Validation of an innovative instrument of Positive Oral Health and Well-Being (POHW)

Abstract

Introduction

Most existing measures of oral health focus solely on negative oral health, illness, and deficiencies and ignore positive oral health. In an attempt to commence exploration of this challenging field, an innovative instrument was developed, the “Positive Oral Health and Well-Being” (POHW) index. This study aimed to validate this instrument and to explore an initial model of the pathway between oral health attributes and positive oral health.

Methods

A cross-sectional, multicenter study (Israel, USA, and Germany), was conducted. Our conceptual model suggests that positive oral health attributes, which integrate with positive unawareness or positive awareness on the one hand and with positive perception on the other hand, may result via appropriate oral health behavior on positive oral health. The 17-item self-administered index was built on a theoretical concept by four experts from Israel and Germany. Reliability, factor, and correlation analyses were performed. For external correlations and to measure construct validity of the instrument, we utilized the oral health impact profile-14, self-perceived oral impairment, life satisfaction, self-perceived well-being, sociodemographic and behavioral data, and oral health status indices.

Results

Four hundred and seventy participants took part in our three-center study. The combined data set reliability analyses detected two items which were not contributing to the index reliability. Thus, we tested a 15-item construct, and a Cronbach’s α value of 0.933 was revealed. Primary factor analysis of the whole sample indicated three subconstructs which could explain 60 % of variance. Correlation analyses demonstrated that the POHW and OHIP-14 were strongly and negatively associated. The POHW correlated strongly and positively with general well-being, moderately with life satisfaction, and weakly with the perceived importance of regular dental checkups. It correlated moderately and negatively with perceived oral impairment, and marginally and negatively with dental caries experience (DMFT) and periodontal health status (CPI) scores. When DMFT and CPI clinical measurements were categorized, a higher score of POHW was revealed for better oral health.

Discussion

Our study introduced a new instrument with good reliability and sound correlations with external measures. This instrument is the first to allow measurability of positive instead of impaired oral health. We utilized subjective–psychological and functional–social measures. The current results indicate that by further exploring our conceptual model, POHW may be of importance for identifying patients with good and poor oral health, and building an effective and inexpensive strategy for prevention, by being able to evaluate the effect of interventions in a standardized way.

Introduction

It is often argued that medicine and psychology have dealt reasonably well with illness, but very poorly with health [1]. Notwithstanding, researchers have indicated a paradigm shift toward a salutogenic perspective, which refers to Antonovsky’s concept of coherence [2, 3]. This concept focuses on an individual’s own resources to support health and/or to prevent illness, instead of treating symptoms [2]. In recent years, a new field of research, positive health, has emerged, which “aims to encourage existing scientific and clinical disciplines to expand their conception of health by breaking through the zero point of the absence of disease to consider what is on the other side” [1 (p. 4), 4]. It was primarily the developing field of positive psychology [5, 6] and the impact of Antonovsky’s salutogenetic concept [2, 3], which resulted in a “paradigm shift.” Patients are not only bearers of defects, dysfunctions, and non-compliant behavior toward the instructions of medical practitioners, but instead have a potential for self-care abilities. They have their own strength, virtues, and resources and can act as partners in the prevention of health affliction. This would require that the (future) patient has an awareness of his oral health and not only a cognitive understanding that he should care for his oral health to prevent future defects. In most cases, dentists still have to care for defects and oral health impairments, because patients are used to thinking about positive oral health and health care only when oral health is absent and an intervention by dentists is required. Therefore, not only dentists but also (future) patients require an awareness of oral health. We need an operationalization of positive oral health (not only its absence), and an instrument which “sensitizes” the awareness of positive oral health on the one hand (i.e., the patient responds to specific items and starts to reflect), and measures this positive health perception (i.e., the dentist is able to monitor this health perception during the course of an intervention or during prophylactic treatments).

