Clinical and subjective evaluation of implants in patients with hypodontia: a two-year observation study.

BACKGROUND: Hypodontia compromises appearance and function and is challenging to manage clinically. OBJECTIVES: To assess the impact of implant retained crowns on quality of life of patients and to determine clinical performance of implant retained crowns in these patients. METHODS: In a 24-month prospective observation study, patients with non-syndromic mild hypodontia manifested with missing teeth in the anterior maxilla were included. Pre-treatment screening included a clinical and radiographic examination and completion of an OHIP-20. Narrow neck SLActive TiZr implants (Roxolid® , Straumann AG, Switzerland) were provided and restored with single unit crowns. Implant stability was recorded at time of placement and abutment connection. Standardized radiographs were recorded at time of surgery, abutment connection and 12- and 24-month follow-up visits, and distance between implant shoulder and first bone contact was measured. Oral health-related quality of life was calculated using OHIP-20 scores at 12- and 24-month visits compared with pre-treatment scores. Pink (PES) and white (WES) aesthetic scores were used to objectively assess aesthetic outcome of treatment. RESULTS: Twenty implants were placed in 12 patients (seven females, five males; mean [SD] age 19.33 [2.37] years). There was a significant improvement in oral health-related quality of life following treatment (P = 0.026), and the effect size of this change was 1.17 indicating a large clinically meaningful change. Mean PES and WES scores were high, indicated a satisfactory aesthetic outcome at 24 months. Crestal bone-level changes were considered small. CONCLUSION: Favourable clinical outcomes were observed. Implant retained crowns had a large and clinically meaningful impact on quality of life of patients with hypodontia.

Failure rates of class V restorations in the management of root caries in adults - a systematic review.

OBJECTIVE: The aim of this systematic review was to compare cumulative failure rates of different restorative materials in carious class V lesions on the root surfaces of adult patients. BACKGROUND: The prevalence of root caries is set to increase in the coming years as a result of ageing of the population and a concomitant reduction in levels of edentulousness. Evidence is needed to assist practitioners to select the most appropriate restorative material for use in these lesions. METHODS: A search of the literature was undertaken using the electronic databases of PubMed, Embase, CENTRAL and OpenSIGLE using keywords relevant to the search question. Two review authors conducted the electronic search independently, and any conflict was resolved by discussion. The references quoted in the full text articles extracted were hand searched for any further eligible studies. RESULTS: Sixty non-duplicate citations were screened. Following review of the titles, abstracts, texts and application of the pre-determined inclusion/exclusion criteria, five studies remained. CONCLUSION: There is a need for more research in this area as many of the studies identified in this systematic review treated post-radiation, xerostomic patients which are not typical of the general population. Increased adherence to CONSORT guidelines for reporting is also advised to facilitate future systematic review and meta-analysis in this area.

Impact of tooth replacement on the nutritional status of partially dentate elders.

OBJECTIVES: The aim of this study was to compare the impact of two different tooth replacement strategies on the nutritional status of partially dentate older patients. Nutritional status was measured using the full version of the Mini Nutritional Assessment (MNA) and the short form of the Mini Nutritional Assessment (MNA-SF). MATERIALS AND METHODS: A randomised controlled clinical trial was conducted (Trial Registration no. ISRCTN26302774). Partially dentate patients aged 65 years and older were recruited and randomly allocated to the two different treatment groups: the removable partial dentures (RPD) group and the shortened dental arch (SDA) group. Nutritional status was measured using the MNA and MNA-SF administered at baseline and 1, 6 and 12 months after treatment intervention by a research nurse blinded to the treatment group allocation of all participants. RESULTS: Data collected using the full version of the MNA showed significant improvements in mean MNA scores over the length of the study (p < 0.05). For the entire patient group, there was a mean increase of 0.15 points at 6 months and a further increase of 0.19 points at 12 months. These increases were similar within the treatment groups (p > 0.05). For MNA-SF, the analysis showed that there were no significant differences recorded over the data collection points after treatment intervention (p < 0.05). CONCLUSION: Tooth replacement using conventional and functionally orientated treatment for the partially dentate elderly showed significant improvements in MNA score 12 months after intervention. CLINICAL RELEVANCE: Prosthodontic rehabilitation may play an important role in the nutritional status of partially dentate elders.

