Patient Perception and Satisfaction with Implant Therapy in a Predoctoral Implant Education Program: A Preliminary Study Damian J. Lee, DDS, MS, FACP,1 Judy Chia-Chun Yuan, DDS, MS,2 Philip J. Hedger, DMD, MS,3 Emily J. Taylor, DMD, MS, FACP,3 Rand F. Harlow, DDS,4 Kent L. Knoernschild, DMD, MS, FACP,5 Stephen D. Campbell, DDS, MMSc, FACP,6 & Cortino Sukotjo, DDS, MMSc, PhD7 1
Assistant Professor, Director, Advanced Education in Prosthodontics Program, Division of Restorative Sciences and Prosthodontics, The Ohio State University College of Dentistry, Columbus, OH 2 Assistant Professor, Director, Predoctoral Implant Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 3 Former resident, Advanced Education in Prosthodontic Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 4 Clinical Assistant Professor, Codirector, Advanced Education in Prosthodontics Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 5 Professor, Director, Advanced Education in Prosthodontics Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 6 Professor, Head of Restorative Dentistry. University of Illinois at Chicago College of Dentistry, Chicago, IL 7 Assistant Professor, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL
Keywords Dental implants; dental education; oral health; quality of life, satisfaction. Correspondence Cortino Sukotjo, Department of Restorative Dentistry, 801 S. Paulina St., Rm 365B (MC 555), Chicago, IL 60612. E-mail: [email protected] The University of Illinois-Chicago College of Dentistry receives support for the predoctoral implant educational program from Dentsply Implants and Nobel Biocare in the form of unrestricted educational grants. The research submitted here is not directly supported. The authors acknowledge Dentsply and Nobel Biocare for their educational grant and support. Accepted June 25, 2014 doi: 10.1111/jopr.12260
Abstract Purpose: The purpose of this study was to assess the level of satisfaction and quality of life for patients receiving mandibular implant-supported overdenture (IOD) or single-tooth implant (STI) therapy in a predoctoral dental implant program. Materials and Methods: Patients who received IOD and STI therapy and presented for recall visits at University of Illinois-Chicago College of Dentistry Predoctoral Implant Program were recruited. IOD treatment included placement of two endosseous implants in the mandibular canine region, followed by two abutments for resilient attachments. STI treatment included placement of endosseous implants, abutments, and cement-retained crowns. A modified Oral Health Impact Profile (OHIP)-14 questionnaire was given at least 6 months following insertion of implant-supported prostheses for both groups. Patient age, gender, distribution of STI, and OHIP-14 data were gathered and analyzed. Descriptive statistics were used to assess post-treatment data; Mann-Whitney U test was used to analyze the differences between groups older and younger than mean age and gender among the IOD and STI groups. Results: Fifty-one consecutive patients in the IOD (60.7% male, 39.2% female, mean age 63.7) and 50 consecutive patients in the STI group (58.0% female, 42.0% male, mean age 50.8) were included in this recall study. In the STI group, 69 implants were placed for 50 patients; the most common region was the maxillary posterior quadrant (49.3%). Scores from modified OHIP-14 ranged from 0.14 to 0.78 for the IOD group and 0.02 to 0.18 for the STI group. Both IOD and STI data showed satisfaction with the treatment outcome. There was a significant difference found between men and women among the IOD group pertaining to questions regarding pronouncing words, sense of taste, meal interruption, and feeling embarrassed from OHIP-14, but not between the age groups. Also, no significant differences were noted for gender or age group within the STI patients and OHIP-14 scores. Conclusion: Dental implant therapy provided in a predoctoral setting had a significant impact on the quality of life and a high level of satisfaction for patients seeking implant treatment.
Patient perception is important when assessing the indications and outcomes of implant-supported prostheses. Domains for evaluating successful long-term treatment outcomes in implants
have been proposed: survival/longevity, functional/physical, economic, and psychological.1,2 Within the psychological domain, preference, function, hygiene, comfort, esthetics, and
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patient satisfaction are the measures for success.1,2 Objective measures for the success of implant-supported prostheses have been reported largely as implant and prosthesis survival rates, bone and tissue response, or masticatory efficiency.1-9 Subjective findings may include patient satisfaction, self-concept and body image, and rehabilitation of function for the improvement of oral-health-related quality of life (OHRQoL).2,10-16 Many studies have evaluated both objective and subjective outcomes of implant-supported prostheses for edentulous patients.17-23 OHRQoL and patient satisfaction have been assessed to compare subjective variables more objectively. The Oral Health Impact Profile (OHIP) was developed to provide a comprehensive measure of the consequences of oral disorders and their effects on OHRQoL.22,24 Allen et al applied the OHIP-49 questionnaire to compare conventional complete dentures with implant-supported overdentures (IOD) and observed a significant improvement in satisfaction and OHRQoL with the latter.18 Awad and Feine performed a randomized, controlled trial to assess patient satisfaction after receiving either mandibular conventional dentures or IODs; results showed that two IOD provided patients with more satisfaction.19 Some studies have evaluated outcomes of single-tooth implant (STI)-supported prostheses;25-29 those outcomes have been measured and reported in varying ways.30 Outcomes that relate to perception of care using conventional and immediate implant placement and restoration have been reported.25,26 However, reports of outcomes have been more anecdotal rather than standardized outcomes that could be compared among studies.30 Systematic assessment of outcomes using OHIP has been completed for partially edentulous patients,31-33 yet none of these directly related to the outcomes of treatment provided by dental students in the academic environment. Little patient-centered evidence supports the anecdotally known favorable outcomes in the academic environment with predoctoral dental student providers. Dental implants are an integral part of predoctoral dental education, and providing comprehensive, patient-centered care must be a primary goal for all dental institutions.34 The Commission on Dental Accreditation (CODA) requires all graduates from accredited dental institutions be competent in replacing missing teeth using dental implants.34 Past studies have emphasized the importance of having an established dental implant curriculum and identified the need for incorporating the experience in both pre-patient and patient care level.35-41 Dental implant therapy provided by dental students has shown favorable long-term survival.37-44 Many dental students consider implant training to be an important part of their predoctoral dental education.45 However, evidence that supports perceived value from patients’ perspectives is required. Patient perception of their oral health care is a core issue in evaluating the quality of service provided by dental students, as well as assessing the impact it may have on patient QoL. Limited available literature exists on patient perceptions of dental implant therapy provided by predoctoral dental students, especially based on patients’ age and gender.46-48 The use of OHIP-49 has been validated and used; however, some research settings do not allow the use of the full OHIP-49.22,49 Therefore, OHIP-14 was developed as a shorter form that may allow a more
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straightforward clinical assessment.49 Slade showed that OHIP14 provides satisfactory validity and reliability, and shows the same pattern of variations as OHIP-49.49 Furthermore, using a standardized, validated, and objective measurement such as OHIP-14 to assess patient perception has not been widely used to assess predoctoral student treatment outcomes with fixed or removable dental implant prostheses. The purposes of this study were to: (1) assess the level of satisfaction and OHRQoL of mandibular IOD and STI patients in the University of Illinois-Chicago College of Dentistry (UIC COD) predoctoral implant program using a modified version of OHIP-14 and (2) assess the level of patient satisfaction based on age and gender for both IOD and STI patients. The null hypothesis was that there would be no differences in the level of patient satisfaction with implant therapy at the predoctoral level compared to published results in the literature. Also, it was hypothesized that the level of patient satisfaction would not be different for IOD and STI patients, in relation to age and gender.