Fredrickson and Joiner [7 (p. 48)] found evidence for an “upward spiral dynamic between positive emotions and personal and social resources.” According to Fredrickson’s [8] “broaden-and-build model,” positive emotions (i.e., appearing after the perception of positive oral health) may result in positive health behavior (i.e., responsible health care), while negative emotions (i.e., fear in response to painful oral health affections and treatments) may result in avoidance reactions or even denial of health problems. Fredrickson clearly argued that positive emotions broaden cognition and may build resources.

In a recent article, Seligman addressed positive health which “describes a state beyond the mere absence of disease and is definable and measurable” [1 (p. 3)]. It is related to three existing approaches concerned with good health: disease prevention, health promotion, and wellness, but has distinct features and emphases. According to this, the global comprehensive notion of “positive health” can be broken down into biological (the positive ends of physiological function and anatomical structure distributions), subjective (sense of well-being, optimism, health-related locus of control, etc.), and functional aspects (how well does the individual function). Like risk factors of illness, these three aspects are classes of potential assets for health. This field is now under investigation to test the hypothesis that “positive health predicts increased longevity, decreased health costs, better mental health in aging, and better prognosis when illness strikes” [1 (p. 6)].

Despite substantial achievements in oral health of worldwide populations, problems still remain in many communities all over the world. Dental caries and periodontal diseases are considered as being the most important global oral health burdens. Tooth loss, oral mucosal lesions, oropharyngeal cancers, and orodental trauma are also major public health problems [9, 10]. Most existing measures of oral health focus solely on negative oral health, illness, and deficiencies and ignore positive health [11–13].

The significant role of psychological and social factors in oral disease and health is evidenced and has been firmly established in an extensive number of epidemiological surveys. Oral health has a profound effect on general health and quality of life [11–16]. In parallel, in the last decades, a paradigm shift in dental research has occurred from a strictly biomedical model, which was narrow, biologically based with undue emphasis on disease, to a biopsychosocial model, which is more holistic, incorporating issues such as functioning and well-being. This is more compatible with the primary purpose of health care, namely restoring and enhancing health [11]. As part of his conceptual model of oral health [17], Locker discussed the three aspects of disability dimension: physical, psychological, and social. Regarding the positive notion of “ability,” these aspects correspond with the biological, subjective, and functional aspects of Seligman’s theory. Nevertheless, a scientific discipline of oral health and well-being does not exist, and it is believed that the inclusion of “positive oral health” would increase the understanding of oral health as a biological, psychological, and social phenomenon [11–13].

In their article about the concept of positive health in oral health research [12], Locker and Gibson claimed that “the notion of positive health, irrespective of its merits and public policy implications, provides a context for methodological and theoretical debate that can only serve to enrich theory and practice with respect to measures of health and quality of life and therapeutic interventions at the individual and population levels” (p. 171). Locker also added that “research is needed to develop comprehensive predictive models of oral health outcomes that facilitate interventions at individual and population levels” [2 (p. 172)]. Recently, Baker, Gibson, and Locker emphasized conceptual and methodological misperceptions within the literature of sociodental indicators and the need to “understand the complexity of oral health from within a patient—centered perspective” [18 (p. 533)].

In an attempt to commence and explore this challenging and undetected field in oral health, an international team of researchers developed an innovative instrument, in order to operationalize and measure Positive Oral Health and Well-Being, and is intended to be used for both research and identification of patients’ subjective oral health perception. This study aimed to validate this instrument and to suggest an initial model of the pathway between oral health attributes and positive oral health.

Methods

Participants

A cross-sectional, anonymous, multicenter study (Israel, USA, and Germany), utilizing a convenience sample stratified for age and gender, was conducted.

The IRB committee in each center approved the study, and informed consent was signed by the participants. Sociodemographic and behavioral data included age, gender, marital status, education, employment status, dental care utilization, oral hygiene habits, and smoking.

All patients filled the respective questionnaires by themselves in the respective dental centers. To fill the three-page questionnaire, participants required an average of 5 min.

Measures

Positive Oral Health and Well-Being

The Positive Oral Health and Well-Being (POHW) questionnaire was built on a theoretical concept referring to Seligman [1] and Locker [17] by three experts from Israel and Germany. For this purpose, the respective dimensions of putative relevance were discussed extensively and finally consented upon (content/face validity) in a research meeting in 2012 at the Witten/Herdecke University, Germany. The items were formulated with the input of English, German, and Hebrew language speakers, and thus, the three language versions are as consistent as possible with respect to the underlying intentions.

