Eur J Oral Sci 2002; 110: 425–433 Copyright
Eur J Oral Sci 2002

Printed in UK. All rights reserved European Journal of

Oral Sciences
ISSN 0909-8836

Mike T. John1, Donald L. Patrick2,

The German version of the Oral Health Gary D. Slade3
1
Department of Prosthodontics, School of
Impact Profile – translation and Dentistry, Martin Luther University Halle-
Wittenberg, Halle (Saale), Germany;
2
Department of Health Services, University of
psychometric properties Washington, Seattle, WA, USA; 3Department of
Dental Ecology, UNC School of Dentistry,
Chapel Hill, NC, USA
John MT, Patrick DL, Slade GD. The German version of the Oral Health Impact Profile
– translation and psychometric properties. Eur J Oral Sci 2002; 110: 425–433
Eur J
Oral Sci, 2002

The need for cross-culturally adapted oral-health specific health outcome measures is
increasingly recognized in Germany. Following accepted cultural adaptation tech-
nique guidelines, we report the development of the German version of the Oral Health
Impact Profile (OHIP). The original 49 items were translated using a forward–back-
ward method. A de novo development of German items established content validity. A
priori hypothesized associations between the OHIP summary score and self-reported
oral health and five oral disorders were confirmed in a random sample of the general
population (n ¼ 163, age 20–60 yr). These associations were interpreted as support for
Mike T. John, Department of Prosthodontics,
construct validity. The instrument’s responsiveness, as indicated by a mean OHIP
Martin Luther University Halle-Wittenberg,
summary score change from 45.0 to 28.3, was established in 67 consecutive patients Große Steinstrasse 19, D)06097 Halle/Saale,
treated for temporomandibular disorder pain (age 19–85 yr; 72% women). Test-retest Germany
reliability was demonstrated by intraclass correlation coefficients of 0.63–0.92 for
Telefax: +49–345–5573779
dimensions and summary scores (convenience sample, n ¼ 30, age 18–85 yr; 53% E-mail: mike.john@medizin.uni-halle.de
women). Internal consistency was high (Cronbach’s a > 0.74). Sufficient discrimina-
tive and evaluative psychometric properties of the Oral Health Impact Profile German Key words: quality of life; oral health; behavioral
version (OHIP-G) make the instrument suitable for assessment of oral health-related sciences; reliability; validity
quality of life in cross-sectional as well as longitudinal studies. Accepted for publication September 2002

The impact of oral disorders and interventions on
patients’ perceived oral health state and oral health-
related quality of life (OHRQoL) is increasingly recog-
nized as an important component of health (1).
Subjective indicators used to measure OHRQoL can be
of benefit in evaluating oral health for political, theor-
etical and practical purposes (2). Such measures of
patients’ perceived oral health are increasingly in
demand for epidemiological and clinical studies in
Germany (3) because they add a complementary out-
come dimension to the traditional use of clinical oral
disease indicators. Although well-tested and standar-
dized assessment instruments for measuring OHRQoL
are available in the Anglo-American literature, such
instruments do not exist in Germany.
The English-language Oral Health Impact Profile
(OHIP) (4), originally developed in Australia, is an
intensively used instrument. It consists of 49 items which
are grouped into seven domains based on a conceptual
model of oral health that uses the framework of the
World Health Organization (WHO) International Clas-
sification of Impairments, Disabilities and Handicaps
(5). A short version of the instrument has also been
developed (6). The OHIP questionnaire has well-docu-
mented psychometric properties (4). In cross-sectional
studies, it has been used in the general population (7) as
well as in patients with specific oral disorders such as
temporomandibular disorders and orofacial pain (8). In
addition, the OHIP has been used in longitudinal studies
(9) and its sensitivity to change has been demonstrated in
clinical trials (10). These characteristics suggest that a
German-language version of the OHIP questionnaire
would be valuable. However, a thorough translation of
the OHIP into German would not necessarily ensure
applicability across nations because of cultural diversity.
Guidelines for cross-cultural validation of health-related
quality of life measures have been developed (11). In
addition, psychometric testing of the translated instru-
ment in the new cultural context (cross-cultural adapta-
tion) is recommended (12).
This article presents the translation and the psycho-
metric testing of the German version of the Oral Health
Impact Profile (OHIP-G).
Material and Methods
The German version of the OHIP was developed in two
steps using 516 subjects from six independent samples
(Table 1). First, the instrument was translated into German
using state-of-the-art cultural adaptation techniques (11).
The second step involved the assessment of validity, reli-
ability, responsiveness, preference weights, and appropriate
recall periods for the OHIP-G.
426 John et al.

Determination of the recall period and

periodontal diseases, 10 patients with current orthodontic treatment, 10 patients with diseases of the oral mucosa, 10 patients from the Department of Prosthodontics (with a treatment
*Martin Luther University, Halle-Wittenberg, Germany. –Ten patients with temporomandibular disorders (TMD), 10 edentulous patients (with complete dentures), 10 patients with
The Oral Health Impact Profile

Convergent and groups validity and

Groups validity and responsiveness

development of items in Germany
The English-language Oral Health Impact Profile (OHIP-E)
has 49 items which are grouped into seven subscales. For
Type of investigation each of the 49 OHIP questions, subjects are asked how
Content validity ¼ Ôde novoÕ

completeness of questions
frequently they have experienced the impact. Responses are
made on a Likert-type scale (0 ¼ never, 1 ¼ hardly ever,

Assignment of weights
Test–retest reliability
internal consistency
2 ¼ occasionally, 3 ¼ fairly often, 4 ¼ very often).

