Oral Health–Related Quality of Life in Partially Edentulous Patients Treated with Removable, Fixed, Fixed-Removable, and Implant-Supported Prostheses Amal Ali Swelem, BDS, MS, PhDa/Konstantin G. Gurevich, BDS, MS, PhD, DrScib/ Ekaterina G. Fabrikant, BDS, MS, PhDc/Mona H.A. Hassan MBChB, MPH, DrPHd/ Shorouq Aqou, BDS, MScCH(HPTE), PhDe
Purpose: This study investigated changes in oral health–related quality of life (OHRQoL) in partially edentulous patients treated with removable dental prostheses (RDPs), fixed dental prostheses (FDPs), fixed-removable (combined) restorations (COMBs), and implant-supported fixed prostheses (ISFPs). Materials and Methods: A total of 200 patients (30 to 50 years old) were enrolled: 45 received RDPs, 32 received FDPs, 66 received COMBs, and 57 received ISFPs. OHRQoL was measured using the shortened version of the Oral Health Impact Profile (OHIP-14) before treatment and 6 weeks and 6 months after treatment. Treatment groups were sex-neutral; however, significant differences were found relative to age and Kennedy classification. A general linear model was used to explore the interaction of age and Kennedy classification with treatment modality. Results: Pretreatment analysis revealed that the psychologic discomfort domain showed the greatest negative impact on OHRQoL, while functional limitation had the smallest effect. Within-group comparison revealed a significant decrease in OHIP scores throughout the study in all groups except the younger age group treated with RDPs after 6 weeks. Between-group comparison revealed significant differences among the treatment groups. The least amount of OHRQoL improvement was recorded for RDPs for both age groups at 6 weeks and for the younger age group at 6 months. There were no significant differences between FDPs and ISFPs. Conclusions: All treatments produced significant improvement in OHRQoL. The least amount of improvement was observed in patients with RDPs. OHRQoL changes in patients treated with FDPs and ISFPs were comparable. The same treatment can have different impacts on the OHRQoL of partially edentulous individuals depending on their age and Kennedy classification. Int J Prosthodont 2014;27:338–347. doi: 10.11607/ijp.3692
aAssistant
Professor, Oral and Maxillofacial Rehabilitation Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Removable Prosthodontic Department, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt. bProfessor and Chair, Moscow State University of Medicine and Dentistry, Moscow, Russia. cAssistant Professor, Moscow State University of Medicine and Dentistry, Moscow, Russia. dProfessor of Biostatistics, Department of Preventive Dental Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Biostatistics, High Institute of Public Health, Alexandria University, Alexandria, Egypt. eAssistant Professor and Consultant of Orthodontics, Preventive Dental Sciences Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia. Correspondence to: Dr Amal Ali Swelem, Faculty of Dentistry, King Abdulaziz University, P0 Box 80209, Jeddah 21589, Saudi Arabia. Email: [email protected] ©2014 by Quintessence Publishing Co Inc.
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I
n the past, dental researchers considered clinicianbased outcome measures to be more important than subjective patient-based measures.1,2 Recently, however, researchers have begun to focus more on patient perceptions of oral health and oral treatment to better understand the effect of treatment on patients’ quality of life.3,4 Oral health–related quality of life (OHRQoL) characterizes patients’ perceptions of oral health and can therefore be used to measure patient-perceived benefits of dental treatment.5 Tooth loss can affect different aspects of patients’ lives, including appearance, function, and interpersonal relationships; thus, tooth loss can impair quality of life.6 Partial tooth loss can be treated using different prosthodontic options. Conventionally, the success of these treatments has been evaluated from a clinicians’ point of view. However, a technical and clinically satisfactory prosthesis is not necessarily a predictor of
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Swelem et al
good patient satisfaction.7–11 Research suggests that clinicians and patients define the concept of success differently.11,12 Dentists typically assess prostheses according to predetermined success criteria based on technical standards, but these criteria rarely consider the needs, attitudes, or expectations of the individual patient.13,14 For this reason, the use of patient-centered outcome measures may help facilitate a more appropriate, patient-oriented prosthetic solution. Patient satisfaction measures such as visual analog scales have been used by several investigators7,8,11,14–24 as subjective assessment tools. However, previous studies have shown that validated questionnaires that address OHRQoL provide a more comprehensive evaluation of oral health and dental treatment than single patient-centered questions addressing patient satisfaction.2,25 Over the last two decades, several OHRQoL instruments have been introduced, of which the Oral Health Impact Profile (OHIP) is the most commonly used,26 sophisticated, and comprehensive.2,27 The original OHIP consists of seven domains comprising 49 items that describe the impact of oral health conditions on aspects of function, daily living, and social relations.28 The dimensions are hierarchically ordered so that the impacts described are considered gradually more disruptive to a patient’s life.29 The OHIP instrument has been translated into a variety of languages, with validated cross-cultural equivalence.2 OHIP-14, a shorter and more patient-friendly version, consists of 14 questions that cover the same seven domains as the OHIP-49. Several investigators26,30–32 have used the OHIP-14 to study the impact of different dental treatments on patients’ OHRQoL. The dental literature is rich in studies assessing OHRQoL in completely edentulous patients treated with either conventional or implant-supported prostheses.10,16,17,22,26,30,31,33–39 Several studies have also assessed OHRQoL in partially edentulous individuals.2,5,32,40–47 The treatment options for partially edentulous patients include fixed dental prostheses (FDPs), removable dental prostheses (RDPs), implantsupported fixed prostheses (ISFPs), and combined fixed-removable restorations (COMBs). Relatively few studies have investigated and compared the effects of different treatment options on the OHRQoL of partially edentulous patients. Furuyama et al2 compared OHRQoL in patients treated with ISFPs and RDPs. John et al5 and Szabo et al48 compared OHRQoL in patients treated with FDPs and RDPs. Sonoyama et al40 and Petricevic et al49 compared OHRQoL in patients treated with FDPs and ISFPs. To the present authors’ knowledge, only one recent study, conducted by Kimura et al,47 compared RDPs, FDPs, and ISFPs in terms of OHRQoL. However, a comparison of all four treatment options has not been performed to date,
and no studies have evaluated OHRQoL outcomes in patients rehabilitated with COMBs. This study aimed to investigate changes in OHRQoL among partially edentulous patients following treatment with one of four types of prosthesis: RDPs, FDPs, ISFPs, and COMBs. It has been universally accepted that implants provide better satisfaction than non-implant treatment and are thus expected to provide better OHRQoL2; therefore, the hypothesis of the study was that ISFPs would demonstrate the greatest improvement in the OHRQoL of partially edentulous patients.
Materials and Methods Study Population Partially edentulous patients were selected from the dental clinics of Moscow State University of Medicine and Dentistry, Moscow, Russia, from September 2006 to June 2008. Inclusion criteria included (1) one or more missing teeth in either or both arches, (2) good general health that would not interfere with dental treatment, (3) no temporomandibular disorders or parafunctional habits (bruxism/clenching), and (4) capable of reading and writing in Russian (language of the questionnaires and informed consent form). To receive ISFPs, patients had to be free from any systemic disease that would be likely to compromise implant therapy and show adequate bone volume for implant placement without bone augmentation. Patients were excluded if they (1) presented with an acute oral disease, (2) reported pain in the orofacial region, (3) had psychologic or psychiatric conditions that could influence their reaction to treatment, or (4) had learning difficulties that precluded them from understanding the questionnaires. Each candidate was given a full written and oral description of the study protocol. A convenience sample of 200 eligible cooperative patients (100 men and 100 women) who agreed to attend follow-up visits were enrolled after providing written informed consent. The patients ranged from 30 to 50 years in age (mean age: 41.8 years). The study protocol was approved by the local ethical committee of Moscow State University of Medicine and Dentistry. The possible treatment options for each clinical situation were explained thoroughly to each patient. The patient then chose one of the possible treatments based on his or her preferences and/or economic status. The study population was then divided into four groups based on the treatment received: Group 1 included patients who received RDPs; group 2 included patients who received FDPs; group 3 included patients who received COMBs, which were identified as either RDPs supported by surveyed crowns or
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OHRQoL in Partially Edentulous Patients
Table 1 Demographic Data and Kennedy Classification Among Treatment Groups COMB (n = 66) Sex Male Female Age (y) 30–40 40–50 Mean (SD)* Kennedy class Maxilla Class I Class I mod 1 Class I mod 3 Class II mod 1 Class II mod 2 Class II mod 3 Class III Class III mod 1 Class III mod 2 Class III mod 3 Class IV Dentate Mandible Class I Class I mod 1 Class I mod 2 Class II mod 1 Class II mod 2 Class III Class III mod 1 Dentate
FDP (n = 32)
RDP (n = 45)
ISFP (n = 57)
n
%
n
%
n
%
n
%
31 35
47.0 53.0
15 17
46.9 53.1
22 23
48.9 51.1
32 25
56.1 43.9
Total (N = 200) n 100 100
%
P
50.0 50.0
.741
14 21.2 52 78.8 44.2 (6.1)a
6 18.8 26 81.2 44.4 (6.5)b
17 37.8 28 62.2 44.6 (6.6)c
39 68.4 18 31.6 35.4 (5.9)abc
76 38.0 124 62.0 41.8 (7.4)
4 3 4 5 8 7 5 15 5 2 – 8
6.1 4.5 6.1 7.6 12.1 10.6 7.6 22.7 7.6 3.0 0.0 12.1
– – – – – – 5 20 – – – 7
0.0 0.0 0.0 0.0 0.0 0.0 15.6 62.5 0.0 0.0 0.0 21.9
– – 6 15 – – – – – 9 – 15
0.0 0.0 13.3 33.3 0.0 0.0 0.0 0.0 0.0 20.0 0.0 33.3
2 – – – – – 17 14 2 2 7 13
3.5 0.0 0.0 0.0 0.0 0.0 29.8 24.6 3.5 3.5 12.3 22.8
6 3 10 20 8 7 27 49 7 13 7 43
3.0 1.5 5.0 10.0 4.0 3.5 13.5 24.5 3.5 6.5 3.5 21.5
.000§
9 9 3 3 13 2 27 –
13.6 13.6 4.5 4.5 19.7 3.0 40.9 0.0
5 – – – – 8 19 –
15.6 0.0 0.0 0.0 0.0 25.0 59.4 0.0
13 9 9 – 8 6 – –
28.9 20.0 20.0 0.0 17.8 13.3 0.0 0.0
– – – 5 – 16 19 17
0.0 0.0 0.0 8.8 0.0 28.1 33.3 29.8
27 18 12 8 21 32 65 17
13.5 9.0 6.0 4.0 10.5 16.0 32.5 8.5
.000§
.000† .000‡
Mod = modification. *Same superscript letters denote high statistical significance (P < .01). †Highly statistically significant (P < .01; chi-square test). ‡Highly statistically significant (P < .01; ANOVA). §Highly statistically significant (P < .01; Monte Carlo).