A preliminary report of the cost-effectiveness of tooth replacement strategies for partially dentate elders.

OBJECTIVE: To compare the cost-effectiveness of conventional treatment using partial dentures with functionally orientated treatment to replace missing teeth for partially dentate elders using a randomised controlled clinical trial. BACKGROUND: In many countries, including the Republic of Ireland, the only publically funded treatment option offered to partially dentate older patients is a removable partial denture. However, evidence suggests that these removable prostheses are unpopular with patients and can potentially increase the risk of further dental disease and subsequent tooth loss. MATERIALS AND METHODS: Fourty-four partially dentate patients aged 65 years and older were recruited. Patients were randomly assigned to the two treatment arms of the study. The conventional treatment group received removable partial dentures to replace all missing natural teeth. The functionally orientated group was restored to a Shortened Dental Arch (SDA) of 10 occluding contacts using resin-bonded bridgework (RBB). The costs associated with each treatment were recorded. Effectiveness was measured in terms of the impact on oral health-related quality of life (OHRQoL) using OHIP-14. RESULTS: Both groups reported improvements in OHRQoL 1 month after completion of treatment. The conventional treatment group required 8.3 clinic visits as compared to 4.4 visits for the functionally orientated group. The mean total treatment time was 183 min 19 s for the conventional group vs. 124 min 8 s for the functionally orientated group. The average cost of treatment for the conventional group was 487.74 Euros compared to 356.20 Euros for the functional group. CONCLUSIONS: Functionally orientated treatment was more cost-effective than conventional treatment in terms of treatment effect and opportunity costs to the patients' time.

Prosthodontic care for elderly patients.

UNLABELLED: For older patients, clinicians should consider maintaining teeth and using functionally-orientated treatment strategies as an alternative to removable prostheses. When the remaining dentition has a poor prognosis, key teeth should be preserved as overdenture abutments and a gradual transition to edentulousness planned. Where complete dentures are provided, these can be retained using dental implants to overcome many of the problems associated with conventional replacement dentures. CLINICAL RELEVANCE: The elderly population of today is better informed and more demanding of oral healthcare providers than previous generations. Clinicians should be aware of all the prosthodontic treatment options available for older patients.

Tooth loss and oral health-related quality of life: a systematic review and meta-analysis.

BACKGROUND: It is increasingly recognized that the impact of disease on quality of life should be taken into account when assessing health status. It is likely that tooth loss, in most cases being a consequence of oral diseases, affects Oral Health-Related Quality of Life (OHRQoL). The aim of the present study is to systematically review the literature and to analyse the relationship between the number and location of missing teeth and oral health-related quality of life (OHRQoL). It was hypothesized that tooth loss is associated with an impairment of OHRQoL. Secondly, it was hypothesized that location and distribution of remaining teeth play an important role in this. METHODS: Relevant databases were searched for papers in English, published from 1990 to July 2009 following a broad search strategy. Relevant papers were selected by two independent readers using predefined exclusion criteria, firstly on the basis of abstracts, secondly by assessing full-text papers. Selected studies were grouped on the basis of OHRQoL instruments used and assessed for feasibility for quantitative synthesis. Comparable outcomes were subjected to meta-analysis; remaining outcomes were subjected to a qualitative synthesis only. RESULTS: From a total of 924 references, 35 were eligible for synthesis (inter-reader agreement abstracts κ = 0.84 ± 0.03; full-texts: κ = 0.68 ± 0.06). Meta-analysis was feasible for 10 studies reporting on 13 different samples, resulting in 6 separate analyses. All studies showed that tooth loss is associated with unfavourable OHRQoL scores, independent of study location and OHRQoL instrument used. Qualitative synthesis showed that all 9 studies investigating a possible relationship between number of occluding pairs of teeth present and OHRQoL reported significant positive correlations. Five studies presented separate data regarding OHRQoL and location of tooth loss (anterior tooth loss vs. posterior tooth loss). Four of these reported highest impact for anterior tooth loss; one study indicated a similar impact for both locations of tooth loss. CONCLUSIONS: This study provides fairly strong evidence that tooth loss is associated with impairment of OHRQoL and location and distribution of tooth loss affect the severity of the impairment. This association seems to be independent from the OHRQoL instrument used and context of the included samples.

