Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2012 39; 438445
Quality of life and stimulus perception in patients
rehabilitated with complete denture
M . C . G O I A T O , L . C . B A N N W A R T , A . M O R E N O , D . M . DOS S A N T O S , A . P . M A R T I N I
& L . V . P E R E I R A Department of Dental Materials and Prosthodontics, Faculty of Dentistry of Aracatuba, UNESP Univ Estadual
Paulista, Aracatuba, Sao Paulo, Brazil
SUMMARY The objective of this study was to evaluate
and correlate quality of life (QoL), and stimulus
perception of complete denture users, before and
after the insertion of new prostheses. We selected 60
patients using bimaxillary complete conventional
dentures who needed to replace their prostheses.
During anamnesis, we collected demographic data
and applied the Oral Health Impact Profile for
Edentulous Patients (OHIP-EDENT) questionnaire
and stimulus perception questionnaire (PERCEP-
TION). Before installation of new prostheses, the
patients responded to OHIP-EDENT questionnaire,
and on the day of installation, they responded to
PERCEPTION questionnaire. At the patients
3-month follow-up, we re-administered the OHIP-
EDENT and PERCEPTION questionnaires. The Wil-
coxon and MacNemar tests were used to compare
Introduction
Improved quality of life (QoL) together with a decline
in mortality rates have led to growth of the elderly
population worldwide (1). Despite a global decrease in
the edentulism rate, with the great numbers of people
reaching an advanced age, the number of patients
without teeth continues high (2, 3). Although edent-
ulism is not necessarily a part of the natural ageing
process, age remains a strong factor in its incidence
(4, 5).
The majority of edentulous patients have trouble
performing essential functional tasks, such as eating,
chewing and producing phonemes (4, 6). Additionally,
over time, dentition loss leads to atrophy of dental
2012 Blackwell Publishing Ltd
patient responses between the time points analysed.
Most of the OHIP-EDENT items showed a highly
significant impact of the new prostheses on oral
health (P 0003). The PERCEPTION questionnaire
data indicated that the patients experienced signif-
icant improvements (P < 005) in terms of their
sensations with the new prostheses. Cross-lagged
data analysis did not show any causality between
the OHIP-EDENT and PERCEPTION questionnaires
(ZPF test, P = 0772). We concluded that the treat-
ment was effective with respect to the patients QoL
and their adaptation to the new prostheses.
KEYWORDS: oral health-related quality of life, oral
health impact profile, complete dentures patient
satisfaction, questionnaires
Accepted for publication 9 December 2011
support structures and loss of muscle tone, which have
unfavourable effects on facial aesthetics (4).
Adapting the base of prosthesis to subjacent tissues is
important in enabling an adequate biomechanical
response to be obtained and thus ultimately is critical
in making the prosthesis comfortable for the patient.
However, patients personal adaptation to their pros-
thesis, which depends on emotional and psychosocial
factors and their expectations regarding their rehabil-
itation, is as important as the aforementioned clinical
adaptation (1, 711).
Thus, the objectives of this study were to evaluate
the QoL and to examine the presence of stimulus
perception of complete denture users before versus
3 months after the insertion of new prostheses and to
doi: 10.1111/j.1365-2842.2011.02285.x
 QUALITY OF LIFE WITH COMPLETE DENTURE
analyse the correlation between QoL and stimulus
perception.
Materials and methods
Subjects
Of a sample of 92 patients who sought treatment for a
complete denture, 60 were selected, following an initial
clinical exam, between April 2010 and June 2010. The
inclusion criteria for the selection of the patients were as
follows: (1) Use of bimaxillary complete dentures for
more than 5 years; (2) the presence of adequate healthy
tissue to support the prosthesis; (3) adequate cognitive
ability and understanding to respond to the questions
posed. The old dentures presented great wear of the
acrylic denture teeth, decreased occlusal vertical dimen-
sion (OVD) and instability owing to the continuous
resorption of residual ridge. Patients were excluded
whether they had signs or symptoms of temporomandib-
ular disorders, as confirmed by the Dworkin and LeResche
(12) Research Diagnostic Criteria questionnaire.
The patients chosen received information about the
treatment to be used and signed an informed consent
form, in accordance with the recommendations of the
Committee on Ethics in Human Research (Procedure
FOA 10-18333), which approved the study. After the
patients were selected, we collected clinical and demo-
graphic data of interest for the study.
Fabrication of complete dentures
New complete dentures were made according to the
procedures recommended by Zarb et al. (13). The
technique employed for denture fabrication consisted
of obtaining preliminary impressions using stock trays
and condensed silicone material*. The preliminary casts
were fabricated to make custom trays for definitive
impressions. Border moulding was performed with
heavy body condensation silicone, and the definitive
impressions were made with zinc oxide-eugenol
impression paste spread over the entire fitting surface
of the tray, including the moulded borders. Definitive
impressions were poured with type IV dental gypsum
to obtain the master casts.
*Zetaplus; Zhermack, Rovigo, Italy.
Lysanda, Sao Paulo, Brazil.
Durone; Dentsply, Petropolis, Brazil.
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439
The maxillary cast for each subject was mounted on a
semi-adjustable articulator using a facebow transfer
register. The OVD for each patient was established using
the physiologic rest position associated with phonetic
and aesthetic methods (13). Centric relation was estab-
lished according to dynamic records based on physio-
logical jaw movements, including opening, closing and
lateral movements performed by the subject (13). These
dynamic records were used to position the mandibular
casts on the articulators at appropriately related posi-
tions. Artificial teeth were selected, and bilateral bal-
anced occlusion was obtained. The dentures were
waxed, processed, finished and polished for insertion
and follow-up (13). The dentures were made with
Trilux artificial teeth with a cusp inclination of 20!.
Adjustments to the resin base and occlusions were
made at the time of installation. Each patient was
instructed how to use the prosthesis while speaking and
chewing and how to clean it. Subsequent monitoring
was employed to evaluate the patients adaptation to
their prostheses and, when necessary, to make adjust-
ments so as to avoid discomfort during use.
OHIP-EDENT questionnaire
Patient QoL was assessed by administering the 19-item
OHIP-EDENT questionnaire. Based on the original
OHIP proposed by Slade in 1994 (14), the OHIP-EDENT
is a version of the OHIP specific for edentulous patients
that was proposed by Souza in 2007 (15). Scoring was
calculated by attributing points to the responses
(0 = never; 1 = sometimes; 2 = almost always). The
OHIP-EDENT was administered to patients before (t1)
and 3 months after (t2) the installation of their new
prostheses. The OHIP-EDENT response data were anal-
ysed over four domains (16): Masticatory-related
complaints (questions 1, 5, 10, and 11); Psychological
discomfort and disability (questions 8, 9, 12, 13, and
14); Social disability (questions 1519); and Oral pain
and discomfort (questions 24, 6, and 7).
PERCEPTION questionnaire
Patient sensations were assessed by administering
the 4-item PERCEPTION questionnaire. The PERCEP-
TION questionnaire evaluates patient uncomfortable
Whip Mix Corporation, Louisville, KY, USA.
Vipi Manufacturer, Sao Paulo, Brazil.
440 M . C . G O I A T O et al.