Materials and methods This study was approved by the UIC Institutional Review Board (Research Protocol #2008–1137). Patients receiving implants and definitive prostheses through the predoctoral implant program at the Implant and Innovations Center, UIC COD were recruited. The UIC COD predoctoral dental implant curriculum was described in detail in previous publications.37,45 Mandibular IOD therapy included placement of two endosseous implants in the mandibular canine/lateral incisor regions placed by residents in oral and maxillofacial surgery, periodontics, and prosthodontics. After 4 months of healing, healing abutments were placed in a two-stage placement approach. Patients received LocatorTM (Zest Anchors, Escondido, CA) abutments 2 to 3 weeks after the second-stage surgery. Retentive components and housings were picked up with denture repair acrylic resin (Dentsply, York, PA) in the existing dentures according to manufacturer recommendations. For STI prostheses, two-stage surgical protocols were followed, along with 4 to 6 months of healing.50 Definitive impressions were made 2 weeks after placement of healing abutments. Prefabricated or custom abutments were used as indicated. The majority of definitive crowns were metal ceramic (N = 65, 94%) and cement-retained (N = 66, 96%). Recall occurred at 1 week, 1 month, 6 months, and 1 year, and then annually for both patient groups. During the recall examination, intraoral examinations were performed to check for any prosthetic complications and peri-implant tissue condition. Periapical radiographs were also taken at the implant site to check for any bony changes. A modified OHIP-14 questionnaire was constructed consisting of 14 total questions. The original OHIP-14 developed by Slade asked for “any problems with your teeth, mouth, or denture.”49 For this study, the questions were modified to apply to mandibular IOD or STI prosthesis patients specifically, with queries addressing “any problems with your implant-supported overdenture” or “implant restoration(s)” (Table 1). A Likert scale (0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly
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Table 1 Post-treatment OHIP-14 survey of IOD and STI patient perceptions (0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, 4 = very often)
Have you had trouble pronouncing any words because of your implant-supported overdenture/restoration? Have you felt that your sense of taste has worsened because of your implant-supported overdenture/restoration? Have you had painful aching in your mouth? Have you found it uncomfortable to eat any foods because of your implant-supported overdenture/restoration? Have you been self-conscious because of your implant-supported overdenture/restoration? Have you felt tense because of your implant-supported overdenture/restoration? Has your diet been unsatisfactory because of your implant-supported overdenture/restoration? Have you had to interrupt meals because of your implant-supported overdenture/restoration? Have you found it difficult to relax because of your implant-supported overdenture/restoration? Have you been a bit embarrassed because of your implant-supported overdenture/restoration? Have you been a bit irritable with other people because of your implant-supported overdenture/restoration? Have you had difficulty doing your usual jobs because of your implant-supported overdenture/restoration? Have you felt that life in general was less satisfying because of your implant-supported overdenture/restoration? Have you been totally unable to function because of your implant-supported overdenture/restoration?
often, 4 = very often) was used to describe the OHRQoL after the insertion of the implant prosthesis. A cover letter, consent form, and questionnaire were given to 51 consecutive IOD and 50 STI patients at least 6 months after completion of the implant restoration during recall examinations. Demographics of patients, implant distribution by site, and means and standard deviations of scores from the modified OHIP-14 questionnaire were calculated from post-treatment satisfaction surveys of each patient. Descriptive statistics were used to analyze post-treatment data. Mann-Whitney U test was performed to analyze the trends of questions answered between men and women within each treatment group. Within both IOD and STI groups, the mean age was determined, and groups older and younger than the mean were compared as well. Statistical software (SPSS v. 20.0; IBM Corp., Armonk, NY) was used for descriptive and statistical analyses. For all analyses, alpha was equal to 0.05.
Results Patient demographics
Fifty-one patients were in the IOD group (60.7% men [n = 31], 39.2% women [n = 20]). The mean age for the IOD group was 63.7 years with an age range from 43 to 84 years. Each patient received two implants, for a total of 102 implants. Fifty patients were in the STI group with 58.0% women (n = 29) and 42.0% men (n = 21). The mean age for the STI group was 50.8 with an age range from 24 to 76 years. Sixty-nine implants were placed for the 50 STI patients. The most common region was the maxillary posterior region (49.3%, n = 34; Table 2). OHIP
Table 1 represents the post-treatment modified OHIP-14 questionnaire results for mandibular IOD and STI; lower scores indicated higher patient satisfaction. The mean scores from modified OHIP-14 ranged from 0.14 to 0.78 for the IOD group. The highest mean score of 0.78 summarized responses to the
IOD (N = 51)
STI (N = 50)
Mean (SD)
Mean (SD)
0.63 (0.84) 0.53 (0.87) 0.57 (0.83) 0.78 (0.98) 0.25 (0.62) 0.35 (0.81) 0.31 (0.81) 0.55 (0.90) 0.16 (0.50) 0.24 (0.73) 0.14 (0.49) 0.21 (0.60) 0.17 (0.70) 0.18 (0.73)
0.02 (0.14) 0.02 (0.14) 0.18 (0.48) 0.16 (0.51) 0.12 (0.63) 0.02 (0.14) 0.04 (0.28) 0.08 (0.57) 0.04 (0.20) 0.12 (0.52) 0.14 (0.53) 0.04 (0.20) 0.12 (0.44) 0.06 (0.31)
Table 2 Distribution of STI placed by region of the mouth 69 implants in 50 patients Total STI placed Posterior maxilla Premolar maxilla Molar maxilla Posterior mandible Premolar mandible Molar mandible Anterior maxilla
N (%) 34 (49.3) 27 (39.1) 7 (10.1) 30 (43.5) 5 (7.2) 25 (36.2) 5 (7.2)
question “Have you found it uncomfortable to eat any foods because of your implant-supported overdenture?” The lowest mean score of 0.14 summarized responses to the question, “Have you been a bit irritable with other people because of your implant restoration(s)?” The mean scores for the STI group ranged from 0.02 to 0.18. The highest score of 0.18 summarized responses to the question “Have you had painful aching in your mouth?” The lowest mean score of 0.02 summarized responses to the questions “Have you had trouble pronouncing any words because of your implant restoration(s)?” “Have you felt that your sense of taste has worsened because of your implant restoration(s)?” and “Have you felt tense because of problems with your implant restoration(s)?” Effects of gender and age
Mann-Whitney U test revealed a significant difference among the IOD patients on the trends of questions answered by gender, specifically questions 1, 2, 4, 8, and 10, which were related to pronunciation, taste, feeling uncomfortable eating, interruptions in meals, and feeling embarrassed. No significant difference was observed between groups older and younger than mean age (Table 3). The STI group showed no significant difference on how the questions were answered by both age and gender (Table 4).