Determining the minimally important difference for the Oral Health Impact Profile-20.

In the context of clinical trials, measurement of change is critical. The aim of this study was to determine the minimally important difference (MID) for the Oral Health Impact Profile-20 (OHIP-20) when used with partially dentate patients undergoing treatment that included the provision of removable partial dentures. In a prospective clinical trial, 51 consecutive patients were provided with removable partial dentures. In addition to demographic and dental status data, patients completed an OHIP-20 prior to treatment. One month postoperatively, patients completed a post-treatment OHIP-20 and a global transition scale. Domains assessed in the global transition scale were appearance, ability to chew food, oral comfort, and speech. The MID for the OHIP-20 was calculated using the anchor-based approach. From the initial sample of 51 patients, 44 completed post-treatment questionnaires and were included in the analysis. Change scores in the four transition domains indicated that new dentures had a positive impact in the majority of subjects, especially in perceived impact on chewing and appearance. The study provided a guideline as to what constitutes the MID for the OHIP-20. This benchmark can be used when interpreting the impact of clinical intervention for replacing missing teeth and for power calculation in statistical analyses.

A qualitative study of trends in patient preferences for the management of the partially dentate state.

OBJECTIVE: To identify factors influencing attitudes of partially dentate adults towards dental treatment in Ireland. BACKGROUND: People are retaining more teeth later in life than ever before. Management of partially dentate older adults will be a major requirement for the future and it is important to determine factors which may influence patients' attitudes to care. SUBJECTS: A purposive sample of 22 partially dentate patients was recruited; 12 women and 12 men, ranging in age from 45 to 75 years. DATA COLLECTION: Semi-structured individual interviews. RESULTS: Dental patients have increasing expectations in relation to (i) a more sophisticated approach to the management of missing teeth and (ii) their right to actively participate in decision making regarding the management of their tooth loss. There is some evidence of a cohort effect with younger patients (45-64 years) having higher expectations. CONCLUSIONS: The evidence of a cohort effect within this study in relation to higher patient expectations indicates that both contemporary and future patients are likely to seek a service based on conservation and restoration of missing teeth by fixed prostheses.

Leadership of a Clinical Academic Health Centre.

The Clinical Academic Health Centre concept involves one or more health service centres forming a partnership with an academic centre, with a primary objective of leveraging of the strengths of both organisations and to hasten the process of knowledge discovery, with accelerated translation of innovations and research outcomes into clinical practice. The underpinning leadership challenge is the creation of a unified vision and mission, ensuring that strategic direction is aligned to the strategy of the major stakeholders.

How long should a shortened dental arch be?

UNLABELLED: Increasing numbers of older adults are retaining teeth into old age. Many of these patients refuse to wear removable partial dentures, and have a high prevalence of dental disease and heavily restored teeth. The shortened dental arch (SDA) concept is a potentially cost-effective way of managing older, partially dentate adults. However, case selection is critical and long term preservation of a functional dentition may not be possible in certain patients. This paper highlights the critical treatment planning issues and outlines treatment strategies aimed at avoiding occlusal instability in patients with shortened dental arches. CLINICAL RELEVANCE: Appropriate application of the shortened dental arch concept will provide satisfactory oral function in the long term for partially dentate adults.

Overcoming the unstable mandibular complete denture: the neutral zone impression technique.

UNLABELLED: This article describes a technique for improving the stability of mandibular complete dentures for patients who have a diminished mandibular neutral zone. The technique involves making an impression which is shaped by the patient's oral musculature, and which defines the shape and contour of the patient's neutral zone. A case report is presented in which the use of this technique is described. It is hoped that this article will increase the awareness of dental practitioners to the use of this technique. CLINICAL RELEVANCE: The neutral zone impression technique is a useful technique when providing mandibular complete dentures. Its use can overcome some of the denture stability difficulties caused in some patients by a more powerful oral musculature, or in patients who have poor or altered neuromuscular control.