The phrasing of the respective items considered positive statements rather than a positive reinterpretation of an affected oral health. It became very clear that the verbalization of items which address an affected oral health was much easier than definite positive statements.

As the term “positive health” can be broken down into biological, subjective, and functional aspects [1], the questionnaire focused on the subjective and functional dimensions of positive oral health, while the biological aspect was not the main focus of the instrument. Aspects of relevance were “awareness,” “perception,” and “behavior.”

A main hypothesis was that people have little specific awareness of positive oral health. Accordingly, we have added and expanded on questions concerning positive awareness toward oral health. Health behavioral models are highly focused on terms of constructs representing the perceived threat, perceived susceptibility, perceived severity, perceived barriers, and perceived benefits. These concepts were proposed as accounting for people’s “readiness to act” [19–21]. In our instrument, perception is used in a positive manner, as a possible direct and indirect predictor of favorable behavior leading to positive oral health. Thus, the items verbalized states of perceived well-being and contentment. Behavior was focused in behavioral capability, which identifies the actions required for the performance.

According to the above and by “breaking through the zero point of the absence of disease to consider what is on the other side” [1], and in order to “enrich theory and practice with respect to measures of health and quality of life” [1, 11], our conceptual model (Fig. 1) suggests that positive oral health attributes (assets and abilities), which integrate with positive unawareness or positive awareness on the one hand, and with positive perception on the other hand, may result via appropriate oral health behavior in positive oral health.

Fig. 1

Conceptual model of Positive Oral Health and Well-Being (POHW) (^©Zini, Büssing, Vered)

The 17 items of the self-administered POHW were scored with a four-point Likert scale scoring agreement/disagreement to the perceived states. High scores indicate a state of positive oral health.

The depicted order of the items follows the underlying theoretical dimensions. According to the proposed model, we defined seven positive integrated groups:

• 1. Subjective unawareness: items 2, 3, and 17

• 2. Subjective awareness: items 9 and 16.

• 3. Functional awareness: items 10, 11, and 12.

• 4. Subjective perception: items 1, 7 and 8.

• 5. Functional perception: items 13, 14, and 15.

• 6. Subjective behavior: items 5 and 6.

• 7. Functional behavior: item 4.

For external correlations and to measure construct validity of the instrument, we utilized the oral health impact profile (OHIP-14) [15], self-perceived oral impairment (POI) [22], life satisfaction (Brief Multidimensional Life Satisfaction Scale, BMLSS-10) [23], self-perceived well-being (Short General Well-being scale, SGWS) [24], sociodemographic and behavioral data, and oral health status indices.

Oral health impact profile (OHIP-14)

We utilized the short version of the OHIP questionnaire (OHIP-14) [15]. The questionnaire provides a numerical equivalent for different health-related conditions, including seven domains: physical disability, psychological discomfort, physical pain, functional limitations, psychological disability, social disability, and handicap. The OHIP-14 presents 14 issues which potentially might be negatively affected by oral health. The questionnaire was applied with the five-point Likert scale ranging from never to always. A high score indicates a negative influence of oral health on quality of life. The total OHIP-14 scores were added as recommended by the “simple count” (SC) method [15]. Potential SC scores range between 0 and 56. For odds ratio and regression analysis, a dichotomous division of the scores was applied: no influence at all = 0, or any influence (scores 1–4) = 1. In our study, the 14 items of the OHIP had a very high internal consistency coefficient (Cronbach’s α = 0.95). Thus, this scale was found to be suitable.

Perceived oral impairment (POI)

Self-perceived oral impairment was measured with a visual analogue scale (VAS) ranging from 0 (not at all) to 100 (unbearable) using the following statement: “In case you suffer from oral problems (i.e., pain, sensitivity, and dysfunction), please indicate how strong you assess your current oral impairment.”

