Patients’ Evaluations of Complete Denture Therapy and Their Association with Related Variables: A Pilot Study Beatriz Ferreira Oliveira Santos,1 Mateus Bertolini Fernandes dos Santos, DDS, MSD, PhD,2 Jarbas Francisco Fernandes Santos,1,3 & Leonardo Marchini, DDS, MSD, PhD4 1
´ Taubate, ´ Brazil Dentistry Department, University of Taubate, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil 3 ˜ Jose´ dos Campos, Brazil University of Vale do Para´ıba, Sao 4 Department of Preventive and Community Dentistry, University of Iowa College of Dentistry, Iowa City, IA 2
The article is associated with the American College of Prosthodontists’ journal-based continuing education program. It is accompanied by an online continuing education activity worth 1 credit. Please visit www.wileyhealthlearning.com/jopr to complete the activity and earn credit.
Keywords Patient expectations; patient satisfaction; complete dentures; prosthodontics. Correspondence Mateus Bertolini Fernandes dos Santos, School of Dentistry, Federal University of Pelotas, Pelotas, RS, Brazil, Rua Gonc¸alves Chaves, 457/502, Pelotas, RS, Brazil 96015-560. E-mail:
[email protected] Funded in part by a grant to the first author ˜ Paulo Research from the State of Sao Foundation—FAPESP (Process #2010/16508–5). No conflicts of interest declared. Accepted August 22, 2014 doi: 10.1111/jopr.12286
Abstract Purpose: Patient satisfaction is an important goal in complete denture therapy, and many factors influence this parameter. This study aimed to evaluate expectations before and satisfaction after therapy with complete dentures. As a secondary objective, other variables that may interfere with patient satisfaction were also evaluated. Material and Methods: A representative sample of 99 patients assigned visual analog scale (VAS) scores to their expectations before and satisfaction after therapy regarding chewing, esthetics, comfort, and phonetics. Demographic data and answers to a questionnaire concerning the dentists’ conduct were recorded. Multiple linear regression was used to evaluate the association among studied variables and patients’ expectation and satisfaction with their dentures. Results: The average VAS scores were high for both expectations and satisfaction, and satisfaction exceeded expectations. Patients’ expectations about esthetics and comfort were associated with age and self-reported time of using complete dentures. Patient satisfaction regarding chewing was associated with the number of postdelivery adjustments. Also, patient satisfaction regarding esthetics was associated with gender and esthetic expectations. In regard to phonetic satisfaction, associations were verified among self-reported time of using complete dentures, comfort and phonetics expectations, and dentists’ explanations. Comfort satisfaction was associated only with educational level. Conclusions: Patient satisfaction regarding complete dentures exceeded expectations and an expressive majority of positive evaluations of the dentists was noticed. Many patient-related variables seemed to influence their evaluations of their dentures.