RDPs and FDPs/crowns in the same arch; and group 4 included patients who received ISFPs. Standard implant placement was performed by the same surgeon and prosthodontist in all patients. All inserted implants retained single crowns. Vanadium-titanium implants (Nobel Biocare) were used. None of the implants in the ISFP group were lost during follow-up and no failures or complications were recorded for the other prosthodontic restorations during the observation period. OHRQoL Measurement OHRQoL was measured using the Russian version of the OHIP-14, which has been shown to be valid and reliable in the Russian population.50 The instrument covered the seven domains—functional limitation, physical pain, psychologic discomfort, physical disability,
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psychologic disability, social disability, and handicap— with two questions each. The five categories of response for each item were as follows: never, usually no, sometimes, usually, and very often. Items were scored on a 5-point Likert scale ranging from 1 (never) to 5 (very often). Higher OHIP total summary scores and subscales for each domain indicated greater OHRQoL impairment. The questionnaire was administered with supervision to all participants at three occasions: before treatment (T0), 6 weeks after treatment (T1), and 6 months after treatment (T2). Participants were given prior explanation and instruction regarding the different aspects of the questionnaire. Statistical Analysis Statistical analysis was performed using SPSS version 16.0 (SPSS). Cronbach’s alpha coefficient was
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Table 2 OHIP-14 Scores Before Treatment* Respondents (%) OHIP
Never
Usually no
Sometimes
Very often
Median
P25–P75
9.5 3.5
12.5 3.5
2.5 1.0 1.0
2.0–5.0 1.0–3.0 1.0–2.0
46.5 20.5
5.0 34.0
4.5 37.0
7.0 3.0 4.0
5.0–8.0 2.0–3.0 3.0–5.0
4.0 18.0
27.5 27.0
34.0 28.5
34.5 26.5
8.0 4.0 4.0
6.0–10.0 3.0–5.0 3.0–5.0
23.5 38.0
33.5 28.5
10.5 23.0
24.0 1.5
8.5 9.0
4.0 2.0 2.0
3.0–6.0 2.0–4.0 1.0–3.0
Psychologic limitation Found it difficult to relax Have been a bit embarrassed
32.0 3.0
30.5 22.0
18.0 26.5
12.5 16.5
7.0 32.0
5.0 2.0 3.0
4.0–8.0 1.0–3.0 2.3–5.0
Social limitation Have been irritable with other people Had difficulty doing usual jobs
15.5 23.5
24.5 26.0
41.5 27.0
9.5 9.0
9.0 14.5
5.0 3.0 3.0
4.0–6.0 2.0–3.0 2.0–3.0
Incapacity (handicap) Felt life in general less satisfactory Have been unable to function
35.0 52.0
23.0 29.0
24.5 13.0
7.0 1.0
10.5 5.0
3.0 2.0 1.0
2.0–5.8 1.0–3.0 1.0–2.0
36.0
29.0–45.0
Functional limitation Had problems pronouncing words Felt sense of taste worsened
54.5 66.0
12.0 25.5
11.5 1.5
Physical pain Had painful aching in mouth Found it uncomfortable to eat food
3.5 2.5
40.5 6.0
Psychologic discomfort Have been self-conscious Felt tense
0.0 0.0
Physical limitation Had an unsatisfactory diet Had to interrupt meals
Usually
Total P25, P75 = 25th and 75th percentiles, respectively. *Cronbach's alpha = 0.925.
used to test the reliability of the OHIP scale. An overall OHIP score was computed by adding the scores of all questions, and the same was done for each subscale. The possible scores for the overall scale ranged from 14 to 70, and the possible scores for each subscale ranged from 2 to 10. A change in score was also computed by subtracting baseline values from follow-up values at 6 weeks and 6 months. Positive scores indicated improvement in OHRQoL and negative scores indicated worsening. As demonstrated by the Shapiro-Wilk test of normality, the distributions of the OHIP scale and subscales were not normal; thus, nonparametric statistics were preferred in data analysis. The proportion, mean, SD, median, and 25th and 75th percentiles were used with the boxplot as summary statistics. The mean age was compared among treatment groups using one-way analysis of variance (ANOVA) with the Scheffe post hoc test. Changes in OHIP scores before and after treatment were examined using the Friedman test followed by the Conover post hoc test for pairwise comparisons between the means of the ranks. Comparison of the median change in
OHIP scores after treatment was performed using the Kruskal-Wallis test of nonparametric ANOVA with the Conover post hoc test. A general linear model was used to explore the interaction effect of age and Kennedy classification with treatment modality on the change in OHIP score 6 months after treatment. All tests were two-sided, and statistical significance was set at .05. The Conover post hoc analysis was performed using the BrightStat software (Brightstat).
Results All 200 patients attended the 6-month follow-up appointments. Demographic data and characteristics of tooth loss and Kennedy classification among the participants are summarized in Table 1. There were significant differences between the treatment groups in terms of age and Kennedy classification but not in terms of sex. Pretreatment analysis revealed that the psychologic discomfort domain showed the greatest negative impact on OHRQoL, while functional limitation had the smallest effect (Table 2).
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OHRQoL in Partially Edentulous Patients
Table 3 OHIP Scores Throughout the Study Period Age: 30–39 y
Age: 40–50 y
Median (P25–P75) OHIP subscale
T0
T1
Median (P 25–P75) T2
P
T0
T1
T2
P
FDP OHIP summary score 39.0 (34.0–39.0) 16.0 (16.0–17.0) 14.0 (14.0–14.0) Functional limitation 2.0 (2.0–2.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Physical pain 7.0 (6.0–7.0) 3.0 (3.0–3.0) 2.0 (2.0–2.0) Psychologic discomfort 10.0 (7.0–10.0) 3.0 (3.0–3.0) 2.0 (2.0–2.0) Physical limitation 3.0 (3.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Psychologic limitation 7.0 (5.0–7.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Social limitation 6.0 (5.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) Incapacity (handicap) 4.0 (4.0–4.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
* – * * * * * *
30.0 (28.0–37.0) 15.0 (15.0–21.0) 14.0 (14.0–15.0) 2.0 (2.0–6.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) 5.5 (5.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–3.0) 8.0 (5.8–9.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) 4.5 (4.0–5.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 4.5 (3.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** ** ** ** ** ** ** **
RDP OHIP summary score 23.0 (23.0–34.0) 26.0 (26.0–30.0) 17.0 (17.0–21.0) Functional limitation 3.0 (3.0–5.0) 5.0 (5.0–5.0) 3.0 (2.0–3.0) Physical pain 6.0 (5.0–6.0) 4.0 (4.0–5.0) 2.0 (2.0–4.0) Psychologic discomfort 5.0 (5.0–5.0) 5.0 (4.0–5.0) 3.0 (3.0–4.0) Physical limitation 2.0 (2.0–5.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) Psychologic limitation 3.0 (3.0–5.0) 3.0 (3.0–4.0) 2.0 (2.0–3.0) Social limitation 2.0 (2.0–6.0) 5.0 (5.0–5.0) 3.0 (3.0–4.0) Incapacity (handicap) 2.0 (2.0–3.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0)
** ** ** ** ** ** * **
39.0 (33.0–59.3) 32.0 (32.0–47.0) 21.0 (20.0–27.3) 6.0 (3.0–9.0) 5.0 (5.0–8.0) 4.0 (4.0–4.8) 7.0 (5.0–7.8) 6.0 (6.0–6.0) 4.0 (3.0–4.0) 7.0 (7.0–9.3) 6.0 (6.0–7.0) 4.0 (2.0–4.0) 4.0 (4.0–8.3) 3.0 (3.0–6.0) 3.0 (2.0–3.0) 5.0 (5.0–8.0) 4.0 (4.0–6.0) 3.0 (3.0–4.0) 5.0 (5.0–9.0) 4.0 (4.0–5.8) 2.0 (2.0–4.8) 5.0 (5.0–8.8) 4.0 (4.0–7.8) 3.0 (2.0–4.8)
** ** ** ** ** ** ** **
COMB OHIP summary score 39.0 (27.0–56.0) 20.0 (17.0–27.0) 15.0 (14.0–17.0) Functional limitation 4.0 (2.0–6.0) 4.0 (3.0–5.0) 3.0 (2.0–3.0) Physical pain 7.0 (7.0–7.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) Psychologic discomfort 6.0 (6.0–10.0) 4.0 (3.0–6.0) 2.0 (2.0–4.0) Physical limitation 6.0 (3.0–7.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) Psychologic limitation 7.0 (4.0–10.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) Social limitation 3.0 (3.0–9.0) 3.0 (2.0–3.0) 2.0 (2.0–2.0) Incapacity (handicap) 6.0 (2.0–7.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** ** ** ** ** ** ** **
46.0 (33.0–52.0) 22.5 (20.0–33.0) 14.0 (14.0–16.0) 3.5 (2.0–6.0) 4.0 (3.0–6.0) 2.0 (2.0–4.0) 8.0 (7.0–8.0) 4.0 (3.0–6.0) 2.0 (2.0–3.0) 8.0 (8.0–10.0) 4.0 (4.0–6.0) 2.0 (2.0–3.0) 6.0 (5.0–8.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 8.0 (5.0–8.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 6.0 (5.0–8.8) 3.0 (2.0–4.0) 2.0 (2.0–3.0) 5.0 (3.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0)
** ** ** ** ** ** ** **
ISFP OHIP summary score 36.0 (28.0–37.0) 17.0 (16.0–19.0) 14.0 (14.0–14.0) Functional limitation 2.0 (2.0–2.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Physical pain 6.0 (5.0–7.0) 3.0 (3.0–4.0) 2.0 (2.0–2.0) Psychologic discomfort 8.0 (6.0–10.0) 4.0 (3.0–4.0) 2.0 (2.0–2.0) Physical limitation 3.0 (2.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Psychologic limitation 6.0 (4.0–7.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Social limitation 5.0 (3.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) Incapacity (handicap) 2.0 (2.0–6.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** – ** ** ** ** ** **
36.0 (32.0–39.3) 19.0 (17.5–22.8) 15.0 (14.0–15.3) 2.0 (2.0–2.3) 2.0 (2.0–4.0) 2.0 (2.0–2.0) 7.0 (7.0–8.0) 4.0 (2.8–4.3) 2.0 (2.0–3.0) 8.0 (7.0–9.0) 4.0 (4.0–5.0) 2.0 (2.0–2.3) 4.0 (3.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 6.0 (4.8–6.3) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 4.0 (4.0–5.3) 2.0 (2.0–3.3) 2.0 (2.0–2.0) 3.0 (3.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** * ** ** ** ** ** **
T0 = baseline; T1 = 6 weeks after treatment; T2 = 6 months after treatment; P25, P75 = 25th and 75th percentiles, respectively. *Statistically significant (P < .05; Friedman test); **highly statistically significant (P < .01; Friedman test).