Life satisfaction

Multidimensional life satisfaction was measured using the 10-item Brief Multidimensional Life Satisfaction Scale (BMLSS-10). The items of the BMLSS address intrinsic (myself, life in general), social (friendships, family life), external (school situation, where I live), and prospective dimensions (financial situation, future prospects); two additional items refer to the health situation and abilities to cope with everyday life. Each item was introduced by the phrase, “I would describe my level of satisfaction as …,” and scored on a seven-point scale from dissatisfaction to satisfaction. The BMLSS sum score is scaled on a 100 % level, where “delighted” equals 100 % (transformed scale score). The internal consistency of this instrument revealed a score of α = 0.92, and thus, this scale was found to be suitable.

General well-being

General well-being was measured with the Short General Well-being scale (SGWS). The item phrasing was as follows: “In general, I regard my overall well-being as high”; “When I think about my general health situation, I feel good”; “When I think about my social contacts, I feel good”; “I feel good in the way I manage my daily activities.” The items were scored on a four-point Likert scale ranging from disagreement to agreement. The internal consistency of this four-item scale revealed a high α = 0.89, and a single-scale structure (eigenvalue 3.0) which explains 75 % of variance. Thus, this scale was found to be suitable.

Clinical examinations (DMF and CPI)

Dental status was assessed by the DMFT (Decay, Missing, and Filled Teeth) index, and periodontal status was assessed by the CPI (Community Periodontal Index), using the WHO guidelines [25]. In each center, clinical examinations were conducted by one dentist, with the aid of a plane mouth mirror and a CPI probe in natural light. Calibration was performed in all study centers by the same epidemiologist (A.Z.) Radiography was not applied. The Community Periodontal Index scale is ordinal: 0 = health; 1 = bleeding; 2 = calculus; 3 = “shallow” periodontal pocket of 4–5 mm; 4 = “deep” periodontal pocket above 6 mm; and 5 = excluded. The mouth is divided into six sextants (tooth numbers: 18–14, 13–23, 24–28, 38–34, 33–43, and 44–48), and CPI examines the following index teeth: 17, 16, 11, 26, 27, 36, 37, 31, 46, 47 (six surfaces of each tooth). For each sextant, the worst score was recorded. A sextant is examined only if there are two or more teeth present and not indicated for extraction.

Statistical analyses

Reliability analysis (Cronbach’s α, corrected item-scale correlation, and difficulty index for internal consistency), factor analysis (to estimate whether the intended topics of Positive Oral Health and Well-Being were represented in the instrument), and correlation analyses (to assess external validity of the instrument) were performed. Reliability and factor analyses (extraction of main components with eigenvalue >1; varimax rotation with Kaiser Normalization) of the inventory were performed according to the standard procedures. All reliability and factor analyses, analyses of variance (ANOVA), and Pearson’s Chi-Square and Spearman’s rho correlation analyses were performed with SPSS Statistics 22.0. We considered a level of p < 0.05 as statistically significant. To assess the equality of variances for tested variables in the univariate analyses, we used Levene’s test which tests homogeneity of variance. In case it was significant (which indicates difference between the variances in the population), we will assume a p < 0.01 as more appropriate. With respect to the correlation analyses (Spearman’s rho), we chose a significance level of 0.001 and regarded correlations r > 0.5 as strong, r between 0.3 and 0.5 as moderate, and r between 0.2 and 0.3 as weak, while an r < 0.1 was regarded as irrelevant. These differences in level of significance were chosen to reduce the effect of “significance by chance” (multiple testing). Test–retest reliability of the POHW questionnaire was calculated comparing results of questionnaires applied to the same 15 examinees within a 2-week interval. The inter-rater reliability agreement was tested by kappa statistics of agreement for each item and for the intra-class correlation coefficient for the total score. A high kappa value (≥0.70) was considered to be acceptable for inter-rater reliability agreement [26–28].

Results

Six hundred and nineteen (619) participants took part in our three-center study: 200 in Israel, 200 in the USA, and 219 in Germany. As presented in Table 1, 51 % were female and 49 % were male, with a mean age of 44 ± 16 years. As shown in Table 1, the samples differed significantly with respect to family status, educational level, and age, but not for gender balance and smoking habits.

