Changes in attitudes toward desire for implant treatment: a longitudinal study of a middle-aged and older Swedish population.

PURPOSE: To assess, at a 10-year interval, changes in attitudes toward desire for implant treatment among middle-aged and older Swedish subjects with respect to dental status. MATERIALS AND METHODS: Three thousand subjects, residents of Orebro County, Sweden, were surveyed via the same questionnaire in 1989 and again in 1999 regarding their possible need for and interest in implant-based prosthodontic treatment. RESULTS: One thousand six hundred sixty-five subjects responded to both surveys. In 1989 few respondents indicated an interest in implant treatment, whereas in 1999, 92% of those who had not indicated an interest in the earlier survey now indicated that they desired implant treatment. The cohort reporting having no teeth had a considerable lower increase in desire. Among those who reported a possible treatment need (ie, missing 1 or more teeth and had not had them replaced or those who wore complete dentures), cost was the most commonly cited reason for declining implant treatment. CONCLUSIONS: There was a dramatic increase in the interest for implant treatment over the period from 1989 to 1999. Changes in awareness of implant treatment, along with an expansion in the number of qualified providers, may have contributed to this increase.

Oral prostheses and oral health-related quality of life: a survey study of an adult Swedish population.

PURPOSE: The purpose of the study was to investigate whether oral health-related quality of life (OHRQOL) in an adult Swedish population could be explained by social attributes; individual attributes; dental status, with a special focus on the role of prosthodontics; and dental care attitudes. MATERIALS AND METHODS: The study was based on responses to a questionnaire sent in 1998 to a random sample of 1,974 persons aged 50 to 75 years (66% response rate). Three factors representing various aspects of OHRQOL were set as dependent variables in multiple-regression models: oral health impact on everyday activities, oral health impact on the psychologic dimension, and oral health impact on oral function. Independent variables in the models were social attributes, individual attributes, number of teeth, denture (ie, type of denture, if present), and dental care attitudes. RESULTS: General health in relation to age peers had the strongest association with all 3 dependent variables, followed by number of teeth and need care--cost barrier. When number of teeth was excluded, removable denture was found to covary with the dependent variables in each of the 3 regression models. CONCLUSION: The number of remaining teeth is more important than the type of denture in explaining OHRQOL. It is less important that a denture is fixed for those with few remaining teeth, in contrast to all others. Explanations are also found in general health and various aspects of dental care costs.

Prosthodontics and the patient. Part 2: Need becoming demand, demand becoming utilization.

PURPOSE: Patients' oral health needs are estimated through dialogue and professional assessment. The concepts of need and demand are vital to studies of dental care and oral health. Need does not always lead to demand for treatment or to utilization, depending on the gatekeeping processes between need and demand and between demand and utilization. Demand must be accepted with the understanding that there is no objective need and that demand depends on the patient's opinion. In accordance with this, the need for prosthodontic treatment is highly individual and is not automatically related to oral health status, making need and demand difficult to measure in that respect. Therefore, sociodental factors should be included and evaluated in studies of need and demand for utilization of prosthodontic care. MATERIALS AND METHODS: This theoretical and analytic paper focuses on the gatekeeping processes between need and demand and between demand and utilization of prosthodontic care. RESULTS: The concept of gatekeeping refers to the social and psychologic processes that transform need into demand and demand into utilization. It implies that they are complex processes that can render great differences between demand and actual utilization. CONCLUSION: It is not possible to estimate a patient's needs for prosthodontic care, since there is no objective need. Demand and utilization are factors that play an important role in the gatekeeping process. These factors are dependent on the patient's opinion, which is influenced by numerous factors.

20-year follow-up of patients receiving high-cost dental care within the Swedish Dental Insurance System: 1977-1978 to 1998-2000.

The objective was to perform a long-term follow-up study of patients that had received high cost dental care within the Swedish National Dental Insurance System in 1977-1978 with special focus on remaining teeth, periodontal disease progression, change in the prevalence of root-filled teeth and teeth with apical periodontitis as well as the survival of fixed prosthetic reconstructions. All 262 patients who had had their treatment plans sent for approval for high-cost dental care in 4 local health insurance districts and who were sampled for base-line studies in 1977-1978, were offered a free clinical examination including radiographs in 1998. 177 patients (68 % of the original sample) could be reached for telephone interview and 104 of them (40 % of the original sample) were examined clinically and radiographically. Comparisons were made with records and radiographs from 1977-1978. The analyses were performed with the individual patient as the studied unit. The low progression of severe periodontal disease during the 20-23 year follow-up period and the decrease in number of teeth with apical periodontitis among a majority of the patients examined, indicated that the dental care received resulted in a limitation of dental disease on the individual level. Furthermore 63 % of the patients had the fixed prosthetic reconstructions, received after approval 1977-1978, in full extention after 20-23 years. However, more tooth losses were observed among the patients in this study than in similar studies in Swedish general populations over the same decades. Furthermore multiple tooth extractions were significantly more frequent in patients with severe periodontitis at baseline and in patients with less apical periodontitis at follow-up in this study. Thus it seems that tooth extraction not seldom was a treatment choice for teeth with severe periodontitis and apical periodontitis among the patients examined clinically in this study.