Translation and back-translation of the English-

language Oral Health Impact Profile
A forward translation was first performed by D. Fink,
Overview of sampling strategies, data collection methods and sample populations by age, gender, and research purpose

Institute of German Dentists (Cologne, Germany), a native

German speaker with an excellent knowledge of English.
% Women

This translation was evaluated by five German dentists from

67
61

72

53

52

61
the Department of Prosthodontics, Martin Luther Univer-
sity Halle-Wittenberg, Germany, who revised this transla-
tion. This version was then revised by a native speaker from
the USA. Two other German dentists and a professional
Age range

translator then back-translated the questionnaire. The

20–60
19–80

19–85

18–85

22–80

18–67

finalized German version was pilot-tested in the Department

of Prosthodontics, Martin-Luther-University Halle-Wit-
tenberg, Germany, and then reviewed by two German
dentists. The final OHIP-G (Appendix) was changed
Age mean (SD)

38.3 (11.3)
45.2 (16.1)

41.3 (15.6)

50.7 (21.1)

43.4 (14.0)

35.4 (11.1)

accordingly after reviewing the results of the de novo

development (described below).

Content validity – de novo development of the OHIP

demand) and 10 patients from the Department of Operative Dentistry (with a treatment demand).

The content of the OHIP-G was further tested by a Ôde-novoÕ

70–

163

136
67

30

50
n

development of the questionnaire according to the method-

Table 1

ology used for the OHIP-E. Subjects in sample A (Table 1)

were asked in a personal interview to report Ôany experiences
Data collection

Questionnaire 
Questionnaire§

Questionnaire§

Questionnaire§

with dental and oral disorders and their denturesÕ they had
ever experienced in their lives. The recorded answers were
Interview

Interview

reduced to a smaller representative collection of statements

each containing a description of a single event associated
with dental and oral disorders. This reduction involved an
analysis of the form and content of the individual statement
Convenience

Convenience

Convenience

Convenience
Sample type

into common themes. The content of the resulting German

Consecutive

items was compared with the translated German OHIP and

Random

the English-language original.

Construct (convergent and groups) validity

patients/staff of the Department of Prosthodontics, MLU*
(E) Individuals from a private general physician’s office and

§Interviewer-supervised, self-administered questionnaire.

Two types of construct validity (13) were investigated.

 Self-administered questionnaire without supervision.
(F) Individuals from a private general physician’s office
(B) Individuals in the metropolitan area of Halle/Saale

Convergent validity describes how closely a measure is

(A) Patients with different oral conditions (School of
Dentistry, MLU*, private practice of orthodontics)

(C) Patients with temporomandibular disorder pain

related to other measures of the same construct and to

which it should be related. A similar concept is groups
(D) Patients with prosthodontic treatment need

validity, where two groups of subjects, one of which has the

trait and the other does not (or has it to a lesser degree),
(Department of Prosthodontics, MLU*)

(Department of Prosthodontics, MLU*)

score differently on the new instrument.

Convergent validity was evaluated by examining the
association between self-reported oral health (very good,
good, fair, poor) and two OHIP-G summary scores: the
number of items reported occasionally, often or very often,
and the sum of all 49 item responses (OHIP-G49). Although
the OHIP-G49 is an ordinal score, it was considered quasi-
interval for the purposes of our analyses (14). Groups
validity was assessed by dividing sample B (Table 1)
according to several self-reported oral conditions with
predicted impact on OHRQoL. We predicted that subjects
with no temporomandibular disorder (TMD) pain, no
Sample

burning mouth sensations, less frequently reported bad

breath, and better self-reported oral health would have

lower OHIP-G49 scores compared with subjects that did not
have these conditions. In addition, it was hypothesized that
self-report of joint clicking or oral habits (defined as biting
on nails, tongue, lip, cheek or objects) would not be notably
associated with oral health-related quality of life.
Spearman rank correlations were calculated to examine
the association between global rating of oral health or fre-
quency of halitosis and the OHIP-G49. Point-biserial cor-
relations which examine the relationship between a
dichotomous and a continuous variable (15) were calculated
to examine the association between TMD pain, self-repor-
ted joint clicking, oral habits and the OHIP-G49.
The ability of the OHIP-G49 to discriminate between
subjects in the general population (sample B, Table 1) and
clinical TMD patients (20–60 yr old, sample C baseline
data, Table 1) was evaluated. A logistic regression model
estimated the probability of being a TMD patient as a
function of the OHIP-G49 when adjusted for age and gen-
der to control for confounding.
Responsiveness
Patients treated for temporomandibular disorder pain
(sample C, Table 1) were chosen for the assessment of the
instrument’s responsiveness. Based on the close relationship
between pain and quality of life (16) we hypothesized that
OHRQoL would improve over a 1-month treatment period.
The difference in OHIP-G49 between baseline and follow up
was tested using the paired t-test. The effect size was cal-
culated as
Mean baseline OHIP-G49  follow up OHIP-G49
standard deviation of baseline OHIP-G49
according to Allen et al. (10).
Reliability
Test-retest reliability was assessed in sample D (Table 1)
using a time-interval of 2 wk between the administration of
the two questionnaires. Intraclass correlation coefficients
(ICCs) were calculated for OHIP-subscales proposed in the
original publication and for the OHIP-G49. Calculations
were performed according to Shrout & Fleiss’s ICC type
2,1 (17). The method of Bland & Altman (18) was used to
compute Ôlimits of agreementÕ around the mean difference.
Internal consistency was measured in sample B (Table 1)
using Cronbach’s a (19) and inter-item correlation for the
OHIP subscales proposed in the OHIP-E publication (4).
Construction of item weights
Item weights reflecting the relative importance of each
statement were obtained using a paired comparison tech-
nique (20). The same procedures as in the OHIP-E publi-
cation (4) were applied to derive item weights in subjects
from sample E (Table 1).
Recall period
We evaluated three recall period options: lifetime exper-
ience, 1-yr recall, and 1-month recall in sample F (Table 1).
Two OHIP-Gs were administered at the same time referring
to different time periods in three groups (1 month vs. 1 yr,
1 month vs. lifetime and 1 yr vs. lifetime prevalence). Sub-
jects first reported the frequency of oral problems for the
Oral Health Impact Profile, German version 427
shorter time interval and immediately after that for the
longer interval before proceeding to the next OHIP ques-
tion. The ICCs (17) were calculated and Bland & Altman’s
method (18) was used to compare the two questionnaires.
Internal consistency for all six OHIPs was measured using
Cronbach’s a (19).
Completeness of the German-version OHIP – burden
of the instrument
The burden of the instrument was assessed in sample F of
Table 1 using the first of the two administered instruments.
The questionnaire was self-administered with no supervi-
sion, that is, the subjects completed the questionnaire
without the possibility of asking for any help or having their
questionnaires checked upon completion. The number of
missing items was calculated.
Missing data
Missing data would compromise the calculation of the
OHIP-G49. Three subjects with more than five missing
items (> 10% of the 49 items) or more than two missing
items in one of the seven OHIP dimensions were discarded.
Remaining missing answers (< 1%) were imputed using
regression imputation within the particular OHIP-E
dimension.
Results
Content validity – de novo development
Asking about Ôany experiences with dental and oral dis-
orders and their denturesÕ elicited 350 answers, which
could be reduced to 53 items. All but one of the original
English-language items were found in our investigation.
This item was Ôdigestion has worsened because of prob-
lems with the teeth, mouth or dentureÕ. Four additional
items were found, two of which have been recommended
by Murray et al. (8) (Ôtaking longer to complete a mealÕ
and Ôavoiding eating with othersÕ) and the two other
items were Ôembarrassing joint noisesÕ/Ôear ringingÕ and
Ôdry mouthÕ.
Additional items were expressed by TMD patients.
Such items were Ôpain in the jointÕ, Ôpain in the jaw
musclesÕ which may have a counterpart in the OHIP-E
(Ôpainful aching in the mouthÕ). ÔDifficulties in opening
the mouth wideÕ in the OHIP-G might be covered by
Ôdifficulties chewing any foodÕ or Ôunable to eat with the
denturesÕ or other functional limitations questions or
physical disability questions in the OHIP-E. Therefore,
they were not considered additional unique items.
Construct validity
All observed associations between self-reported oral
health or self-reported oral conditions and OHRQoL
followed the predicted direction (Table 2). Self-rating of
oral health and three conditions with hypothesized
effects on oral health-related quality of life were very
highly statistically significantly correlated with the
OHIP-G49 (self-reported oral health: rSpearman ¼ 0.56;
428 John et al.