sensations related to having new prostheses: The feeling Table 1. Characteristics of patients in relation to demographic
of a full mouth, pronunciation of sibilant tones, and clinical variables of interest

discomfort related to the prosthesis and excessive

Conventional
salivation. Scoring was calculated based on binary
Variables bimaxillary dentures*
responses (0 = no and 1 = yes). This questionnaire
was administered to the patients at the time their new Gender
Female 43 (717)
prostheses were installed (t1; differ approximately two
Male 17 (283)
hours of the initial application of the OHIP-EDENT Age (years) 710 (76)
questionnaire) and 3 months later (t2). Civil status
Single 6 (100)
Married 39 (650)
Statistical analysis Divorced 8 (117)
Widower 7 (133)
Descriptive statistical analyses (including frequency
Family income
distributions and percentages) were performed on the <5 times Brazilian minimum wage 46 (767)
patients demographic data and their responses to both 5 times Brazilian minimum wage 14 (233)
questionnaires. Scores obtained for each question were Satisfied with old prosthesis
compared between the two periods using non-para- Yes 23 (383)
No 27 (450)
metric tests. The Wilcoxon test (paired) was applied to
Do not know 10 (167)
the OHIP-EDENT results, whereas the MacNemar
(paired) test was applied to the PERCEPTION question- *Values in parentheses are expressed as percentage.