Trends in indirect dentistry: 7. Communicating design features for fixed and removable prostheses.

UNLABELLED: Clear and effective communication of design features between dental practitioners and dental technicians has long been recognized as central to the production of high quality fixed and removable prostheses. In this respect, there is extensive evidence to demonstrate that the quality of communication achieved from general dental practice is not always adequate. Failure to communicate design features effectively can lead to errors in the fabrication of prostheses, or in the production of prostheses with a potential to cause damage to oral structures. CLINICAL RELEVANCE: The aim of this paper is to describe why it is important to communicate adequate design features clearly to dental laboratories.The paper also describes how this may be achieved for a variety of fixed and removable prostheses.

Two-year survival of ART restorations placed in elderly patients: A randomised controlled clinical trial.

OBJECTIVES: Older dentate adults are a high caries risk group who could potentially benefit from the use of the atraumatic restorative treatment (ART). This study aimed to compare the survival of ART and a conventional restorative technique (CT) using rotary instruments and a resin-modified glass-ionomer for restoring carious lesions as part of a preventive and restorative programme for older adults after 2 years. METHODS: In this randomised controlled clinical trial, 99 independently living adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations. The survival of restorations was assessed by an independent and blinded examiner 6 months, 1 year and 2 years after restoration placement. RESULTS: Ninety-six (67.6%) and 121 (76.6%) restorations were assessed in the ART and CT groups, respectively, after 2 years. The cumulative restoration survival percentages after 2 years were 85.4% in the ART and 90.9% in the CT group. No statistically significant between group differences were detected (p=0.2050, logistic regression analysis). CONCLUSIONS: In terms of restoration survival, ART was as effective as a conventional restorative approach to treat older adults after 2 years. This technique could be a useful tool to provide dental care for older adults particularly in the non-clinical setting. ( TRIAL REGISTRATION NUMBER: ISRCTN 76299321). CLINICAL SIGNIFICANCE: The results of this study show that ART presented survival rates similar to conventional restorations in older adults. ART appears to be a cost-effective way to provide dental care to elderly patients, particularly in out of surgery facilities, such as nursing homes.

The impact of rehabilitation using removable partial dentures and functionally orientated treatment on oral health-related quality of life: a randomised controlled clinical trial.

OBJECTIVES: This study aimed to compare two different tooth replacement strategies for partially dentate older patients; namely functionally orientated treatment according to the principles of the shortened dental arch (SDA) and conventional treatment using removable partial dentures (RPDs) using a randomised controlled clinical trial. The primary outcome measure for this study was impact on oral health-related quality of life (OHRQoL) measured using the short form of the oral health impact profile (OHIP-14). METHODS: Patients aged 65 years and older were randomly allocated to two different treatment groups: the RPD group and the SDA group. For the RPD group each patient was restored to complete arches with cobalt-chromium RPDs used to replace missing teeth. For the SDA group, patients were restored to a premolar occlusion of 10 occluding pairs of natural and replacement teeth using resin bonded bridgework (RBB). OHRQoL was measured using the OHIP-14 questionnaire administered at baseline, 1 month, 6 months and 12 months after treatment intervention. RESULTS: In total, 89 patients completed the RCT: 44 from the RPD group and 45 from the SDA group. Analysis using a mixed model of covariance (ANCOVA) illustrated that treatment according to the SDA concept resulted in significantly better mean OHIP-14 scores compared with RPD treatment (p<0.05). This result was replicated in both treatment centres used in the study. CONCLUSIONS: In terms of impact on OHRQoL, treatment based on the SDA concept achieved significantly better results than that based on RPDs 12 months after treatment intervention (trial registration no. ISRCTN26302774). CLINICAL SIGNIFICANCE: Functionally orientated treatment delivery resulted in significantly better outcomes compared to removable dentures in terms of impact on OHRQoL.

Assessment of oral health related quality of life.

In Dentistry, as in other branches of Medicine, it has been recognised that objective measures of disease provide little insight into the impact of oral disorders on daily living and quality of life. A significant body of development work has been undertaken to provide health status measures for use as outcome measures in dentistry. In descriptive population studies, poor oral health related quality of life is associated with tooth loss. There is a less extensive literature of longitudinal clinical trials, and measurement of change and interpretation of change scores continues to pose a challenge. This paper reviews the literature regarding the development and use of these oral health related QoL measures and includes an appraisal of future research needs in this area.