Table 2 subjects from the general population indicated by an

Convergent and groups validity: associations between self-repor-
ted oral health and self-report of five oral conditions and the
OHIP-G49
No of items reported per
subject
odds ratio of 1.05 (95% confidence interval (CI) 1.03–
1.06, P < 0.001). Thus, the odds in favor of being a
TMD patient increased significantly by an estimated 5%
for each additional unit of the OHIP-G49, adjusted for
age and gender.

Often or Occasionally,
Responsiveness
OHIP-G49 very often often, or very often
n (mean) (mean) (mean) The mean OHIP-G49 changed from 45.0 ± 30.9 to
28.3 ± 23.3 among TMD patients during the 1-month
Self-reported oral health
Very good 13 3.8 0.2 1.0 treatment period. The mean change score of 16.7 (95%
Good 106 10.3 0.4 2.6 CI 10.9–22.6) was very highly statistically significant.
Fair 39 29.6 1.6 7.9
Poor 5 60.8 5.6 13.2
Reliability
Temporomandibular disorder pain*
No 146 13.8 0.6 3.5 The median ICC for the seven OHIP-E subscales was
Yes 17 34.4 2.6 9.1 0.83 (range 0.63–0.92; Table 3). A statistically significant
Burning mouth sensations– improvement of OHRQoL was observed for the OHIP-
No 161 15.5 0.8 4.0 G49 and for the subscale Ôphysical painÕ. Limits of ag-
Yes 2 51.5 6.5 8.5 reement indicating the interval where 95% of the test–
Halitosis retest differences are located presented considerable
Never 61 8.1 0.3 1.9 variability for the subscales and the OHIP-G49.
Hardly ever 44 16.0 0.6 4.0 Internal consistency (Cronbach’s a) of the OHIP-G49
Sometimes 50 24.4 1.4 6.2 and OHIP dimensions ranged between 0.74 and 0.96
Often 8 22.6 2.3 7.6 (Table 4). Average inter-item correlation was between
Report of joint clicking§ 0.24 and 0.54.
No 128 15.0 0.7 3.9 All results from test–retest reliability and internal
Yes 35 19.4 1.3 4.7 consistency analyses were consistent with each other.
Report of oral habits 
No 98 14.1 0.6 3.7
Yes 65 18.8 1.1 4.7 Construction of item weights
Total 163 German item weights ranged between 0.69 and 2.39. This
range was slightly larger than the English-language
*Temporomandibular disorder pain in the last month accord-
ing to a question in the Research Diagnostic Criteria for weights (1.11–2.18). The slope of the function relating
Temporomandibular Disorders (37). English-language weights to German weights was 0.76
–Burning mouth sensations in the last 6 months according to a (95% CI 0.36–1.15). The intercept was 0.4 (95% CI
question from the National Health Interview Survey 1989 (38). )0.25)1.05). Confidence intervals around slope and
§Joint clicking as part of the question for joint noises according intercept included a value for the slope of 1 and a value
to the Helkimo Index (39). for the intercept of 0, demonstrating that the relative
 Defined as biting on nails, tongue, lip, cheek, or objects.
ranking of items by the German- and English-language
subjects were compatible. Although German- and
English-language weights were correlated (r ¼ 0.49,
frequency of halitosis: rSpearman ¼ 0.38; TMD pain last
month: rpoint-biserial ¼ 0.31). For self-reported joint
clicking and oral habits, where no effects on OHRQoL Table 3
were anticipated, clinically relevant and statistically
significant associations with the OHIP-G49 were not Test–retest reliability measured by intraclass correlation coeffi-
cients (ICCs) for the OHIP-G49 and seven subscales
observed (rpoint-biserial ¼ 0.09 for clicking; rpoint-biserial ¼
0.11 for oral habits). No correlation coefficient was Dimension Mean Limits of
calculated for burning mouth sensations because only (number of items) ICC difference– agreement
two subjects reported positive sensations.
OHIP-G49 (49) 0.92 3.2* )9.7 to 16.2
Functional limitation (9) 0.88 0.9 )3.8 to 5.6
Differentiating between TMD patients and subjects from Physical pain (9) 0.82 1.2* )4.8 to 7.1
the general population: Classifying subjects with a pre- Psychological discomfort (5) 0.84 0.3 )3.6 to 4.2
dicted probability of ‡ 0.5 by the logistic regression Physical disability (9) 0.92 0.0 )3.7 to 3.8
model as TMD patients resulted in a sensitivity of 34% Psychological disability (6) 0.69 0.5 )3.3 to 4.3
and a specificity of 94% in a sample of 56 TMD patients Social disability (5) 0.70 0.3 )2.0 to 2.5
and 163 subjects from the general population. Overall, Handicap (6) 0.63 0.1 )3.5 to 3.7
79% of all subjects were correctly classified. The OHIP- *P < 0.05 (paired t-test, df 29).
G49 was able to discriminate between TMD patients and –Baseline score minus follow-up score.
 Oral Health Impact Profile, German version 429