Table 1 Sociodemographic characteristics of study participants

The acceptability of the POHW questionnaire was full, all participants completed it, no difficulties were reported, and no participants declined.

Reliability analysis of the POHW

To test the reliability of the POHW, the questionnaire was initially employed separately and independently for each of the respective centers (Israel, USA, and Germany). Test–retest reliability for all factors revealed kappa statistics ranging from 0.75 to 0.94.

In order to eliminate items from the 17-item pool that were not contributing to the questionnaire reliability, an item-scale correlation was employed. Those with a low item-scale correlation were removed, i.e., item 2 (“I am not aware of any impairment to my oral health”) and item 5 (“It is important for me to regularly visit my dentist for routine checkups”). Because of its clinical importance, item 5 was used as an indicator item. Thus, we ultimately tested a 15-item construct in the three samples.

With this 15-item construct, analyses of the Israeli sample revealed an α of 0.908, the USA sample revealed an α of 0.95, and the German sample revealed an α of 0.92. The combined data set (Table 2) indicated that the tested 15 items had a Cronbach’s α of 0.93, a very good reliability level. For all further analyses, we will refer to analyses using the combined data set.

Table 2 Reliability and factor analyses of POHW item pool among the combined study sample

The item difficulty index of the combined data set was 0.73 (mean item score 2.20/3), most of the 15 items were in the acceptable range from 0.2 to 0.8, while the difficulty index of items 4, 6, 10, and 15 pointed to “ceiling effects.” Particularly, item 4 (“I actively take care of my oral health every day”) and the indicator item 5 (“It is important for me to regularly visit my dentist for routine checkups”) represent socially desired behaviors, and thus, these “ceiling effects” were considered as important with respect to the underlying aims.

Factor analysis of the POHW

To estimate whether the intended topics of the POHW were all contributing to the same construct, we performed exploratory factor analyses. To account for putative cultural differences, these analyses were performed initially in the three separate samples. While in the German and the USA, exploratory factor analysis pointed to two factors, the Israel sample showed four factors (among them, two factors with only two items each which are a split of the two factors found in the other samples). These respective items loading to these factors are more or less identical in all three samples. Thus, for the following analyses, we combined the data sets, but show the data nevertheless separately for the different samples.

A Kaiser–Meyer–Olkin value of 0.93 (measure for the degree of common variance) indicated that the item pool of all three samples is suitable for a factorial validation. Primary factor analysis of the whole sample indicated two subconstructs (all with initial eigenvalue >1) which would explain 60 % of variance (Table 2), i.e., a seven-item main factor (eigenvalue 7.78; α = 0.90) which would explain 31 % of variance, a seven-item factor (eigenvalue 1.26; α = 0.89) which would explain further 29 % of variance. Item 14 would load on both factors with weak power and was thus not used for the two factors.

Factor 1 includes items addressing good feelings and satisfaction with oral health and the status of teeth and gums (“Good Feelings”), while items of factor 2 address the positive impact of self-perceived oral health on life and health concerns (“Positive Impact”).

Because the instrument was intended to be used as an index, all further analyses refer to the respective sum score of the 15 items (POHW-15—“Positive Oral Health and Well-Being” scale), and both subscales.

Correlation analyses

In order to assess external validity of the instrument, we correlated the POHW-15 scale (and also its subscales) with the OHIP-14, which measures health afflictions (Table 3). As expected with reference to the theoretical concept, both scores were strongly and inversely associated. Moreover, the POHW-15 and its subscales correlated strongly and positively with general well-being, moderately with life satisfaction and perceived oral impairment, and weakly with the perceived importance of regular dental checkups (indicator item 5).

Table 3 External validity of POHW by correlation analyses

Thus, with respect to the POHW-15, these correlations are sound from a theoretical point of view and may indicate construct validity. However, with respect to the clinical indicators, only the POHW subscale “Good Feelings” correlated weakly with DMFT and CPI. Neither the OHIP-14 nor the POHW subscale “Positive Impact” correlated significantly with CPI and only marginally with DMFT.