Table 3 shows the OHIP scores for all treatment modalities and age groups at baseline and follow-up. Generally, OHIP summary scores and most subscale scores in all groups demonstrated a significant decrease throughout the study; however, this decrease was more evident in the first 6 weeks. Younger patients treated with RDPs demonstrated a negative change after 6 weeks. All posttreatment summary scores were higher in the RDP group compared to the other treatment modalities.
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Between-group comparisons are presented in Table 4 and Fig 1. Comparison of the median change scores revealed significant differences among the treatment groups at the two follow-up intervals. From baseline to 6 weeks, RDP treatment in both age groups was significantly different from all other treatment modalities for nearly all domains. From baseline to 6 months, RDP treatment was significantly different from all other treatment modalities in the younger age group. COMB treatment was significantly different from RDP and
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Table 4 Change in OHIP-14 Subscales Age: 30–39 y Median (P25–P75) OHIP subscale
Age: 40–50 y Median (P 25–P75)
T0–T1
T0–T2
0.0 (0.0–0.0) –2.0 (–2.0–0.0)
0.0 (0.0–0.0) 0.0 (0.0–3.0)
0.0 (0.0–2.0) –2.0 (1.0–1.5)
0.0 (0.0–4.0) –1.0 (2.0–3.5)
–1.0 (0.0–1.0) 0.0 (0.0–0.0) **
0.0 (1.0–3.0) 0.0 (0.0–0.0) **
–2.0 (0.0–0.0) –1.0 (0.0–0.0) **
0.0 (0.0–2.0) 0.0 (0.0–0.0) NS
3.0 (4.0–4.0)
4.0 (5.0–5.0)
3.0 (3.0–3.0)
3.0 (3.0–3.0)
0.0 (2.0–2.0) 3.0 (4.0–5.0) 1.0 (3.0–4.0) **
1.0 (4.0–4.0) 0.0 (0.0–0.0) 3.0 (4.0–5.0) **
0.0 (1.0–1.5) 2.0 (4.0–5.0) 2.0 (3.0–4.0) **
2.0 (3.0–4.0) 5.0 (5.0–6.0) 4.0 (5.0–5.0) **
Psychologic discomfort FDP RDP COMB ISFP P
4.0 (7.0–7.0) 0.0 (0.0–1.0) 0.0 (2.0–7.0) 2.0 (6.0–6.0) **
5.0 (8.0–8.0) 1.0 (2.0–2.0) 2.0 (4.0–8.0) 3.0 (6.0–7.5) **
3.0 (3.0–6.0) 1.0 (1.0–2.5) 2.0 (4.0–6.0) 2.0 (4.0–5.0) **
4.0 (6.0–6.0) 3.0 (5.0–5.5) 4.0 (6.0–8.0) 5.0 (6.0–7.0) **
Physical limitation FDP RDP COMB ISFP P
1.0 (1.0–3.0) 0.0 (0.0–1.0) 1.0 (2.0–5.0) 0.0 (1.0–3.0) **
1.0 (1.0–3.0) 0.0 (0.0–3.0) 1.0 (4.0–5.0) 0.0 (1.0–3.0) **
0.0 (1.0–2.0) 1.0 (1.0–3.0) 2.0 (3.0–4.0) 1.0 (1.0–2.0) **
0.0 (1.0–2.0) 1.0 (1.0–5.5) 3.0 (4.0–6.0) 1.0 (2.0–4.0) **
Psychologic limitation FDP RDP COMB ISFP P
3.0 (5.0–5.0) 0.0 (0.0–1.0) 2.0 (3.0–8.0) 2.0 (4.0–5.0) **
3.0 (5.0–5.0) 1.0 (1.0–2.0) 2.0 (5.0–8.0) 2.0 (4.0–5.0) **
2.0 (2.0–3.0) 1.0 (1.0–2.0) 2.0 (3.0–5.5) 2.0 (2.0–4.0) **
2.0 (2.5–3.0) 2.0 (2.0–4.0) 3.0 (4.5–6.0) 3.0 (4.0–4.0) **
2.0 (4.0–4.0) –3.0 (–3.0–1.0) 0.0 (1.0–6.0) 1.0 (2.0–4.0) **
3.0 (4.0–4.0) –1.0 (–1.0–2.0) 1.0 (1.0–7.0) 1.0 (3.0–4.0) **
1.0 (2.0–3.0) 1.0 (1.0–2.5) 0.5 (3.0–5.0) 1.0 (2.0–2.0) NS
1.0 (2.5–3.0) 2.0 (3.0–4.0) 2.0 (3.5–6.0) 2.0 (2.0–3.0) **
0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (4.0–5.0) 0.0 (0.0–4.0) **
0.0 (0.0–0.0) 0.0 (0.0–1.0) 0.0 (4.0–5.0) 0.0 (0.0–4.0) *
0.0 (0.0–1.0) 0.0 (1.0–1.5) 0.0 (1.0–3.0) 1.0 (1.0–3.0) **
0.0 (0.0–1.0) 2.0 (3.0–4.0) 1.0 (2.0–3.5) 1.0 (1.0–3.0) **
Functional limitation FDP RDP COMB ISFP P Physical pain FDP RDP COMB ISFP P
Social limitation FDP RDP COMB ISFP P Incapacity (handicap) FDP RDP COMB ISFP P
T0–T1
T0–T2
T0 = baseline; T1 = 6 weeks after treatment; T2 = 6 months after treatment; NS = not significant (Kruskal-Wallis); change = baseline minus follow-up (positive values indicate improvement and negative values indicate worsening). *Statistically significant (P < .05; Kruskal-Wallis); **highly statistically significant (P < .01; Kruskal-Wallis).
FDP treatments in the older age group. There were no significant differences between FDPs and ISFPs. The general linear model revealed a significant interaction effect of age and Kennedy classification with treatment modality on OHIP changes. For Kennedy Class III and IV patients, OHRQoL improved
the most after treatment with FDPs and ISFPs in the younger age group, while COMBs and ISFPs were superior in the older age group. For Kennedy Class I and II patients, RDPs were inferior to ISFPs in the younger age group but somewhat superior to ISFPs in the older age group (Fig 2 and Table 5).
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OHRQoL in Partially Edentulous Patients
Age (y)
Age (y)
30–39
30–39
40–50
P < .05
Change (before – after 6 months)
Change (before – after 6 weeks)
40 30
40–50
50
P < .05 P < .05
20 10 0
40 30 20 10 0
Combined
FDP
RDP
ISFP
Combined
a
FDP
RDP
ISFP
b
Kennedy
Kennedy
I, II
I, II
III, IV
III, IV
Means Log10 change in OHIP
Means Log10 change in OHIP
Figs 1a and 1b Change in OHIP-14 scores according to age (a) from baseline to 6 weeks and (b) from baseline to 6 months after treatment. Positive values indicate improvement in OHRQoL, and negative values indicate worsening.
1.4
1.2
1.0
.8 Combined
FDP
RDP
1.6
1.4
1.2
1.0
ISFP
Combined
a
FDP
RDP
ISFP
b
Figs 2a and 2b Interaction effect of age and Kennedy classification with treatment modality on OHIP changes in the (a) younger age group (30–39 years) and (b) older age group (40–50 years) (non-estimable means are not plotted).