Table 4 reached by the OHIP-G referring to the recall period of

Internal consistency measured for the OHIP-G49 and seven the last month (0.92/0.96).
subscales

Dimension Cronbach’s Average inter-item Completeness of the German-version OHIP – Burden

(number of items) a correlation
OHIP-G49 (49) 0.96 0.35
Functional limitation (9) 0.74 0.24
Physical pain (9) 0.84 0.38
Psychological Discomfort (5) 0.82 0.47
Physical disability (9) 0.84 0.36
Psychological disability (6) 0.81 0.42
Social disability (5) 0.85 0.54
Handicap (6) 0.88 0.54
P < 0.001), the limit of agreement of 0.61 indicated
notable differences in values of individual weights
between the two measures.
Applying the weights in the OHIP summary score
calculation of sample B (Table 1) resulted in a very high
correlation (rSpearman > 0.99) between the simple sum of
item responses and the weighted sum of the item
responses. The strong correlation between the two
OHIP-G49s suggests that both summary scores were
exchangeable. Therefore, the simpler score, the sum of all
49 unweighted items, was preferred.
Recall period
Among the three recall period comparisons, the com-
parison of mean OHIP-G49 using 1-month recall and
1-yr recall had the highest ICC and the narrowest limits
of agreement. Mean scores for 1-month recall and 1-yr
recall did not differ significantly (Table 5). On average,
subjects reported 1.2 units of the OHIP-G49 more when
asked about problems in the last year compared with
problems in the past month. This suggested that indi-
vidual’s answers referring to these recall periods were
similar, on average, although considerable differences
were noted with limits of agreement in the range )9.2 to
11.6 OHIP-G49 units. Questions concerning lifetime
experience of OHIP-G49 indicated a less impaired
OHRQoL than the 1-month recall (mean difference )5.7;
95% CI )0.5 to )10.8). No difference was observed
between 1-yr and lifetime. However, the ICC was mod-
erate and the limits of agreement indicated a wide range
of differences. Internal consistency measured by Cron-
bach’s a (‡ 0.90) was high for all three recall periods
administered twice. The highest internal consistency was
of the instrument
Two subjects (1.5% out of 136) had more than 20
missing items, which might severely compromise the
interpretation of the OHIP-G. They were considered
complete non-responders. Another subject did not fulfill
the criteria of having five or less missing items in total or
more than two missing items in one dimension, which
would probably compromise the calculation of OHIP-
G49 or dimension scores. Therefore, for 98% of the
subjects, the OHIP-G49 and dimension scores could be
calculated. Most subjects filled the questionnaire in
8–12 min.
Discussion
When used as a self-completed questionnaire among a
variety of patient- and population samples, the German
version of the Oral Health Impact Profile was found to
be a valid and reliable instrument with psychometric
properties similar to the English-language original. The
OHIP-G has sufficient discriminative and evaluative
psychometric properties. Therefore, it is suitable for
cross-sectional as well as longitudinal studies.
To adapt the OHIP cross-culturally, we followed a
5-step procedure recommended by Guillemin et al. (11),
with only minor modification. For example, the guide-
lines suggested a multidisciplinary review committee
whereas only two dentists formed our committee to
review the translated version. Bilingual people recom-
mended to participate in such adaptation studies (12)
were in short supply in our study. We used only one
person – the native US-speaker currently at the Institute
of English and American language and literature at the
University of Halle as a bilingual person. We did not
encounter notable difficulties in this translation and ad-
aptation process.
It was a strength of our adaptation process that the
final translation result could be compared with the de
novo development of OHIP-items. This ensured cross-
cultural equivalence because our de novo development
of the OHIP presented the same content of the German
version when compared with the English ori-
ginal. According to Guillemin et al. (11), important
components of equivalence in cross-cultural validation

Table 5
Comparison of OHIP summary scores of different pairs of recall periods using intraclass correlation coefficients (ICC) and the Bland-
Altman method (18)

1 yr vs. 1 month (n ¼ 40) Lifetime vs. 1 month (n ¼ 48) Lifetime vs. 1 yr (n ¼ 45)