Although some prosthodontists and dental educators are concerned with whether complete denture training should be removed from the dental curriculum,1 the number of edentulous patients will increase until the year 2020, due to an increase in the elderly population.1,2 Within this increase in the rate of edentulism, there is also an increasing number of elderly people seeking dental treatment to improve their quality of life through better oral health,3,4 which partly depends on their satisfaction with dental treatment.5 Patient satisfaction is an important goal to achieve in oral rehabilitation,6 and it can be used to evaluate the success of these rehabilitations.5-9 It is important to note that patients and dentists evaluate their expectations and satisfaction differently regarding the same denture therapy.7 These different evaluations could be sources of conflicts
between patients and dentists, with a negative influence on the dentist/patient relationship leading to a potential reduction in patient satisfaction.10 Dentists usually assess prosthesis success using predetermined clinical criteria, which do not consider the needs, expectations, and attitudes of individual patients.4 Since patients and dentists evaluate their expectations and satisfaction regarding the same therapy differently, it is important to establish a good dentist/patient relationship in order to understand patients’ wishes and to help set reasonable expectations that can be met with the chosen therapy.11,12 A well-conducted treatment, providing good adaptation of denture bases and occlusion, is very important to promoting adequate biomechanical responses, as well as to providing comfort during the use of the devices.4 Despite the construction of technically correct prostheses, a minority of complete
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denture wearers are not satisfied with their dentures, regardless of their quality.13-15 Patient adaptation to prostheses depends on psychosocial and emotional factors and on pretreatment expectations, which are considered a psychosomatic phenomenon.5 Also, as stated by Feine et al,16 complete denture therapy satisfaction should be based on living with the treatment as a more realistic objective than a cure for edentulousness. Previous studies have compared esthetic and functional expectations before and satisfaction after implant rehabilitation6 and insertion of complete dentures5,7 and have found different results. The patients studied by Bellini et al5 and Baracat et al6 gave higher post- than pretreatment scores (expectations); however, Marachlioglou et al7 observed the opposite outcome. Nevertheless, all of these studies showed high scoring for both expectations and post-treatment scores. Patient satisfaction with dentures is multifactorial and has already been associated with age, sex, past prosthetic history, and psychological factors.5,17 However, a recent study found that although patients presented positive perceptions of complete denture therapy, the satisfaction with this kind of therapy is not influenced by sex, educational level, evaluation of previous dentures, or marital status.18 Despite these differences, patient expectations before dental treatment seem to play an important role in satisfaction rates after treatment,19 but this relationship is not observed in all samples of complete denture wearers.5 Also, a patient’s personality and attitude toward new dentures are considered very important factors in achieving satisfaction,4 and dentists should try to improve communication with patients in an attempt to overcome psychological or social issues that may interfere with treatment success.7,12 However, the influence of some of these variables (such as sex, age, expectations) has not been found in all studies, and the extent of each of variable’s influence on patient evaluation of complete denture therapy is still unknown. Considering the above, the aim of this study was to evaluate the expectations before and satisfaction after therapy with complete dentures in patients who sought such treatment. As a secondary objective, other variables, such as sex, age, educational level, marital status, self-reported time of using complete dentures, number of postdelivery adjustments, and patients’ evaluations of the dentists’ conduct, that may influence patients’ evaluations of complete denture therapy were also evaluated. Considering previous studies,5-7,9 the following null hypotheses were formulated: (1) satisfaction after treatment will not exceed expectations; (2) associations will not occur among patients’ expectation, and post-treatment scores and clinical- and patient-related variables will occur; and (3) patients’ evaluations of dentists’ conduct will not be associated with patients’ evaluations of complete denture therapy.
Materials and methods Participants
The sample was calculated to be representative (power sample score = 0.6582, alpha = 0.05, hypothesized p = 0.0072) of Taubat´e municipality and was obtained from those patients who received complete dentures, which were all custom-made following a previously described5 technique, at the dental clinic of the University of Taubat´e. One hundred twenty patients were 352
invited to participate in the study, and 99 agreed to participate. Sixty-one were men (61.6%) and the mean age was 53 years old (SD = 12.8), with maximum and minimum ages of 81 and 32 years. All patients who agreed to participate signed an informed consent form. The study was approved by the Committee for Ethics in Research of the University of Taubat´e (CEP/UNITAU protocol number 264/10). Scoring patients’ expectations before and satisfaction after complete denture therapy