Table 5 G eneral Linear Model for Change in OHIP Scores 6 Months After Treatment According to Treatment Modality, Age, and Kennedy Classification* Source of variation
Sum of squares
df
Mean square
F
P
Age
0.07
1
0.07
2.43
.121
Kennedy
0.24
1
0.24
7.67
.006
Treatment modality
2.88
3
0.96
31.19
.000
Treatment modality × age
0.41
3
0.14
4.44
.005
Treatment modality × Kennedy
0.27
2
0.13
4.35
.014
Error
5.81
189
0.03
Total
331.32
200
*R2 = 0.459 (adjusted R2 = 0.431).
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Swelem et al
Discussion The results of this study showed that improvements in oral health were achieved with any of the applied treatment modalities. While RDPs demonstrated smaller changes than FDPs or COMBs, no differences were observed among tooth- or implant-supported FDPs. Patients had a considerably impaired level of OHRQoL before treatment. The psychologic discomfort domain was the most affected. This is in agreement with Nickenig et al,43 who found that the most frequently reported problems during preoperative OHRQoL assessment in partially edentulous patients were related to psychologic disappointment. Physical pain was the second-most impacted domain; 37% of the participants “found it uncomfortable to eat.” This complaint is one of the most commonly reported pretreatment problems.51 For obvious reasons, such a complaint is an expected consequence of tooth loss. In agreement with the present study, previous studies of completely and partially edentulous patients have demonstrated significant OHRQoL improvement after prosthodontic rehabilitation.5,26,30,32,34,36,41,47,49,52 This result could be attributed to the improved function and increased sense of security provided by the rehabilitation process, thus improving patients’ daily activities. This improvement was more pronounced during the first follow-up period. It has been reported that immediate effects of prosthodontic therapy, including the noticeable decrease in both frequency and severity of pretreatment problems, are expected mainly during the first month after treatment,5,32,51 after which patients become adapted to their prostheses.5 The only exception was for younger patients treated with RDPs, who initially were more irritable, lacked confidence, and reported difficulty speaking with and adapting to their RDPs. In fact, betweengroup comparisons revealed that the least amount of OHRQoL improvement was recorded for the RDP group. These results are consistent with those of other investigators, who reported that OHRQoL levels of partially edentulous patients were found to be superior with FDPs5 or ISFPs2,53 compared to RDPs. According to Szentpetery et al51 and the present results, pretreatment problems decreased more in number and more rapidly in FDP wearers than in RDP wearers. These results support the authors’ clinical experience that FDPs are a more natural means of replacing missing teeth and require shorter adaptation periods than RDPs, especially in younger individuals. Interestingly, there was also a significant difference between COMBs and RDPs. The authors could not find any studies in the dental literature that compared these two treatments specifically; hence, direct comparison to the literature was not possible. However,
most COMB patients in this study were in the older age range. Improvements after prosthodontic therapy have been shown to be higher in older patients, who are usually less worried about the long-term survival or future complications of their restorations and thus have lower expectations.49 The results revealed statistically insignificant differences between FDPs and ISFPs. These findings are consistent with those of other investigators40,49 and support the claim that comparable results can be achieved by FDPs regardless of whether they are supported by implants. It is noteworthy, however, that 6 weeks after treatment, OHIP scores were slightly higher in the ISFP group than in the FDP group, especially in older patients. Similar findings were observed by Petricevic et al,49 who attributed this result to the more complicated treatment when using implants, which includes surgical intervention and higher costs and thus may raise patients’ initial apprehension regarding the durability of the restoration. Therefore, the initial hypothesis that ISFPs would demonstrate the greatest OHRQoL improvement could be partially rejected. ISFPs demonstrated better OHRQoL outcomes than RDPs and COMBs but were comparable to FDPs. In fact, FDPs were slightly superior. Statistical analysis revealed insignificant differences between COMBs and ISFPs at the end of the follow-up period in the older age group. This may imply that COMBs provide OHRQoL levels comparable to ISFPs. However, these results should be interpreted with caution and cannot be generalized. As mentioned previously, this finding could be age-related. Further, baseline scores were the highest in the COMB group, especially in the older patients, indicating that the OHRQoL in this group was initially much more impaired than in the other treatment groups. More than half of the cases were categorized as either Kennedy Class I or II, indicating a greater number of posterior teeth missing. It has been reported that the greater the number of missing occlusal units (posterior teeth), the greater the OHRQoL impairment in patients with distal extension edentulous areas.54 Hence, this insignificant difference may be age-related or due to the “greater” impact of rehabilitation in COMB patients who demonstrated poorer OHRQoL initially. When analyzing the treatment modality–Kennedy class interaction, the results discussed above appear consistent with the results of the general linear model, which revealed that in bounded saddle cases (Kennedy Class III and IV), FDPs and ISFPs provided better OHRQoL improvement in younger patients, while COMBs were superior in older patients. In patients showing distal extension (Kennedy Class I and II), ISFPs were superior to RDPs in the younger age group. However, regression analysis revealed that
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OHRQoL in Partially Edentulous Patients
treating Kennedy Class I and II patients in the older age group with RDPs provided somewhat better OHRQoL improvement than treating them with ISFPs. The need for a greater number of implants in distal extension cases may have aggravated the psychologic pressure of a more extensive surgical implant procedure in older patients. To the authors’ knowledge, this is the first study to evaluate OHRQoL outcomes for all four possible prosthodontic treatment modalities in partially edentulous patients. Hence, the results of this study may help to fill a research gap in the dental literature. However, one limitation of this study was the unequal distribution of patients among the prosthodontic groups. Further, the direct contribution of other sociodemographic variables, such as social class, income, and educational attainment, was not assessed. Future studies are needed to investigate these factors and their correlating impacts with larger samples and longer follow-up periods.
Conclusions Within the limitations of this study, the following conclusions could be drawn: •• All prosthodontic treatments produced significant improvements in the patients’ OHRQoL at the end of the 6-month follow-up period. •• The least amount of improvement was observed in patients treated with removable partial dentures. •• Changes in OHRQoL in patients treated with fixed dental prostheses and implant-supported fixed prostheses were comparable. •• The same prosthodontic treatment can have different impacts on the OHRQoL of partially edentulous individuals depending on their age and Kennedy classification.
Acknowledgments The authors reported no conflicts of interest related to this study.
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21. MacEntee MI, Walton JN, Glick N. A clinical trial of patient satisfaction and prosthodontic needs with ball and bar attachments for implant-retained complete overdentures: Three year results. J Prosthet Dent 2005;93:28–37. 22. Ellis JS, Burawi G, Walls A, Thomason JM. Patient satisfaction with two designs of implant supported removable overdentures; ball attachment and magnets. Clin Oral Implants Res 2009; 20:1293–1298. 23. Van der Bilt A, Burgers M, Van Kampen FMC, Cune MS. Mandibular implant-supported overdentures and oral function. Clin Oral Implants Res 2010;21:1209–1213. 24. Cheng T, Sun G, Huo J, He X, Wang Y, Ren Y. Patient satisfaction and masticatory efficiency of single implant-retained mandibular overdentures using the stud and magnetic attachments. J Dent 2012;40:1018–1023. 25. Reisene S, Locker D. Disease Prevention and Oral Health Promotion: Socio-Dental Sciences in Action. Copenhagen: Munksgaard, 1995. 26. Mumcu E, Bilhan H, Geckili O. The effect of attachment type and implant number on satisfaction and quality of life of mandibular implant-retained overdenture wearers. Gerodontolgy 2012; 29:e618–e623. 27. Locker D. Health outcomes of oral disorders. Int J Epidemiol 1995;24(suppl 1):S85–S89. 28. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994;11:3–11. 29. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284–290. 30. Berretin-Felix G, Filho HN, Padovani CR, Machado WM. A longitudinal study of quality of life of elderly with mandibular implant-supported fixed prostheses. Clin Oral Implants Res 2008; 19:704–708. 31. Brennan M, Houston F, O’Sullivan M, O’Connel B. Patient satisfaction and oral health–related quality of life outcomes of implant overdentures and fixed complete dentures. Int J Oral Maxillofac Implants 2010;25:791–800. 32. Barreto AO, Martins de Aquino LM, Luz de Aquino AR, Roncalli AG, Aguiar do Amaral B, Carreiro AP. Impact on quality of life of removable partial denture wearers after 2 years of use. Braz J Oral Sci 2011;10:50–54. 33. Awad MA, Locker D, Korner-Bitensky N, Feine JS. Measuring the effect of intra-oral implant rehabilitation on health-related quality of life in a randomized controlled clinical trial. J Dent Res 2000;79:1659–1663. 34. Allen PF, McMillan AS, Walshaw D. A patient-based assessment of implant stabilized and conventional complete dentures. J Prosthet Dent 2001;85:141–147. 35. Ellis JS, Pelekis ND, Thomason JM. Conventional rehabilitation of edentulous patients: The impact on oral health–related quality of life and patient satisfaction. J Prosthodont 2007;16:37–42. 36. Butt AM, Ahmed B, Parveen N, Yazdanie N. Oral health related quality of life in complete dentures. Pakistan Oral Dent J 2009;29:397–402. 37. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology 2010;27:3–10. 38. Albaker AM. The oral health–related quality of life in edentulous patients treated with conventional complete dentures. Gerodontology 2013;30:61–66.