ICC 0.95 0.48 0.78

Limits of agreement )9.2 to 11.6 )41.1 to 29.7 )24.7 to 24.3
Mean difference (95% confidence interval) 1.2 ()0.5 to 2.9) )5.7 ()10.8 to )0.5) )0.2 ()3.9 to 3.5)
430 John et al.
are semantic (equivalence of the meaning of words),
idiomatic (that equivalents are found for certain idioms
and colloquialism which are not translatable), experien-
tial (situation evoked or depicted in the original OHIP
should fit the German cultural context), and conceptual
(validity of the concept explored and the events experi-
enced by people in the German population) equivalence.
Herdman et al. (21) introduced the concept of func-
tional equivalence, which is Ôthe extent to which an in-
strument does what it is supposed to do equally well in
two or more culturesÕ. The combination of de novo
development of the OHIP-G and the translation process
of the OHIP-E ensured this. Although more refined
translation processes exist (22), i.e. by using quality rat-
ings of translation and sophisticated statistical analyses,
our translation process ensured at least minimal criteria
according to other published requirements for a suc-
cessful adaptation process (23). There is evidence that
combining elements from Ôresource intensiveÕ and
Ôresource-savingÕ strategies (24) in a moderately resource-
intensive translation is able to produce adequate results
(25). We consider our approach as falling into that
category.
Not unexpectedly, our findings differed from the
OHIP-E in only a few specific respects. In our de novo
development, we were able to find three statements about
handicap which were added to the OHIP-E from another
instrument. While dental patient samples were used for
development of both the OHIP-E and OHIP-G, under-
lying differences in the patient populations might be
responsible for slight differences in wording and the
identification of additional mostly TMD-related items in
the German version.
Construct validity of the OHIP-G was similar to that
of the OHIP-E, which is well established (4). Here, an
expected association between social impact and perceived
need to visit a dentist was found and differences between
dentate and edentulous subjects were demonstrated.
Relationships between OHRQoL and site of last dental
visit (private dentist, public clinic), perceived need for
dental treatment, financial hardship, number of missing
anterior teeth, number of missing unreplaced anterior
teeth, number of teeth with attrition, number of reported
medical conditions, and age were demonstrated (6).
Our study also demonstrated responsiveness of the
OHIP-G49 to treatment – a property that is considered
by some to be an additional aspect of validity and not a
distinct psychometric property in addition to reliability
and validity (26). We observed an effect size of 0.54 in
patients with TMD pain, a result that is almost identical
to the report of an effect size of 0.5 (2) for patients
referred to a craniofacial pain unit.
Our weight assignment results are consistent with
findngs reported by Allison et al. (27) who found that
item weights generated by an Australian sample showed a
similar ranking when compared with those generated by a
sample of English-speaking Canadians and a sample of
French-speaking Canadians, although the weight magni-
tudes were quite different. This may be an indication
of little cultural variation of the construct OHRQoL as
measured by OHIP. Nonetheless, hoped-for improve-
ments in measurement properties by using item weights in
cross-sectional or longitudinal studies have not been
demonstrated for the OHIP (10,28). Based on our findings
and literature results, we do not recommend weighting of
OHIP-G items for most purposes.
Findings from the Sickness Impact Profile – a general
health status measure (29) – support a remarkable sta-
bility of health status values across cultures. A study in
head and neck cancer patients using a HRQoL instrument
that was developed for multinational trials suggested
that the cultural background did not substantially
influence the majority of HRQoL domains (30). It was
hypothesized that the role of cultural background may
depend upon the instrument and subject group studied.
Based on our study, the OHIP seems to be an instrument
well-suited for multinational research because of a lack
of substantial differences in the cross-cultural concepts of
OHRQoL.
The original OHIP-E publication specified that all 49
questions should refer to a fixed time-period, but did not
recommend a specific one. We found that a 1-month
recall period for the OHIP-G had the highest internal
consistency, although no substantial differences among
the three different recall periods were observed. The
single statistically significant difference in mean OHIP-
G49 scores was observed when 1-month and lifetime
recall periods were compared. At first, it may seem
paradoxical that higher scores were found for the
1-month recall period compared with the lifetime recall
period. The finding may indicate that, as people age, they
experience a higher rate of impacts from chronic oral
conditions that have worsened over time. Hence, they
may report impacts occurring Ôvery oftenÕ during the last
month compared with ÔoccasionallyÕ over their lifetime,
reflecting the lower average rate of impacts occurring
throughout their lives. However this interpretation is
speculative. The response format for the OHIP asks Ôhow
often have you had the following problems during the
last …Õ, relying on subjects to make their own subjective
evaluation of frequency. It is not known whether subjects
think in terms of the absolute number of impacts or an
average rate of impacts. For example, some may regard
12 episodes of pain as Ôvery oftenÕ, whether or not they all
occurred within the previous month; others may consider
12 episodes of pain within the previous year to be
equivalent to one episode of pain within the previous
month. Finally, it is possible that there is a response bias,
in which respondents forget about impacts experienced
earlier in life, causing them to underestimate their true
lifetime level of impact. Regardless of these speculated
effects, it was encouraging to observe no statistically and
clinically significant difference between 1-month and 1-yr
recall (the two recall periods reported most frequently in
the literature). The similarity of the 1-month and 1-yr
results may reflect a tendency for subjects to use their
recent impression about OHRQoL and extrapolate to
the 1-yr period. Although we did not have data available
comparing OHIP-G validity when different recall periods
were used, from a theoretical point of view, a short recall
period is preferred because memory is expected to be
more accurate over shorter periods. Hence, for the