For the assessment of expectations before and satisfaction after complete denture therapy, a visual analogue scale (VAS) was used with a numerical sequence from 0 to 10, where 0 represented the worst and 10 the best possible outcome. The numbers chosen by the patients before the commencement of treatment (pretreatment scores) corresponded to their expectations concerning the therapy. After completing therapy, the chosen numbers (post-treatment scores) corresponded to the evaluation of the patients’ satisfaction with the outcomes of therapy. In both situations, before and after treatment, the patients assigned scores to four aspects of complete denture outcomes: esthetics, chewing, comfort, and phonetics. Clinical and patient-related variables assessment
The sex, age, educational level, marital status, self-reported time of using complete dentures, and number of postdelivery adjustments were noted using an appropriate form. A questionnaire, using a Likert-type scale, was also prepared with the aim of noting the patients’ evaluations of the dentists’ conduct, based on previously developed questionnaires.20,21 The questionnaire was translated from its original English version into Portuguese and then was translated back to English to confirm the accuracy of the verbiage. The postdelivery adjustments consisted of finding and adjusting the cause of sore areas due to the new dentures and were made on a weekly basis, when needed. Data analysis
The data were tabulated, and descriptive statistics were formulated. Student’s paired t-test was used to compare preand post-treatment VAS scores. Furthermore, a multiple linear regression model was used to determine the influence of age, educational level, marital status (where the answer to the status is positive = 1 and negative = 0), gender (where women = 0 and men = 1), and self-reported time of using complete dentures on patients’ expectation prior to the start of complete denture therapy (pretreatment scores). No variable selection process was used in this model. Another multiple linear regression model was used to determine the influence of previous expectations, age, educational level, marital status, gender, self-reported time of using complete dentures, number of adjustments after delivery, and questionnaire answers on patient satisfaction scores after complete denture therapy (post-treatment scores). The backward stepwise method was used for variable selection in this model; the threshold chosen for inclusion and exclusion were 0.100, respectively.
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Patients’ Evaluation of Complete Dentures
Table 1 Patients’ scores for expectation before (pre) and satisfaction after (post) therapy with complete dentures for the entire sample Chewing
Average SD p-value *
Esthetics
Phonetics
Comfort of use
Pre
Post
Pre
Post
Pre
Post
Pre
Post
8.56 1.02
9.00 0.80
8.73 1.03
9.51 0.73
8.60 1.16
8.89 1.14
8.64 1.20
8.91 0.82
∗
0.001
< 0.001
∗
0.052
0.060
Statistically significant difference (Student paired t-test).
Table 2 Mean average of answers to questions 1 to 9 of the questionnaire concerning patients’ evaluation of the dentists’ conduct (n = 99), where 1 represented the worst and 5 the best possible evaluation
Question 1. The dentists I saw thoroughly explained the recommended treatment before it commenced. Question 2. I am confident that I received good dental care. Question 3. The dentists I saw usually explained what they were going to do. Question 4. The dentists I saw were friendly to me. Question 5. The dentists I saw always treated me with respect. Question 6. The dentists I saw allowed me to express my opinion. Question 7. The dentists I saw were very careful to check everything when examining their patients. Question 8. The dentists I saw answered my questions.
All statistical tests were performed with 95% confidence level (Minitab v15, Minitab Inc., State College, PA). There were no violations of assumptions of normality (as tested by KS test), linearity, multicollinearity, or homoscedasticity (as verified by Scatterplot graphics) of the residuals before running the multiple regression.
Results Of the studied sample, 65 patients were married, 8 were divorced, 12 were single, and 14 were widowed. Regarding educational level, 25 patients had finished elementary school, 73 had finished high school, and only 1 had graduated from college. Table 1 shows the patients’ expectations (Pre) and posttreatment scores (Post) for the entire sample, where it is possible to observe that VAS scores after therapy exceeded previous expectations. This difference was significant for chewing (p = 0.001) and for esthetics (p < 0.001). The average number of postdelivery adjustments was 1.1 ± 0.7, ranging from 0 to 3, and the average self-reported time of using complete dentures was 7.3 ± 5.0 years, with maximum and minimum values of 30 and 0 (less than 1) years. With regard to the questionnaire regarding patients’ evaluation of the dentists’ conduct, it was possible to verify an expressive majority of positive evaluations (Table 2). Table 3 presents the models summary of the added variables in the multiple linear regression, where significant associations were observed among chewing satisfaction with number of postdelivery adjustments; esthetic satisfaction with gender and esthetic expectation; phonetic satisfaction with self-reported time of using complete dentures, question 3 (The dentists I saw usually explained what they were going to do), comfort expectations, and phonetic expectations; and comfort satisfaction with education level.