39. Jabbour Z, Emami E, de Grandmont P, Rompre PH, Feine JS. Is oral health–related quality of life stable following rehabilitation with mandibular two-implant overdentures? Clin Oral Implants Res 2012;23:1205–1209. 40. Sonoyama W, Kuboki T, Okamoto S, et al. Quality of life assessment in patients with implant-supported and resin-bonded fixed prosthesis for bounded edentulous spaces. Clin Oral Implants Res 2002;13:359–364. 41. Grossmann AC, Hassel AJ, Schilling O, Lehmann F, Koob A, Rammelsberg P. Treatment with double crown-retained removable partial dentures and oral health–related quality of life in middle and high-aged patients. Int J Prosthodont 2007;20:576–578. 42. Inukai M, Baba K, John MT, Igarashi Y. Does removable partial denture quality affect individuals’ oral health? J Dent Res 2008;87:736–739. 43. Nickenig H, Wichmann M, Andreas SK, Eitner S. Oral health–related quality of life in partially edentulous patients: Assessments before and after implant therapy. J Craniomaxillofac Surg 2008;36:477–480. 44. Armellini DB, Heydecke G, Witter DJ, Creugers NHJ. Effect of removable partial dentures on oral health–related quality of life in subjects with shortened dental arches: A 2-center crosssectional study. Int J Prosthodont 2008;21:524–530. 45. Fueki F, Yoshida E, Igarashi Y. A structural equation model relating objective and subjective masticatory function and oral health-related quality of life in patients with removable partial dentures. J Oral Rehabil 2011;38:86–94. 46. Inoue M, John MT, Tsukasaki H, Furuyama C, Baba K. Denture quality has a minimal effect on health-related quality of life in patients with removable dentures. J Oral Rehabil 2011;38:818–826. 47. Kimura A, Arakawa H, Noda K, et al. Response shift in oral health–related quality of life measurement in patients with partial edentulism. J Oral Rehabil 2012;39:44–54. 48. Szabo G, John MT, Szanto I, Marada G, Kende D, Szentpetery A. Impaired oral health–related quality of life in Hungary. Acta Odontol Scand 2011;69:108–117. 49. Petricevic N, Celebic A, Rener-Sitar K. A 3-year longitudinal study of quality of life outcomes of elderly patients with implant- and tooth-supported fixed partial dentures in posterior dental regions. Gerodontology 2012;29:c956–c963. 50. Barer GM, Gurevich KG, Smirniagina VV, Fabrikant EG. Validation of Oral Health Impact Profile (OHIP) quality of life questionnaire in Russian patients with evidence of chronic generalized periodontitis [Abstract; in Russian]. Stomatologiia 2007; 86(5):27–30. 51. Szentpetery AG, John MT, Slade GD, Setz JM. Problems reported by patients before and after prosthodontic treatment. Int J Prosthodont 2005;18:124–130. 52. Heydecke G, Locker D, Awad MA, Lund JP, Feine JS. Oral and general health–related quality of life with conventional and implant dentures. Community Dent Oral Epidemiol 2003;31:161–168. 53. Kuboki T, Okamoto S, Suzuki H, et al. Quality of life assessment of bone-anchored fixed partial denture patients with unilateral mandibular distal-extension edentulism. J Prosthet Dent 1999; 82:182–187. 54. Baba K, Igarashi Y, Nishiyama A, et al. The relationship between missing occlusal units and oral health–related quality of life in patients with shortened dental arches. Int J Prosthodont 2008;21:72–74.
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Purpose: This study investigated changes in oral health–related quality of life (OHRQoL) in partially edentulous patients treated with removable dental prostheses (RDPs), fixed dental prostheses (FDPs), fixed-removable (combined) restorations (COMBs), and implant-supported fixed prostheses (ISFPs). Materials and Methods: A total of 200 patients (30 to 50 years old) were enrolled: 45 received RDPs, 32 received FDPs, 66 received COMBs, and 57 received ISFPs. OHRQoL was measured using the shortened version of the Oral Health Impact Profile (OHIP-14) before treatment and 6 weeks and 6 months after treatment. Treatment groups were sex-neutral; however, significant differences were found relative to age and Kennedy classification. A general linear model was used to explore the interaction of age and Kennedy classification with treatment modality. Results: Pretreatment analysis revealed that the psychologic discomfort domain showed the greatest negative impact on OHRQoL, while functional limitation had the smallest effect. Within-group comparison revealed a significant decrease in OHIP scores throughout the study in all groups except the younger age group treated with RDPs after 6 weeks. Between-group comparison revealed significant differences among the treatment groups. The least amount of OHRQoL improvement was recorded for RDPs for both age groups at 6 weeks and for the younger age group at 6 months. There were no significant differences between FDPs and ISFPs. Conclusions: All treatments produced significant improvement in OHRQoL. The least amount of improvement was observed in patients with RDPs. OHRQoL changes in patients treated with FDPs and ISFPs were comparable. The same treatment can have different impacts on the OHRQoL of partially edentulous individuals depending on their age and Kennedy classification. Int J Prosthodont 2014;27:338–347. doi: 10.11607/ijp.3692
aAssistant
Professor, Oral and Maxillofacial Rehabilitation Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Removable Prosthodontic Department, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt. bProfessor and Chair, Moscow State University of Medicine and Dentistry, Moscow, Russia. cAssistant Professor, Moscow State University of Medicine and Dentistry, Moscow, Russia. dProfessor of Biostatistics, Department of Preventive Dental Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Biostatistics, High Institute of Public Health, Alexandria University, Alexandria, Egypt. eAssistant Professor and Consultant of Orthodontics, Preventive Dental Sciences Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia. Correspondence to: Dr Amal Ali Swelem, Faculty of Dentistry, King Abdulaziz University, P0 Box 80209, Jeddah 21589, Saudi Arabia. Email: [email protected] ©2014 by Quintessence Publishing Co Inc.
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I
n the past, dental researchers considered clinicianbased outcome measures to be more important than subjective patient-based measures.1,2 Recently, however, researchers have begun to focus more on patient perceptions of oral health and oral treatment to better understand the effect of treatment on patients’ quality of life.3,4 Oral health–related quality of life (OHRQoL) characterizes patients’ perceptions of oral health and can therefore be used to measure patient-perceived benefits of dental treatment.5 Tooth loss can affect different aspects of patients’ lives, including appearance, function, and interpersonal relationships; thus, tooth loss can impair quality of life.6 Partial tooth loss can be treated using different prosthodontic options. Conventionally, the success of these treatments has been evaluated from a clinicians’ point of view. However, a technical and clinically satisfactory prosthesis is not necessarily a predictor of
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Swelem et al
good patient satisfaction.7–11 Research suggests that clinicians and patients define the concept of success differently.11,12 Dentists typically assess prostheses according to predetermined success criteria based on technical standards, but these criteria rarely consider the needs, attitudes, or expectations of the individual patient.13,14 For this reason, the use of patient-centered outcome measures may help facilitate a more appropriate, patient-oriented prosthetic solution. Patient satisfaction measures such as visual analog scales have been used by several investigators7,8,11,14–24 as subjective assessment tools. However, previous studies have shown that validated questionnaires that address OHRQoL provide a more comprehensive evaluation of oral health and dental treatment than single patient-centered questions addressing patient satisfaction.2,25 Over the last two decades, several OHRQoL instruments have been introduced, of which the Oral Health Impact Profile (OHIP) is the most commonly used,26 sophisticated, and comprehensive.2,27 The original OHIP consists of seven domains comprising 49 items that describe the impact of oral health conditions on aspects of function, daily living, and social relations.28 The dimensions are hierarchically ordered so that the impacts described are considered gradually more disruptive to a patient’s life.29 The OHIP instrument has been translated into a variety of languages, with validated cross-cultural equivalence.2 OHIP-14, a shorter and more patient-friendly version, consists of 14 questions that cover the same seven domains as the OHIP-49. Several investigators26,30–32 have used the OHIP-14 to study the impact of different dental treatments on patients’ OHRQoL. The dental literature is rich in studies assessing OHRQoL in completely edentulous patients treated with either conventional or implant-supported prostheses.10,16,17,22,26,30,31,33–39 Several studies have also assessed OHRQoL in partially edentulous individuals.2,5,32,40–47 The treatment options for partially edentulous patients include fixed dental prostheses (FDPs), removable dental prostheses (RDPs), implantsupported fixed prostheses (ISFPs), and combined fixed-removable restorations (COMBs). Relatively few studies have investigated and compared the effects of different treatment options on the OHRQoL of partially edentulous patients. Furuyama et al2 compared OHRQoL in patients treated with ISFPs and RDPs. John et al5 and Szabo et al48 compared OHRQoL in patients treated with FDPs and RDPs. Sonoyama et al40 and Petricevic et al49 compared OHRQoL in patients treated with FDPs and ISFPs. To the present authors’ knowledge, only one recent study, conducted by Kimura et al,47 compared RDPs, FDPs, and ISFPs in terms of OHRQoL. However, a comparison of all four treatment options has not been performed to date,
and no studies have evaluated OHRQoL outcomes in patients rehabilitated with COMBs. This study aimed to investigate changes in OHRQoL among partially edentulous patients following treatment with one of four types of prosthesis: RDPs, FDPs, ISFPs, and COMBs. It has been universally accepted that implants provide better satisfaction than non-implant treatment and are thus expected to provide better OHRQoL2; therefore, the hypothesis of the study was that ISFPs would demonstrate the greatest improvement in the OHRQoL of partially edentulous patients.