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Table 3 Mann-Whitney U test for IOD patients
Questions Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
p-value for comparison between gender
Comparison by gender (male female)
p-value for comparison by age (younger vs. older than mean age: 57 years old)
F M>F
0.910 0.108 0.119 0.554 0.391 0.522 0.111 0.409 0.352 0.242 0.208 0.401 0.961 0.212
M>F
M>F M>F
*Denotes statistical significance (α = 0.05). Table 4 Mann-Whitney U test for STI patients
Questions
p-value for comparison between gender
p-value for comparison by age (younger vs. older than mean age: 57 years)
0.240 0.395 0.948 0.714 0.224 0.395 0.395 0.395 0.224 0.720 0.491 0.224 0.504 0.794
0.182 0.182 0.591 0.858 0.284 0.453 0.453 0.453 0.057 0.185 0.606 0.057 0.103 0.057
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Discussion Both IOD and STI results suggested that patients were satisfied with treatment. All mean scores for the OHIP-14 were below 1.0, suggesting that implant treatment in both groups had a positive impact on the patients’ OHRQoL. The results from this study examined the level of satisfaction and impact on QoL of dental implant therapy and are comparable to other studies from dental institutional settings. Moghadam et al reported a range of 85% to 96% of patient satisfaction in esthetics, comfort, and function for patients treated in a predoctoral implant program and questioned via telephone interview.48 Improvements in chewing, appearance, and enhanced QoL were also related to emotional and social improvements from treatments provided in teaching environments.43,46 Therefore, the null hypothesis of 528
having no differences in the level of patient satisfaction with implant therapy at the predoctoral level compared to previously published results was accepted. Patients have differing expectations and abilities to accommodate to the provided therapies. In general, reported outcomes of patients who received mandibular IOD led to larger OHIP means and standard deviations than those reported by patients who received STI prostheses. Although direct comparisons cannot be made between therapy groups, the lower values for STI patients possibly suggested a more favorable and consistent meeting of patient expectations compared to those who received mandibular overdentures. For patients who received IODs, mean OHIP values and their standard deviations were greatest with regard to pronunciation, selection of foods, and disruption of meals during use of the IOD prosthesis. Results suggested some patients had extremely positive results or difficulties based upon categories defined by OHIP-14. This study did not correlate the reported patient outcomes to specific clinical presentation or situations; future studies are indicated to relate patient reports to clinical presentation. Nevertheless, results of this study indicated positive patient-centered outcomes that favored dental implant over denture therapy as a part of the predoctoral dental curriculum. For patients who received STIs, mean OHIP values and their standard deviations were greatest with discomfort. Whether this discomfort was related to current status of the implant prostheses or previous experiences leading up to completion of the prosthesis was not clearly indicated during the survey. The authors were unable to correlate the results to a patient’s clinical situation. Like the IOD group, a similar and more robust study in the future could correlate the patient-centered outcomes to each patient’s clinical presentation. Nevertheless, also like the IOD group, this study further indicated positive patient-centered outcomes that favor patient therapy with STI as a part of the predoctoral dental curriculum. Patient satisfaction based on gender was significantly different in the IOD group for certain questions but not in the STI group. Differences in factors related to function, such as pronunciation, taste, and interruption in meals, were mainly reported by men in the IOD group. As for influence of gender on patient satisfaction and OHRQoL, reports have shown that men value eating as an important part of OHRQoL, while women emphasize confidence as having more impact on oral health.14 In contrast to the findings from this study, women have previously reported oral health having a more significant impact in their lives, both positive and negative.11 Interestingly, age did not have any influence on the level of patient satisfaction and OHRQoL. Previous studies have reported age having a profound and significant impact on perceived oral health due to the deterioration of oral health status for the elderly population and the prolonged influence on psychosocial and physiological function domain.11,15 Other important factors that influence OHRQoL, such as socioeconomic status or number of remaining teeth, are also interesting topics in the clinical outcomes of dental institutions. Results from this study indicate that dental students can provide good results with meaningful impact on patients’ lives. Patients have sought care at dental institutions for implant
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treatment because they typically offer low-cost programs for surrounding communities and underserved populations.37,42,44,48 This study also indicated that predoctoral students provided STI therapy that met the patient satisfaction. Many studies have also examined the success and survival of STI therapy and OHRQoL.16,26,29,31 However, no study has been performed in the predoctoral educational setting using OHIP-14. Improvement in comfort with eating, esthetics, phonetics, and overall satisfaction is well-documented with STI therapy.26,29 By having well-defined and stringent patient selection criteria,37,42 implant educational programs can select the patients most suitable for predoctoral treatment and can provide successful comprehensive therapy. With increasing financial burdens in society, patients seeking implant care at dental institutions as an alternative to private practice can be anticipated. While studies have addressed patient treatment in the predoctoral dental setting,43,44,46,48 more studies on clinical outcomes, especially long-term and qualitative analyses are needed. Merit exists in using a previously standardized instrument for reliable data collection and analysis, as health status questionnaires should have good psychometric properties such as reliability, validity, and precision.22 While other qualitative studies in the predoctoral implant programs used their own questionnaires,43,46,48 this study used OHIP-14 modified to address both IOD and STI patients during recall examinations. Using a validated and objective measuring instrument can enhance the evaluation of the treatment outcomes and confirm improvements in QoL in a systematic and scientific manner. This study reported only post-therapy data collected at the designated 6-month recall, and was therefore unable to compare pre- and post-therapy outcomes. Other studies have recorded pre- and post-treatment data and reported significant improvements for mandibular IOD and for STI. Mandibular IOD do make significant differences in patient OHRQoL, which has led to the recognition of this therapy approach as the first choice option for the edentulous patient.23 For partially edentulous patients, pre- and post-therapy data using OHIP-G 21 have indicated significantly less psychological dissatisfaction.31 Specifically, patients were less worried about dental problems and had less dissatisfaction with appearance due to problems with their teeth, mouth, and dentures.31 In the future, studies that evaluate pre- and post-therapy patient-centered outcomes from those who received therapy in a predoctoral dental implant program are indicated. Assessing patient satisfaction and OHRQoL is an integral part of incorporating behavioral science into clinical practice in predoctoral education. CODA standards indicate that all dental graduates must be competent in the application of behavioral science principles and patient-centered approaches to promote, improve, and maintain oral health.34 Graduates must also be competent in evaluating treatment outcome. Emphasis must be placed on patient satisfaction as a vital part of assessing treatment outcome and the long-term benefits on QoL.34 Using modified OHIP-14 during dental implant patient recall examinations is an innovative way for predoctoral students to learn about the psychosocial benefits of implant therapy. While the predoctoral curriculum may include other psychosocial education in patient management, using a reliable, easy-to-use,