In contrast, the OHIP-14 showed similar, yet inverse and weaker correlations (Table 3). Of importance might be the fact that the OHIP-14 did not significantly correlate with patients’ perceived importance of regular dental checkups, while the POHW-15 was moderately (and positively) associated. However, the frequency of dental visits per years was neither significantly associated with POHW-15 nor with the OHIP-14.

With regard to dental caries experience, the DMFT scores correlated weakly and negatively with POHW-15 scale “Good Feelings” and positively with OHIP-14. With respect to periodontal health status, the CPI scores correlated weakly and positively with the POHW-15 scale “Good Feelings” but not significantly with the OHIP-14 (Table 3).

POHW scores and oral health

Mean POHW score (ranged between 0 and 45) was 32.75 ± 9.38. The lower quarter (25th percentile) was at 27.00, and the upper quarter (75th percentile) was at 40.00. To assess the number of persons with low, moderate, and high oral health perception, patients were categorized with respect to their POHW scores, i.e., very low (mean POHW score <1 SD; 17 %), low (mean score <1/2 SD; 12 %), moderate (mean scores ±1/2 SD; 34 %), good (mean scores >1/2 SD; 23 %), and very good (mean scores >1 SD; 15 %).

Applying these categories indicated that particularly patients with very low oral health scores had strongly higher scores for the OHIP-14 and self-perceived oral impairment (Table 4). In contrast, those with good to very good oral health scores had moderately to strongly lower health affections.

Table 4 Categorized POHW mean scores and relation to oral health affections

The POHW-15 (and its subscales) and also the OHIP-14 scores did not significantly differ with respect to gender or family status (data not shown). However, individuals with high educational level had the highest POHW-15 scores and the lowest OHIP-14 scores (Table 5). Interestingly, the Jerusalem sample had the best oral health scores (POHW-15 and OHIP-14), while the USA sample had lowest (Table 5). Using univariate analyses (test of inter-subject effects and Levene’s test significant with p = 0.019), we tested the influence of the variables gender, education, and origin (country) on POHW-15 and found that we have to consider effects of the country (F = 6.6; p = 0.001). The POHW-15 scores differ particularly between Israel and USA (p = 0.001), and weaker between Israel and Germany (p = 0.037), but not between Germany and USA (p = 0.471), which both had lower scores compared to Israel (see Table 5). Moreover, education was of relevance only in trend (F = 2.8; p = 0.062), but not in gender (F = 0.1; p = 0.719). In these detail analyses, county and education showed the strongest variance with respect to the POHW-15 scores (F = 10.7; p < 0.001).

Table 5 Means of POHW and OHIP scores in the sample with respect to demographic data

Patients visiting the dentists for routine checkups (assuming good oral health status) indeed had the highest POHW-15 scores and the lowest OHIP-14 scores when compared to patients coming for first aid dental care or planned dental care visits (Table 5), which is in line with the underlying theory. With regard to dental caries experience, patients with DMFT scores up to 13 had significantly higher POHW-15 scores than those with DMF scores >13, while the OHIP-14 showed only a positive trend to lower scores (Table 5).

With regard to periodontal health status (worst CPI score), participants with healthy gums (worst CPI = 0) revealed statistically significant higher POHW-15 scores as compared to subjects with gum bleeding and dental calculus (CPI = 1 and 2), and periodontal pockets (CPI = 3 and 4) scores, and had lower OHIP-14 scores (Table 6).

Table 6 Mean POHW and OHIP scores referred to dental and periodontal status

Discussion

Our data indicate that the 15-item POHW questionnaire is a valid and reliable instrument. To the best of our knowledge, our study is the first to measure specifically the phenomenon of positive oral health and not negative oral health. In contrast to the OHIP-14 which assesses the physical disability, psychological discomfort, physical pain, functional limitations, psychological disability, social disability, and handicap, the two subscales of the new instrument (POHW-15) focus on good feelings and satisfaction with oral health and the status of teeth and gums (“Good Feelings”) on the one hand, and the positive impact of self-perceived oral health on life and health concerns (“Positive Impact”) on the other hand. This means that positive oral health is related to the perceived importance of care for personal health.