Indications for removable partial dentures: a literature review.

PURPOSE: The purpose of this report was to evaluate indications for the use of removable partial dentures based on a comprehensive literature review. MATERIALS AND METHODS: Using a model similar to a Delphi process, the literature relating to the indications and contraindications for the prescription of removable partial dentures was discussed by seven experienced educators in a 2.5-day workshop. RESULTS: Evidence for indications and contraindications for the prescription of removable partial dentures is not clearly stated in the literature; however, some basic principles are defined. There appears to be a trend in favor of the use of the shortened dental arch concept or implant-supported restorations instead of conventional removable partial dentures, given the evidence that the long-term use of removable dentures is associated with increased risks of caries and periodontitis and low patient acceptance. The presence of sound abutment teeth appears to encourage the use of removable partial dentures, as the fixed partial denture alternative requires sacrifice of healthy hard tissues. When economic factors influence the decision-making process, removable partial dentures are often chosen. CONCLUSION: While evidence-based indications and contraindications for prescribing removable partial dentures are still lacking, major underlying principles for clinical decision making are identified.

Prosthodontics and the patient: what is oral rehabilitation need? Conceptual analysis of need and demand for prosthodontic treatment. Part 1: a conceptual analysis.

PURPOSE: The concepts of need and demand are central in studies on dental care. In the literature, a normative definition is often used, but it pays little attention to the individual's personal comfort and quality of life. Need and demand for prosthodontic services are difficult to measure, as prosthodontic treatment is highly individual and not closely related to edentulousness. Need, however defined, does not always lead to demand for treatment, depending on a variety of factors. MATERIALS AND METHODS: The present article is part of a larger study in which the intention is to evaluate need and demand for prosthodontic treatment among the participants in a 1989 and 1999 longitudinal study of a population sample. As the first step, this article reports a conceptual analysis of the need concept from the literature. RESULTS: Need is stated as socially established in the interaction between patient and clinician. It makes demand dependent on available treatment options from the care provider and society. In the prosthetic treatment decision-making process, the emancipatory perspective with the patient-clinician dialogue is of utmost importance to achieve an optimal treatment result. CONCLUSION: The professional attitude toward need must be that there is no true objective or subjective need. Need is established only in a communicative dialogue with mutual respect between the professional and the patient.

Dimensions of oral health-related quality of life in an adult Swedish population.

The concept of oral health-related quality of life (OHRQOL) is investigated in this study. The aim was to explore the dimensionality of variables measuring OHRQOL in an adult Swedish population and to discuss the findings in relation to existing indices. The study was based on responses to a 1998 questionnaire sent to a random sample of 1974 persons aged between 50 and 75 years. There were 22 variables based on questions concerning oral situation and the impact on 7 theoretically different dimensions of QOL. The majority were satisfied with their oral health situation. During the previous 12 months, 16% of the population had experienced problems with their mouth or teeth on at least one occasion per mouth. Principal components analysis was used to analyze the dimensionality of the variables. Three factors accounted for 59% of the variance: (1) Physical and social disability, (2) psychological discomfort and disability, and (3) functional limitation and physical pain. The perception of OHRQOL is multidimensional, but the dimensions are not equally important. The dimensions of OHRQOL found in the present study are similar to those of existing instruments.

A prospective randomized clinical study comparing implant-supported fixed prostheses and overdentures in the edentulous mandible: prosthodontic production time and costs.