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object instrument to assess patient satisfaction in dental treatment during a recall examination can be valuable. By establishing a standardized and structured approach to the routine recall examination, an opportunity for predoctoral students to evaluate dental implant patients in a comprehensive and structured manner is available. A consistent method of evaluating patient outcomes can also be used for other treatment modalities. Predoctoral students and practitioners would benefit from thoroughly examining the patient and treatment outcomes in all phases of dentistry using the OHIP approach. The following limitations were noted for this study, where pretreatment data were not obtained. Therefore, any comparison or analysis of the impact of treatment could not be analyzed. Because of the short duration, this preliminary data could have influenced patient satisfaction to be more positive. Also, the type of data and timing may have influenced the outcome of this study. Due to the large standard deviation in the data, there may be statistical unpredictability. The surveys were given to patients 6 months after the completion of implant care, rather than after long-term observation. Therefore, well-controlled populations with longer observation periods may yield different results. For STI patients, because the vast majority of patients used cement-retained restorations, the effects of screw-retained restorations on patient satisfaction were not considered in the investigation. This area could be further explored in future studies. Last, a modified version of OHIP-14 was used, and some researchers have expressed limitations in the range of its application, especially in assessing esthetics.27,28 Others have used OHIP-esthetic for discriminating and evaluating problems with dental esthetic outcomes as a singular domain of OHRQoL.27,28 Therefore, future studies using other forms of OHIP to enhance the assessment of OHRQoL, perhaps especially in the area of esthetics, would be of benefit to a predoctoral dental curriculum in the assessment of the program’s ability to meet patient expectations, the ultimate goal of comprehensive patient therapy.
Conclusions This study used a modified OHIP-14 to assess the level of patient satisfaction and OHRQoL for patients who received IOD and STI prostheses. Under the conditions of this preliminary study, the following conclusions were drawn about dental implant therapy completed in a predoctoral dental clinical setting: 1. Mandibular IOD and STI prostheses led to overwhelmingly favorable questionnaire results regarding all aspects of modified OHIP-14-assessed patient QoL and satisfaction with treatment with implants in a predoctoral clinical setting. 2. There was a significant difference between men and women among IOD patients on how they answered questions related to pronunciation, taste, feeling uncomfortable eating, interruptions in meals, and feeling embarrassed. STI patients did not show any significant differences based on gender. 3. No significant differences were noted regarding all aspects of modified OHIP-14 between different age groups for both IOD and STI patients.
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References 1. Carr AB: Successful long-term treatment outcomes in the field of osseointegrated implants: prosthodontic determinants. Int J Prosthodont 1998;11:502-512 2. Carr A, Wolfaardt J, Garrett N: Capturing patient benefits of treatment. Int J Oral Maxillofac Implants 2011;26 (Suppl):85-92; discussion 101-102 3. Geertman ME, Slagter AP, van ‘t Hof MA, et al: Masticatory performance and chewing experience with implant-retained mandibular overdentures. J Oral Rehabil 1999;26:7-13 4. Albrektsson T, Zarb G, Worthington P, et al: The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25 5. Zarb GA, Schmitt A: The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part III: problems and complications encountered. J Prosthet Dent 1990;64:185-194 6. Zarb GA, Schmitt A: The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto Study. Part II: the prosthetic results. J Prosthet Dent 1990;64:53-61 7. Zarb GA, Schmitt A: The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study. Part I: surgical results. J Prosthet Dent 1990;63:451-457 8. Boerrigter EM, Stegenga B, Raghoebar GM, et al: Patient satisfaction and chewing ability with implant-retained mandibular overdentures: a comparison with new complete dentures with or without preprosthetic surgery. J Oral Maxillofac Surg 1995;53:1167-1173 9. van Kampen FM, van der Bilt A, Cune MS, et al: Masticatory function with implant-supported overdentures. J Dent Res 2004;83:708-711 10. Guckes AD, Scurria MS, Shugars DA: A conceptual framework for understanding outcomes of oral implant therapy. J Prosthet Dent 1996;75:633-639 11. McGrath C, Bedi R: Gender variations in the social impact of oral health. J Ir Dent Assoc 2000;46:87-91 12. McGrath C: Oral health behind bars: a study of oral disease and its impact on the life quality of an older prison population. Gerodontology 2002;19:109-114 13. McGrath C, Bedi R: A study of the impact of oral health on the quality of life of older people in the UK-findings from a national survey. Gerodontology 1998;15:93-98 14. McGrath C, Bedi R: The importance of oral health to older people’s quality of life. Gerodontology 1999;16:59-63 15. McGrath C, Bedi R: Population based norming of the UK oral health related quality of life measure (OHQoL-UK). Br Dent J 2002;193:521-524; discussion 17 16. Abu Hantash RO, Al-Omiri MK, Al-Wahadni AM: Psychological impact on implant patients’ oral health-related quality of life. Clin Oral Implants Res 2006;17:116-123 17. Allen PF, McMillan AS, Locker D: An assessment of sensitivity to change of the oral health impact profile in a clinical trial. Community Dent Oral Epidemiol 2001;29:175-182 18. Allen PF, McMillan AS, Walshaw D: A patient-based assessment of implant-stabilized and conventional complete dentures. J Prosthet Dent 2001;85:141-147 19. Awad MA, Feine JS: Measuring patient satisfaction with mandibular prostheses. Community Dent Oral Epidemiol 1998;26:400-405 20. Heydecke G, Locker D, Awad MA, et al: Oral and general health-related quality of life with conventional and implant dentures. Community Dent Oral Epidemiol 2003;31:161-168