Materials and Methods Study Population Partially edentulous patients were selected from the dental clinics of Moscow State University of Medicine and Dentistry, Moscow, Russia, from September 2006 to June 2008. Inclusion criteria included (1) one or more missing teeth in either or both arches, (2) good general health that would not interfere with dental treatment, (3) no temporomandibular disorders or parafunctional habits (bruxism/clenching), and (4) capable of reading and writing in Russian (language of the questionnaires and informed consent form). To receive ISFPs, patients had to be free from any systemic disease that would be likely to compromise implant therapy and show adequate bone volume for implant placement without bone augmentation. Patients were excluded if they (1) presented with an acute oral disease, (2) reported pain in the orofacial region, (3) had psychologic or psychiatric conditions that could influence their reaction to treatment, or (4) had learning difficulties that precluded them from understanding the questionnaires. Each candidate was given a full written and oral description of the study protocol. A convenience sample of 200 eligible cooperative patients (100 men and 100 women) who agreed to attend follow-up visits were enrolled after providing written informed consent. The patients ranged from 30 to 50 years in age (mean age: 41.8 years). The study protocol was approved by the local ethical committee of Moscow State University of Medicine and Dentistry. The possible treatment options for each clinical situation were explained thoroughly to each patient. The patient then chose one of the possible treatments based on his or her preferences and/or economic status. The study population was then divided into four groups based on the treatment received: Group 1 included patients who received RDPs; group 2 included patients who received FDPs; group 3 included patients who received COMBs, which were identified as either RDPs supported by surveyed crowns or
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OHRQoL in Partially Edentulous Patients
Table 1 Demographic Data and Kennedy Classification Among Treatment Groups COMB (n = 66) Sex Male Female Age (y) 30–40 40–50 Mean (SD)* Kennedy class Maxilla Class I Class I mod 1 Class I mod 3 Class II mod 1 Class II mod 2 Class II mod 3 Class III Class III mod 1 Class III mod 2 Class III mod 3 Class IV Dentate Mandible Class I Class I mod 1 Class I mod 2 Class II mod 1 Class II mod 2 Class III Class III mod 1 Dentate
FDP (n = 32)
RDP (n = 45)
ISFP (n = 57)
n
%
n
%
n
%
n
%
31 35
47.0 53.0
15 17
46.9 53.1
22 23
48.9 51.1
32 25
56.1 43.9
Total (N = 200) n 100 100
%
P
50.0 50.0
.741
14 21.2 52 78.8 44.2 (6.1)a
6 18.8 26 81.2 44.4 (6.5)b
17 37.8 28 62.2 44.6 (6.6)c
39 68.4 18 31.6 35.4 (5.9)abc
76 38.0 124 62.0 41.8 (7.4)
4 3 4 5 8 7 5 15 5 2 – 8
6.1 4.5 6.1 7.6 12.1 10.6 7.6 22.7 7.6 3.0 0.0 12.1
– – – – – – 5 20 – – – 7
0.0 0.0 0.0 0.0 0.0 0.0 15.6 62.5 0.0 0.0 0.0 21.9
– – 6 15 – – – – – 9 – 15
0.0 0.0 13.3 33.3 0.0 0.0 0.0 0.0 0.0 20.0 0.0 33.3
2 – – – – – 17 14 2 2 7 13
3.5 0.0 0.0 0.0 0.0 0.0 29.8 24.6 3.5 3.5 12.3 22.8
6 3 10 20 8 7 27 49 7 13 7 43
3.0 1.5 5.0 10.0 4.0 3.5 13.5 24.5 3.5 6.5 3.5 21.5
.000§
9 9 3 3 13 2 27 –
13.6 13.6 4.5 4.5 19.7 3.0 40.9 0.0
5 – – – – 8 19 –
15.6 0.0 0.0 0.0 0.0 25.0 59.4 0.0
13 9 9 – 8 6 – –
28.9 20.0 20.0 0.0 17.8 13.3 0.0 0.0
– – – 5 – 16 19 17
0.0 0.0 0.0 8.8 0.0 28.1 33.3 29.8
27 18 12 8 21 32 65 17
13.5 9.0 6.0 4.0 10.5 16.0 32.5 8.5
.000§
.000† .000‡
Mod = modification. *Same superscript letters denote high statistical significance (P < .01). †Highly statistically significant (P < .01; chi-square test). ‡Highly statistically significant (P < .01; ANOVA). §Highly statistically significant (P < .01; Monte Carlo).
RDPs and FDPs/crowns in the same arch; and group 4 included patients who received ISFPs. Standard implant placement was performed by the same surgeon and prosthodontist in all patients. All inserted implants retained single crowns. Vanadium-titanium implants (Nobel Biocare) were used. None of the implants in the ISFP group were lost during follow-up and no failures or complications were recorded for the other prosthodontic restorations during the observation period. OHRQoL Measurement OHRQoL was measured using the Russian version of the OHIP-14, which has been shown to be valid and reliable in the Russian population.50 The instrument covered the seven domains—functional limitation, physical pain, psychologic discomfort, physical disability,
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psychologic disability, social disability, and handicap— with two questions each. The five categories of response for each item were as follows: never, usually no, sometimes, usually, and very often. Items were scored on a 5-point Likert scale ranging from 1 (never) to 5 (very often). Higher OHIP total summary scores and subscales for each domain indicated greater OHRQoL impairment. The questionnaire was administered with supervision to all participants at three occasions: before treatment (T0), 6 weeks after treatment (T1), and 6 months after treatment (T2). Participants were given prior explanation and instruction regarding the different aspects of the questionnaire. Statistical Analysis Statistical analysis was performed using SPSS version 16.0 (SPSS). Cronbach’s alpha coefficient was
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Swelem et al
Table 2 OHIP-14 Scores Before Treatment* Respondents (%) OHIP
Never
Usually no
Sometimes
Very often
Median
P25–P75
9.5 3.5
12.5 3.5
2.5 1.0 1.0
2.0–5.0 1.0–3.0 1.0–2.0
46.5 20.5
5.0 34.0
4.5 37.0
7.0 3.0 4.0
5.0–8.0 2.0–3.0 3.0–5.0
4.0 18.0
27.5 27.0
34.0 28.5
34.5 26.5
8.0 4.0 4.0
6.0–10.0 3.0–5.0 3.0–5.0
23.5 38.0
33.5 28.5
10.5 23.0
24.0 1.5
8.5 9.0
4.0 2.0 2.0
3.0–6.0 2.0–4.0 1.0–3.0
Psychologic limitation Found it difficult to relax Have been a bit embarrassed
32.0 3.0
30.5 22.0
18.0 26.5
12.5 16.5
7.0 32.0
5.0 2.0 3.0
4.0–8.0 1.0–3.0 2.3–5.0
Social limitation Have been irritable with other people Had difficulty doing usual jobs
15.5 23.5
24.5 26.0
41.5 27.0
9.5 9.0
9.0 14.5
5.0 3.0 3.0
4.0–6.0 2.0–3.0 2.0–3.0
Incapacity (handicap) Felt life in general less satisfactory Have been unable to function
35.0 52.0
23.0 29.0
24.5 13.0
7.0 1.0
10.5 5.0
3.0 2.0 1.0
2.0–5.8 1.0–3.0 1.0–2.0
36.0
29.0–45.0
Functional limitation Had problems pronouncing words Felt sense of taste worsened
54.5 66.0
12.0 25.5
11.5 1.5
Physical pain Had painful aching in mouth Found it uncomfortable to eat food
3.5 2.5
40.5 6.0
Psychologic discomfort Have been self-conscious Felt tense
0.0 0.0
Physical limitation Had an unsatisfactory diet Had to interrupt meals
Usually
Total P25, P75 = 25th and 75th percentiles, respectively. *Cronbach's alpha = 0.925.
used to test the reliability of the OHIP scale. An overall OHIP score was computed by adding the scores of all questions, and the same was done for each subscale. The possible scores for the overall scale ranged from 14 to 70, and the possible scores for each subscale ranged from 2 to 10. A change in score was also computed by subtracting baseline values from follow-up values at 6 weeks and 6 months. Positive scores indicated improvement in OHRQoL and negative scores indicated worsening. As demonstrated by the Shapiro-Wilk test of normality, the distributions of the OHIP scale and subscales were not normal; thus, nonparametric statistics were preferred in data analysis. The proportion, mean, SD, median, and 25th and 75th percentiles were used with the boxplot as summary statistics. The mean age was compared among treatment groups using one-way analysis of variance (ANOVA) with the Scheffe post hoc test. Changes in OHIP scores before and after treatment were examined using the Friedman test followed by the Conover post hoc test for pairwise comparisons between the means of the ranks. Comparison of the median change in
OHIP scores after treatment was performed using the Kruskal-Wallis test of nonparametric ANOVA with the Conover post hoc test. A general linear model was used to explore the interaction effect of age and Kennedy classification with treatment modality on the change in OHIP score 6 months after treatment. All tests were two-sided, and statistical significance was set at .05. The Conover post hoc analysis was performed using the BrightStat software (Brightstat).
Results All 200 patients attended the 6-month follow-up appointments. Demographic data and characteristics of tooth loss and Kennedy classification among the participants are summarized in Table 1. There were significant differences between the treatment groups in terms of age and Kennedy classification but not in terms of sex. Pretreatment analysis revealed that the psychologic discomfort domain showed the greatest negative impact on OHRQoL, while functional limitation had the smallest effect (Table 2).