Average
SD
3.88 3.94 3.82 3.94 3.98 3.98 3.84 4.37
0.79 0.78 0.79 0.79 0.77 0.76 0.78 0.49
The results for ANOVA testing the models of the added variables are presented in Table 4. Also, it is possible to observe the coefficients, p-value, confidence interval, correlations, and collinearity statistics for the added variables in the multiple regression, where collinearity was not observed in any model (Table 5). Post-treatment scores regarding esthetics were associated with gender and esthetic expectations, where women gave higher esthetic post-treatment scores than men did, and the higher the expectation, the higher the post-treatment score. Post-treatment scores regarding phonetics were associated with self-reported time of using complete dentures (where patients who wore complete dentures for longer periods presented lower values of satisfaction for phonetics), comfort, and phonetics expectations (where patients with higher expectations regarding comfort gave lower scores for phonetics satisfaction, and the inverse occurred to phonetics expectations), and question 3 of the questionnaire regarding patients’ evaluations of the dentists’ conduct (i.e., “The dentists I saw usually explained what they were going to do”), where the better the evaluation of the dentists’ conduct, the higher satisfaction scores for phonetics. Post-treatment scores regarding comfort were associated only with educational level, where the lower the educational level the higher the satisfaction scores for comfort.
Discussion The first null hypothesis, that satisfaction after treatment will not exceed expectations, was rejected by the results of this study, in agreement with previous studies in the literature,2,5,6 which corroborates the hypothesis raised by Bellini et al,5 that the establishment of a friendly and respectful relationship between patients and dentists during denture making may result in higher satisfaction after treatment; however, it has not been
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Table 3 Models summary of the added variables in the multiple regression Change statistics
Dependent Chewing satisfaction
Esthetic satisfaction Esthetic satisfaction Phonetic satisfaction Phonetic satisfaction Phonetic satisfaction
Phonetic satisfaction
Comfort satisfaction
Predictors
R2
Adjusted R2
Std. error of the estimate
R2 change
F change
Sig. F change
Constant, number of postdelivery adjustments Constant, gender Constant, gender, esthetic expectation Constant, time of use Constant, time of use, question 3 Constant, time of use, question 3, comfort expectation Constant, time of use, question 3, comfort expectation, phonetic expectation Constant, educational level
0.068
0.058
0.771
0.068
7.079
0.009
0.078 0.134
0.068 0.116
0.708 0.689
0.078 0.056
8.194 6.222
0.005 0.014
0.063 0.113
0.053 0.095
1.111 1.086
0.063 0.051
6.485 5.486
0.012 0.021
0.153
0.126
1.067
0.039
4.415
0.038
0.202
0.168
1.041
0.049
5.750
0.018
0.040
0.030
0.809
0.040
4.011
0.048
observed by all researchers on this topic.7,9 A recent study by Siqueira et al22 assessed expectations and satisfaction with regard to removable dental prosthesis therapy and also did not verify satisfaction exceeding expectation scores. These authors argue that satisfaction with dental prostheses is multifactorial, involving technical and patient-related variables. Thus, it may be appropriate to provide special attention to the patients during the treatment, in an attempt to understand their motivation and to verify their adaptation profile to the dentures. Dentists may also keep in mind that some patients need more comprehensive care during their period of adaptation.5 The second null hypothesis, that no differences among patients’ expectations and post-treatment scores related to gender, age, educational level, marital status, self-reported time of using complete dentures, and number of postdelivery adjustments would occur, was rejected. Regarding gender differences, women presented higher satisfaction (post-treatment scores) than men for esthetics. This result is similar to previous studies,11,23 which noticed that women also gave higher scores than men to implant-supported prostheses. Contrarily, in another study,24 women gave lower scores than men for complete denture esthetics and ability to chew, which could be attributed to women’s negative self-perception of oral health.25 Other studies found no differences regarding scores among men and women.5,7,9,22,26 There is still a need for further investigation regarding the influence of gender on such variables, and it may be supposed that cultural factors as well as economic and media images could affect it.26 In the literature, educational level presents conflicting results regarding expectations and satisfaction with oral rehabilitation. Baracat et al6 did not find a significant association between esthetic and functional expectations and educational level in patients who received implant treatment. However, Celebi´c