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21. Rashid F, Awad MA, Thomason JM, et al: The effectiveness of 2-implant overdentures – a pragmatic international multicentre study. J Oral Rehabil 2011;38:176-184 22. Slade GD, Spencer AJ: Development and evaluation of the oral health impact profile. Community Dent Health 1994;11:3-11 23. Feine JS, Lund JP: Treatment outcomes of fixed or removable implant-supported prostheses in the edentulous maxilla. J Prosthet Dent 2000;84:372-373 24. Locker D, Slade G: Oral health and the quality of life among older adults: the oral health impact profile. J Can Dent Assoc 1993;59:830-833, 837–838, 844 25. Cannizzaro G, Felice P, Leone M, et al: Immediate versus early loading of 6.5 mm-long flapless-placed single implants: a 4-year after loading report of a split-mouth randomised controlled trial. Eur J Oral Implantol 2012;5:111-121 26. den Hartog L, Slater JJ, Vissink A, et al: Treatment outcome of immediate, early and conventional single-tooth implants in the aesthetic zone: a systematic review to survival, bone level, soft-tissue, aesthetics and patient satisfaction. J Clin Periodontol 2008;35:1073-1086 27. Mehl C, Kern M, Freitag-Wolf S, et al: Does the oral health impact profile questionnaire measure dental appearance? Int J Prosthodont 2009;22:87-93 28. Wong AH, Cheung CS, McGrath C: Developing a short form of oral health impact profile (OHIP) for dental aesthetics: OHIP-aesthetic. Community Dent Oral Epidemiol 2007;35:6472 29. Belser UC, Schmid B, Higginbottom F, et al: Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants 2004;19 (Suppl):30-42 30. Torabinejad M, Anderson P, Bader J, et al: Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review. J Prosthet Dent 2007;98:285-311 31. Nickenig HJ, Wichmann M, Andreas SK, et al: Oral health-related quality of life in partially edentulous patients: assessments before and after implant therapy. J Craniomaxillofac Surg 2008;36:477-480 32. 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 33. Strassburger C, Kerschbaum T, Heydecke G: Influence of implant and conventional prostheses on satisfaction and quality of life: a literature review. Part 2: qualitative analysis and evaluation of the studies. Int J Prosthodont 2006;19:339-348 34. Accreditation CoD: Accreditation Standards for Dental Education Programs. Chicago, American Dental Association, 2010 35. Lim MV, Afsharzand Z, Rashedi B, et al: Predoctoral implant education in U.S. dental schools. J Prosthodont 2005;14:4656 36. Afsharzand Z, Lim MV, Rashedi B, et al: Predoctoral implant dentistry curriculum survey: European dental schools. Eur J Dent Educ 2005;9:37-45 37. Lee DJ, Harlow RE, Yuan JC, et al: Three-year clinical outcomes of implant treatments provided at a predoctoral implant program. Int J Prosthodont 2011;24:71-76 38. Kronstrom M, McGrath L, Chaytor D: Implant dentistry in the undergraduate dental education program at Dalhousie University. Part 1: clinical outcomes. Int J Prosthodont 2008;21:124128
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39. Maalhagh-Fard A, Nimmo A: Eleven-year report on a predoctoral implant dentistry program. J Prosthodont 2008;17:64-68 40. Maalhagh-Fard A, Nimmo A, Lepczyk JW, et al: Implant dentistry in predoctoral education: the elective approach. J Prosthodont 2002;11:202-207 41. Wilcox CW, Huebner GR, Mattson JS, et al: Placement and restoration of implants by predoctoral students: the Creighton experience. J Prosthodont 1997;6:61-65 42. Jahangiri L, Choi M: A model for an integrated predoctoral implant curriculum: implementation and outcomes. J Dent Educ 2008;72:1304-1317 43. Johannsen A, Westergren A, Johannsen G: Dental implants from the patients perspective: transition from tooth loss, through amputation to implants – negative and positive trajectories. J Clin Periodontol 2012;39:681-687 44. McCracken MS, Aponte-Wesson R, O’Neal SJ, et al: Low-cost implant overdenture option for patients treated in a predoctoral dental school curriculum. J Dent Educ 2006;70:662-666 45. Yuan JC, Kaste LM, Lee DJ, et al: Dental students’ perceptions on implant pre-patient care, clinical curriculum and plans in
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46.
47.
48.
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providing implant treatment: one institution’s experience. J Dent Educ 2011;75:750-760 Harrison P, Polyzois I, Houston F, et al: Patient satisfaction relating to implant treatment by undergraduate and postgraduate dental students–a pilot study. Eur J Dent Educ 2009;13:184188 Farino M, Branscum A, Robinson FG, et al: Programmatic effectiveness of a university-based implant training program: long-term, patient-centered outcomes. J Long Term Eff Med Implants 2010;20:343-351 Moghadam M, Dias R, Kuyinu E, et al: Predoctoral fixed implant patient satisfaction outcome and challenges of a clinical implant competency. J Dent Educ 2012;76:437-442 Slade GD: Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997;25:284-290 Buser D, Mericske-Stern R, Bernard JP, et al: Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res 1997;8:161-172
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Assistant Professor, Director, Advanced Education in Prosthodontics Program, Division of Restorative Sciences and Prosthodontics, The Ohio State University College of Dentistry, Columbus, OH 2 Assistant Professor, Director, Predoctoral Implant Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 3 Former resident, Advanced Education in Prosthodontic Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 4 Clinical Assistant Professor, Codirector, Advanced Education in Prosthodontics Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 5 Professor, Director, Advanced Education in Prosthodontics Program, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 6 Professor, Head of Restorative Dentistry. University of Illinois at Chicago College of Dentistry, Chicago, IL 7 Assistant Professor, Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL
Keywords Dental implants; dental education; oral health; quality of life, satisfaction. Correspondence Cortino Sukotjo, Department of Restorative Dentistry, 801 S. Paulina St., Rm 365B (MC 555), Chicago, IL 60612. E-mail: [email protected] The University of Illinois-Chicago College of Dentistry receives support for the predoctoral implant educational program from Dentsply Implants and Nobel Biocare in the form of unrestricted educational grants. The research submitted here is not directly supported. The authors acknowledge Dentsply and Nobel Biocare for their educational grant and support. Accepted June 25, 2014 doi: 10.1111/jopr.12260
Abstract Purpose: The purpose of this study was to assess the level of satisfaction and quality of life for patients receiving mandibular implant-supported overdenture (IOD) or single-tooth implant (STI) therapy in a predoctoral dental implant program. Materials and Methods: Patients who received IOD and STI therapy and presented for recall visits at University of Illinois-Chicago College of Dentistry Predoctoral Implant Program were recruited. IOD treatment included placement of two endosseous implants in the mandibular canine region, followed by two abutments for resilient attachments. STI treatment included placement of endosseous implants, abutments, and cement-retained crowns. A modified Oral Health Impact Profile (OHIP)-14 questionnaire was given at least 6 months following insertion of implant-supported prostheses for both groups. Patient age, gender, distribution of STI, and OHIP-14 data were gathered and analyzed. Descriptive statistics were used to assess post-treatment data; Mann-Whitney U test was used to analyze the differences between groups older and younger than mean age and gender among the IOD and STI groups. Results: Fifty-one consecutive patients in the IOD (60.7% male, 39.2% female, mean age 63.7) and 50 consecutive patients in the STI group (58.0% female, 42.0% male, mean age 50.8) were included in this recall study. In the STI group, 69 implants were placed for 50 patients; the most common region was the maxillary posterior quadrant (49.3%). Scores from modified OHIP-14 ranged from 0.14 to 0.78 for the IOD group and 0.02 to 0.18 for the STI group. Both IOD and STI data showed satisfaction with the treatment outcome. There was a significant difference found between men and women among the IOD group pertaining to questions regarding pronouncing words, sense of taste, meal interruption, and feeling embarrassed from OHIP-14, but not between the age groups. Also, no significant differences were noted for gender or age group within the STI patients and OHIP-14 scores. Conclusion: Dental implant therapy provided in a predoctoral setting had a significant impact on the quality of life and a high level of satisfaction for patients seeking implant treatment.