samples studied here, we recommend using the 1-month
period because it accomplished both aims, namely to
capture the present status and to give a most accurate
impression about perceived oral health.
Estimates for test-retest reliability of the OHIP-G were
better than for the English-language original (ICC 0.42–
0.77) (4). Differences in the populations studied might
contribute to these differences. More importantly, we
restricted the time between the administration of the
questionnaires to 2 wk, whereas the English-language
version presented an interval of 3 months.
A different aspect of reliability is the homogeneity of
the items. It is recommended that items should correlate
with the total score above 0.20 (31). This was the case for
OHIP-G items. Coefficient a should be between 0.70 and
0.90 (32). All German subscales reached this level. Our
results were slightly better than the English-language
original (Cronbach’s a 0.37–0.83) (4).
The burden for the subjects was usually acceptable
with the self-administered questionnaire. The rejection
rate and the number of missing items was very low,
which corroborates findings with the OHIP-E (6). The
general impression of a low burden and high accepta-
bility of the instrument is supported by the use of the
OHIP-G in clinical interviews and as a self-administered
questionnaire (with and without supervision and control)
(33).
Although the OHIP-G has many advantages, it might
characterize only one aspect of OHRQoL. Other
instruments exist, especially in the English literature,
which describe possibly different OHRQoL aspects. This
situation is not unique for oral health. Two well-known
general health status measures, the SF-36 (34) and the
WHOQOL instrument (35) differ substantially in the
conceptual breadth claimed. In a situation where no
unanimously agreed-upon definition of quality of life
exists (36), other internationally accepted instruments
warrant a cross-cultural adaptation to enrich the concept
of oral health-related quality of life in Germany. How-
ever, based on the widespread international use of the
OHIP-E we expect that the German counterpart will be a
well-accepted instrument for clinical trials and health
surveys.
Acknowledgments – The authors are grateful to Dr S. Pfeifer,
Naumburg, Germany, for his help with the data collection, Dr
S. F. Dworkin, Departments of Oral Medicine and Psychiatry,
University of Washington, Seattle, WA, USA, and Dr W.
Micheelis, Institute of German Dentists, Cologne, Germany,
for their contributions to the preparation of this manuscript.
The study was supported by Deutsche Akademie der
Naturforscher Leopoldina Grant BMBF-LPD 9901/8–4.
References
1. Reisine S, Locker D. Societal, psychological, and economic
impacts of oral conditions and treatments. In: Cohen LK Gift
HC, eds. Disease prevention and oral health promotion.
Copenhagen, Denmark: Munksgaard, 1995; 33–71.
2. Locker D. Applications of self-reported assessments of oral
health outcomes. J Dent Educ 1996; 60: 494–500.
Oral Health Impact Profile, German version 431
3. John M, Micheelis W. Lebensqualitätsforschung in der Zahn-
medizin: Konzepte, Erfahrungen und Perspektiven. Cologne,
Germany: Institut der Deutschen Zahnärzte, 2000; 3–5.
4. Slade GD, Spencer AJ. Development and evaluation of the
Oral Health Impact Profile. Community Dent Health 1994; 11:
3–11.
5. Locker D. Measuring oral health: a conceptual framework.
Community Dent Health 1988; 5: 3–18.
6. Slade GD. Derivation and validation of a short-form oral
health impact profile. Community Dent Oral Epidemiol 1997;
25: 284–290.
7. Slade GD, Spencer AJ. Social impact of oral conditions
among older adults. Aust Dent J 1994; 39: 358–364.
8. Murray H, Locker D, Mock D, Tenenbaum HC. Pain and
the quality of life in patients referred to a craniofacial pain unit.
J Orofac Pain 1996; 10: 316–323.
9. Slade GD. Assessing change in quality of life using the Oral
Health Impact Profile. Community Dent Oral Epidemiol 1998;
26: 52–61.
10. Allen PF, Mcmillan AS, Locker D. An assessment of sen-
sitivity to change of the Oral Health Impact Profile in a clinical
trial. Community Dent Oral Epidemiol 2001; 29: 175–182.
11. Guillemin F, Bombardier C, Beaton D. Cross-cultural
adaptation of health-related quality of life measures: literature
review and proposed guidelines. J Clin Epidemiol 1993; 46:
1417–1432.
12. Hunt SM, Alonso J, Bucquet D, Niero M, Wiklund I,
McKenna S. Cross-cultural adaptation of health measures.
European Group for Health Management and Quality of Life
Assessment. Health Policy 1991; 19: 33–44.
13. Streiner DL, Norman GR. Health measurement scales, 2nd
edn. Oxford, UK: Oxford University Press, 1995; 144–162.
14. Cohen ME. Analysis of ordinal dental data: evaluation of
conflicting recommendations. J Dent Res 2001; 80: 309–313.
15. Norman GF, Streiner DL. Biostatistics – the bare essentials,
2nd edn. Hamilton, Canada: B.C. Decker, 2000; 230–235.
16. Skevington SM. Investigating the relationship between pain
and discomfort and quality of life, using the WHOQOL. Pain
1998; 76: 395–406.
17. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing
rater reliability. Psychol Bull 1979; 86: 420–428.
18. Bland JM, Altman DG. Statistical methods for assessing
agreement between two methods of clinical measurement.
Lancet 1986; 1: 307–310.
19. Cronbach LJ. Coefficient alpha and the internal reliability of
tests. Psychometrika 1951; 16: 297–334.
20. McKenna SP, Hunt SM, McEwen J. Weighting the serious-
ness of perceived health problems using Thurstone’s method of
paired comparisons. Int J Epidemiol 1981; 10: 93–97.
21. Herdman M, Fox-Rushby J, Badia X. A model of equivalence
in the cultural adaptation of HRQoL instruments: the uni-
versalist approach. Qual Life Res 1998; 7: 323–335.
22. Bullinger M. German translation and psychometric testing of
the SF-36 Health Survey: preliminary results from the IQOLA
Project. International Quality of Life Assessment. Soc Sci Med
1995; 41: 1359–1366.
23. Bullinger M, Anderson R, Cella D, Aaronson N. Devel-
oping and evaluating cross-cultural instruments from minimum
requirements to optimal models. Qual Life Res 1993; 2: 451–
459.
24. Guyatt GH. The philosophy of health-related quality of life