naire data. P values <005 were considered statistically Mean value (standard deviation).

significant.
The hypothesis of an association between the
patients OHIP-EDENT and PERCEPTION question-
naires was verified by cross-lagged analysis. For this
evaluation, we calculated the sum of the scores for all of
the questions for each patient, where a higher score
signified a more compromised QoL on the OHIP-EDENT
questionnaire (score range, 038) and signified trou-
bling stimulus perception on the PERCEPTION
questionnaire (score range, 04). Thus, three types
of correlations were performed: Autocorrelations
(between two measures of a variable at different times),
synchronous correlations (between different variables
at the same time) and cross-lagged correlations
(between different variables at different times) (17).
The difference between cross-lagged correlations can be
tested with a modified Pearson-Filon ZPF test (17, 18).
Statistical analysis was performed using SPSS version
19.0 statistical software**.
Results
Patient demographics
The demographic characteristics of the treated patients
are summarised in Table 1. Our study cohort included
**SPSS Inc., Chicago, IL, USA.
more women (717%) than men (283%), and their
mean age was 710 years (range 6087 years). Most
patients stated that they were married (650%), and a
majority of them (767%) had family incomes that did
not exceed five times the countrys stipulated minimum
wage. A higher percentage of patients declared them-
selves dissatisfied with their old prosthesis (450%) than
satisfied (383%) or undecided (167%) (Table 1).
OHIP-EDENT questionnaire
As shown in Table 2, significant (P < 005, t1 vs. t2)
impacts of the new prostheses on oral health were
found for three OHIP-EDENT masticatory-related com-
plaint items (questions 1, 5 and 11), five psychological
discomfort and disability items (questions 8, 9, 12, 13
and 14) and two oral pain and discomfort items
(questions 2 and 3). Significant differences between t1
and t2 were also observed for two social disability items
(questions 17 and 18, P < 005) (Table 2). The
responses to questions 4, 6, 7 (oral pain and discom-
fort), question 10 (masticatory-related complaints) and
questions 15 and 16 (social disability) did not differ
significantly between the time points. In these ques-
tions, the results remained similar in both periods
analysed, with predominance of the answer never.

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 QUALITY OF LIFE WITH COMPLETE DENTURE 441

Table 2. Application results of OHIP-EDENT. Frequency of answers for each question of the OHIP-EDENT (n = 60)

Before installation After 3 months

Questions Never Sometimes Almost always Never Sometimes Almost always P-value

1. Difficulty chewing 20 (333) 20 (333) 20 (333) 33 (550) 24 (400) 3 (50) <0001*

2. Food catching 22 (367) 33 (550) 5 (83) 45 (750) 15 (250) 0 (00) <0001*
3. Dentures not fitting 22 (367) 25 (417) 13 (217) 33 (550) 24 (400) 3 (50) 0003*
4. Painful aching 32 (533) 24 (400) 4 (67) 33 (550) 26 (433) 1 (17) 0459ns
5. Uncomfortable to eat 21 (350) 31 (517) 8 (133) 32 (533) 26 (433) 2 (33) 0010*
6. Sore spot 30 (500) 28 (467) 2 (33) 31 (517) 29 (483) 0 (00) 0586ns
7. Uncomfortable dentures 25 (417) 27 (450) 8 (133) 30 (500) 27 (450) 3 (50) 0130ns
8. Worried 15 (250) 31 (517) 14 (233) 36 (600) 21 (350) 3 (50) <0001*
9. Self-conscious 16 (267) 35 (583) 9 (150) 42 (700) 16 (267) 2 (33) <0001*
10. Avoids eating 26 (433) 34 (567) 0 (00) 38 (633) 20 (333) 2 (33) 0070ns
11. Interrupts meals 45 (750) 15 (250) 0 (00) 58 (967) 2 (33) 0 (00) 0001*
12. Unable to eat 25 (417) 35 (583) 0 (00) 47 (783) 13 (217) 0 (00) <0001*
13. Upset 16 (267) 34 (567) 10 (167) 38 (633) 20 (333) 2 (33) <0001*
14. Has been embarrassed 15 (250) 38 (633) 7 (117) 44 (733) 16 (267) 0 (00) <0001*
15. Avoids going out 47 (783) 13 (217) 0 (00) 54 (900) 6 (100) 0 (00) 0095ns
16. Less tolerant of others 33 (550) 26 (433) 1 (17) 37 (617) 22 (367) 1 (17) 0424ns
17. Irritable with others 29 (483) 30 (500) 1 (17) 41 (683) 18 (300) 1 (17) 0047*
18. Unable to enjoy company 50 (833) 10 (167) 0 (00) 57 (950) 3 (50) 0 (00) 0039*
19. Life unsatisfying 37 (617) 23 (383) 0 (00) 52 (867) 8 (133) 0 (00) 0003*