Patient perception is important when assessing the indications and outcomes of implant-supported prostheses. Domains for evaluating successful long-term treatment outcomes in implants
have been proposed: survival/longevity, functional/physical, economic, and psychological.1,2 Within the psychological domain, preference, function, hygiene, comfort, esthetics, and
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patient satisfaction are the measures for success.1,2 Objective measures for the success of implant-supported prostheses have been reported largely as implant and prosthesis survival rates, bone and tissue response, or masticatory efficiency.1-9 Subjective findings may include patient satisfaction, self-concept and body image, and rehabilitation of function for the improvement of oral-health-related quality of life (OHRQoL).2,10-16 Many studies have evaluated both objective and subjective outcomes of implant-supported prostheses for edentulous patients.17-23 OHRQoL and patient satisfaction have been assessed to compare subjective variables more objectively. The Oral Health Impact Profile (OHIP) was developed to provide a comprehensive measure of the consequences of oral disorders and their effects on OHRQoL.22,24 Allen et al applied the OHIP-49 questionnaire to compare conventional complete dentures with implant-supported overdentures (IOD) and observed a significant improvement in satisfaction and OHRQoL with the latter.18 Awad and Feine performed a randomized, controlled trial to assess patient satisfaction after receiving either mandibular conventional dentures or IODs; results showed that two IOD provided patients with more satisfaction.19 Some studies have evaluated outcomes of single-tooth implant (STI)-supported prostheses;25-29 those outcomes have been measured and reported in varying ways.30 Outcomes that relate to perception of care using conventional and immediate implant placement and restoration have been reported.25,26 However, reports of outcomes have been more anecdotal rather than standardized outcomes that could be compared among studies.30 Systematic assessment of outcomes using OHIP has been completed for partially edentulous patients,31-33 yet none of these directly related to the outcomes of treatment provided by dental students in the academic environment. Little patient-centered evidence supports the anecdotally known favorable outcomes in the academic environment with predoctoral dental student providers. Dental implants are an integral part of predoctoral dental education, and providing comprehensive, patient-centered care must be a primary goal for all dental institutions.34 The Commission on Dental Accreditation (CODA) requires all graduates from accredited dental institutions be competent in replacing missing teeth using dental implants.34 Past studies have emphasized the importance of having an established dental implant curriculum and identified the need for incorporating the experience in both pre-patient and patient care level.35-41 Dental implant therapy provided by dental students has shown favorable long-term survival.37-44 Many dental students consider implant training to be an important part of their predoctoral dental education.45 However, evidence that supports perceived value from patients’ perspectives is required. Patient perception of their oral health care is a core issue in evaluating the quality of service provided by dental students, as well as assessing the impact it may have on patient QoL. Limited available literature exists on patient perceptions of dental implant therapy provided by predoctoral dental students, especially based on patients’ age and gender.46-48 The use of OHIP-49 has been validated and used; however, some research settings do not allow the use of the full OHIP-49.22,49 Therefore, OHIP-14 was developed as a shorter form that may allow a more
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straightforward clinical assessment.49 Slade showed that OHIP14 provides satisfactory validity and reliability, and shows the same pattern of variations as OHIP-49.49 Furthermore, using a standardized, validated, and objective measurement such as OHIP-14 to assess patient perception has not been widely used to assess predoctoral student treatment outcomes with fixed or removable dental implant prostheses. The purposes of this study were to: (1) assess the level of satisfaction and OHRQoL of mandibular IOD and STI patients in the University of Illinois-Chicago College of Dentistry (UIC COD) predoctoral implant program using a modified version of OHIP-14 and (2) assess the level of patient satisfaction based on age and gender for both IOD and STI patients. The null hypothesis was that there would be no differences in the level of patient satisfaction with implant therapy at the predoctoral level compared to published results in the literature. Also, it was hypothesized that the level of patient satisfaction would not be different for IOD and STI patients, in relation to age and gender.
Materials and methods This study was approved by the UIC Institutional Review Board (Research Protocol #2008–1137). Patients receiving implants and definitive prostheses through the predoctoral implant program at the Implant and Innovations Center, UIC COD were recruited. The UIC COD predoctoral dental implant curriculum was described in detail in previous publications.37,45 Mandibular IOD therapy included placement of two endosseous implants in the mandibular canine/lateral incisor regions placed by residents in oral and maxillofacial surgery, periodontics, and prosthodontics. After 4 months of healing, healing abutments were placed in a two-stage placement approach. Patients received LocatorTM (Zest Anchors, Escondido, CA) abutments 2 to 3 weeks after the second-stage surgery. Retentive components and housings were picked up with denture repair acrylic resin (Dentsply, York, PA) in the existing dentures according to manufacturer recommendations. For STI prostheses, two-stage surgical protocols were followed, along with 4 to 6 months of healing.50 Definitive impressions were made 2 weeks after placement of healing abutments. Prefabricated or custom abutments were used as indicated. The majority of definitive crowns were metal ceramic (N = 65, 94%) and cement-retained (N = 66, 96%). Recall occurred at 1 week, 1 month, 6 months, and 1 year, and then annually for both patient groups. During the recall examination, intraoral examinations were performed to check for any prosthetic complications and peri-implant tissue condition. Periapical radiographs were also taken at the implant site to check for any bony changes. A modified OHIP-14 questionnaire was constructed consisting of 14 total questions. The original OHIP-14 developed by Slade asked for “any problems with your teeth, mouth, or denture.”49 For this study, the questions were modified to apply to mandibular IOD or STI prosthesis patients specifically, with queries addressing “any problems with your implant-supported overdenture” or “implant restoration(s)” (Table 1). A Likert scale (0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly
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Table 1 Post-treatment OHIP-14 survey of IOD and STI patient perceptions (0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, 4 = very often)
Have you had trouble pronouncing any words because of your implant-supported overdenture/restoration? Have you felt that your sense of taste has worsened because of your implant-supported overdenture/restoration? Have you had painful aching in your mouth? Have you found it uncomfortable to eat any foods because of your implant-supported overdenture/restoration? Have you been self-conscious because of your implant-supported overdenture/restoration? Have you felt tense because of your implant-supported overdenture/restoration? Has your diet been unsatisfactory because of your implant-supported overdenture/restoration? Have you had to interrupt meals because of your implant-supported overdenture/restoration? Have you found it difficult to relax because of your implant-supported overdenture/restoration? Have you been a bit embarrassed because of your implant-supported overdenture/restoration? Have you been a bit irritable with other people because of your implant-supported overdenture/restoration? Have you had difficulty doing your usual jobs because of your implant-supported overdenture/restoration? Have you felt that life in general was less satisfying because of your implant-supported overdenture/restoration? Have you been totally unable to function because of your implant-supported overdenture/restoration?
