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SUMMARY The objective of this study was to evaluate patient responses between the time points analysed.
and correlate quality of life (QoL), and stimulus Most of the OHIP-EDENT items showed a highly
perception of complete denture users, before and significant impact of the new prostheses on oral
after the insertion of new prostheses. We selected 60 health (P 0003). The PERCEPTION questionnaire
patients using bimaxillary complete conventional data indicated that the patients experienced signif-
dentures who needed to replace their prostheses. icant improvements (P < 005) in terms of their
During anamnesis, we collected demographic data sensations with the new prostheses. Cross-lagged
and applied the Oral Health Impact Profile for data analysis did not show any causality between
Edentulous Patients (OHIP-EDENT) questionnaire the OHIP-EDENT and PERCEPTION questionnaires
and stimulus perception questionnaire (PERCEP- (ZPF test, P = 0772). We concluded that the treat-
TION). Before installation of new prostheses, the ment was effective with respect to the patients QoL
patients responded to OHIP-EDENT questionnaire, and their adaptation to the new prostheses.
and on the day of installation, they responded to KEYWORDS: oral health-related quality of life, oral
PERCEPTION questionnaire. At the patients health impact profile, complete dentures patient
3-month follow-up, we re-administered the OHIP- satisfaction, questionnaires
EDENT and PERCEPTION questionnaires. The Wil-
coxon and MacNemar tests were used to compare Accepted for publication 9 December 2011
analyse the correlation between QoL and stimulus The maxillary cast for each subject was mounted on a
perception. semi-adjustable articulator using a facebow transfer
register. The OVD for each patient was established using
the physiologic rest position associated with phonetic
Materials and methods
and aesthetic methods (13). Centric relation was estab-
lished according to dynamic records based on physio-
Subjects
logical jaw movements, including opening, closing and
Of a sample of 92 patients who sought treatment for a lateral movements performed by the subject (13). These
complete denture, 60 were selected, following an initial dynamic records were used to position the mandibular
clinical exam, between April 2010 and June 2010. The casts on the articulators at appropriately related posi-
inclusion criteria for the selection of the patients were as tions. Artificial teeth were selected, and bilateral bal-
follows: (1) Use of bimaxillary complete dentures for anced occlusion was obtained. The dentures were
more than 5 years; (2) the presence of adequate healthy waxed, processed, finished and polished for insertion
tissue to support the prosthesis; (3) adequate cognitive and follow-up (13). The dentures were made with
ability and understanding to respond to the questions Trilux artificial teeth with a cusp inclination of 20!.
posed. The old dentures presented great wear of the Adjustments to the resin base and occlusions were
acrylic denture teeth, decreased occlusal vertical dimen- made at the time of installation. Each patient was
sion (OVD) and instability owing to the continuous instructed how to use the prosthesis while speaking and
resorption of residual ridge. Patients were excluded chewing and how to clean it. Subsequent monitoring
whether they had signs or symptoms of temporomandib- was employed to evaluate the patients adaptation to
ular disorders, as confirmed by the Dworkin and LeResche their prostheses and, when necessary, to make adjust-
(12) Research Diagnostic Criteria questionnaire. ments so as to avoid discomfort during use.
The patients chosen received information about the
treatment to be used and signed an informed consent
OHIP-EDENT questionnaire
form, in accordance with the recommendations of the
Committee on Ethics in Human Research (Procedure Patient QoL was assessed by administering the 19-item
FOA 10-18333), which approved the study. After the OHIP-EDENT questionnaire. Based on the original
patients were selected, we collected clinical and demo- OHIP proposed by Slade in 1994 (14), the OHIP-EDENT
graphic data of interest for the study. 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
Fabrication of complete dentures
(0 = never; 1 = sometimes; 2 = almost always). The
New complete dentures were made according to the OHIP-EDENT was administered to patients before (t1)
procedures recommended by Zarb et al. (13). The and 3 months after (t2) the installation of their new
technique employed for denture fabrication consisted prostheses. The OHIP-EDENT response data were anal-
of obtaining preliminary impressions using stock trays ysed over four domains (16): Masticatory-related
and condensed silicone material*. The preliminary casts complaints (questions 1, 5, 10, and 11); Psychological
were fabricated to make custom trays for definitive discomfort and disability (questions 8, 9, 12, 13, and
impressions. Border moulding was performed with 14); Social disability (questions 1519); and Oral pain
heavy body condensation silicone, and the definitive and discomfort (questions 24, 6, and 7).
impressions were made with zinc oxide-eugenol
impression paste spread over the entire fitting surface
PERCEPTION questionnaire
of the tray, including the moulded borders. Definitive
impressions were poured with type IV dental gypsum Patient sensations were assessed by administering
to obtain the master casts. the 4-item PERCEPTION questionnaire. The PERCEP-
TION questionnaire evaluates patient uncomfortable
*Zetaplus; Zhermack, Rovigo, Italy.