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et al,27 using a different methodology, found that patients with low levels of education were more satisfied in general with their esthetic appearance, which is in agreement with our findings. In our results, there was no association between educational level and expectations (pretreatment scores), but educational level was the only variable that remains inversely associated with post-treatment scores to comfort. Previous expectations (pretreatment scores) for esthetics and phonetics correlated positively with their respective satisfaction (post-treatment scores), suggesting that complete denture therapy fulfilled the esthetic and phonetic expectations of the patients, since patients who gave higher scores for expectations also gave higher scores for their satisfaction for these parameters. The fact that the number of postdelivery adjustments was not associated with post-treatment scores for removable dental prosthesis therapy was verified.22 This study found an association between post-treatment scores for chewing and the number of postdelivery adjustments, where patients who needed more postdelivery adjustments gave lower scores for chewing satisfaction outcomes. Regarding self-reported time of using complete dentures, an association between the self-reported time of using complete dentures and patient satisfaction with phonetics was observed, where patients who wore complete dentures for longer periods presented lower values of satisfaction regarding this aspect. A possible explanation of this inverse correlation is that older patients, especially those wearing the same dentures for a long period, have difficulty adapting to new dentures, even a small change in tooth position may affect the pronunciation of some phonemes. It is also reported that elderly patients (who comprise the majority of complete denture wearers) often have hearing impairments and present greater difficulty in changing speech patterns.28
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Patients’ Evaluation of Complete Dentures
Table 4 ANOVA testing the models of the added variables Dependent Chewing satisfaction
Predictors Number of postdelivery adjustments
Esthetic satisfaction
Gender
Esthetic satisfaction
Gender, esthetic expectation
Phonetic satisfaction
Time of use
Phonetic satisfaction
Time of use, question 3
Phonetic satisfaction
Time of use, question 3, comfort expectation
Phonetic satisfaction
Comfort satisfaction
Time of use, question 3, comfort expectation, phonetic expectation
Educational level
Model
Sum of squares
Mean square
F
p-value
7.079
0.009
3.534 0.476
7.428
0.001
3.534
7.428
0.001
8.008 1.235
6.485
0.012
7.241 1.180
6.136
0.003
6.505
5.708
0.001
5.933
0.000
4.011
0.048
Regression
4.217
4.217
Residual Total Regression Residual Total Regression
57.783 62.000 4.109 48.639 52.747 7.069
0.596
Residual Total Regression Residual Total Regression Residual Total Regression
45.679 52.747 8.008 119.770 127.778 14.482 113.295 127.778 19.514
0.476
Residual Total Regression
108.264 127.778 25.755
1.140
Residual Total Regression Residual Total
102.022 127.778 2.628 63.554 66.182
1.085