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OHRQoL in Partially Edentulous Patients
Table 3 OHIP Scores Throughout the Study Period Age: 30–39 y
Age: 40–50 y
Median (P25–P75) OHIP subscale
T0
T1
Median (P 25–P75) T2
P
T0
T1
T2
P
FDP OHIP summary score 39.0 (34.0–39.0) 16.0 (16.0–17.0) 14.0 (14.0–14.0) Functional limitation 2.0 (2.0–2.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Physical pain 7.0 (6.0–7.0) 3.0 (3.0–3.0) 2.0 (2.0–2.0) Psychologic discomfort 10.0 (7.0–10.0) 3.0 (3.0–3.0) 2.0 (2.0–2.0) Physical limitation 3.0 (3.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Psychologic limitation 7.0 (5.0–7.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Social limitation 6.0 (5.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) Incapacity (handicap) 4.0 (4.0–4.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
* – * * * * * *
30.0 (28.0–37.0) 15.0 (15.0–21.0) 14.0 (14.0–15.0) 2.0 (2.0–6.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) 5.5 (5.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–3.0) 8.0 (5.8–9.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) 4.5 (4.0–5.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 4.5 (3.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** ** ** ** ** ** ** **
RDP OHIP summary score 23.0 (23.0–34.0) 26.0 (26.0–30.0) 17.0 (17.0–21.0) Functional limitation 3.0 (3.0–5.0) 5.0 (5.0–5.0) 3.0 (2.0–3.0) Physical pain 6.0 (5.0–6.0) 4.0 (4.0–5.0) 2.0 (2.0–4.0) Psychologic discomfort 5.0 (5.0–5.0) 5.0 (4.0–5.0) 3.0 (3.0–4.0) Physical limitation 2.0 (2.0–5.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) Psychologic limitation 3.0 (3.0–5.0) 3.0 (3.0–4.0) 2.0 (2.0–3.0) Social limitation 2.0 (2.0–6.0) 5.0 (5.0–5.0) 3.0 (3.0–4.0) Incapacity (handicap) 2.0 (2.0–3.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0)
** ** ** ** ** ** * **
39.0 (33.0–59.3) 32.0 (32.0–47.0) 21.0 (20.0–27.3) 6.0 (3.0–9.0) 5.0 (5.0–8.0) 4.0 (4.0–4.8) 7.0 (5.0–7.8) 6.0 (6.0–6.0) 4.0 (3.0–4.0) 7.0 (7.0–9.3) 6.0 (6.0–7.0) 4.0 (2.0–4.0) 4.0 (4.0–8.3) 3.0 (3.0–6.0) 3.0 (2.0–3.0) 5.0 (5.0–8.0) 4.0 (4.0–6.0) 3.0 (3.0–4.0) 5.0 (5.0–9.0) 4.0 (4.0–5.8) 2.0 (2.0–4.8) 5.0 (5.0–8.8) 4.0 (4.0–7.8) 3.0 (2.0–4.8)
** ** ** ** ** ** ** **
COMB OHIP summary score 39.0 (27.0–56.0) 20.0 (17.0–27.0) 15.0 (14.0–17.0) Functional limitation 4.0 (2.0–6.0) 4.0 (3.0–5.0) 3.0 (2.0–3.0) Physical pain 7.0 (7.0–7.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) Psychologic discomfort 6.0 (6.0–10.0) 4.0 (3.0–6.0) 2.0 (2.0–4.0) Physical limitation 6.0 (3.0–7.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) Psychologic limitation 7.0 (4.0–10.0) 2.0 (2.0–4.0) 2.0 (2.0–2.0) Social limitation 3.0 (3.0–9.0) 3.0 (2.0–3.0) 2.0 (2.0–2.0) Incapacity (handicap) 6.0 (2.0–7.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** ** ** ** ** ** ** **
46.0 (33.0–52.0) 22.5 (20.0–33.0) 14.0 (14.0–16.0) 3.5 (2.0–6.0) 4.0 (3.0–6.0) 2.0 (2.0–4.0) 8.0 (7.0–8.0) 4.0 (3.0–6.0) 2.0 (2.0–3.0) 8.0 (8.0–10.0) 4.0 (4.0–6.0) 2.0 (2.0–3.0) 6.0 (5.0–8.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 8.0 (5.0–8.0) 3.0 (2.0–4.0) 2.0 (2.0–2.0) 6.0 (5.0–8.8) 3.0 (2.0–4.0) 2.0 (2.0–3.0) 5.0 (3.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0)
** ** ** ** ** ** ** **
ISFP OHIP summary score 36.0 (28.0–37.0) 17.0 (16.0–19.0) 14.0 (14.0–14.0) Functional limitation 2.0 (2.0–2.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Physical pain 6.0 (5.0–7.0) 3.0 (3.0–4.0) 2.0 (2.0–2.0) Psychologic discomfort 8.0 (6.0–10.0) 4.0 (3.0–4.0) 2.0 (2.0–2.0) Physical limitation 3.0 (2.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Psychologic limitation 6.0 (4.0–7.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0) Social limitation 5.0 (3.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) Incapacity (handicap) 2.0 (2.0–6.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** – ** ** ** ** ** **
36.0 (32.0–39.3) 19.0 (17.5–22.8) 15.0 (14.0–15.3) 2.0 (2.0–2.3) 2.0 (2.0–4.0) 2.0 (2.0–2.0) 7.0 (7.0–8.0) 4.0 (2.8–4.3) 2.0 (2.0–3.0) 8.0 (7.0–9.0) 4.0 (4.0–5.0) 2.0 (2.0–2.3) 4.0 (3.0–6.0) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 6.0 (4.8–6.3) 2.0 (2.0–3.0) 2.0 (2.0–2.0) 4.0 (4.0–5.3) 2.0 (2.0–3.3) 2.0 (2.0–2.0) 3.0 (3.0–5.0) 2.0 (2.0–2.0) 2.0 (2.0–2.0)
** * ** ** ** ** ** **
T0 = baseline; T1 = 6 weeks after treatment; T2 = 6 months after treatment; P25, P75 = 25th and 75th percentiles, respectively. *Statistically significant (P < .05; Friedman test); **highly statistically significant (P < .01; Friedman test).
Table 3 shows the OHIP scores for all treatment modalities and age groups at baseline and follow-up. Generally, OHIP summary scores and most subscale scores in all groups demonstrated a significant decrease throughout the study; however, this decrease was more evident in the first 6 weeks. Younger patients treated with RDPs demonstrated a negative change after 6 weeks. All posttreatment summary scores were higher in the RDP group compared to the other treatment modalities.
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Between-group comparisons are presented in Table 4 and Fig 1. Comparison of the median change scores revealed significant differences among the treatment groups at the two follow-up intervals. From baseline to 6 weeks, RDP treatment in both age groups was significantly different from all other treatment modalities for nearly all domains. From baseline to 6 months, RDP treatment was significantly different from all other treatment modalities in the younger age group. COMB treatment was significantly different from RDP and
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Swelem et al
Table 4 Change in OHIP-14 Subscales Age: 30–39 y Median (P25–P75) OHIP subscale
Age: 40–50 y Median (P 25–P75)
T0–T1
T0–T2
0.0 (0.0–0.0) –2.0 (–2.0–0.0)
0.0 (0.0–0.0) 0.0 (0.0–3.0)
0.0 (0.0–2.0) –2.0 (1.0–1.5)
0.0 (0.0–4.0) –1.0 (2.0–3.5)
–1.0 (0.0–1.0) 0.0 (0.0–0.0) **
0.0 (1.0–3.0) 0.0 (0.0–0.0) **
–2.0 (0.0–0.0) –1.0 (0.0–0.0) **
0.0 (0.0–2.0) 0.0 (0.0–0.0) NS
3.0 (4.0–4.0)
4.0 (5.0–5.0)
3.0 (3.0–3.0)
3.0 (3.0–3.0)
0.0 (2.0–2.0) 3.0 (4.0–5.0) 1.0 (3.0–4.0) **
1.0 (4.0–4.0) 0.0 (0.0–0.0) 3.0 (4.0–5.0) **
0.0 (1.0–1.5) 2.0 (4.0–5.0) 2.0 (3.0–4.0) **
2.0 (3.0–4.0) 5.0 (5.0–6.0) 4.0 (5.0–5.0) **
Psychologic discomfort FDP RDP COMB ISFP P
4.0 (7.0–7.0) 0.0 (0.0–1.0) 0.0 (2.0–7.0) 2.0 (6.0–6.0) **
5.0 (8.0–8.0) 1.0 (2.0–2.0) 2.0 (4.0–8.0) 3.0 (6.0–7.5) **
3.0 (3.0–6.0) 1.0 (1.0–2.5) 2.0 (4.0–6.0) 2.0 (4.0–5.0) **
4.0 (6.0–6.0) 3.0 (5.0–5.5) 4.0 (6.0–8.0) 5.0 (6.0–7.0) **
Physical limitation FDP RDP COMB ISFP P
1.0 (1.0–3.0) 0.0 (0.0–1.0) 1.0 (2.0–5.0) 0.0 (1.0–3.0) **
1.0 (1.0–3.0) 0.0 (0.0–3.0) 1.0 (4.0–5.0) 0.0 (1.0–3.0) **
0.0 (1.0–2.0) 1.0 (1.0–3.0) 2.0 (3.0–4.0) 1.0 (1.0–2.0) **
0.0 (1.0–2.0) 1.0 (1.0–5.5) 3.0 (4.0–6.0) 1.0 (2.0–4.0) **
Psychologic limitation FDP RDP COMB ISFP P
3.0 (5.0–5.0) 0.0 (0.0–1.0) 2.0 (3.0–8.0) 2.0 (4.0–5.0) **
3.0 (5.0–5.0) 1.0 (1.0–2.0) 2.0 (5.0–8.0) 2.0 (4.0–5.0) **
2.0 (2.0–3.0) 1.0 (1.0–2.0) 2.0 (3.0–5.5) 2.0 (2.0–4.0) **
2.0 (2.5–3.0) 2.0 (2.0–4.0) 3.0 (4.5–6.0) 3.0 (4.0–4.0) **
2.0 (4.0–4.0) –3.0 (–3.0–1.0) 0.0 (1.0–6.0) 1.0 (2.0–4.0) **
3.0 (4.0–4.0) –1.0 (–1.0–2.0) 1.0 (1.0–7.0) 1.0 (3.0–4.0) **
1.0 (2.0–3.0) 1.0 (1.0–2.5) 0.5 (3.0–5.0) 1.0 (2.0–2.0) NS
1.0 (2.5–3.0) 2.0 (3.0–4.0) 2.0 (3.5–6.0) 2.0 (2.0–3.0) **
0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (4.0–5.0) 0.0 (0.0–4.0) **
0.0 (0.0–0.0) 0.0 (0.0–1.0) 0.0 (4.0–5.0) 0.0 (0.0–4.0) *
0.0 (0.0–1.0) 0.0 (1.0–1.5) 0.0 (1.0–3.0) 1.0 (1.0–3.0) **
0.0 (0.0–1.0) 2.0 (3.0–4.0) 1.0 (2.0–3.5) 1.0 (1.0–3.0) **
Functional limitation FDP RDP COMB ISFP P Physical pain FDP RDP COMB ISFP P
Social limitation FDP RDP COMB ISFP P Incapacity (handicap) FDP RDP COMB ISFP P
T0–T1
T0–T2
T0 = baseline; T1 = 6 weeks after treatment; T2 = 6 months after treatment; NS = not significant (Kruskal-Wallis); change = baseline minus follow-up (positive values indicate improvement and negative values indicate worsening). *Statistically significant (P < .05; Kruskal-Wallis); **highly statistically significant (P < .01; Kruskal-Wallis).