Lysanda, Sao Paulo, Brazil. Whip Mix Corporation, Louisville, KY, USA.
Durone; Dentsply, Petropolis, Brazil. Vipi Manufacturer, Sao Paulo, Brazil.
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
significant.
The hypothesis of an association between the
patients OHIP-EDENT and PERCEPTION question- more women (717%) than men (283%), and their
naires was verified by cross-lagged analysis. For this mean age was 710 years (range 6087 years). Most
evaluation, we calculated the sum of the scores for all of patients stated that they were married (650%), and a
the questions for each patient, where a higher score majority of them (767%) had family incomes that did
signified a more compromised QoL on the OHIP-EDENT not exceed five times the countrys stipulated minimum
questionnaire (score range, 038) and signified trou- wage. A higher percentage of patients declared them-
bling stimulus perception on the PERCEPTION selves dissatisfied with their old prosthesis (450%) than
questionnaire (score range, 04). Thus, three types satisfied (383%) or undecided (167%) (Table 1).
of correlations were performed: Autocorrelations
(between two measures of a variable at different times),
OHIP-EDENT questionnaire
synchronous correlations (between different variables
at the same time) and cross-lagged correlations As shown in Table 2, significant (P < 005, t1 vs. t2)
(between different variables at different times) (17). impacts of the new prostheses on oral health were
The difference between cross-lagged correlations can be found for three OHIP-EDENT masticatory-related com-
tested with a modified Pearson-Filon ZPF test (17, 18). plaint items (questions 1, 5 and 11), five psychological
Statistical analysis was performed using SPSS version discomfort and disability items (questions 8, 9, 12, 13
19.0 statistical software**. 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
Results
(questions 17 and 18, P < 005) (Table 2). The
responses to questions 4, 6, 7 (oral pain and discom-
Patient demographics
fort), question 10 (masticatory-related complaints) and
The demographic characteristics of the treated patients questions 15 and 16 (social disability) did not differ
are summarised in Table 1. Our study cohort included significantly between the time points. In these ques-
tions, the results remained similar in both periods
**SPSS Inc., Chicago, IL, USA. analysed, with predominance of the answer never.
Table 2. Application results of OHIP-EDENT. Frequency of answers for each question of the OHIP-EDENT (n = 60)
Questions Never Sometimes Almost always Never Sometimes Almost always P-value
Wilcoxon test.
ns
Non-significant, P > 005; *Significant, P < 005.
Table 3. Application results of PERCEPTION. Frequency of answers for each question of the PERCEPTION (n = 60)
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*
McNemar test.
*Significant, P < 005.
improves the patients comfort with the prosthesis more socially distanced, with life dissatisfaction feelings
during its use, enhancing patients masticatory effi- because of their buccal problems; however, after reha-
ciency and their ability to eat properly. Thus, we believe bilitation with new dentures, this distancing and
that agreeable mastication is an important factor in dissatisfaction diminished significantly.
improving oral health with complete dentures. One serious consequence of edentulism with poorly
The second domain of the OHIP-EDENT relates to adapted total prostheses is social isolation (27, 28). Our
incapacity and psychological discomfort. The psycho- results are in accordance with previous studies that
logical factors involve expectations, impact on QoL and stated that the absence of teeth and or use of a poorly
how a patient copes with edentulism and the use of adapted prosthesis restrict the diet and make people feel
complete dentures. The responses to all of the items in socially uncomfortable, leading them to take their
this domain differed significantly between t1 and t2 meals away from others (810, 27). Negative effects of
(Table 2). edentulism on patients social lives can be minimised
Therefore, in the present study, the psychological through rehabilitation with new complete prostheses or
impact of losing teeth was an important factor in the implant-retained prostheses (27). These patients feel
QoL of patients rehabilitated with dentures. Consider- safe to eat, talk and laugh, and their social and family
ing that the mouth is important for making facial life are restored.
expressions, such as smiling, the dentures serve as an In the oral pain and discomfort domain of the OHIP-
important psychological function (1, 810, 19). The EDENT, we observed significant differences between
significant results regarding worries, embarrassment the patients responses at t1 versus at t2 for the food
and distress of the patients in relation to their denture, catching and dentures not fitting items (Table 2). The
mouth and teeth may be due to the loss of facial significant change of these items after 3 months of new
harmony (reduction in the OVD) (9). Moreover, denture insertion may be explained by the intermax-
patients appreciate a new and well-adapted complete illary position, denture teeth anatomy, denture base
prosthesis for enabling better retention of the resin base shape and adaptation of the denture base to the
at the residual ridge. It is also important to highlight supporting tissues, which promotes greater comfort
that the aesthetic appearance is fundamental to ones during chewing, improves the ability to crush the food
mental wellbeing; and the rehabilitation with new and increases denture stability.