often, 4 = very often) was used to describe the OHRQoL after the insertion of the implant prosthesis. A cover letter, consent form, and questionnaire were given to 51 consecutive IOD and 50 STI patients at least 6 months after completion of the implant restoration during recall examinations. Demographics of patients, implant distribution by site, and means and standard deviations of scores from the modified OHIP-14 questionnaire were calculated from post-treatment satisfaction surveys of each patient. Descriptive statistics were used to analyze post-treatment data. Mann-Whitney U test was performed to analyze the trends of questions answered between men and women within each treatment group. Within both IOD and STI groups, the mean age was determined, and groups older and younger than the mean were compared as well. Statistical software (SPSS v. 20.0; IBM Corp., Armonk, NY) was used for descriptive and statistical analyses. For all analyses, alpha was equal to 0.05.
Results Patient demographics
Fifty-one patients were in the IOD group (60.7% men [n = 31], 39.2% women [n = 20]). The mean age for the IOD group was 63.7 years with an age range from 43 to 84 years. Each patient received two implants, for a total of 102 implants. Fifty patients were in the STI group with 58.0% women (n = 29) and 42.0% men (n = 21). The mean age for the STI group was 50.8 with an age range from 24 to 76 years. Sixty-nine implants were placed for the 50 STI patients. The most common region was the maxillary posterior region (49.3%, n = 34; Table 2). OHIP
Table 1 represents the post-treatment modified OHIP-14 questionnaire results for mandibular IOD and STI; lower scores indicated higher patient satisfaction. The mean scores from modified OHIP-14 ranged from 0.14 to 0.78 for the IOD group. The highest mean score of 0.78 summarized responses to the
IOD (N = 51)
STI (N = 50)
Mean (SD)
Mean (SD)
0.63 (0.84) 0.53 (0.87) 0.57 (0.83) 0.78 (0.98) 0.25 (0.62) 0.35 (0.81) 0.31 (0.81) 0.55 (0.90) 0.16 (0.50) 0.24 (0.73) 0.14 (0.49) 0.21 (0.60) 0.17 (0.70) 0.18 (0.73)
0.02 (0.14) 0.02 (0.14) 0.18 (0.48) 0.16 (0.51) 0.12 (0.63) 0.02 (0.14) 0.04 (0.28) 0.08 (0.57) 0.04 (0.20) 0.12 (0.52) 0.14 (0.53) 0.04 (0.20) 0.12 (0.44) 0.06 (0.31)
Table 2 Distribution of STI placed by region of the mouth 69 implants in 50 patients Total STI placed Posterior maxilla Premolar maxilla Molar maxilla Posterior mandible Premolar mandible Molar mandible Anterior maxilla
N (%) 34 (49.3) 27 (39.1) 7 (10.1) 30 (43.5) 5 (7.2) 25 (36.2) 5 (7.2)
question “Have you found it uncomfortable to eat any foods because of your implant-supported overdenture?” The lowest mean score of 0.14 summarized responses to the question, “Have you been a bit irritable with other people because of your implant restoration(s)?” The mean scores for the STI group ranged from 0.02 to 0.18. The highest score of 0.18 summarized responses to the question “Have you had painful aching in your mouth?” The lowest mean score of 0.02 summarized responses to the questions “Have you had trouble pronouncing any words because of your implant restoration(s)?” “Have you felt that your sense of taste has worsened because of your implant restoration(s)?” and “Have you felt tense because of problems with your implant restoration(s)?” Effects of gender and age
Mann-Whitney U test revealed a significant difference among the IOD patients on the trends of questions answered by gender, specifically questions 1, 2, 4, 8, and 10, which were related to pronunciation, taste, feeling uncomfortable eating, interruptions in meals, and feeling embarrassed. No significant difference was observed between groups older and younger than mean age (Table 3). The STI group showed no significant difference on how the questions were answered by both age and gender (Table 4).
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Table 3 Mann-Whitney U test for IOD patients
Questions Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
p-value for comparison between gender
Comparison by gender (male female)
p-value for comparison by age (younger vs. older than mean age: 57 years old)
F M>F
0.910 0.108 0.119 0.554 0.391 0.522 0.111 0.409 0.352 0.242 0.208 0.401 0.961 0.212
M>F
M>F M>F
*Denotes statistical significance (α = 0.05). Table 4 Mann-Whitney U test for STI patients
Questions
p-value for comparison between gender
p-value for comparison by age (younger vs. older than mean age: 57 years)
0.240 0.395 0.948 0.714 0.224 0.395 0.395 0.395 0.224 0.720 0.491 0.224 0.504 0.794
0.182 0.182 0.591 0.858 0.284 0.453 0.453 0.453 0.057 0.185 0.606 0.057 0.103 0.057
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14
Discussion Both IOD and STI results suggested that patients were satisfied with treatment. All mean scores for the OHIP-14 were below 1.0, suggesting that implant treatment in both groups had a positive impact on the patients’ OHRQoL. The results from this study examined the level of satisfaction and impact on QoL of dental implant therapy and are comparable to other studies from dental institutional settings. Moghadam et al reported a range of 85% to 96% of patient satisfaction in esthetics, comfort, and function for patients treated in a predoctoral implant program and questioned via telephone interview.48 Improvements in chewing, appearance, and enhanced QoL were also related to emotional and social improvements from treatments provided in teaching environments.43,46 Therefore, the null hypothesis of 528
having no differences in the level of patient satisfaction with implant therapy at the predoctoral level compared to previously published results was accepted. Patients have differing expectations and abilities to accommodate to the provided therapies. In general, reported outcomes of patients who received mandibular IOD led to larger OHIP means and standard deviations than those reported by patients who received STI prostheses. Although direct comparisons cannot be made between therapy groups, the lower values for STI patients possibly suggested a more favorable and consistent meeting of patient expectations compared to those who received mandibular overdentures. For patients who received IODs, mean OHIP values and their standard deviations were greatest with regard to pronunciation, selection of foods, and disruption of meals during use of the IOD prosthesis. Results suggested some patients had extremely positive results or difficulties based upon categories defined by OHIP-14. This study did not correlate the reported patient outcomes to specific clinical presentation or situations; future studies are indicated to relate patient reports to clinical presentation. Nevertheless, results of this study indicated positive patient-centered outcomes that favored dental implant over denture therapy as a part of the predoctoral dental curriculum. For patients who received STIs, mean OHIP values and their standard deviations were greatest with discomfort. Whether this discomfort was related to current status of the implant prostheses or previous experiences leading up to completion of the prosthesis was not clearly indicated during the survey. The authors were unable to correlate the results to a patient’s clinical situation. Like the IOD group, a similar and more robust study in the future could correlate the patient-centered outcomes to each patient’s clinical presentation. Nevertheless, also like the IOD group, this study further indicated positive patient-centered outcomes that favor patient therapy with STI as a part of the predoctoral dental curriculum. Patient satisfaction based on gender was significantly different in the IOD group for certain questions but not in the STI group. Differences in factors related to function, such as pronunciation, taste, and interruption in meals, were mainly reported by men in the IOD group. As for influence of gender on patient satisfaction and OHRQoL, reports have shown that men value eating as an important part of OHRQoL, while women emphasize confidence as having more impact on oral health.14 In contrast to the findings from this study, women have previously reported oral health having a more significant impact in their lives, both positive and negative.11 Interestingly, age did not have any influence on the level of patient satisfaction and OHRQoL. Previous studies have reported age having a profound and significant impact on perceived oral health due to the deterioration of oral health status for the elderly population and the prolonged influence on psychosocial and physiological function domain.11,15 Other important factors that influence OHRQoL, such as socioeconomic status or number of remaining teeth, are also interesting topics in the clinical outcomes of dental institutions. Results from this study indicate that dental students can provide good results with meaningful impact on patients’ lives. Patients have sought care at dental institutions for implant