OHIP-EDENT, Oral Health Impact Profile for assessing edentulous subjects.

Values in parentheses are expressed as percentage.

Wilcoxon test.
ns
Non-significant, P > 005; *Significant, P < 005.

between t1 and t2 was positive and significant, respec-

PERCEPTION questionnaire
As shown in Table 3, highly significant improvement in
sensation following a 3-month habituation to new
prostheses was verified for all four PERCEPTION items
(P 0001, t1 vs. t2).
Questionnaire data interaction
The autocorrelations at OHIP-EDENT responses
between t1 and t2 and at PERCEPTION responses
tively (r = 041, P < 001; r = 045, P < 0001) (Fig. 1).
However, there were no significant differences in
synchronous correlations between OHIP-EDENT and
PERCEPTION responses at t1; and OHIP-EDENT and
PERCEPTION responses at t2, respectively (r = 024;
r = )025).
Additionally, as shown in Fig. 1, a cross-lagged
analysis of the data did not show significant causality
between OHIP-EDENT and PERCEPTION questionnaire
responses (ZPF test, P = 0772), confirming that there

Table 3. Application results of PERCEPTION. Frequency of answers for each question of the PERCEPTION (n = 60)

Upon installation After 3 months

Questions No Yes No Yes P-value

1. Do you have the feeling of a full mouth 24 (400) 36 (600) 58 (967) 2 (33) <0001*
2. Do you have any difficulty pronouncing sibilant tones? 36 (600) 24 (400) 54 (900) 6 (100) <0001*
3. Do you feel any discomfort with the prosthesis? 27 (450) 33 (550) 45 (750) 15 (250) 0001*
4. Are you salivating excessively? 42 (700) 18 (300) 57 (950) 3 (50) <0001*

Values in parentheses are expressed as percentage.

McNemar test.
*Significant, P < 005.