translation. Qual Life Res 1993; 2: 461–465.
25. Perneger TV, Leplege A, Etter JF. Cross-cultural adapta-
tion of a psychometric instrument: two methods compared.
J Clin Epidemiol 1999; 52: 1037–1046.
26. Hays RD, Hadorn D. Responsiveness to change: an aspect
of validity, not a separate dimension. Qual Life Res 1992; 1:
73–75.
27. Allison P, Locker D, Jokovic A, Slade G. A cross-cultural
study of oral health values. J Dent Res 1999; 78: 643–649.
28. Allen PF, Locker D. Do item weights matter? An assessment
using the oral health impact profile. Community Dent Health
1997; 14: 133–138.
432 John et al.
29. Patrick DL, Sittampalam Y, Somerville SM, Carter WB,
Bergner M. A cross-cultural comparison of health status
values. Am J Public Health 1985; 75: 1402–1407.
30. Allison PJ. Health-related quality of life comparisons in
French and English-speaking populations. Community Dent
Health 2001; 18: 214–218.
31. Streiner DL, Norman GR. Health measurement scales, 2nd
edn. Oxford, UK: Oxford University Press, 1995; 54–68.
32. Nunnally JC, Bernstein I. Psychometric theory, 2nd edn.
New York, NY, USA: McGraw-Hill 1994; 248–292.
33. John M. Mehrdimensionaler Therapieerfolg für schmerzhafte
kraniomandibuläre Dysfunktionen (CMD). Dtsch Zahnärztl Z
1999; 54: 391–394.
34. Ware JE, Snow KK, Kosinski M, Gandeck B. SF-36 health
survey: manual and interpretation guide, Boston, MA: The
Health Institute, New England Medical Center, 1993 3:1–3:22
35. Whoqol Group. The World Health Organization Quality of
Life assessment (WHOQOL): position paper from the World
Health Organization. Soc Sci Med 1995; 41: 1403–1409.
36. Kane RL. Scaling the heights of quality of life. J Clin Epidemiol
2001; 54: 1079–1080.
37. Dworkin SF, Leresche L. Research diagnostic criteria for
temporomandibular disorders: review, criteria, examinations
and specifications, critique. J Craniomandib Disord 1992; 6:
301–355.
38. Lipton JA, Ship JA, Larach-Robinson D. Estimated preval-
ence and distribution of reported orofacial pain in the United
States. J Am Dent Assoc 1993; 124: 115–121.
39. Helkimo M. Studies on function and dysfunction of the mas-
ticatory system. II. Index for anamnestic and clinical dysfunc-
tion and occlusal state. Swed Dent J 1974; 67: 101–121.
Appendix
Oral Health Impact Profile German version (OHIP-G)
Questions and weights
Funktionelle Einschränkungen (functional limitation)
1. Hatten Sie im vergangenen Monat Schwierigkeiten
beim Kauen von Nahrungsmitteln aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.578
2. Hatten Sie im vergangenen Monat Schwierigkeiten,
bestimmte Worte auszusprechen aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.434
3. Haben Sie im vergangenen Monat bemerkt, dass ein
Zahn nicht gesund aussieht? 1.417
4. Hatten Sie im vergangenen Monat das Gefühl, dass Ihr
Aussehen beeinträchtigt wurde aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.687
5. Hatten Sie im vergangenen Monat den Eindruck,
Sie hätten Mundgeruch aufgrund von Problemen mit
Ihren Zähnen, im Mundbereich oder mit Ihrem Zahnersatz?
2.158
6. Hatten Sie im vergangenen Monat das Gefühl, Ihr
Geschmackssinn war beeinträchtigt aufgrund von
Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 1.441
7. Haben sich im vergangenen Monat Speisereste in Ihren
Zähnen oder am Zahnersatz festgesetzt? 1.783
8. Hatten Sie im vergangenen Monat das Gefühl,
Ihre Verdauung war gestört aufgrund von Problemen mit
Ihren Zähnen, im Mundbereich oder mit Ihrem Zahnersatz?
1.863
9. Hatten Sie im vergangenen Monat das Gefühl, dass Ihr
Zahnersatz schlecht sitzt? 1.732
Schmerzen (physical pain)
10. Hatten Sie im vergangenen Monat Schmerzen im
Mundbereich? 1.726
11. Hatten Sie im vergangenen Monat einen wunden,
entzündeten Kiefer bzw. Mund? 2.043
12. Hatten Sie im vergangenen Monat Kopfschmerzen
aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.987
13. Hatten Sie im vergangenen Monat empfindliche
Zähne, z. B. bei heißen kalten Speisen bzw. Getränken?
1.097
14. Hatten Sie im vergangenen Monat Zahnschmerzen?
2.087
15. Hatten Sie im vergangenen Monat Schmerzen am
Zahnfleisch? 1.654
16. War es Ihnen im vergangenen Monat unangenehm,
bestimmte Nahrungsmittel zu essen aufgrund von
Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 0.945
17. Hatten Sie im vergangenen Monat wunde Stellen in
Ihrem Mund? 1.999
18. Hat im vergangenen Monat Ihr Zahnersatz
unangenehm gedrückt? 1.479
Psychisches Unwohlsein/Unbehagen (psychological
discomfort)
19. Haben Sie sich im vergangenen Monat Sorgen
gemacht aufgrund von Zahn- bzw. Mundproblemen? 1.569
20. Hatten Sie im vergangenen Monat ein Gefühl der
Unsicherheit in Zusammenhang mit Ihren Zähnen, Ihrem
Mund oder Ihrem Zahnersatz? 1.587
21. Hatten Sie im vergangenen Monat das Gefühl, dass
es Ihnen ganz schlecht geht aufgrund von Zahn- bzw.
Mundproblemen? 1.412
22. Haben Sie sich im vergangenen Monat wegen des
Aussehens Ihrer Zähne oder Ihres Zahnersatzes unwohl/
unbehaglich gefühlt? 1.456
23. Haben Sie sich im vergangenen Monat angespannt
gefühlt aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.325
Physische Beeinträchtigung (physical disability)
24. Ist es im vergangenen Monat vorgekommen, dass Sie
nur undeutlich sprechen konnten aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.856
25. Ist es im vergangenen Monat vorgekommen, dass
andere Leute bestimmte Worte von Ihnen missverstanden
haben aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.624
26. Hatten Sie im vergangenen Monat den Eindruck, Ihr
Essen war geschmacklich weniger gut aufgrund von
Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 1.088
27. Konnten Sie im vergangenen Monat Ihre Zähne nicht
richtig putzen aufgrund von Problemen mit Ihren Zähnen,
im Mundbereich oder mit Ihrem Zahnersatz? 2.122
28. Mussten Sie im vergangenen Monat darauf
verzichten, bestimmte Speisen zu essen aufgrund von
Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 1.413
29. Ist Ihre Ernährung im vergangenen Monat
unbefriedigend gewesen aufgrund von Problemen mit Ihren
Zähnen, im Mundbereich oder mit Ihrem Zahnersatz? 1.739
30. Ist es im vergangenen Monat vorgekommen, dass Sie
aufgrund von Problemen mit Ihrem Zahnersatz damit nicht
essen konnten? 2.094