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treatment because they typically offer low-cost programs for surrounding communities and underserved populations.37,42,44,48 This study also indicated that predoctoral students provided STI therapy that met the patient satisfaction. Many studies have also examined the success and survival of STI therapy and OHRQoL.16,26,29,31 However, no study has been performed in the predoctoral educational setting using OHIP-14. Improvement in comfort with eating, esthetics, phonetics, and overall satisfaction is well-documented with STI therapy.26,29 By having well-defined and stringent patient selection criteria,37,42 implant educational programs can select the patients most suitable for predoctoral treatment and can provide successful comprehensive therapy. With increasing financial burdens in society, patients seeking implant care at dental institutions as an alternative to private practice can be anticipated. While studies have addressed patient treatment in the predoctoral dental setting,43,44,46,48 more studies on clinical outcomes, especially long-term and qualitative analyses are needed. Merit exists in using a previously standardized instrument for reliable data collection and analysis, as health status questionnaires should have good psychometric properties such as reliability, validity, and precision.22 While other qualitative studies in the predoctoral implant programs used their own questionnaires,43,46,48 this study used OHIP-14 modified to address both IOD and STI patients during recall examinations. Using a validated and objective measuring instrument can enhance the evaluation of the treatment outcomes and confirm improvements in QoL in a systematic and scientific manner. This study reported only post-therapy data collected at the designated 6-month recall, and was therefore unable to compare pre- and post-therapy outcomes. Other studies have recorded pre- and post-treatment data and reported significant improvements for mandibular IOD and for STI. Mandibular IOD do make significant differences in patient OHRQoL, which has led to the recognition of this therapy approach as the first choice option for the edentulous patient.23 For partially edentulous patients, pre- and post-therapy data using OHIP-G 21 have indicated significantly less psychological dissatisfaction.31 Specifically, patients were less worried about dental problems and had less dissatisfaction with appearance due to problems with their teeth, mouth, and dentures.31 In the future, studies that evaluate pre- and post-therapy patient-centered outcomes from those who received therapy in a predoctoral dental implant program are indicated. Assessing patient satisfaction and OHRQoL is an integral part of incorporating behavioral science into clinical practice in predoctoral education. CODA standards indicate that all dental graduates must be competent in the application of behavioral science principles and patient-centered approaches to promote, improve, and maintain oral health.34 Graduates must also be competent in evaluating treatment outcome. Emphasis must be placed on patient satisfaction as a vital part of assessing treatment outcome and the long-term benefits on QoL.34 Using modified OHIP-14 during dental implant patient recall examinations is an innovative way for predoctoral students to learn about the psychosocial benefits of implant therapy. While the predoctoral curriculum may include other psychosocial education in patient management, using a reliable, easy-to-use,
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object instrument to assess patient satisfaction in dental treatment during a recall examination can be valuable. By establishing a standardized and structured approach to the routine recall examination, an opportunity for predoctoral students to evaluate dental implant patients in a comprehensive and structured manner is available. A consistent method of evaluating patient outcomes can also be used for other treatment modalities. Predoctoral students and practitioners would benefit from thoroughly examining the patient and treatment outcomes in all phases of dentistry using the OHIP approach. The following limitations were noted for this study, where pretreatment data were not obtained. Therefore, any comparison or analysis of the impact of treatment could not be analyzed. Because of the short duration, this preliminary data could have influenced patient satisfaction to be more positive. Also, the type of data and timing may have influenced the outcome of this study. Due to the large standard deviation in the data, there may be statistical unpredictability. The surveys were given to patients 6 months after the completion of implant care, rather than after long-term observation. Therefore, well-controlled populations with longer observation periods may yield different results. For STI patients, because the vast majority of patients used cement-retained restorations, the effects of screw-retained restorations on patient satisfaction were not considered in the investigation. This area could be further explored in future studies. Last, a modified version of OHIP-14 was used, and some researchers have expressed limitations in the range of its application, especially in assessing esthetics.27,28 Others have used OHIP-esthetic for discriminating and evaluating problems with dental esthetic outcomes as a singular domain of OHRQoL.27,28 Therefore, future studies using other forms of OHIP to enhance the assessment of OHRQoL, perhaps especially in the area of esthetics, would be of benefit to a predoctoral dental curriculum in the assessment of the program’s ability to meet patient expectations, the ultimate goal of comprehensive patient therapy.
Conclusions This study used a modified OHIP-14 to assess the level of patient satisfaction and OHRQoL for patients who received IOD and STI prostheses. Under the conditions of this preliminary study, the following conclusions were drawn about dental implant therapy completed in a predoctoral dental clinical setting: 1. Mandibular IOD and STI prostheses led to overwhelmingly favorable questionnaire results regarding all aspects of modified OHIP-14-assessed patient QoL and satisfaction with treatment with implants in a predoctoral clinical setting. 2. There was a significant difference between men and women among IOD patients on how they answered questions related to pronunciation, taste, feeling uncomfortable eating, interruptions in meals, and feeling embarrassed. STI patients did not show any significant differences based on gender. 3. No significant differences were noted regarding all aspects of modified OHIP-14 between different age groups for both IOD and STI patients.
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