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442 M . C . G O I A T O et al.
Fig. 1. Cross-lagged analysis for the effects of installing new
complete denture. OHIP-EDENT, OHIP-EDENT questionnaire;
PERCEPTION, PERCEPTION questionnaire; t1, upon installation;
t2, 3 months after the installation.
was no correlation between OHIP-EDENT responses at
t1 and PERCEPTION at t2; and PERCEPTION responses
at t1 and OHIP-EDENT at t2 (r = 009; r = )007).
Discussion
The demographics of the present cohort study (median
age = 709 years, with 43 women and 17 men)
(Table 1) are in line with prior reports, indicating that
most edentulous patients are women with a median age
of 653 ! 99 years (16) and 742 ! 729 years (19);
though, Belline (1) observed a lower median age for a
population without teeth ("60 years). Patients dissat-
isfaction with their old prostheses may have stemmed
from several factors, key among them maladaptation of
the base of the prostheses, cuspid resin wear and tear
and changes to the vertical dimension. These factors are
known to negatively affect prosthesis retention, eating
and phonetic, resulting in higher levels of dissatisfac-
tion (911).
In this study, treatment of rehabilitated patients with
a total loss of teeth was analysed in terms of patient QoL
by administering the OHIP-EDENT before and
3 months after rehabilitation with a new complete
denture. Many factors can be important in determining
acceptance and better QoL with ones prostheses. Prior
studies have reported that acceptability, satisfaction and
QoL in patients rehabilitated were related to ones
ability to chew and talk, comfort, retention and
aesthetics and that those patients who were most
concerned with prosthesis functionality were more
likely to be satisfied with their dentures (1, 1921).
The OHIP-EDENT items are divided into four domains,
as described earlier; in what follows, we will discuss
those items for which the patients responses differed
significantly between the two time points.
All responses to items in the first domain of the
OHIP-EDENT (Table 2) differed significantly between t1
and t2, with the exception of the item avoids eating.
The significant results obtained for chewing, discomfort
and inability of eating could be related to the fact that
the old dentures were discomfort to the patients and
the new one provided greater chewing efficiency and fit
to the supporting tissues. Therefore, the complains
regarding the old denture may be owing to its pro-
longed and continued use, and the presence of resin
denture teeth wear as well, which causes cuspids
loosing and reduces the triturating areas, resulting in a
reduced OVD, ultimately producing mastication defi-
ciencies. In these cases, patients tend to compensate for
cuspid loss by using a greater bite force to crush foods
(811).
Furthermore, this phenomenon accelerates bone
re-absorption that occurs after the loss of dentition,
causing maladaption of the resin denture base of the
complete denture and thus leaving it slightly loose
around the patients residual ridge. This factor and
the problems caused by the reduced OVD can cause
great discomfort to the patients when they are eating
and may significantly reduce their masticatory effi-
ciency (10, 11). The decrease in masticatory efficiency
can significantly affect patients nutrition (22) as the
subjects alter their diet and swallow large pieces of
food that could not be crushed during mastication
and, consequently, cause reduction in nutrient
absorption (23). So, these patients prefer soft foods
rather than those with high content of fibre such as
raw vegetables, fresh fruit and meat (2325). An
inadequate diet causes serious health problems to the
patients such as gastrointestinal disorders and obesity,
which interferes in their physical and social status
(25).
Studies have shown that patients with complete
dentures are generally more concerned with chewing
than with aesthetics results (19, 26). The results
obtained by Ellis et al. (19) were similar of those
observed herein, and those authors noted that the
QoL was associated with the first OHIP domain follow-
ing the installation of new more comfortable prosthe-
ses. It could be supposed that the rehabilitation with
new dentures re-established the OVD and the anatomy
of the teeth, restoring the cuspids and the triturating
areas, thereby improving the efficiency of mastication.
In addition, functional moulding of the residual ridge
that gives the prosthesis greater retention and stability
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 QUALITY OF LIFE WITH COMPLETE DENTURE
improves the patients comfort with the prosthesis
during its use, enhancing patients masticatory effi-
ciency and their ability to eat properly. Thus, we believe
that agreeable mastication is an important factor in
improving oral health with complete dentures.
The second domain of the OHIP-EDENT relates to
incapacity and psychological discomfort. The psycho-
logical factors involve expectations, impact on QoL and
how a patient copes with edentulism and the use of
complete dentures. The responses to all of the items in
this domain differed significantly between t1 and t2
(Table 2).
Therefore, in the present study, the psychological
impact of losing teeth was an important factor in the
QoL of patients rehabilitated with dentures. Consider-
ing that the mouth is important for making facial
expressions, such as smiling, the dentures serve as an
important psychological function (1, 810, 19). The
significant results regarding worries, embarrassment
and distress of the patients in relation to their denture,