PURPOSE: This work compared implant-supported fixed prostheses and overdentures in the edentulous mandible in a randomized prospective study of treatment results, clinical working hours, laboratory working hours, and laboratory costs including materials. MATERIALS AND METHODS: Seventeen subjects agreed to participate. Three standard Brånemark implants were placed between the mental foramina in each patient. After the connection of standard abutments, subjects were randomly assigned to the fixed prosthesis group (n = 11) or overdenture group (n = 6). Subjects in the fixed group were provided with prostheses according to the All-in-One concept. Subjects in the overdenture group received a conventional denture retained by a Dolder bar system. RESULTS: One implant was lost in the fixed prosthesis group after 1 year. A new implant was placed, and the prosthesis was refitted. Mean clinical working hours were 3.1 in the fixed prosthesis group and 4.1 in the overdenture group. Mean laboratory working hours were 12.5 in the fixed prosthesis group and 7.7 in the overdenture group. Total laboratory costs, including materials, were on average about 1,700 US dollars for the fixed prosthesis and 1,350 US dollars for the overdenture. CONCLUSION: A fixed implant-supported prosthesis in the edentulous mandible could be provided at about the same cost as an overdenture using the method described. Provided that the early survival results prove to be long lasting, the choice between a fixed and a removable prosthesis need not be a matter of economy.

The dentist's communicative role in prosthodontic treatment.

PURPOSE: Dentist-patient verbal communication is important for patient satisfaction. The aim of this study was to investigate the dentist's role in the provider-patient relationship as to verbal communication and patient satisfaction with the treatment outcome in prosthetic dentistry. The dentist-specific properties were analyzed in random coefficient modeling. MATERIALS AND METHODS: Sixty-one dentist-patient pairs were followed through 61 prosthodontic treatment periods. The treatment performed was fixed prosthodontic restorations on teeth or implants. One encounter at the end of each treatment period was tape recorded. The verbal communication on the recordings was analyzed using an interaction analysis instrument. Various measures of communication were used, summarizing the variational pattern of verbal interaction. Two different aspects of the patient satisfaction concept were used as dependent variables: cure (overall patient satisfaction with prosthodontic treatment), and care (patient satisfaction with a particular dental encounter during the prosthodontic treatment period). RESULTS: In the multilevel model for care, the dentist variance was mostly explained by the communication variables. In the cure model, there was no dentist variance. The communication patterns used by the dentists thus influenced patient satisfaction in a short-term perspective but not in an intermediate perspective. CONCLUSION: Patient evaluation of the care during an encounter is dependent on the dentist's verbal communication activity during the encounter, but this communication has no impact on the patient evaluation of overall prosthetic treatment outcome in the intermediate time perspective.

The combination syndrome: a literature review.

Although combination syndrome is recognized by many clinicians, documented observations seem to be rare. The aim of this article was to critically review the literature regarding combination syndrome to evaluate the evidence for this concept. A search of the dental literature with Medline/PubMed through July 2002, focusing on the combination syndrome and related features, was undertaken and combined with a hand search of older references and textbooks on removable prosthodontics.

Underlying dimensions of verbal communication between dentists and patients in prosthetic dentistry.

The study explores whether the task-focused and socio-emotional dimensions of clinical communication is recognizable in the verbal communication context of prosthetic dentistry, as well as if there are other dimensions of communication in that context. Sixty-one audio recordings were made at three specialist clinics of prosthetic dentistry in Sweden. Sixty-one patients and 15 dentists participated. Sixty-one prosthetic rehabilitation periods were followed. Tooth- or implant-supported fixed prostheses were placed during this time. One visit near the end of each rehabilitation period was audiorecorded. The verbal communication was analyzed with the Roter Interaction Analysis System (RIAS)-dental. The categories were subjected to exploratory factor analysis. Patient and dentist verbal behavior could not be defined exclusively as socio-emotional or task-focused but had to be defined in other dimensions; Emotional exchange, information exchange-patient horizon, relation building exchange, information exchange-dentist horizon, and administrative and counseling exchange. Since the 'emotional exchange' factor was found to capture the largest share of the variance in the communicated patterns, the present study suggests that prosthetic care in dentistry is basically a human relationship with strong emotional communicative content.

Utilization of dental health services among middle-aged people in Sweden and Denmark.

In 1999, questionnaires were sent to random samples of 1001 Swedish citizens aged 55-79 years and 1175 Danish citizens aged 45-69 years. Various questions were asked concerning dental conditions, dental visit frequency per year, and money spent annually on dental care, etc. The objectives were to assess differences in the utilization of dental services and to compare out-of-pocket costs for dental care in Sweden and Denmark with control for age, gender, dental conditions and income. More than 80% of the subjects reported that a dentist had examined them less than 1 year previously. However, 77% of the Danes reported dental visits twice a year or more compared to 28% of the Swedes. Although the Danes reported a more frequent use of dental services, they had poorer dental conditions compared to the Swedes. Even though the Swedes used dental services less often than the Danes did, more subjects reported high 12-month out-of-pocket costs. In the present study, separate models were constructed for the two countries because there could be different mechanisms at play, as indicated by the results. The different insurance systems along with different degrees of commercialization in the two countries might be the most decisive factors in this context.