Developing short-form measures of oral health-related quality of life.

OBJECTIVES: Using the item-impact method, we developed an alternative short-form Oral Health Impact Profile (OHIP) that has good psychometric properties and minimal floor effects. METHODS: OHIP data were collected from a sample of older Canadians at two points in time. Data from the first administration were used to develop a 14-item short-form measure; data from the second compare the latter's psychometric properties with those of the original short form developed by Slade (1997), who used a controlled regression procedure. RESULTS: The short form based on the item-impact method had only two items in common with the short form derived from the regression approach and contained more high-prevalence items. The regression short form was subject to marked floor effects, while the impact short form had floor effects comparable to those of the full 49-item OHIP. The former discriminated between dentate and edentulous subjects, while the latter did not. Both discriminated between dentate subjects who did and did not wear dentures, those with and without dry mouth, and those with and without chewing problems. Both were also significantly associated with self-ratings of oral health, satisfaction with oral health, and self-perceived need for dental treatment. The strength of the associations was somewhat stronger with the regression short form, indicating that it performed better as a discriminatory instrument. However, because of its floor effects, it was markedly less sensitive to change than the impact short form. There was an indication that item-impact methods of shortening oral health-related quality of life measures produced more stable results across samples than the statistical approach. CONCLUSIONS: Because the content validity of short-form measures is always compromised, different short forms are required for different purposes and different patient populations. The regression short form developed by Slade (1997) is likely to be better when the aim is to discriminate, while the impact short form developed here may be preferable when the aim is to describe the oral health-related quality of life of populations or to detect change.

Case report: management of the flabby ridge: re-visiting the principles of complete denture construction.

Displaceable tissue on edentulous ridges may present a considerable clinical challenge to dental practitioners when providing complete dentures. Surgical excision techniques or use of dental implants has provided clinicians with methods of addressing this particular difficulty. However careful consideration and application of the principles of complete denture construction can provide a less invasive and less complex form of treatment. This article describes one such clinical scenario, and demonstrates the use of a suitable impression technique that is based on successful manipulation of the thermoplastic nature of the impression material.

Quality of materials supplied to dental laboratories for the fabrication of cobalt chromium removable partial dentures in Ireland.

The adequacy of prescription for fabrication of cobalt chromium removable partial dentures is often regarded as being less than ideal. This study examines the nature and quality of written instructions and master impression sent to dental laboratories in Ireland for fabrication of cobalt chromium removable partial denture frameworks. Questionnaires were issued to dental laboratories seeking specific information relating to the materials (impression materials and trays) and written instructions supplied, as well as the technicians' opinion regarding the suitability of these materials. One hundred completed questionnaires were returned. One-third of master impressions were made using a plastic stock tray and alginate; technicians felt that one-fifth of master impressions were unsuitable; almost three-fifths of written instructions were inadequate. The quality of clinical information examined was found to be less than adequate.

A modified copy technique for obturator prostheses.

Prosthodontic rehabilitation of patients following intra-oral surgical resection is often challenging for both the clinician and patient. With a general increase in life expectancy, it is reasonable that a definitive obturator prosthesis will need to be replaced at least once in the lifetime of a patient. The ability of a patient to become accustomed to such a new prosthesis is often limited by their increased age, and diminished neuromuscular skills and limited tissue support following surgical resection. The purpose of this paper is to describe a duplicating technique for obturator prostheses that has been adapted from conventional complete denture prosthodontics.

The 'combination syndrome' revisited.

The 'combination syndrome' may present a considerable clinical and technical challenge to the dental practitioner. This clinical scenario classically relates to changes found in the mouth following use of a maxillary complete denture that has opposed natural mandibular anterior teeth. While this condition was first recognized over 30 years ago, the associated difficulties still pervade the practice of prosthetic dentistry today. The purpose of this article is to describe treatment of two patients who exhibited clinical features of this condition, and review some of the relevant literature on this condition.