FDP treatments in the older age group. There were no significant differences between FDPs and ISFPs. The general linear model revealed a significant interaction effect of age and Kennedy classification with treatment modality on OHIP changes. For Kennedy Class III and IV patients, OHRQoL improved
the most after treatment with FDPs and ISFPs in the younger age group, while COMBs and ISFPs were superior in the older age group. For Kennedy Class I and II patients, RDPs were inferior to ISFPs in the younger age group but somewhat superior to ISFPs in the older age group (Fig 2 and Table 5).
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OHRQoL in Partially Edentulous Patients
Age (y)
Age (y)
30–39
30–39
40–50
P < .05
Change (before – after 6 months)
Change (before – after 6 weeks)
40 30
40–50
50
P < .05 P < .05
20 10 0
40 30 20 10 0
Combined
FDP
RDP
ISFP
Combined
a
FDP
RDP
ISFP
b
Kennedy
Kennedy
I, II
I, II
III, IV
III, IV
Means Log10 change in OHIP
Means Log10 change in OHIP
Figs 1a and 1b Change in OHIP-14 scores according to age (a) from baseline to 6 weeks and (b) from baseline to 6 months after treatment. Positive values indicate improvement in OHRQoL, and negative values indicate worsening.
1.4
1.2
1.0
.8 Combined
FDP
RDP
1.6
1.4
1.2
1.0
ISFP
Combined
a
FDP
RDP
ISFP
b
Figs 2a and 2b Interaction effect of age and Kennedy classification with treatment modality on OHIP changes in the (a) younger age group (30–39 years) and (b) older age group (40–50 years) (non-estimable means are not plotted).
Table 5 G eneral Linear Model for Change in OHIP Scores 6 Months After Treatment According to Treatment Modality, Age, and Kennedy Classification* Source of variation
Sum of squares
df
Mean square
F
P
Age
0.07
1
0.07
2.43
.121
Kennedy
0.24
1
0.24
7.67
.006
Treatment modality
2.88
3
0.96
31.19
.000
Treatment modality × age
0.41
3
0.14
4.44
.005
Treatment modality × Kennedy
0.27
2
0.13
4.35
.014
Error
5.81
189
0.03
Total
331.32
200
*R2 = 0.459 (adjusted R2 = 0.431).
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Swelem et al
Discussion The results of this study showed that improvements in oral health were achieved with any of the applied treatment modalities. While RDPs demonstrated smaller changes than FDPs or COMBs, no differences were observed among tooth- or implant-supported FDPs. Patients had a considerably impaired level of OHRQoL before treatment. The psychologic discomfort domain was the most affected. This is in agreement with Nickenig et al,43 who found that the most frequently reported problems during preoperative OHRQoL assessment in partially edentulous patients were related to psychologic disappointment. Physical pain was the second-most impacted domain; 37% of the participants “found it uncomfortable to eat.” This complaint is one of the most commonly reported pretreatment problems.51 For obvious reasons, such a complaint is an expected consequence of tooth loss. In agreement with the present study, previous studies of completely and partially edentulous patients have demonstrated significant OHRQoL improvement after prosthodontic rehabilitation.5,26,30,32,34,36,41,47,49,52 This result could be attributed to the improved function and increased sense of security provided by the rehabilitation process, thus improving patients’ daily activities. This improvement was more pronounced during the first follow-up period. It has been reported that immediate effects of prosthodontic therapy, including the noticeable decrease in both frequency and severity of pretreatment problems, are expected mainly during the first month after treatment,5,32,51 after which patients become adapted to their prostheses.5 The only exception was for younger patients treated with RDPs, who initially were more irritable, lacked confidence, and reported difficulty speaking with and adapting to their RDPs. In fact, betweengroup comparisons revealed that the least amount of OHRQoL improvement was recorded for the RDP group. These results are consistent with those of other investigators, who reported that OHRQoL levels of partially edentulous patients were found to be superior with FDPs5 or ISFPs2,53 compared to RDPs. According to Szentpetery et al51 and the present results, pretreatment problems decreased more in number and more rapidly in FDP wearers than in RDP wearers. These results support the authors’ clinical experience that FDPs are a more natural means of replacing missing teeth and require shorter adaptation periods than RDPs, especially in younger individuals. Interestingly, there was also a significant difference between COMBs and RDPs. The authors could not find any studies in the dental literature that compared these two treatments specifically; hence, direct comparison to the literature was not possible. However,
most COMB patients in this study were in the older age range. Improvements after prosthodontic therapy have been shown to be higher in older patients, who are usually less worried about the long-term survival or future complications of their restorations and thus have lower expectations.49 The results revealed statistically insignificant differences between FDPs and ISFPs. These findings are consistent with those of other investigators40,49 and support the claim that comparable results can be achieved by FDPs regardless of whether they are supported by implants. It is noteworthy, however, that 6 weeks after treatment, OHIP scores were slightly higher in the ISFP group than in the FDP group, especially in older patients. Similar findings were observed by Petricevic et al,49 who attributed this result to the more complicated treatment when using implants, which includes surgical intervention and higher costs and thus may raise patients’ initial apprehension regarding the durability of the restoration. Therefore, the initial hypothesis that ISFPs would demonstrate the greatest OHRQoL improvement could be partially rejected. ISFPs demonstrated better OHRQoL outcomes than RDPs and COMBs but were comparable to FDPs. In fact, FDPs were slightly superior. Statistical analysis revealed insignificant differences between COMBs and ISFPs at the end of the follow-up period in the older age group. This may imply that COMBs provide OHRQoL levels comparable to ISFPs. However, these results should be interpreted with caution and cannot be generalized. As mentioned previously, this finding could be age-related. Further, baseline scores were the highest in the COMB group, especially in the older patients, indicating that the OHRQoL in this group was initially much more impaired than in the other treatment groups. More than half of the cases were categorized as either Kennedy Class I or II, indicating a greater number of posterior teeth missing. It has been reported that the greater the number of missing occlusal units (posterior teeth), the greater the OHRQoL impairment in patients with distal extension edentulous areas.54 Hence, this insignificant difference may be age-related or due to the “greater” impact of rehabilitation in COMB patients who demonstrated poorer OHRQoL initially. When analyzing the treatment modality–Kennedy class interaction, the results discussed above appear consistent with the results of the general linear model, which revealed that in bounded saddle cases (Kennedy Class III and IV), FDPs and ISFPs provided better OHRQoL improvement in younger patients, while COMBs were superior in older patients. In patients showing distal extension (Kennedy Class I and II), ISFPs were superior to RDPs in the younger age group. However, regression analysis revealed that
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OHRQoL in Partially Edentulous Patients
treating Kennedy Class I and II patients in the older age group with RDPs provided somewhat better OHRQoL improvement than treating them with ISFPs. The need for a greater number of implants in distal extension cases may have aggravated the psychologic pressure of a more extensive surgical implant procedure in older patients. To the authors’ knowledge, this is the first study to evaluate OHRQoL outcomes for all four possible prosthodontic treatment modalities in partially edentulous patients. Hence, the results of this study may help to fill a research gap in the dental literature. However, one limitation of this study was the unequal distribution of patients among the prosthodontic groups. Further, the direct contribution of other sociodemographic variables, such as social class, income, and educational attainment, was not assessed. Future studies are needed to investigate these factors and their correlating impacts with larger samples and longer follow-up periods.
Conclusions Within the limitations of this study, the following conclusions could be drawn: •• All prosthodontic treatments produced significant improvements in the patients’ OHRQoL at the end of the 6-month follow-up period. •• The least amount of improvement was observed in patients treated with removable partial dentures. •• Changes in OHRQoL in patients treated with fixed dental prostheses and implant-supported fixed prostheses were comparable. •• The same prosthodontic treatment can have different impacts on the OHRQoL of partially edentulous individuals depending on their age and Kennedy classification.
Acknowledgments The authors reported no conflicts of interest related to this study.
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