the relationship between Oral Health-Related Quality of Life (OHRQOL) and Decayed, Missing, and Filled (DMF) scores among participants. Among individuals who reported experiencing a negative impact on their OHRQOL (N = 266), the average DMF score was 13.7 ± 4.4, with scores ranging from 2 to 25. In comparison, those who reported a moderate impact had an average DMF score of 10.7 ± 3.6, with a range of 0 to 21. Statistical analysis indicated a significant association between OHRQOL impact and DMF scores (p < 0.001), suggesting that individuals with greater OHRQOL impairment tended to have higher DMF scores. Differences in the average of DMF among the studied sample according to their OHRQOL Impact are shown in Table 7, Fig. 5.

Differences in average DMF among the studied sample according to their OHRQL impact

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DMF average among the studied sample in relation to the periodontitis stage

The Decayed, Missing, and Filled (DMF) index may act as a mediator variable, potentially influencing the functional and esthetic impact on Oral Health-Related Quality of Life (OHRQOL). Statistical analysis suggested a significant association between the average DMF score and the stage of periodontitis (p = 0.013). Stages II and III of periodontitis were the most frequently observed among participants. Those with Stage II periodontitis had an average DMF score of 12.2 ± 4, with scores ranging from 2 to 23. Meanwhile, participants with Stage III periodontitis had an average DMF score of 12.7 ± 4.7, with scores ranging from 6 to 23. Differences in average DMF among the studied sample according to periodontitis stage Shown in Table 8, Fig. 6.

Differences in the average of DMF among the studied sample according to their periodontitis stage

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The removable and fixed prosthesis in relation to OHRQOL impact

In our study, among participants who reported experiencing a negative impact on their Oral Health-Related Quality of Life (OHRQOL), 163 individuals (61.3%) did not have a removable prosthesis. In comparison, among those who reported only a fair impact, 115 out of 134 participants (85.8%) were without a removable prosthesis. Statistical analysis indicated a significant association between the presence of a dental prosthesis and OHRQOL (p < 0.001), suggesting that prosthesis use may be linked to variations in perceived oral health-related quality of life. The distribution of the studied sample according to the presence of removable & fixed prosthesis in relation to OHRQOL Impact is presented in Table 9, Fig. 7.

Frequency of type of removable prosthesis of the study population according to their OHRQOL impact

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The bleeding on probing (gingivitis) and its presence in percentage in relation to the OHRQOL impact

All participants in the sample showed bleeding on probing, indicating gingivitis, affecting 100% of them. The extent of bleeding was most commonly observed within the 25–50% range. Out of 266 participants, 172 experienced a negative impact on Oral Health-Related Quality of Life (OHRQOL) and had bleeding on probing within this range. The findings suggested that gingivitis significantly impacts Oral Health-Related Quality of Life (OHRQOL) with a p-value of 0.004. The distribution of the studied sample according to bleeding on probing (gingivitis) and its percentage in relation to OHRQOL Impact shown in Table 10, Fig. 8.

Frequency of the percentage of bleeding on probing of the study population according to their OHRQOL impact

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Teeth brushing in relation to OHRQOL

Among the 266 participants whose Oral Health-Related Quality of Life (OHRQOL) was negatively impacted, 118 individuals (44.4%) did not brush their teeth at all. In comparison, of the 134 participants reporting a fair impact on their OHRQOL, 57 individuals (42.5%) did not practice tooth brushing. Notably, even among those who brushed their teeth daily (N = 95), 62.1% still experienced negative impacts on their OHRQOL. The analysis indicates that tooth brushing significantly impacts Oral Health-Related Quality of Life (OHRQOL) with a p-value of 0.013. The distribution of the studied sample according to teeth brushing in relation to OHRQOL Impact is shown in Table 11, Table 12 displays the results of a multiple logistic regression analysis examining selected variables associated with the impact of the OHRQOL score. Table 13 presents a multiple logistic regression model evaluating the relationship between several independent variables and the stage of periodontitis. Table 14 presents the Logistic Regression of some independent variables in relation to the periodontitis stages. Figure 9 illustrates the frequency of tooth brushing among the study population according to their OHRQOL impact.

Frequency of teeth brushing frequency of the study population according to their OHRQOL impact

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This study examined the impact of periodontitis on the oral health-related quality of life (OHRQOL) of elderly individuals in Egypt, revealing significant negative effects, particularly in psychological and physical domains. These findings underscore the urgent need for public health strategies and personalized interventions to alleviate the burden of periodontal disease in this population.

Key factors associated with periodontitis severity included gender, age, education level, smoking status, and type 2 diabetes. Although lower education is typically linked to poorer oral health behaviors, our study found no direct statistical significance, suggesting that factors like smoking and diabetes might have a more profound impact.

Periodontitis significantly diminishes the quality of life for older adults in Egypt, especially regarding their psychological and physical well-being. This calls for targeted interventions and increased public awareness to enhance oral health in this demographic. Further research with larger populations is necessary to explore the relationship between periodontitis stage-grade and OHRQOL.

AAP:

American Academy of Periodontology

ASU:

Ain Shams University

BOP:

Bleeding on Probing

CAMPAS:

Central Agency for Public Mobilization and Statistics

CAL:

Clinical Attachment Level

CEJ:

Cemento-enamel Junction

CI:

Confidence Interval

DM:

Diabetes Meletus

DMF:

Decayed, Missed, Filled

EFP:

European Federation of Periodontology

FDASU-REC:

Faculty of Dentistry Ain-Shams University Research Ethics Committee

GBD:

Global Burden of Diseases

HRQOL:

Health-Related Quality of Life

HTN:

Hypertension

LMICS:

Low and Middle-Income Countries

NCD:

Non-Communicable Diseases

NIH:

National Institute of Health

OECD:

Organization for Economic Cooperation and Development

OHRQOL.:

Oral Health-Related Quality of Life

PI:

Plaque Index

PPD:

Probing Pocket Depth

QOL:

Quality of Life

SUNT:

Sound Untreated Natural Teeth

UN:

United Nations

WHO:

World Health Organization

YLD.:

Years Lived with Disability

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All authors read and approved the final manuscript.

Correspondence to Aya Hosny Taha Zahran.

The research adhered to established ethical guidelines, the study was approved by the Faculty of Dentistry, Ain Shams University Research Ethics Committee (FDASU-REC), and the research ethical committee, the Egyptian Ministry of Health and Population MOHP. A participant’s confidentiality is protected, and their data is fully secured following ethical guidelines. All participants signed a written informed consent form before the clinical examination. In the case of illiterate patients reading the consent form aloud to the participants. Ensuring they fully understood the study details and obtaining verbal consent in the presence of a witness, having the witness sign the consent form on behalf of the participant.

Not applicable.

The authors declare no competing interests.

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