57 Risk Factors and Oral Health-Related Quality of Life Cross, 2011). When no cleaning tools were used, it was also marked as a risk factor (Ivory Cross, 2011). The frequency of dentist and dental hygienist visits were marked as a risk factor if patients visited the dentist and dental hygienist once a year or less [6,7,15]. Financial risk factors were marked as a risk factor when respondents stated that they did not have enough money to take care of their oral health or if respondents stated that they had no insurance for dental care [9]. 3. Oral health-related quality of life (OHIP-49) The Oral Health Impact Profile-49 (OHIP-49) [23,24] was used as a self-report questionnaire to assess participants’ OHRQoL over the last month. The OHIP consists of 49 items, distributed among seven dimensions: functional limitation (nine items), physical pain (nine items), psychological discomfort (five items), physical disability (nine items), psychological disability (six items), social disability (five items), and handicap (six items) [23]. Respondents were asked how frequently they experienced the phenomenon in the last month and responses were recorded using a 5-point Likert scale, where higher scores indicate worse functioning (0= never, 1= hardly ever, 2=occasionally, 3=fairly often, and 4=very often). OHRQoL impairment was determined by the total OHIP-49 total score, ranging from 0 (no adverse impacts within the last month) to 196 (all 49 impacts are experienced ‘very often’ within the last month). The OHIP-49 is reported to be valid and reliable [23,24]. The total OHIP-49 Cronbach’s alpha in the current study was 0.91 for cases and 0.90 for controls. Cronbach’s alphas for all subscales (case|control) were satisfactory. For functional limitation 0.79|0.74, physical pain 0.82|0.77, psychological discomfort 0.80|0.85, physical disability 0.71|0.74, psychological disability 0.82|0.91, social disability 0.73|0.79, and handicap 0.71|0.83. The questions of the 14-item Oral Health Impact Profile (OHIP-14) [23,24] which is the shorter version of the OHIP-49, were used to calculate the estimation of prevalence of impact on OHRQoL in case and control group. OHIP-14 scores were ranging from 0 (no adverse impacts within the last month) to 56 (all 14 impacts are experienced ‘very often’ within the last month). The cut-off scores for the OHIP-14 were used [9,25,26], since cut-off scores for the OHIP-49 were were never studied in previous research. ‘A negative impact on OHRQoL’ indicates that participants reported in line with existing literature: ‘occurring fairly often’ or ‘often’ on one or more of the OHIP-14 items [9,25,26]. ‘No impact on OHRQoL’ indicates that participants did report in line with existing literature: “Never”, “Hardly Ever”, “Occasion3
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