prostheses can raise patients self-esteem and self- Prior to rehabilitation, these patients had worn
confidence levels. complete dentures for more than 5 years. The contin-
We observed that patients who previously faced uous use and the prolonged contact of these dentures
embarrassing situations with their badly adapted den- with oral fluids, associated with the hygiene methods
tures, either because of lack of retention or poor can lead to loss of material from the denture base. This
aesthetics, felt more comfortable after their new pros- may be related to the materials solubility or lixiviation
theses were installed. The inability to eat properly and (29) that leads to a porous formation or even removes
the insecurity to smile or talk to other people owing to the most external polished layer of the material (30)
the instability of the old dentures, decrease patients and facilitates the retention of eating particles in the old
self-esteem and promote feelings of inferiority and denture. Moreover, the overuse of denture can cause its
shame (24, 25). In the present study, the rehabilitation instability owing to incorrect positioning of intermax-
with conventional complete dentures recovered illary relations, which can further cause muscular
patients confidence to perform simple tasks and changes. The loss of OVD because of the wear of
significantly improved the masticatory efficiency, aes- denture teeth (loss or decrease of cuspids angulations
thetics and stability of the denture, ensuring greater of the artificial teeth) possibly reduces the creation of
patients quality of life. oblique loads that tends to stabilise the lower denture.
All responses to items in the third domain of the Consequently, OVD changes reduce masticatory effi-
OHIP-EDENT, which analysed social problems, differed ciency (811).
significantly between t1 and t2 (Table 2), with the Based on our results, it was possible to observe that
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 significant change in almost all factors evaluated here-
had difficulty eating with their old prostheses were in. It positively interferes on the chewing, health,
physical status, self-confidence, self-esteem, re-inser- 8. Goiato MC, Ribeiro P do P, Garcia AR, dos Santos DM.
tion into society and quality of life of those patients. Complete denture masticatory efficiency: a literature review.
J Calif Dent Assoc. 2008;36:683686.
In our clinical experience, the feeling of a full
9. Goiato MC, Garcia AR, dos Santos DM. Electromyographic
mouth, excessive salivation, difficulties in pronouncing activity of the mandible muscles at the beginning and end of
sibilant tones and discomfort are the most common masticatory cycles in patients with complete dentures.
complaints upon installation of complete dentures. This Gerontology. 2008;54:138143.
general observation was confirmed in the present 10. Goiato MC, Garcia AR, Dos Santos DM, Zuim PR. Analysis of
statistical analysis. Our data further indicated that these masticatory cycle efficiency in complete denture wearers.
J Prosthodont. 2010;19:1013.
issues improve significantly by 3 months post-rehabil-
11. Goiato MC, Garcia AR, dos Santos DM, Zuim PR, Sundefeld
itation (Table 3). This issue may be related to the ML, Pesqueira AA. Silent period of masticatory cycles in
adaptation period with new dentures. During this time, dentate subjects and complete denture wearers. J Prosth-
the patients certainly presented difficulty in talking, odont. 2011;20:130134.
smiling and eating, which affected their psychosocial 12. Dworkin SF, LeResche L. Research diagnostic criteria for
temporomandibular disorders: review, criteria, examinations
state; however, in most of cases, it was observed for a
and specifications, critique. J Craniomandib Disord. 1992;6:
short period of time. Patient adaptation to this 301355.
re-establishment varies as adaptation depends on neu- 13. Zarb GA, Bolender CL. Prosthodontic treatment for edentu-
romuscular control (811, 31); but we were able to see lous patients. Complete dentures and implant-supported
that 3 months was sufficient for the majority of patients prostheses. 20th ed. St Louis: Mosby; 2004.
14. Slade GD, Spencer AJ. Development and evaluation of the
to achieve improvements in these symptoms (9).
oral health impact profile. Community Dent Health.
1994;11:311.
Conclusion 15. Souza RF, Patrocnio L, Pero AC, Marra J, Compagnoni MA.
Reliability and validation of a Brazilian version of the Oral
Complete denture rehabilitation was an effective treat- Health Impact Profile for assessing edentulous subjects. J Oral
ment in terms of QoL and perception for the cohort of Rehabil. 2007;34:821826.
16. Souza RF, Leles CR, Guyatt GH, Pontes CB, Della Vecchia
patients examined in this study, although causality
MP, Neves FD. Exploratory factor analysis of the Brazilian
between patient perceptions and QoL was not estab- OHIP for edentulous subjects. J Oral Rehabil. 2010;37:202
lished. 208.
17. Stober T, Danner D, Lehmann F, Seche AC, Rammelsberg P,
Hassel AJ. Association between patient satisfaction with
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