This new instrument is not intended to replace the OHIP-14 and other instruments of oral health-related quality of life, but to add an additional and relevant perspective. We see an advantage of the POHW-15 because it is indeed strongly associated with general well-being and significantly associated with patients’ self-ascribed importance of regular dental routine checkups. These variables are not significantly associated with the OHIP-14. Of particular interest, the POHW subscale “Good Feelings” differed significantly with respect to dental status and periodontal status. This association was more evident than that of OHIP-14 scores for dental status and periodontal health status. In dentistry, the DMFT which measure caries experience, and the CPI index which measures periodontal health status are the most common tools for measuring health and disease. The present findings are of importance as they emphasize the association of positive oral health with healthier biological–physical status. The biological–physical measures for the most part will vary with the medical disorder under study [1]. Nevertheless, further research is needed to substantiate these associations.

With respect to the construct validity, the observed associations between the POHW-15 and measures of affected oral health (OHIP and POI), and positive correlation with general well-being and life satisfaction are plausible from a conceptual point of view.

Since the introduction of the “sociodental indicators” by Cohen and Jago a few decades ago [29], a considerable amount of research has been conducted in this field [11–16]. Even though the field of positive health is now recognized in patient assessment in medicine and social sciences, a scientific discipline of Positive Oral Health and Well-Being does not exist in dentistry. Existing models and instruments operationalize oral health exclusively from a deficiency perspective such as functional impairment which affects daily life concerns and social restrictions [11, 12, 16].

Following the biopsychosocial model, which incorporated issues such as functioning and well-being, we adopted the definitions of Seligman’s positive health “assets” [1] and Locker’s “abilities” [17] and constructed a questionnaire with regard to the following oral health “attributes”:

• Subjective–psychological attributes: when a person feels well, defined by high positive measures of several psychological states, a sense of positive well-being, the absence of bothersome symptoms, a sense of confidence about one’s body, and an internal health-related locus of control, optimism, high life satisfaction, and positive emotion [1].

• Functional–social attributes: How well does the individual function; the optimal state of adaptation between one’s bodily function and the positive physical requirements and demands of one’s chosen lifestyle, and meeting all the demands of one’s job, family, and social life [1].

• Biological–physical attributes: the positive ends of physiological function and anatomical structure distributions [1]. There are biological variables which are relevant to health, but these are generally specifically related to disorders. As previously mentioned, the biological aspect is not part of our instrument but only served in the validation and reliability assessment of the questionnaire.

As shown in our conceptual model (Fig. 1), we suggest that oral health, subjective, functional, and biological attributes, which integrate with positive unawareness or positive awareness on the one hand, and with positive perception on the other hand, may result via appropriate oral health behavior in positive oral health.

Current research in positive health seeks to determine which potential health properties actually produce longer life, lower morbidity, lower healthcare utilization, better prognosis when illness does strike, and higher quality of life [1]. We prefer to address these biological–physical, subjective–psychological, and functional–social indicators as oral health attributes.

This study of course has limitations. First of all, the cross-sectional design does not allow causal conclusions. Whether or not the perception of a good oral health status really prevents oral health afflictions and may increase autonomous attempts for adequate health care remains to be shown. Additionally, the three samples may not be representative for the whole diversity of a given population (particularly with respect to socioeconomic status). Therefore, larger and more representative studies are needed.

In summary, our study introduced a new instrument with good reliability and sound correlations with external measures. This instrument is the first which measures positive oral health instead of impaired oral health. The questionnaire, so far, was tested in three languages and was found to be valid both separately and in the combined population. Our questionnaire utilizes subjective–psychological and functional–social measures, and the current results indicate that it might be of importance for research and clinical practice, particularly in the context of sociodental indicators. The further exploration of our conceptual model should contribute toward more optimal identification of patients with good and poor oral health, an effective and inexpensive strategy for prevention, and potential capability to evaluate interventions and preventive programs in a standardized manner.