mouth and teeth may be due to the loss of facial
harmony (reduction in the OVD) (9). Moreover,
patients appreciate a new and well-adapted complete
prosthesis for enabling better retention of the resin base
at the residual ridge. It is also important to highlight
that the aesthetic appearance is fundamental to ones
mental wellbeing; and the rehabilitation with new
prostheses can raise patients self-esteem and self-
confidence levels.
We observed that patients who previously faced
embarrassing situations with their badly adapted den-
tures, either because of lack of retention or poor
aesthetics, felt more comfortable after their new pros-
theses were installed. The inability to eat properly and
the insecurity to smile or talk to other people owing to
the instability of the old dentures, decrease patients
self-esteem and promote feelings of inferiority and
shame (24, 25). In the present study, the rehabilitation
with conventional complete dentures recovered
patients confidence to perform simple tasks and
significantly improved the masticatory efficiency, aes-
thetics and stability of the denture, ensuring greater
patients quality of life.
All responses to items in the third domain of the
OHIP-EDENT, which analysed social problems, differed
significantly between t1 and t2 (Table 2), with the
exception of the items avoid going out and less patients rehabilitated with new complete dentures had
tolerant of others. Our data indicated that patients who
had difficulty eating with their old prostheses were
2012 Blackwell Publishing Ltd
443
more socially distanced, with life dissatisfaction feelings
because of their buccal problems; however, after reha-
bilitation with new dentures, this distancing and
dissatisfaction diminished significantly.
One serious consequence of edentulism with poorly
adapted total prostheses is social isolation (27, 28). Our
results are in accordance with previous studies that
stated that the absence of teeth and or use of a poorly
adapted prosthesis restrict the diet and make people feel
socially uncomfortable, leading them to take their
meals away from others (810, 27). Negative effects of
edentulism on patients social lives can be minimised
through rehabilitation with new complete prostheses or
implant-retained prostheses (27). These patients feel
safe to eat, talk and laugh, and their social and family
life are restored.
In the oral pain and discomfort domain of the OHIP-
EDENT, we observed significant differences between
the patients responses at t1 versus at t2 for the food
catching and dentures not fitting items (Table 2). The
significant change of these items after 3 months of new
denture insertion may be explained by the intermax-
illary position, denture teeth anatomy, denture base
shape and adaptation of the denture base to the
supporting tissues, which promotes greater comfort
during chewing, improves the ability to crush the food
and increases denture stability.
Prior to rehabilitation, these patients had worn
complete dentures for more than 5 years. The contin-
uous use and the prolonged contact of these dentures
with oral fluids, associated with the hygiene methods
can lead to loss of material from the denture base. This
may be related to the materials solubility or lixiviation
(29) that leads to a porous formation or even removes
the most external polished layer of the material (30)
and facilitates the retention of eating particles in the old
denture. Moreover, the overuse of denture can cause its
instability owing to incorrect positioning of intermax-
illary relations, which can further cause muscular
changes. The loss of OVD because of the wear of
denture teeth (loss or decrease of cuspids angulations
of the artificial teeth) possibly reduces the creation of
oblique loads that tends to stabilise the lower denture.
Consequently, OVD changes reduce masticatory effi-
ciency (811).
Based on our results, it was possible to observe that
significant change in almost all factors evaluated here-
in. It positively interferes on the chewing, health,
444 M . C . G O I A T O et al.
physical status, self-confidence, self-esteem, re-inser-
tion into society and quality of life of those patients.
In our clinical experience, the feeling of a full
mouth, excessive salivation, difficulties in pronouncing
sibilant tones and discomfort are the most common
complaints upon installation of complete dentures. This
general observation was confirmed in the present
statistical analysis. Our data further indicated that these
issues improve significantly by 3 months post-rehabil-
itation (Table 3). This issue may be related to the
adaptation period with new dentures. During this time,
the patients certainly presented difficulty in talking,
smiling and eating, which affected their psychosocial
state; however, in most of cases, it was observed for a
short period of time. Patient adaptation to this
re-establishment varies as adaptation depends on neu-
romuscular control (811, 31); but we were able to see
that 3 months was sufficient for the majority of patients
to achieve improvements in these symptoms (9).
Conclusion
Complete denture rehabilitation was an effective treat-
ment in terms of QoL and perception for the cohort of
patients examined in this study, although causality
between patient perceptions and QoL was not estab-
lished.
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Correspondence: Dr Marcelo Coelho Goiato, Department of Dental
Materials and Prosthodontics, Faculty of Dentistry of Aracatuba,
UNESP Univ Estadual Paulista, Jose Bonifacio, 1193, Aracatuba, Sao
Paulo 16015-050, Brazil. E-mail: goiato@foa.unesp.br