Removable partial denture design: a need to focus on hygienic principles?

PURPOSE: The purpose of this study was to critically analyze important hygienic/secondary prophylactic and biomechanical aspects of removable partial denture (RPD) design. MATERIALS AND METHODS: The literature related to traditional biomechanical design and open/hygienic design of RPDs was discussed by the authors at a 2.5-day workshop. The written report was circulated among the authors until a consensus was reached. RESULTS: There is little scientific support for most of the traditional design principles of RPDs, nor has patient satisfaction shown any correlation with design factors. However, there is evidence that an open/hygienic design is more important than biomechanical aspects for long-term oral health. The biomechanical importance of some components is questioned, e.g., indirect retention and guiding planes. Alternative connector designs that reduce risks of tissue injury are described. Direct retainers and pontics are discussed in relation to the possibilities they offer for gingival relief. CONCLUSION: Greater attention should be paid to RPD design principles that minimize the risks of tissue injury and plaque accumulation in accordance with modern concepts of preventive dentistry.

Subjective need for implant treatment among middle-aged people in Sweden and Denmark.

BACKGROUND: The use of oral implants in prosthodontics has become widespread and regarded as a predictable treatment modality. However, there is a lack of knowledge among the general population about the prevalence and need for implant treatments. PURPOSE: This study was undertaken to register and compare the prevalence of dental implants and the subjective need for implant treatment among people in Sweden and Denmark. MATERIALS AND METHODS: Random samples taken from the national population registers in Sweden and Denmark comprised 1001 Swedish subjects aged 55 to 79 years and 1175 Danish subjects aged 45 to 69 years. Subjects were requested to fill out questionnaires regarding dental conditions, subjective need for implant treatment, whether they had received treatment with dental implants during the previous 10 years, and so on. RESULTS: Of the Swedes, 4.8% reported that they had dental implants, compared with 2.5% of the Danes. In the Swedish sample, age was significantly associated with subjective need for implant treatment. In the Danish sample, women showed a significantly higher subjective need for implant treatment than did men. CONCLUSIONS: Compared with the Swedish sample, the subjective need for treatment with dental implants was higher in the Danish sample, although the patient fees were substantially higher in Denmark.

Dental care utilization: a study of 50- to 75-year-olds in southern Sweden.

This study investigates dental care utilization in an adult population in Southern Sweden in relation to dental and social conditions, attitudes to costs, and perceived need to obtain dental services. The study was based on responses to a questionnaire sent in 1998 to a random sample, 1974 persons, aged 56-75 years. The response rate was 66%. A significantly higher probability of dental care utilization less than once a year was found for men, for those with few remaining teeth, and for those with removable dentures. A higher probability of dental care utilization less than once a year was found for those who stated perceived need to obtain dental care with no possibility because of the cost and for those who stated that the cost had influenced their attendance for dental care. The results showed that there were differences for sex and dental conditions in dental care utilization and that dental care utilization was related to attitudes towards costs of dental care.

Dentist-patient communication and patient satisfaction in prosthetic dentistry.

PURPOSE: Dentist-patient verbal communication dimensions on patient satisfaction were investigated in a prosthodontic context, controlling for the age and gender of patients and dentists and the amount of delivered prosthodontic treatment. Two concepts of satisfaction were defined, one for the single visit (satisfaction with care), and one for the overall result (satisfaction with treatment outcome). MATERIALS AND METHODS: Audio recordings of 61 patients meeting 15 dentists were made in three specialist clinics of prosthetic dentistry. The prosthodontic treatment periods with fixed tooth- or implant-supported prostheses, on average 20 months, were monitored by questionnaires. One visit near the end of each treatment period was audio recorded. The recorded verbal communication was analyzed with the Roter Interaction Analysis System-Dental. RESULTS: Bivariate analysis showed that patients of female dentists were more satisfied in the long-term perspective than patients of male dentists. In logistic multivariate regression models, the verbal communication dimensions "information-dentist horizon" and "information-patient horizon," together with the mouth involvement of the prosthodontics, influenced patient satisfaction with treatment outcome. CONCLUSION: Patients undergoing extensive prosthodontic rehabilitation should be given the opportunity to ask and talk about their dental health, and dentists should minimize their question-asking and orientating behavior during the encounters to help improve patient satisfaction with treatment outcome.