Considering that the patient/professional relationship is a key factor for the success of denture therapy,2,7,22 this study used a questionnaire to assess patients’ evaluation of dentists’ conduct, which allowed us to test the third and last null hypothesis of this study: that patient evaluation of the dentists’ conduct will not be related to patients’ evaluations of complete dentures. This null hypothesis was partially confirmed, since only question 3 (i.e., “The dentists I saw usually explained what they were going to do”) associated with post-treatment scores regarding phonetics. These findings highlight the importance of the explanations that were given by dentists during the patients’ first consultations, and is also in agreement with a previous study.22 A proper conversation allows the dentist to offer realistic explanations of the dentures’ limitations (mainly regarding possible phoneticsrelated issues on the very first time using new dentures) before starting the treatment and can serve as an important factor in achieving patient satisfaction.7 Thus, the success of denture therapy is a result not only of the dentists’ skills but also of their ability to relate to the patients and understand their needs.22 The limitations of this study include the use of a quantitative approach and statistical association-based analysis, which limit the evaluation of a cause-effect relationship among the evaluated variables. The sample size should be considered a
6.439
2.628 0.655
limitation of this study. The type of statistics used in this study would have needed 15 participants per variable and therefore the current sample is not enough, dramatically increasing the risk for type 2 error. Considering this, this study could be considered adequate as a pilot study, providing a good sense of the variables that should be evaluated in further studies; however, the present results must be analyzed with caution. It is interesting to see that the present model could only explain 16.8% of phonetics satisfaction. Also, adding variables to the model did not change the satisfaction by much (every variable accounted for less than 5% each). It looks like these factors are related to satisfaction with phonetics, but 84% of it could be explained with other variables not studied here. It would be important to identify these in further studies. Regarding the methods of this study, both the VAS and Likert-type scale present some weaknesses, such as responsiveness in different settings and the wording of the answers possibly affecting the responses.29 However, both scales have been evaluated and seem to be reliable, valid, and responsive.30-32 New investigations using a qualitative approach and broader samples may further improve our understanding of the factors that influence patients’ expectations before and satisfaction after complete denture therapy.
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Table 5 Coefficients, p-value, confidence interval for the added variables in the multiple regression Unstandardized coefficients Dependent Chewing satisfaction
Esthetic satisfaction Esthetic satisfaction
Phonetic satisfaction Phonetic satisfaction
Phonetic satisfaction
Phonetic satisfaction
Comfort satisfaction
Standardized coefficients
Predictors
B
Std. error
Beta
t
p-value
Lower bound
Upper bound
Constant Number of postdelivery adjustment Constant Gender Constant Gender Esthetic expectation Constant Time of use Constant Time of use Question 3 Constant Time of use Question 3 Comfort expectation Constant Time of use Question 3 Comfort expectation Phonetic expectation Constant Educational level
9.304 −0.281
0.138 0.106
−0.261
67.392 −2.661
0.000 0.009
9.030 −0.491
9.578 −0.071
9.763 −0.419 8.295 −0.513 0.175 9.303 −0.057 8.069 −0.059 0.327 9.757 −0.059 0.313 −0.189 8.461 −0.051 0.294 −0.273 0.236 9.477 −0.073
0.115 0.146 0.599 0.147 0.070 0.197 0.022 0.561 0.022 0.140 0.974 0.022 0.137 0.090 1.094 0.021 0.134 0.095 0.099 0.295 0.036
84.992 −2.862 13.847 −3.480 2.494 47.164 −2.547 14.385 −2.690 2.342 10.014 −2.738 2.278 −2.101 7.737 −2.413 2.191 −2.885 2.398 32.131 −2.003
0.000 0.005 0.000 0.001 0.014 0.000 0.012 0.000 0.008 0.021 0.000 0.007 0.025 0.038 0.000 0.018 0.031 0.005 0.018 0.000 0.048
9.535 −0.709 7.106 −0.806 0.036 8.911 −0.101 6.956 −0.102 0.050 7.823 −0.102 0.040 −0.368 6.290 −0.093 0.028 −0.460 0.041 8.892 −0.145
9.991 −0.128 9.484 −0.221 0.314 9.694 −0.013 9.183 −0.015 0.604 11.692 −0.016 0.585 −0.010 10.633 −0.009 0.560 −0.085 0.432 10.062 0.000
−0.279 −0.342 0.245 −0.250 −0.259 0.225 −0.259 0.216 −0.199 −0.225 0.203 −0.286 0.240 −0.199
Conclusion Patient satisfaction regarding complete dentures exceeded their expectations, and an expressive majority of positive evaluations of the dentists was noticed. Many patient-related variables seemed to influence their evaluations of their dentures.
6.
Acknowledgment
8.
The authors would like to thank our statistician, J Adams.
9.
7.
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