31. Ist es im vergangenen Monat vorgekommen, dass Sie
das Lächeln vermieden haben aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.738
32. Mussten Sie im vergangenen Monat Mahlzeiten
unterbrechen aufgrund von Problemen mit Ihren Zähnen,
im Mundbereich oder mit Ihrem Zahnersatz? 1.420
Psychische Beeinträchtigung (psychological disability)
33. Ist es im vergangenen Monat vorgekommen, dass Ihr
Schlaf unterbrochen wurde aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.575
34. Ist es im vergangenen Monat vorgekommen, dass Sie
sehr verärgert waren aufgrund von Problemen mit Ihren
Zähnen, im Mundbereich oder mit Ihrem Zahnersatz? 1.612
35. Hatten Sie im vergangenen Monat Schwierigkeiten zu
entspannen aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.580
36. Haben Sie sich im vergangenen Monat bedrückt/
depressiv gefühlt aufgrund von Problemen mit Ihren
Zähnen, im Mundbereich oder mit Ihrem Zahnersatz? 2.157
37. Ist es im vergangenen Monat vorgekommen, dass Sie
sich schlechter konzentrieren konnten aufgrund von
Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 1.824
38. Haben Sie sich im vergangenen Monat ein wenig
verlegen gefühlt aufgrund von Problemen mit Ihren Zähnen,
im Mundbereich oder mit Ihrem Zahnersatz? 1.166
Soziale Beeinträchtigung (social disability)
39. Haben Sie es im vergangenen Monat vermieden, außer
Haus zu gehen aufgrund von Problemen mit Ihren Zähnen,
im Mundbereich oder mit Ihrem Zahnersatz? 0.691
40. Waren Sie im vergangenen Monat weniger nachsichtig
im Umgang mit Ihrem Ehepartner oder Ihrer Familie
aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.982
41. Hatten Sie im vergangenen Monat allgemein
Schwierigkeiten, mit anderen Menschen zurechtzukommen
aufgrund von Problemen mit Ihren Zähnen, im Mundbereich
oder mit Ihrem Zahnersatz? 1.682
42. Waren Sie im vergangenen Monat anderen Menschen
gegenüber eher reizbar aufgrund von Problemen mit Ihren
Zähnen, im Mundbereich oder mit Ihrem Zahnersatz? 1.791
Oral Health Impact Profile, German version 433
43. Ist es Ihnen im vergangenen Monat schwergefallen,
Ihren alltäglichen Beschäftigungen nachzugehen aufgrund
von Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 2.103
Benachteiligung/Behinderung (handicap)
44. Hatten Sie im vergangenen Monat den Eindruck, dass
sich Ihre Allgemeingesundheit verschlechtert hat aufgrund
von Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz? 1.861
45. Haben Sie im vergangenen Monat finanzielle
Einbußen hinnehmen müssen aufgrund von Problemen
mit Ihren Zähnen, im Mundbereich oder mit Ihrem
Zahnersatz? 1.287
46. Ist es im vergangenen Monat vorgekommen, dass Sie
die Gesellschaft anderer Menschen nicht so recht genießen
konnten aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.197
47. Hatten Sie im vergangenen Monat den Eindruck, dass
Ihr Leben ganz allgemein weniger zufriedenstellend war
aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.594
48. Waren Sie im vergangenen Monat vollkommen
unfähig etwas zu tun aufgrund von Problemen mit Ihren
Zähnen, im Mundbereich oder mit Ihrem Zahnersatz? 2.392
49. Ist es im vergangenen Monat vorgekommen, dass
Sie bei Ihrer Arbeit nicht so leistungsfähig waren wie
üblich aufgrund von Problemen mit Ihren Zähnen, im
Mundbereich oder mit Ihrem Zahnersatz? 1.509
Additional German items
50. Haben Sie es im vergangenen Monat vermieden, mit
anderen Personen gemeinsam zu essen aufgrund von
Problemen mit Ihren Zähnen, im Mundbereich oder mit
Ihrem Zahnersatz?
51. Hat es im vergangenen Monat länger gedauert, eine
Mahlzeit zu beenden aufgrund von Problemen mit Ihren
Zähnen, im Mundbereich oder mit Ihrem Zahnersatz?
52. Hatten Sie im vergangenen Monat ein Sie störendes
Geräusch im Kiefergelenk?
53. Hatten Sie im vergangenen Monat einen unangenehm
trockenen Mund?